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A short history of general practice: The coming of family practice

Stephen Gillam is a semi-retired GP and public health specialist who has written extensively in both fields. He is the author of ‘Of Patient Bearing – A History of General Practice in Eight Generations‘ and winner of the RCGP and Society of Apothecaries Rose Prize in the history of British General Practice.

Introduction

My great great great grand-father George Skrimshire (1802-1877) represented the third generation of generalists. He joined his uncle William as an apprentice in Wisbech. In his deed of indenture, George forswore ‘fornicating…matrimony contract, Taverns, Inns or Alehouses… Cards, Dice, Tables or any other unlawful games… His said Masters the said Apprentice in the Art of Surgery and Pharmacy which they now useth shall teach and instruct during the said term of five years.’  Training already involved the instillation of a more professional ethos.

On March 31st 1823, he received his Certificate of Satisfactory Apprenticeship, ‘having conducted himself with great proficiency and as far as respects his moral conduct entirely to (their) satisfaction.’ He then moved to London, to ‘walk the wards’ at Guy’s Hospital and prepare for his Licentiate of the Society of Apothecaries.

In 1841, George moved to Norfolk, and the house where I live now. He worked hard to establish his practice. Whether Holt was well chosen for the medical opportunities it presented is open to question. There was no lack of competition and his wife Lavinia wrote of ‘a very sad first year, no sickness scarcely at all’. Together they were there to rear 13 children of whom four went into medicine.

Rising status, falling self-esteem

Many doctors in the early nineteenth century felt they were held in low regard by a public happy to employ the practitioner charging the lowest fee.

Many doctors in the early nineteenth century felt they were held in low regard by a public happy to employ the practitioner charging the lowest fee. Status came to rest on acquired standards of behaviour rather than superior knowledge. Peterson describes a ‘social chasm’ between medicine and other ‘liberal professions.’1 Less than 20% of practitioners came from the families of gentry or other non-medical professionals. Historians are less harsh. ‘The lawyer and the doctor took the lead amongst the middle classes of Middlemarch, or in the suburbs of London…’2 For in the first half of the nineteenth century, specialisation had not yet become the pathway to prosperity or high status.

Why then did these reliable all-rounders not establish themselves as equals? In large part, it was because the practice of pharmacy was a reminder of their original trade and the apothecary’s shop. It blurred their distinction from the reviled druggist. Then as now, many GPs felt that to become a respectable member of the medical profession, they would have to abandon pharmacy while others defended the right to dispense as a skill best performed by one with a medical education and the opportunity to observe the effects of their actions.

The social insecurity of the GP was aggravated by continuing acrimony within the profession. ‘The way things are constituted the general practitioner finds himself treated rather as a tradesman than a gentleman.’3 Some of this disdain lingers today in the commonplace perception of GPs as financially motivated businessmen by comparison with their supposedly more altruistic consultant colleagues.

GP Income

Private practice was the main source. Although reliable data are limited, between 1780 and 1820 doctors improved their financial position to a greater extent than other groups.4 Thereafter, it declined due to overcrowding and market forces. Like students today, they were under early pressure. Between 1815 and 1850, around £1000 (four years’ income) was needed to cover an apprenticeship.33 An 1842 guide to parents reminded them that ‘by the time when a physician earns his bread and cheese he has no longer the teeth to eat them with.’5

George and his successors derived income as vaccinators and school doctors. Their most important additional appointments were as ‘parish surgeons’ before and ‘union surgeons’ following the Poor Law Amendment Act of 1834. As union surgeons, they were paid less for looking after larger numbers of sick poor. The status of medical officer was thus degraded and GPs suffered financially as a consequence. From the average salary of £69 per annum practitioners had to provide drugs and dressings.6

Overall, GP incomes therefore changed little between 1820 and 1850. Indeed, taking the costs of living into account, the Eighteenth century surgeon apothecary was more prosperous. A minimum of £200/year was needed for a way of life that included domestic servants, private education for children, the necessary standards of house, furniture and dress. Most commonly, income during this period was between £150-200 in the country, £300-500 in larger towns.

The relative sparsity of data raises the suspicion of deliberate concealment. Income tax was re-imposed by Robert Peel in 1842 for incomes over £150 and this may have prompted reticence. GPs came under schedule D and could deduct all expenses incurred in the course of work. Creative accounting has always been a useful skill in general practice.

If real incomes were lower in mid-century, buying into a successful practice or succeeding father or uncle was the surest route to prosperity. More than half the population and more than half of all GPs lived in rural areas. Country practice was generally less well paid. GPs therefore often hovered for years on bare subsistence.

Public approbation

An Act to Regulate the Qualifications of Practitioners in Medicine and Surgery was finally passed in 1858. This established the General Medical Council, a medical register and forever reified the distinction between physicians, surgeons and general practitioners. The latter thereafter acquired exclusive rights of referral to hospital specialists and their role as ‘gatekeepers’. In the oft-quoted aphorism: ‘The physician and surgeon retained the hospital but the GP retained the patient.’7

The extent to which regulation benefited patients is disputed but doctors consolidated their professional monopoly. Yet in one respect the Medical Act resembled the 1815 Apothecaries Act: to the majority of practitioners it was a disappointment as it failed to wholly outlaw quackery.

The GP was expected to sit patiently at the bedside through long hours and to deal with any emergency at any time of day or night.

