Divide and Conquer: A Comparative History of Medical Specialization (review)

One of the striking features of modern medicine has been the multiplication of specialties and the growing proportion of physicians engaged in specialized rather than general practice. This trend has engaged the attention of health-policy analysts, who worry about rising health-care costs and the decline of primary care. In Divide and Conquer, George Weisz provides the first systematic account of the deep historical roots of this phenomenon. The book is a tour de force and deserves a wide readership in the health-policy world, as well as among historians and sociologists of medicine and the professions.

Weisz is not the first historian to address the question of specialization. Many readers of this journal will know George Rosen's classic study The Specialization of Medicine, With Particular Reference to Ophthalmology (1944; reprinted 1972), which attributed specialization in large part to the development of pathological anatomy and organic localism, as well as major studies of British and American medicine by Rosemary Stevens, in which the recent growth of medical and surgical specialties is a central concern. We also have a few other monographs on specialization in particular national settings, and many histories of individual specialties, mostly in one country and often filiopietistic. Weisz's approach is different. He deals with four major national cases—the United States, Britain, France, and Germany—emphasizing what he calls "systems" of specialties rather than particular specialties. Unlike some earlier works, Divide and Conquer takes the long view, reaching back to the end of the eighteenth century, and it is rigorously analytical throughout.

Weisz divides his book into three main parts. The first traces the development of specialization in the nineteenth century; it occurred in major urban centers, starting in Paris, primarily in research and teaching rather than in medical practice. The second part covers the period from the late nineteenth century to World War II and the immediate postwar era, during which specialties became a dominant form of practice, and the four countries developed national systems to regulate them. The third part interrupts the narrative to examine the experience of women practitioners and selected areas of specialization within a cross-national framework; the fields discussed include surgery, internal medicine (which was not recognized in Britain and France), obstetrics and women's health, diseases of the organs of the head, stomatology and dentistry, and venereology (often combined with dermatology). The narrative resumes with an epilogue on the period since 1950, which covers, among many other topics, the effort to create uniform standards within the European Union.

It is exceptionally difficult to summarize the findings of a richly detailed work that—quite appropriately—rejects a single master narrative, a uniform theoretical approach, and monocausal explanations. Though specialization as a long-range trend was "overdetermined" and therefore unsurprising, it was to a large extent a contingent phenomenon, heavily influenced by political and social forces and institutional traditions within each country. There was no one path to specialization, and for that matter, no singular and invariable national models—though certain broad national characteristics stand out, at least within each of Weisz's three major periods. Britain saw the most resistance to specialization, had (as it still does) the fewest specialists, and in the twentieth century assigned a gate-keeping function to GPs. The lack of national health insurance in the twentieth-century United States created a very different environment for specialists than in the other three countries. The late regulation of specialties in twentieth-century France reflected weak professional organizations and the importance of the state in French political culture; it took a new national Order of Physicians, created during World War II by the Vichy government, to institute a regulatory regime. The German experience reflected governmental decentralization, which continued after national unification in 1871, and the strength of professional associations.

All of this may seem unabashedly untrendy, and it is. Divide and Conquer is a study of...