The Clinical Gaze and the Doctor-Patient Relationship
Foucault (1989) recognised that ‘hands on’ clinical training existed inprotoclinics before the establishment of the clinic in 1790′s France. For example, Rutherford (1695 to 1779) was giving bedside clinical teaching to medical students in Edinburgh in 1748. What was different for Foucault was not that clinical teaching at Paris was no longer undertaken on an ad hoc basis. Nor was it because there was potentially a vast number of patients involved – 20,000 or so – when compared with the protoclinic numbers of roughly less than 100 patients per annum. This in itself obviously did signify a significant break with the past. What separated the protoclinic from the clinic proper was its application of the medical gaze as a diagnostic and teaching tool. This not only led to new ways of defining, understanding and classifying disease, but also engendered a change in the doctor-patient relationship. In the clinic, the disease not the patient mattered. This was reinforced, as Foucault notes, by the lowly social status and poverty-stricken nature of those treated. Here we see how the clinic contributed to the formation of the modern medical profession through the separation of medical and lay worlds and the reversal of the doctor-patient power relationship. As both Johnson (1972) and Jewson (1974 and 1976) note, whereas traditionally the patient acted as a patron and largely determined the dynamics of the medical encounter as well as the course of treatment, the shift to hospital medicine across Europe in the nineteenth century gradually led to the subordination of the patient to medical authority. In other words, the patients’ narrative of their personal experience of illness and disease became secondary to the doctor’s esoteric clinical-anatomical experimental expertise. As Jewson (1976: 235) states: ‘Henceforth the medical investigator was accorded respect on the basis of the authority inherent in his occupational role rather than on the basis of his individually proven worth. The public guarantee of the safety and efficacy of theories and therapies no longer rested upon the patients’ approval of their contents.’
In summary, by the middle of the eighteenth century the continental ‘medical gaze’ of modern medicine was entering England via Scottish medicine and beginning its rise to prominence. It was creating a new type of medical practitioner, the early forerunner of the modern general practitioner, who had been trained in medicine, surgery, midwifery, chemistry and pharmacy. These well trained doctors needed to generate an income and began to enter general practice (mainly but not solely in the Middle and North of England treating the middle class) and brought with them the idea of the differential fee: the wealthy paying more than the poor. This practice upset their London based counterparts, just as much as Scottish medicines rejection of the Galenic medical tradition did. It was this mixture of economic and epistemological difference between the various elements of the medical profession that ultimately led to the 1815 Apothecaries Act, and so laid the foundations for the 1858 Medical Act.
The 1815 Apothecaries Act
The Royal College of Physicians may have accepted the licensing privileges of the surgeons and apothecaries but it had rejected the idea that these tradesmen possessed the same social status of the physician as gentleman. Certainly, the College claimed their profession was different to the apothecaries’ trade, as no gentleman would allow himself to be seen to be a tradesman. Indeed, while the surgeons and apothecaries could conduct examinations and issue licenses, Physicians were the regulatory elite. For instance, Physicians claimed the right to supervise the preparations of the apothecaries. The surgeons and apothecaries resented the elevated position of the physician and saw the upward social mobility inherent in the changing world around them as an opportunity to reap social and economic rewards. However, by the middle of the 18th century the apothecaries in particular had their own problems. The potential for upwards social mobility brought about by the industrial revolution was a two way street. The apothecaries increasingly found themselves coming under pressure from shopkeepers trading in drugs. These individuals – the early forerunner of the modern chemist – were marketplace entrepreneurs who retailed and dispensed medicines. The latter part of the eighteenth century as well as the early part nineteenth century was seen by many individuals to be the golden age of charlatans and quacks. However, the rise of the druggist meant the ‘apothecaries, the largest order of medical practitioners, began to feel themselves encroached on from below. The result was that when unqualified practice grew to sufficient proportions the apothecaries felt that something should be done’ (Newman 1957: 58).
