The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900–1940 by James A. Schafer, Jr. (review)

Traditionally, studies of medical professionalism have tended to concentrate on the changing role of the hospital as the “doctor’s workshop.” With the notable exception of Christopher Crenner’s insightful study of Richard Cabot, the ways that twentieth century doctors practiced outside the hospital’s walls have remained largely neglected.¹ Although the doctor’s office was (and still is) a key setting for the delivery of medical care, we know surprisingly little about its evolution over the course of the twentieth century. So the appearance of James Schafer’s book is most welcome.

Schafer came up with a novel way of approaching Philadelphia’s medical history: by looking at the geographical distribution of physicians’ offices. How, he asked, did newly minted physicians decide where to open up their practices, and how did their office locations change over the course of a medical career? Finding that physicians tended to cluster in certain areas of the city, he then explored those choices as a function both of access to scientific and technological resources (e.g., hospitals) and of preferences for particular kinds of patients. Philadelphia was a wise choice for such a study, in that its physicians and medical institutions provide a good cross section of national trends as well as left behind a rich archival record. Moreover, the city has inspired a wealth of excellent social histories, a literature that Schafer makes effective use of in his book.

By painstakingly tracking the location of doctors’ offices in Philadelphia, Schafer shows that “by the early twentieth century, unevenly distributed doctor’s offices had emerged as the central feature of the geography of private medical practice” (p. 81). Heeding Daniel Cathell’s advice, doctors avoided the “run-down, going-to-wreck section” and preferred neighborhoods where “the rich are neither too rich nor the poor too poor” (p. 83). Those trends only accelerated as medical education began to change. In the pre-1920 period, all young doctors anticipated going from medical school to set up a general practice; some planned to stay in that role while others hoped gradually to get enough experience to become part- or full-time specialists. By the 1940s, Schafer shows, this pattern had altered dramatically, largely due to the growing trend toward doing a one year hospital internship after completing the M.D.; instead of the varied and often eye-opening diversity of a city general practice, young doctors experienced a hospital culture in which they learned to be dismissive of charity patients and to aspire to impress private patients. After completing the internship, ambitious young physicians increasingly avoided general practice altogether and instead set up specialty practices in one of Philadelphia’s affluent suburbs.

Overall, Schafer argues, “market demand rather than patient need directed the location decisions of many doctors” (p. 87). Thus while medical leaders fiercely defended the idea that free market principles would ensure all classes of Americans access to good medical care, the reality was sadly different. Already by the late 1920s, studies of medical practice confirmed that in Philadelphia’s poorest areas, in particular its African American neighborhoods, finding a general practitioner was increasingly hard. Starting in the late 1960s, social scientists would document this unequal distribution of physicians and declare it the sign of a new “urban health crisis,” unaware of how deeply those disparities were rooted in the city’s history (p. 176).

Schafer’s work is a very effective wedding of the histories of medicine and business. He manages to bring economics back into the formation of professional ideas and behaviors without being reductionist in his interpretations. While resisting the temptation to overgeneralize from his evidence, Schafer supports his arguments with a wide variety of primary evidence, including advertisements, directories, advice manuals, and census data. And he is painstaking in his efforts to place...