The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900-1940

Chapter 5: From Center City to Suburb

134 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 or X-rays.1 As technologically sophisticated care became the hallmark of “modern ” scientific medicine in the early twentieth century, health care costs began to rise. Cost inflation forced structural changes in patient care, whether in the hospital or in the doctor’s office. Hospital administrators built new semiprivate and private wards in order to attract more paying patients, thereby changing the charitable mission of hospital care.2 Private practice doctors struggled to adapt as well, often debating whether to purchase expensive new diagnostic equipment. Most solo practices could not afford an X-ray machine or laboratory facilities and staff in the 1920s and 1930s, but a group practice might. For the doctor who clung to individual business ownership, alternatives included outsourcing new diagnostic services to private laboratories or developing closer ties to large hospitals, where private patients could be referred for diagnostic services unavailable in the office. The conundrum for the modernizing doctor was that referring patients elsewhere meant losing billable services. Besides affecting the structure of hospital and office practice, rising costs limited patient access to the benefits of modern medicine. By the 1910s, scholars , social reformers, and labor activists called attention to these problems. Their concern that sickness contributed to poverty and dependency inspired From Center City to Suburb Chapter 5 From Center City to Suburb 135 the first national movement to subsidize health care—the campaign for compulsory health insurance for industrial workers. Unlike similar campaigns in Europe, the American campaign ultimately failed due to ineffective leadership, growing opposition from the medical profession and some conservative labor leaders, and the increasingly persuasive claim by 1920 that compulsory health insurance was un-American.3 The problems of rising costs and declining access only worsened with time, as revealed by the widely read reports of the Committee on the Costs of Medical Care from 1928 to 1933.4 As the financial burdens of sickness and hospitalization increased, policy debates centered on ways to share risk, whether by new private insurance plans, public finance of health care through taxation, or some public-private scheme. Although bold legislative efforts to establish national health insurance failed repeatedly in the 1930s and 1940s, these efforts exposed the structural problems of health care such as the unequal distribution of health care services like doctor’s offices. This chapter examines the changing geography of private medical practice in American cities during this turbulent period. Contemporary analysis of the changing distribution of doctor’s offices in the 1920s and 1930s primarily examined regional, state, and county patterns. These works compared the personal and professional traits of doctors with the locational characteristics of areas with low versus high doctor-to-population ratios. Personal and professional traits included the size of the doctor’s hometown , the location of the doctor’s alma mater, and other factors such as the doctor’s specialization (if any) and experience (or years since graduation). Locational characteristics included the community’s size, average or median income, number of hospitals, and percentage of residents living in urban areas. Generally, these early studies found that doctors favored practicing in urban and wealthy areas; in particular, specialists and young doctors were flocking to growing cities, and at a much greater pace than the population as a whole.5 The incomes of doctors also increased with community size and wealth, which indicated to contemporaries that consumer demand shaped the geography of private practice to a much greater degree than community health needs.6 As Assistant Surgeon General Joseph W. Mountin wondered in 1942, “Can the undirected forces in a free society be relied upon to effect an equitable distribution of physicians?” For Mountin, the answer was “no,” at least “so long as there remain gross differences as well as deficiencies in individual and community resources.”7 Unevenly distributed doctor’s offices were but one manifestation of growing inequality between the poor and the wealthy, the rural and the urban. 136 Part Two: 1920–1940 Yet precious few studies in the 1920s and 1930s examined health care distribution problems within American cities, where there were equally alarming...