From Occupational Pluralism to Professional Unity: The Rise of Medical Professionalization from the Ancient World to the Mid-20th Century

By Adam J. Pearson

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19th century physician displaying techniques in the preparation of chemical therapeutics.

The history of the professionalization of medicine from the ancient world to the mid-20th century represents a process of gradual evolution from competitive occupational pluralism to a unified medical profession with a legal monopoly, powerful authority, and collective solidarity.

To begin, medical practitioners in the Ancient World operated in the context of diverse groups from varied healing traditions. In Egypt, according to Herodotus’ Histories, priestly craft physicians (swnw) practiced in a fragmented world of local healers who each specialized in a single kind of illness (e.g. diseases of the head or belly) (Wallis 2016a, 16). In Greece, much like Egyptian swnw and Mesopotamian priest-therapists (asipu), Hippocratic healers (iatroi) sought to distinguish themselves through their reputed prognostic accuracy, as the emphasis on preserving one’s reputation in the Hippocratic Corpus’ “Prognosis” and “Oath” reveals (Wallis 2016b, 12). Embracing the value of competition (agon) in medicine, as in philosophy, Hippocratic physicians grappled with exorcists, religious healers, root-cutters, folk-healers, and midwives (Nutton 1995, 11-12). Indeed, Ancient Greek medical practice was highly unregulated; as Nutton notes (1995), there were “no examinations, no memberships requirements,” and there was great doctrinal variety even between different Hippocratic Corpus treatises (16).

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“Hippocrates” by Robert Thom.

By the Hellenistic period, literate medicine was fractured into “sects” of “healers adhering to particular theories and appealing to earlier authorities,” such as Herophileans and Erasistrateans (Nutton 1995, 36). Galen later reclassified these sects into theory-driven ‘rationalists’ and experience-emphasizing ‘Empiricists,’ from whose arguments emerged the “corpuscle-centered” Methodists (Wallis 2016c, 12).  In an early, but significant move towards professionalization, Hellenistic healers began to convene in ‘Workshops’ of 20 or more practitioners (Nutton 1995, 37). Meanwhile, in Rome, which birthed the etymological Latin root (professio) of the English ‘profession’ through its legal system, physicians like Galen competed with the ‘kitchen medicine’ of well-educated nobles’ (Wallis 2016c, 16). By Late Antiquity, Galen’s dissection-enriched Hippocratic medicine was systematized for Muslim practitioners by translators and encyclopedists such as Hunayn and Ibn Sina; however, even in the Muslim world, Galenic-Islamic physicians competed with folk medical healers and a strong contingent of female medical practitioners (Pormann & Savage-Smith 2007, 33).

In the Medieval period, the rise of universities with faculties of medicine in Paris, Bologna, and Montpelier initiated a substantial shift towards scholarly institutionally-standardized medical education for Hippocratic-Galenic physicians (Wallis 2016e, 15). Although universities conferred prestige on male MDs while banning women from their ranks, however, they conferred no medical monopolies; physicians jousted with a wide variety of “irregulars” ranging from empirics to apothecaries, itinerant oculists, dentists, bonesetters, midwives, barbers, and clergy who imitated their Scholastic counterparts (McVaugh 1997, 61; Wallis 2016f, 21).

Burial-of-plague-victims-The-Black-Death

Artistic rendition of the Burial of Plague Victims: The Black Death.

By the Renaissance, in the wake of the Black Death, new public health initiatives to combat plague did not immediately translate into governmental regulation of the ongoing competition between irregulars and university-trained physicians and surgeons influenced by Vesalius’ anatomical breakthroughs (Wallis 2016g, 29).  In the 16th century, however, some governments, such as that of Henry VIII in Britain, began to organize and regulate some practitioners by the creation of companies like the Barber-Surgeons Company (Weisz 2016a, 5).