The apothecaries wanted a review of the regulation of the medical marketplace and had the support of the Royal College of Physicians – only because the College elite were worried about the rise of the general medical practitioners. Who were increasingly registering as surgeon-apothecaries and calling for reform of the existing training and practice arrangements. As Louden (1995: 238) notes ‘the surgeon-apothecaries/general practitioners wanted to run their own show by being in charge of the selection, examination and certification of those who chose their branch of the profession. They had no intention of being subservient to any superior body’. The College of Physicians saw an opportunity to stamp their authority on medical practice and training. They sponsored the 1815 Apothecaries Act, which endorsed apothecary control over medical dispensation. More importantly, the Act made it a legal requirement for general practitioners to take Apothecaries examinations. It also reinforced the subservience of the apothecary to the physician. In one stroke, the Physicians reminded the apothecary and the general practitioner of their place in the medical hierarchy. Holloway (1966: 128) notes that ‘the general practitioners demand for an Act of Parliament to further their advancement was so skilfully manipulated by the College of Physicians that the Act passed tended to degrade rather than to elevate the rank and file of the profession. The general practitioner was subjected to the direct control of a London mercantile company, still largely engaged in the wholesale drug trade, and to the indirect supervision of the College of Physicians, whose policy was to make permanent the subordinate and inferior status of the apothecary.’
An Upwardly Mobile Profession
The College of Physicians seemed to have put the general practitioner in their place. However, the 1815 Act took place against a background of increasing discontent amongst provincial physicians, surgeons and surgeon-apothecaries regarding the standard of medical education in some universities and teaching hospitals. That is in addition to the continued activities of unlicensed medical practitioners, including cooks, blacksmiths, druggists and grocers, amongst others. It soon became apparent that the Society of Apothecaries did not possess the work force to prosecute quackery. The grocer and the blacksmith who also treated the sick did so without fear of prosecution. Indeed, the 1841 census revealed that of the 30,000 individuals who declared themselves ‘doctors’ only 11,000 appeared on approved registers (Moran and Wood 1993). Additionally, incensed by the fact that they were viewed as tradesmen instead of members of a learned profession, general practitioners fanned the flames for reform by lobbying parliament for the establishment of a Royal College of General Practitioners. This was unsuccessful because the Royal College of Surgeons would not agree to general practitioners conducting surgical examinations. In turn, the general practitioners could not conceive of a college that did not conduct surgical examinations. However, a National Association of General Practitioners in Medicine, Surgery and Midwifery was formed in 1842. This contributed to the growing realisation by Royal College’s of Physicians and Surgeons that the organisation of the regulatory and training arrangements had to be re-evaluated.
A key factor that heavily influenced the College of Physician’s eventual support for reform was that by the mid-Nineteenth century a generation of London Physicians had been directly influenced by Scottish and French medicine. A large number spent a ‘gap year’ in France as part of their initial clinical education. Consequently, ‘experience, from the dissection table and the hospital wards, flowed through the careers of multitudinous young Englishmen as they made the journey out and back….The year in France was, far from a passive period of observation, a veritable tour de main’ (Maulitz 1987: 136). Additionally, the recent introduction of the stethoscope was beginning to secure modern medicine’s future in English medicine. Physicians were as conscious of the possibility of upward social mobility as their fellow surgeons, apothecaries and general practitioners. They saw that the growing association of medicine with science was changing the nature of the doctor-patient relationship to their advantage and they realised the political utility in establishing a united medical profession whose practitioners were self-governing and equal in the eyes of the law. As an editorial in the medical periodical Lancet reported after the enactment of the 1858 Medical Act: ‘Medicine in this country has, both in regards to Science and Polity entered into a new era. with our free institution there is scarcely a limit to the influence which the profession may come to exert in the state now that it acquired a collective and political existence’ (Lancet editorial 1858: 148).
