American Pediatrics: The Social Dynamics of Professionalism, 1880-1980

AMERICAN PEDIATRICS

AMERICAN PEDIATRICS

The Social Dynamics of

Professionalism, 1880-1980

SYDNEY A. HALPERN

UNIVERSITY OF CALIFORNIA PRESS

BERKELEY LOS ANGELES LONDON

University of California Press

Berkeley and Los Angeles, California

University of California Press, Ltd.

London, England

Copyright ® 1988 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Halpern, Sydney A. (Sydney Ann)

American pediatrics.

Bibliography: p.

Includes index.

1. Pediatrics—United States—History

I. Title. [DNLM: 1. Pediatrics—history—

United States. 2. Professional Practice—history—

United States. WS 11 AAi H12a]

RJ42.U5H36 1988 362.1'9892'00973 87-30222

ISBN 0-520-05195-5 (alk. paper)

Printed in the United States of America

123456789

To the memory of my father

Jules Halpern, physicist

Contents

Contents

Acknowledgments

Chapter One Introduction

Specialization as a Variant of Professionalization

Unique Features of Pediatrics

Constructing the Analysis

Chapter Two Professionalization as Historical Process

Work Patterns and Collective Action

Isomorphism and Occupational Environments

Organizational Innovation as a Generative Factor

Control over Markets and Organizational Arrangements

Analysis and Historical Narrative

Chapter Three The Inception of a Medical Specialty

Childhood and Social Meliorism

Hospitals for the Young

Pediatric Careers

Pathways to Formal Organization

Advancing the Field of Pediatrics

Professional Ethos of the Partial Specialists

Dynamics of Occupational Inception

Chapter Four Autonomy within American Medical Schools

Expanding Institutional Arenas

Tum-of-the-Century Work Patterns

Transformation of American Medical Colleges

Professional Program Reformulated

Social Movement and Professional Ethos

Response of the Scientific Elite

Dynamics of Professionalization

Chapter Five Consolidating the Market for Child-Health Services

Demand Is Created

The Infant-Welfare Clinic

Invention of a Professional Service

Child-Health Campaigns

Impact of Demand on the Specialty

Market Consolidation

Counselors of Health

From Public Clinic to Private Office

Formal Market Structures

The Pediatrician as Family Advisor

Continuing Occupational Processes

Chapter Six Birth of a Scientific Subspecialty: Pediatric Endocrinology

Scientific Possibilities and Specialized Clinics

Emerging Careers and Initial Professional Structures

From Scientific to Market Structures

Segmentation in Postwar Pediatrics

Chapter Seven Resurgence of the Generalist: Psychosocial Pediatrics

Trends in Community Practice as Generative Factors

The Academic Origins of Psychosocial Pediatrics

Support from Above

The Pediatric Generalist as Subspecialist

From Health Supervision to Behavioral Problems

Enduring Processes in New Contexts

Chapter Eight Concluding Remarks

Recapitulation: Occupational Processes

Recapitulation: Pediatrics and the American Family

Continuities among Medical Segments

Specialties and Medicine at Large

Implications Beyond Medicine?

Notes

Index

Acknowledgments

I am extremely grateful for the assistance of those who served as informants for this book: twenty-six pediatricians; two pediatric psychologists; and staff members of five pediatric societies, two child-health organizations, three private foundations, and five federal agencies. These individuals interrupted busy schedules and answered my questions with care and graciousness. Without their help, I could not have reconstructed developments in pediatrics following World War II. Special thanks to Morris Green, chair of pediatrics at Indiana University, who provided me with the mimeographed newsletters of the postwar Ambulatory Pediatric Association and to Melvin Grumbach, then pediatric chair at the University of California in San Francisco, who loaned me professional correspondences and memos concerning the evolution of pediatric endocrinology and was a sounding board for my ideas on pediatric subspecialties.

Many others helped me gain access to data on nineteenth and early twentieth-century pediatrics. I drew much of the book’s historical material from the library collections at the Berkeley and San Francisco campuses of the University of California. Reference librarians there were of tremendous aid. Special thanks to Nancy Zinn, Head of Special Collections and Archivist at the University of California, San Francisco, who gave me exceptionally competent assistance on numerous occasions. In the course of tracking down difficult-to-obtain sources and in making extensive revisions to the manuscript after leaving the Bay Area, I used the services of archivists and librarians at eight additional institutions. I am grateful for their help and for that of the late physician-historian Samuel Radbill who generously shared the contents of his private collection on the history of American pediatrics.

