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The Business of Private Medical Practice

Doctors, Specialization, and Urban Change in Philadelphia, 1900-1940

by James A. Schafer Jr.

Publication Year: 2014

Unevenly distributed resources and rising costs have become enduring problems in the American health care system. Health care is more expensive in the United States than in other wealthy nations, and access varies significantly across space and social classes. James A. Schafer Jr. shows that these problems are not inevitable features of modern medicine, but instead reflect the informal organization of health care in a free market system in which profit and demand, rather than social welfare and public health needs, direct the distribution and cost of crucial resources.The Business of Private Medical Practice is a case study of how market forces influenced the office locations and career paths of doctors in one early twentieth-century city, Philadelphia, the birthplace of American medicine. Without financial incentives to locate in poor neighborhoods, Philadelphia doctors instead clustered in central business districts and wealthy suburbs. In order to differentiate their services in a competitive marketplace, they also began to limit their practices to particular specialties, thereby further restricting access to primary care. Such trends worsened with ongoing urbanization.Illustrated with numerous maps of the Philadelphia neighborhoods he studies, Schafer’s work helps underscore the role of economic self-interest in shaping the geography of private medical practice and the growth of medical specialization in the United States.

Published by: Rutgers University Press

Title Page, Copyright Page, Dedication

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pp. i-vi

Contents

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pp. vii-viii

Figures

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pp. ix-x

List of Maps

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pp. xi-xii

Tables

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pp. xii-xiv

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Acknowledgments

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pp. xv-xviii

As I near the end of this long journey, it is a great pleasure to reflect upon the many family, friends, mentors, students, and colleagues who have given me inspiration and encouragement over the years. Without them, this book would not have been possible. I first want to thank my parents, Jim and Margy, and my sister, Kirsti, for their unwavering love and support. I could not have asked for a...

List of Abbreviations

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pp. xix-xx

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Introduction

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pp. 1-12

The health care “system” in the United States has many problems, with rising costs and declining access being the two most intractable. By any measure, we have the most expensive health care system in the world. As I write this introduction, the latest data on national health expenditure (NHE) show that the United States spent $2.6 trillion in 2010. This tally was equivalent to $8,402...

Part I: 1900-1920

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Chapter 1: The Primacy of Private Practice

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pp. 16-38

In a small, well-worn memorandum book, young Dr. DeForest Porter Willard Jr. (1884–1957), kept track of the highlights of his life and career in Philadelphia in the early twentieth century (table 3). His parents began the memo book to record childhood milestones, such as first words spoken, but Dr. Willard assumed authorship during adolescence. Apart from jotting...

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Chapter 2: The Doctor as Business Owner

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pp. 39-70

As American doctors aspired to new professional status, an internal debate raged about the proper role of the commercialism in medicine, and Philadelphia doctors were no exception. For example, in a contentious paper read before the Philadelphia County Medical Society in 1901, Dr. John B. Roberts distinguished “proper and just enterprise and thrift in one’s professional work and what is an

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Chapter 3: Downtown Specialists and Neighborhood GPs

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pp. 71-100

In her unpublished autobiography, Dr. Catherine MacFarlane recounted her medical career in Philadelphia, from studying as a medical student at Woman’s Medical College (1895–1898), to training as an intern at Woman’s Hospital (1898–1899), to working and teaching in an obstetrical clinic (1899–1901), to setting up her first private medical practice (1901), to specializing in gynecology...

Part II: 1920-1940

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Chapter 4: New Career Paths, New Business Methods

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pp. 103-133

When Dr. Carl C. Fischer finished his internship year at Hahnemann Hospital and then passed his state board examinations in 1929, his career was no different from all of the other newly minted medical doctorates in Pennsylvania after 1914, the year in which the state became the first to require internship for licensure. Young doctors no longer entered private practice directly, but rather...

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Chapter 5: From Center City to Suburb

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pp. 134-175

Besides signaling new career paths and business practices, especially in large cities, increased specialization and hospital-based medicine also transformed patient care. Not only had traditional services been shifted from the home to the hospital, such as attendance at childbirth, but a variety of new surgical procedures and diagnostic tests were centered in hospitals, such as tonsillectomies...

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Conclusion

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pp. 176-184

The Business of Private Medical Practice analyzes the urban origins of one of our nation’s most intractable health care access problems: the uneven distribution of doctor’s offices, or private medical practices. Unlike early studies of the location of doctor’s offices published from the 1920s to the 1940s, which focused on rural-urban divisions at the county, state, and regional level,...

Appendix: Notes on Sources and Methods

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pp. 185-194

Notes

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pp. 195-238

Index

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pp. 239-250

About the Author, Series Page

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pp. 251-254


E-ISBN-13: 9780813561769
E-ISBN-10: 0813561760
Print-ISBN-13: 9780813561752
Print-ISBN-10: 0813561752

Page Count: 272
Illustrations: 13 graphs, 11 maps, 20 tables
Publication Year: 2014

Series Title: Critical Issues in Health and Medicine
Series Editor Byline: Edited by Janet Golden and Rima D. Apple