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  • The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900–1940 by James A. Schafer Jr.
  • Jim Higgins
James A. Schafer Jr. The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900–1940 (New Brunswick, NJ: Rutgers University Press, December 2013). Pp. 276. Cloth and paper, $32.95.

James A. Schafer’s The Business of Private Medical Practice is an outstanding addition to the historiography of medicine. Schafer examines the formative years of private practice in the early twentieth century when science, mandatory hospital internships, and rapidly changing urban demographics influenced the financial and spatial decisions reached by both general practitioners and specialists.

As the twentieth century dawned, medical advances enhanced the ability of physicians to successfully treat an expanding circle of diseases, traumas, and chronic conditions. These developments—from aseptic surgical techniques to an expanding array of inoculations and antitoxins—wrought profound changes on the medical profession that are well understood by historians. One critical area, however, has gone unstudied during this period of rapid scientific change: the ways in which physicians in private practice responded to both the advances in their profession and, concomitantly, the changes that occurred in the American city during the height of immigration [End Page 205] from Europe and migration of African Americans from the rural south. Historians acknowledged that private physicians were forced to respond to these factors, but hitherto no systematic study of private practice physicians and their responses has been undertaken.

With so many factors informing the business decisions of private practice physicians, a book on the subject might easily bog down. Schafer has avoided the problem through superb organization. The Business of Private Medical Practice is organized into two broad parts; one spans the period 1900–1920 and the second 1920–1940. The first portion of the book illustrates the expectations of patient and physician with special care taken to explain private practice as both clinic and small business. Schafer is arguably at his best when explicating the business end of private practice medicine, seemingly leaving no detail unexplored, from the need for newly minted physicians to scrimp during their first few years in practice, to the selection of successive office locations over the course of a career. In this regard, Schafer’s skillful use of maps and graphs (forty-four are included) enables readers to conceptualize physicians’ movements in the highly competitive Philadelphia medical marketplace. Indeed, without visual representations, the movements of doctors’ offices would be little more than a crazy quilt of neighborhood names and references to the central business district.

Schafer does well, also, in his explanation of the marked differences in the number of general practitioners in each ward, with the densely populated immigrant and African American sections of the city equipped with few doctors though their need for medical services far exceeded the more sparsely populated, but private practice–dense, middle-class sections of the city. This pattern emerged partly for financial reason—laborers were less likely to pay their medical bills on time—but also because the medical profession was mostly male and white, with all the prejudices that attended such backgrounds. In a further cleavage of private practice patterns, general practitioners tended to avoid the upscale medical offices of the city’s downtown while specialists flocked to such locations as their proximity to hospitals and innovations in urban transportation allowed specialists to afford the high rents associated with downtown office space.

The second half of his work concentrates on post–World War I changes in private practice, exemplified by the required period of hospital internship and the move of the middle and upper classes from the city proper to suburban communities along intraurban rail lines. As medical education and running a private practice increased in both complexity and expense, private [End Page 206] practice physicians felt keenly the need to begin realizing a profit to pay for educational expenses, precious new equipment, and office rent. As well, the automobile meant the successful physician could maintain a downtown office, or perhaps two offices to serve city and suburban patients, while moving efficiently from suburban home to city office. Indeed, the wholesale movement of the...

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