In the formative stages of the research, I benefited from the intellectual support and criticism of sociologists Joyce Bird, Kathleen Gerson, Jane Grant, Barbara Heyns, David Hummon, Robert Jackson, Robert Mayer, Neil Smelser, Ann Stueve, Paul van Seters; American historian Samuel Haber; medical historian Gert Brieger; and health-policy analyst Philip Lee. Smelser, chairman of my dissertation committee at Berkeley, kindled and guided my interest in the study of changing social structures. Haber, also a committee member, was the source of innumerable insights into the history of American professions. Brieger made valuable comments on early drafts of the manuscript. Jackson importantly influenced my thinking about social processes.

I rewrote and added to the dissertation manuscript extensively before arriving at the final version of the book. A number of scholars made intellectual contributions during this phase of my work: sociologists Robert Bell, Richard T. Campbell, Arthur Stinch- combe, and Stephen Warner; psychologist James G. Kelly; and health-policy analyst Janet Perloff. Bell responded to several drafts of key chapters. Perloff s critique of a version of chapter 7 was the stimulus for its substantial revision. Kelly provided abundant comments on the entire manuscript.

The National Center for Health Services Research (NCHSR), Office of the Assistant Secretary for Health, supported the study that produced this book through grant number RO3 HS 03687. The Office of Social Science Research (OSSR) and the Department of Sociology at the University of Illinois at Chicago (UIC) provided resources to enter several chapters of the manuscript into the university’s mainframe computer so that revisions could be handled more easily. My thanks to Barbara Heyns for facilitating my application to NCHSR and Robert L. Hall for his assistance in obtaining fonds from OSSR. William Bridges and Christopher Ross, colleagues in the UIC sociology department, helped me solve problems downloading computer files containing book chapters from the university mainframe to my personal computer. Bridges provided generous practical assistance when malfunctioning software threatened to erase a chapter of the book. I am indebted to Brieger and to health policy analyst Victor Rodwin for their help in shepherding the manuscript into publication. Finally, my thanks to the editors and staff*at the University of California Press who have made the final stages of the book’s preparation an enjoyably cooperative enterprise.

Chapter One

Introduction

American pediatricians offer a highly distinctive professional service. They are physicians of childhood, treating children’s illnesses, providing care for healthy youngsters and counsel for parents. Supervision of well children is at the center of the pediatrician’s domain. These physicians administer vaccines. They weigh, measure, and assess children, monitoring the course of growth and development. They offer normative advice to parents on the problems of child management and training. The advice-giving role of pediatricians is embodied in the figure of Benjamin Spock, author of the best-selling manual, Baby and Child Care. Through face-to-face consultations with such specialists, Americans seek to assuage the uncertainties and anxieties of parenthood. Pediatricians and the services they provide are widely recognized by the American public. In 1980, parents took preadolescent children for more than fifty-three million visits with pediatricians. This constituted 60 percent of all physician visits made by children under the age of eleven. Among children under two, the annual rate of office visits to pediatricians averaged 3.5 per child.¹ That year, there were twenty-eight thousand practicing pediatricians.²

But if pediatric care is highly sought after today, in historical terms it is a recent innovation. One hundred years ago, medical services dedicated to children did not exist. In 1880 there were fewer than fifty child specialists in the country, none practicing pediatrics on a full-time basis. A special term for the field was just being coined—the first child specialists called themselves pediatrists rather than pediatricians. Medical supervision of healthy children would not be routine for many decades. Americans seldom arranged for private physicians to see their children and parents that did consulted general practitioners not pediatricians.

The advent of specialized medical services for children was not an isolated phenomenon. Since the mid-nineteenth century, some two dozen specialties have emerged and about three times that number of subspecialties. Each of these medical segments offers a discrete variety of medical care. Over the years, specialty divisions became a standard feature of medical practice. Surgery, ophthalmology, psychiatry, orthopedics, and cardiology became household terms. Internists, obstetricians, and pediatricians supplanted general practitioners as frontline physicians. In 1923, just over 10 percent of American physicians were full-scale specialists, a proportion that grew to 20 percent in 1940.³ Entrance into specialties redoubled following World War II. By 1985, the earlier ratio was reversed with only 12 percent of physicians in the fields of general or family practice.⁴ Today the overwhelming majority of physicians are trained and practice in a restricted area of medicine.

