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

Schafer addresses the “growing problem of access to doctor’s offices within American cities” in the first four decades of the twentieth century by studying the “changing social geography and expanding medical marketplace” of Philadelphia (4, 12). Using quantitative and qualitative methods of social and medical history and, less effectively, of economics and policy analysis, he concludes that the “patterns of health care inequities that we have today were forged during the urban transformation of the United States in the early 20th century” (12, 183).

Schafer describes the clinical education, practice locations, and institutional relationships of many men and women who practiced medicine in Philadelphia in five chapters, an introduction, a conclusion and an appendix on methodology. The most compelling data in his book are the stories about individual general practitioners and specialists, which he acquired through diligent research in archival and printed primary sources. Schafer embeds these stories in substantial quantitative evidence about the demography of clinicians and their practice locations.

Schafer synthesizes the stories and quantitative evidence with relevant international secondary literature in the social history of medicine. He rejects conventional interpretations of specialization, institutional development, and practice location as responses either to “externally produced structural changes in medical practice” or “internally generated strategies for acquiring status or legitimacy” (179). Instead, he argues that changes in access to private medical practice during the first four decades of the twentieth century resulted mainly from choices made by participants in a “medical workforce that emerged under the influence of market choices” (179).

Unfortunately, Schaffer does not conclude the book with this ably documented argument. Embracing presentism, he insists that “policymakers must address more fundamental structural causes of our inefficient system: poverty, discrimination and economic self-interest [which] all generate or exacerbate health care inequities” (183).

This leap from scholarship to advocacy may be a result of a discrepancy between Schafer’s knowledge of the literature in the social history of medicine and his relatively uncritical appraisal of the literature of other disciplines of the policy sciences. Inadequate attention to the economics of service delivery early in the book (for example, 41, 56), foreshadows incomplete analysis in the conclusion. There he offers underinformed judgments about, for example, the funding of community health centers since the 1960s, assumptions about markets among contemporary health economists, and current debates about the content and implementation of the Affordable Care Act of 2010 (180–183). As his dissertation evolved into this book, Schafer could have been advised more strongly to avoid advocacy and take pride in his success in “adding individual variables . . . to the analysis of doctors,” and in describing and analyzing the “relationship between urban space, medical careers and the business of private practice” (74–75).