With the advent of the Scientific Revolution and Enlightenment in the 17th and 18th centuries, regular practitioners, and their increasingly scientific and research-oriented medicine, continued to jostle with marginalized irregulars who performed difficult manual operations such as oculists, tooth-drawers, midwives, hernia surgeons, and lithotomists, but governments began to make substantial moves towards professionalization (Weisz 2016a, 7; Weisz 2016g, 8). In post-revolutionary France in the late 18th and early 19th centuries, the French State began to create and enforce a medical monopoly through standardized education, regulated practice, and state examinations and licensing (Weisz 2016f, 24).

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In contrast, in Britain, after the 1858 Medical Act, the British medical professions were unified without a legal medical monopoly by means of a non-mandatory state registry that offered perks to the registered and disadvantaged the non-registered; by the 1880s, however, shared examinations were implemented and general practitioners were certified by means of referrals in consultation with royal colleges (Weisz 2016f, 27). Meanwhile, in the USA of the 1830s and 40s, states abolished licensing requirements until the late 19th century when the AMA promoted licensing, medical reform, and the creation of German-style research universities such as Johns Hopkins (Weisz 2016f, 30-31). After the Flexner Report (1910) proposed majour reforms to American medical education, many medical schools closed, numbers of students declined, licensing reduced the ranks of practitioners, and male MDs gained power to the detriment of women and minorities (Weisz 2016f, 35).

It was in the 19th and 20th centuries, however, that an increasingly unified medical profession began to emerge and legitimize the role of specialists alongside general practitioners. Growing from an “academic category” in the 1830s-1880s, specialization remained unregulated until the 1920s when specialist certification began to develop; by the 1950s, specialized practice began to predominate (Weisz 2016g, 9). According to Weisz (2016g), legitimized specialization grew out of the formation of large research communities in hospitals such as l’Hôpital Pitié Salpêtrière which focused on treatment of the insane, chronically ill, and elderly, out of specialization’s value as a competitive career strategy, out of its capacity to facilitate research, and out of the logic of organized, bureaucratic administration (20-24).

Hôpital Pitié Salpêtrière

L’Hôpital Pitié Salpêtrière, Paris.

Therefore, by the 1870s and 1880s, the medical profession had shifted from a pluralistic constellation of fragmented local occupations representing many social classes towards a unified middle-class profession of specialists and GPs with legally-enforced monopolies (Weisz 2016f, 3). By the late 19th century, physicians began to have international congresses and achieved collective solidarity and professional authority through powerful medical monopolies. Central to this burgeoning professional unity was the stature of science as a cultural authority; indeed, standardizing reforms transformed medical education and grounded doctors’ collective professional identity in both examination-tested science and in empirical practice based on the analysis of “objective” signs, images, and measurements (Weisz 2016f, 13). In the 19th and 20th centuries, the hegemony of this unified science-driven profession of specialists and GPs was cemented through legally-enforced, credential-based, national and provincial monopolies that were both more powerful and vaster in scope than the local, specific, and patronage-based monopolies of guilds, colleges, and companies in the 16th and 17th centuries (Weisz 2016f, 15).

In short, the triumphant 19th and 20th century solidification of a professional medical monopoly was made possible not only through the power of medical science, but also through the drive for political supremacy, the profession’s public health potential, and out of a perceived need for standardized practice, reduced uncertainty, and “congruence of scientific medicine with rational administration” (Weisz 2016f, 21). The rise of medical monopoly was not without its detractors, however; opposition came from advocates of homeopathy, chiropractic medicine, and freedom of choice and practice (Weisz 2016f, 22).

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Doctor Listening Through a Stethoscope (1948).

Finally, after the “golden-age” of medical authority and prestige in the 1950s, governments increasingly asserted control of health-care provision with funding, reimbursement of procedures and medications, and attempts to standardize practice (Weisz 2016f, 40). This infringement of government upon largely self-governing professional medical associations was seen by many doctors as a challenge to their power, authority, and agency as a medical profession. Thus, and in conclusion, although the Western history of healers can be described as an evolution from fragmented, informal occupational pluralism to a unified, medical profession, by the mid-20th century, this profession’s authority and self-regulating power would be challenged by the formidable influence of governments, much to the protest of doctors.

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