Many accounts of the factors underlying these trends identify scientific progress as the principal cause of specialization and physician choice as the primary vehicle. Conventional wisdom holds that medical knowledge is so vast that practitioners cannot assimilate its entirety. Specialization divides knowledge into circumscribed areas which practitioners can realistically hope to master. But explanations of physician choice do not explain the complex organizational changes which accompanied progressive specialization. The long-term trend toward specialization is widely recognized yet few outside the profession are familiar with its organizational features. Medical specialties are not simply divisions of science and practice. They are highly structured occupational units and their emergence involves the creation of new professional institutions. These structures include specialty associations, certifying boards, and standardized training programs. Specialties are institutionalized as separate departments and units within hospitals and medical colleges. They articulate distinct professional ideologies and sustain unique professional roles.

The history of medical specialization in America is characterized by waves in the founding of occupational structures. Specialty societies proliferated in the final third of the nineteenth century. Regular medical school departments appeared in the first two decades of the twentieth century. Certifying boards multiplied during the 1930s and specialty training was standardized in the late 1930s and 1940s. With the stabilization of residency programs, specialties assumed their mature form. Following World War II, subspecialties emerged and the number of specialists rose substantially. But the basic occupational institutions were established by the late 1940s. These structures—associations, departments, certifying boards, formal training programs—provided a foundation for manpower trends of the postwar period. Where did these structures come from? Why and how did they evolve? The present study addresses such questions as it examines the longterm development of one medical segment.

This book tells the story of how pediatrics emerged as an organized professional unit within American medicine. It follows the development of pediatrics from its inception in the final quarter of the nineteenth century to its secure establishment in the 1930s and 1940s and through the rise of pediatric subspecialties following World War II. Its principal focus is emerging occupational structures and the processes through which they evolve. Examining such processes implies attention to the vicissitudes of professional labor: the narrative explores the work patterns, perceptions, and activities of successive generations of child specialists and the changing contexts in which they practice medicine. It is a social history, one which considers the impact of collective action and a broad range of societal factors on the unfolding organization of a profession. My concern with occupational structures and social processes makes the study fundamentally different from previous accounts of the rise of pediatrics. There are already a good number of histories of pediatrics, most written by members of the specialty. The bulk of these accounts fall into one of three categories: scientific histories which trace advances in knowledge and treatment of chidren’s diseases, biographies of eminent contributors to the field, and depictions of the accomplishments of pediatric associations. Several general histories of the specialty combine these strategies and add to them consideration of some social factors operative in the specialty’s development.⁵ Approaches of the first type predomi nate and, in these, pediatrics is conceived of as a division of medical science. The present study is a history of medical institutions, not an account of innovations in diagnosis and treatment.

The book concerns both the unique features of pediatrics and the general patterns through which medical specialties evolve. While remaining faithful to the particulars of the case, I strive to identify patterns and processes that may be common to other occupational segments. My starting point is the assertion that the rise of medical specialties in America is a variant of the phenomenon social scientists call professionalization. While not identical to the development of freestanding professions, the emergence of medical specialties is understood best when viewed in the light of scholarly literature on the rise of professions.⁶ Medical segments are occupational collectivities. Like professions more generally, they seek to improve their standing and exert control over the social and economic organization of their labor. Some additional comments on the sociological study of professions will clarify these assertions and the book’s perspective on medical specialization.

Specialization as a Variant of

Professionalization

Social scientists use the term professionalization for a number of distinct empirical phenomena. One referent is changes in the occupational structure of industrializing societies whereby professionals make up an increasingly large portion of the overall work force. In America, this trend has proceeded during the whole of the twentieth century. Between 1900 and 1970, the professional and technical sector grew from 4.3 percent to 14.0 percent of the total labor force.⁷ The shift took place less through expansion in the ranks of preexisting professions than through the inception and growth of new professions. These proliferated in America during the late nineteenth and early twentieth centuries and included social work, nursing, and ancillary health professions.