The second half of the nineteenth century saw the emergence of the ‘family doctor’. The fictional stereotype was often poor, shabby and old-fashioned, but always accessible and enjoying the confidence of his patients. A users’ guide indeed intoned: ‘Let not your doctor be too useful…and avoid the man whose dress and demeanour indicate puppyism… Be not averse to him if he is slovenly in apparel.’8 The ideal of the family doctor was enormously powerful in shaping public and professional perceptions of contemporary practice. It provided GPs with a new corporate identity – as neither business-like apothecaries nor impassive physicians. In Loved at Last, the GP Mr Gregory ‘bore with noble courage and patient bearing…broken rest… long rides…exercising a skill and knowledge acquired by years of study and acute observation.’9

The GP was expected to sit patiently at the bedside through long hours and to deal with any emergency at any time of day or night. As George’s father wrote to him in 1830: ‘When the stormy winds are blowing and the rain is battering against our windows, often does your mother exclaim, I wonder whether poor George is riding about on this dark and dreary night. When we are sitting round our social fire your sisters observe you are wanting to make up the circle and to join in with your flute in the harmony of the evening.’

The role was a demanding one in other ways. Poverty, competition, the costs of education and establishing a practice were recurrent concerns for practitioners. More corrosive were the emotional and spiritual challenges of the work – the relentless grind of never-ending demands, the exhausting affront of patients’ poverty, and hopelessness in the face of incurable illness. Professional isolation was extreme.

Medical education

As we have seen, until the 1830s medicine was still largely based on Greek and Roman ideas. Little was known of the causes of disease. Enquiring doctors, without university training, looked for explanation by studying natural history and science. Medical studies were more formally structured after 1858 following GMC guidelines. Potential medical students were required to take a preliminary exam to demonstrate liberal educational attainment followed by a minimum of five years in training. Practice was proscribed before the age of 21. Two or three years of pre-clinical studies were followed by three or four years of clinical training, very much as now.

To this day, there is continuing debate over the most appropriate sequencing and balance of theoretical versus practical work, and how to accommodate new sciences. There were concerns that factual cramming restricted their outlook. ‘There is…no profession in which it is more essential that those engaged in it should cultivate the talent of observing, thinking and reasoning for themselves, than it is in ours. You have done not much more than learn the way of learning. The most important part of your education remains.’10 The education of GPs has always been vitiated by the needs of specialists. Students often gained more experience of ‘serious’ (rare) illness in hospital rather than common conditions found in the community.

The recognition of what are nowadays called ‘consultation skills’ date from this period. A good bedside manner was seen as financially expedient too.  A liberal education would fashion the interpersonal skills suitable for a gentleman and facilitate communication with more affluent patients.

The expansion of hospital-based training in the nineteenth century helped to improve the image of medicine – and parental willingness to pay for it. Though some students may have been coarse and lazy (think Dickens’ Ben Allen and Bob Sawyer), most were well-mannered and conscientious. Then as now, there were the initiations of dissecting room and theatre – experiences that toughened the emotional carapace for the rigors of the job.

Key questions for educationalists concerned the character of pre-clinical education, the location of training, curricular content, the relationship of surgery to physic, the place of anatomy and dissection, and the relationship of bedside medicine to experimental science. A century and a half on, we wrestle with the same dilemmas but the roots of present educational practice were firmly in place by the middle of the nineteenth century.

Conclusion

General practitioners failed to achieve parity with physicians and surgeons for multiple reasons. Voluntary hospitals dominated medical education and general practitioners were entirely divorced from teaching. Their leaders were constantly outflanked by the persistent obstructionism of the Physicians and Surgeons. Many of these barriers persisted till the recent past.

The Medical Act is hailed both as a landmark through which the profession put its house in order and as a prime example of monopolization. From this time dates the second of the three pillars of modern-day general practice – the concept of referral rights. The first was the notion of generalism itself; the third being the registered list which emerged early in the next century.

George died in 1877 leaving for his son John Truscott Skrimshire (1835-1912) the prerequisites of prosperity: 15-20 visits/day, an efficient pharmacy run by his apprentice or assistant, the minimum of bad debts and a prominent house on the highway. Traditional person-centred medicine had derived its authority as much from social as from clinical skills. These ‘arts’, always vigorously defended,11 were henceforth combined in the exercise of scientific medicine and a resurgent professionalism. However, general practice remained a wearying and dangerous occupation as we shall see.

This article is one in a five-part series: A short history of general practice:

References

  1. Peterson M. Gentlemen and Medical Men: the Problem of Professional Recruitment. Bulletin of the History of Medicine 1984: 58; 457-73.
  2. Reader W. Professional Men. London: 1966, p 68.
  3. Medical Education and Rank. London Medical Repository 1820; 14: 123-9.
  4. Lindert PH, Williamson JG. English workers’ living standards during the Industrial Revolution. Economic History Review 1983; 36: 1.
  5. Hudson JC. The Parent’s Handbook. London, 1842.
  6. Griffin R. Grievances of the Poor Law Medical Officers. London, 1859.
  7. Stevens R. Medical Practice in Modern England. New Haven: Yale University Press, 1966.
  8. Hints on Choosing a Doctor. A Penny Magazine 1832; 1: 309-10.
  9. Lemon M. Loved at Last, 3 vols. London: Bradbury & Evans, 1864, i, 8.
  10. An introductory discourse on the Duties and Conduct of Medical Students and Practitioners. 1843, 15-17.
  11. Lawrence C. Incommunicable Knowledge. Science, Technology and the Clinical Art in Britain, 1850-1914. J Contemporary History 1985; 20: 517.

Featured image: Three children automatically putting out their tongues for inspection upon meeting the family doctor in Kensington Gardens. Wood engraving after J. Leech, 1861.. Credit: Wellcome Collection. Public Domain Mark

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