Another referent of professionalization is efforts made by such newly emerging occupations to assume the form and acquire the standing of older professions like medicine and law. Sociologists disagree as to what constitutes the essential basis of professional status. Some emphasize a systematic body of knowledge; others point to autonomy in the performance of work, authority, or market control. But it is clear that developing professions mobilize to secure professional privileges and struggle to maximize collective control over the conditions of their labor. Toward these ends, nascent professions adopt the occupational institutions of established professions and claim attributes viewed as typical of this class of occupations.

Professionalization has also referred to a transformation which older professions undergo with the advent of modern industrial capitalism. Beginning in the second half of the nineteenth century, professions like medicine responded to changing social and economic conditions by rebuilding professional institutions and struggling for enhanced legal protection of occupational boundaries. Among their goals were greater control over the conditions of labor and the protection of expanding markets for professional services.

Finally, professionalization may refer to the emergence of specialized occupational units internal to a profession. Specialization is not always sufficiently well developed to be considered a form of professionalization. In many instances, specialties are rudimentary or informal organized groupings. Even where internal differentiation is well developed, occupational structures may be absent. In law, for example, specialization is pervasive but the profession as a whole has resisted the creation of formal specialty divisions. There are no specialized educational tracks and very little certification.⁸

Medicine is one of the professions in which internal differentiation is most thoroughgoing. Yet here the extent to which specialties emulate professions varies cross-nationally.⁹ Medical segments are less highly developed outside the United States than they are within it. But within American medicine, specialties have assumed much the same form as freestanding professions. Indeed medical specialties in the United States function and are organized like professions within a profession.

American medical specialties are like professions in a number of different ways. First, there are substantial similarities in social organization. Freestanding professions establish occupational institutions which function to control and regularize recruitment, entrance, and professional practice. These structures include occupational associations, standardized training programs and, among well-established professions, university-based teaching and re search branches. Through these institutions and organizational divisions, professions transmit professional culture and prescribed occupational roles and advance their intellectual foundations. Medical specialties in the United States have analogous occupational structures. Today there are twenty-three fully institutionalized medical specialties and about three times that number of formally constituted medical subspecialties. Virtually all specialties and subspecialties have their own professional societies. Pediatrics alone has six not including regional and subspecialty associations.¹⁰ Training for specialty practice is standardized with separate residency or fellowship tracks established for each specialty. Residency programs constitute a formally organized tier of professional education which follows the four years of undergraduate medical school. Fellowship programs are yet another tier of professional education. These follow medical residencies and provide training in medical subspecialties. Specialty divisions are integral to the organization of academic medicine with nearly all specialties institutionalized as separate departments or departmental divisions within American medical schools. Furthermore, each specialty articulates an ideology which delineates the tasks and purposes of the field and defines the unique features of the specialist’s occupational role. The resulting professional cultures are distinct from those of other specialties and from the culture of medicine as a whole.

Second, like professions more generally, medical specialties structure markets for the delivery of services. Several sociologists have underscored the importance of market consolidation to the course of professionalization. Building on the work of Max Weber, Jeffrey Berlant and Magali Larson argue that evolving professions systematize new services, present them to the public as recognizable and desirable commodities, and move to consolidate and control the market for service delivery.¹¹ Professional licensure is one tool in market control, providing legal monopolies for the provision of services. Like freestanding professions, medical specialties offer distinct professional commodities and organize markets for service delivery. In the United States, specialties are regularized divisions of the overall market for medical care. A system of specialty certifying boards operates like licensing bodies. There are twenty-one regular boards (and two conjoint boards) which control formal entrance into the twenty-three primary specialties and more numerous subspecialties. The boards examine individual candidates and specify a course of graduate education requisite to certification. Historically, certifying boards preceded and provided impetus for the standardization of residency training. Each board is an autonomously constituted private corporation. While their governing councils include representatives from the AMA and other major professional associations, the boards are controlled by their respective specialty societies.¹²

The board system is unlike professional licensure in that certification has no legal status and is entirely voluntary. There are neither judicial nor formal professional sanctions against any licensed M.D. practicing in a medical specialty for which he or she is not certified. Indeed many physicians conducting specialty practice have never passed board exams.¹³ However, board eligibility—completion of specialized residency programs requisite to certification—is often required for hospital staff* privileges in a specialized field and, in many professional communities, is essential to the construction of colleague referral networks necessary for viable specialty practice. The occupational boundaries established by specialty certification are ones which members of the medical profession can cross. Nonetheless, the boards, along with standardized training programs, function to regularize specialties as arenas of professional practice and as divisions of the general market for medical services.¹⁴

Third, medical specialties share with freestanding professions a propensity to compete among themselves for status and resources. William Goode, among others, notes that professions vie for social rewards including power, prestige, and income. In his view, competition with other occupations is inherent in professions’ attempts to secure preferred legal privileges. Competition takes place among established professions when developments internal to one lead to encroachment onto the terrain of a neighboring profession. J⁵ Among medical specialties, there is perennial conflict over market boundaries, a phenomenon most visible when new fields emerge or existing fields redefine their missions. Conflict is endemic within hospitals and medical schools where specialties compete for prerogatives and institutional resources.¹⁶

Finally, like professionalization, the emergence of medical specialties serves as a means for collective upward mobility. A number of sociologists point out that professionalization is a vehicle for group mobility. Everett Hughes, for example, depicts the emergence of professions as a form of collective social advancement.¹⁷ Social historians link professionalization to the rise of the middle class. The professions expanded and multiplied during a period when the traditional bases of middle-class status were undercut by societal reorganization and the appearance of a new corporate upper class. The reconstituted professions gave the middle class a new foundation for prestige and social integration.¹⁸

Medical specialization serves the analogous function of intraprofessional mobility. Through the formation of specialties, collectivities of physicians raise their standing and improve their competitive position relative to that of other practitioners. As early as the mid-nineteenth century, specialists commanded greater prestige and accrued higher fees than general practitioners, this despite widespread hostility toward specialization among rank and file generalists.¹⁹ In this period, it was largely physicians from the upper strata of American medicine who established specialized (or semispecialized) practices. Historian Charles Rosenberg attests to the existence of a well-defined medical elite within nineteenth-century American cities.²⁰ During most of the century, entrance into this upper strata rested largely on ascribed characteristics and social connections. With the reorganization of medicine and growing legitimacy of medical science during the late nineteenth century, older bases of prestige were thrown into question. At the outset, specialization was a way for an existing professional elite to reassert its social standing. The founders of the first medical specialty societies in America were, as a rule, from the medical elites of eastern seaboard cities. Early associations restricted admission and kept their membership homogeneous.²¹ Entrance into the specialties was democratized before World War II with the creation of certifying boards and the standardization of residency training; specialization became an avenue of mobility open to rank and file physicians.

While the similarities between medical specialties and freestanding professions are extensive, at a certain point the analogy breaks down. Developing medical segments can rely on the occupational privileges of medicine as a whole in a way that has no parallel in the evolution of freestanding professions. The social standing of medicine rose substantially during the period in which specialties evolved. The emergence of specialties no doubt contributed to this improved status. But I will not pursue this observation for the moment. The point here is that individual segments drew upon the rising status of medicine in establishing favorable work arrangements and consolidating markets for their services. For the most part, specialties do not launch campaigns to win popular favor. Few have publicized separate codes of ethics in an effort to win public confidence or appealed to the state for aid in establishing occupational boundaries. With privileges and status conferred by the profession as a whole, legitimacy within medicine is the more central issue for an evolving segment.

The development of medical specialties is unlike that of freestanding professions in that some tasks of professionalization are handled by a superordinate occupational unit. Partly for this reason, the researcher’s attention is drawn to features of occupational evolution not ordinarily emphasized in scholarship on professions. The present study highlights two dimensions of occupational development. The first is the importance of changing work patterns to the inception and consolidation of professional collectivities. Pediatrics was in the first instance a new division of professional labor. It came into being and evolved through shifting work patterns and through the response of practitioners to changing contingencies of labor. The second is the impact of surrounding occupational structures on the form of an emerging segment and the pace of its growth. Pediatricians repeatedly emulated professional institutions established by earlier medical segments and repeatedly responded to pressures that surrounding structures created. The emphasis on work patterns and occupational environments is new to the analysis of professions and at the heart of the account presented here.

Unique Features of Pediatrics

While searching for underlying and perhaps generic dynamics in the rise of pediatrics, the narrative attends to unusual features of the specialty and its historical development. Pediatrics is a field whose evolution is strongly influenced by ideological currents and social reform movements outside the medical profession. Changing notions about childhood and social movements promoting child welfare are important