The 1858 Medical Act
The 1858 Medical Act established the General Council of Medical Education and Registration (subsequently shortened to the General Medical Council). This body would be responsible to Parliament through the Privy Council, but in practice it was autonomous. Its responsibilities were essentially twofold – to maintain a register of qualified medical practitioners and to define the nature of the qualifications necessary to obtain registration. The 1858 Act is often held to be a landmark in the modernisation of medical training and regulation in the United Kingdom. Even today, it is held by many to be a measure that ensures patient safety. For through its enactment the profession entered into a regulatory bargain with the state: it gained the privilege of professional self-regulation in return for promising the public that they could trust the competence of registered medical practitioners. Yet the Act also ensured the continuation of the status quo as the existing medical elites made sure their qualifications alone were accepted by the GMC for the purpose of registration (Gladstone 2000). In addition, their members controlled the GMC’s board. Indeed, of the initial twenty four board members board, nine represented directly the Royal Colleges, twelve the universities whose representatives were naturally senior members of the Colleges, and the remaining three were nominated on the advice of the Privy Council (these were usually medical men). There was no space for general practitioners. This did change until an amendment to the Act in 1886, which allowed the profession to elect by postal vote five doctors from the profession as a whole. It was not until the 1926 that the Privy Council chose to include one layperson on the GMC board. This will be discussed in detail in the next topic.
Victorian Club Government and Medicine’s ‘Club Mentality’
‘In 1858 the GMC was effectively a gentlemen’s club. Its promise that the public could trust those it registered amounted to ensuring that there were no ‘bounders’ in the medical fraternity [sic] who would do dastardly things such as no gentleman would do.’.
Stacey (1992: 204)
It is commonly asserted that medicine’s altruistic principles and close association with science naturally led to its being granted the privilege of professional self-regulation. In contrast, this topic has argued that the organisation of medical regulation occurred in particular social and political circumstances that shaped the nature of the institutional arrangements surrounding the establishment of the GMC. These, it has been argued, favoured the institutionalisation of medical privilege and autonomy. The 1858 Medical Act was designed to regulate the burgeoning health care marketplace and to generate public trust in the competence of medical practitioners. However, it also established a medical hierarchy (with the Royal Colleges at the top) which was in a good position to take full advantage of subsequent developments in the public health sphere, such as the introduction of the National Health Service (NHS). The 1858 Act and the GMC were reflections of the essentially pre-democratic, oligarchic, political structure in which they were founded. As Moran (2004: 28) notes ‘because government was the product of an era of oligarchy, deference and social elitism it was the government of clubs…[and] the government of doctors was patterned on the club system’. He cites Marquand (1988: 178) who says of the ideology of the broader Victorian governing style that ‘[the] atmosphere of British government was that of a club, whose members trusted each other to observe the spirit of the club rules, the notion that the principles underlying the rules should be clearly defined and publicly proclaimed was profoundly alien’. Indeed, medicine’s lack of transparency and accountability continued for the next hundred years. Stacey (1992: 204-5) noted when she joined the GMC as a lay member in the 1970s that it still retrained the air of being an exclusive ‘gentlemen’s club’: ‘One felt that change was accepted reluctantly and that tradition dominated. It was really a place for white men. The few women were tolerated and treated very civilly (albeit their toilets were in basement or attic) but the ethos was male.Life on the Council was not entirely nineteenth century of course; the founding fathers would have felt out of place in a number of ways. But given their pervasive legacy, they would have felt happier there than in many parts of the outside world’.
Sorry Mrs, These are ‘Men Only’ Clubs
An interrelated feature of medicine’s ‘club mentality’ and the wider club government system of the time was their gender bias. Women had been involved in the practice of healing and childbirth for many centuries. However, it was not until the rise of the biomedical model that the medical fraternity deliberately excluded women as they collectively pursued their project to obtain occupational control of the medical register. Ehrenrich and English (1973) trace historical portrayals of women as physically and mentally weak. In doing so they illustrate how these served the interests of male doctors by disqualifying women as healers and qualifying them as patients. The rise of scientific interest in reproductive biology in the eighteenth and nineteenth centuries transformed the female body into an object for detailed examination, with evolutionary theory being used to justify patriarchal social roles. The overwhelming consensus of the male dominated sciences of the time was that ‘women were inherently different from men in their anatomy, physiology, temperament and intellect. In the evolutionary development of the race women had lagged behind men, much as ‘primitive people’ lagged behind Europeans. Even as adults, they remained childlike in body and mind. The reasons for women’s arrested development were the need to preserve her energies for reproduction’ (Russett 1989: 11). The corollary of such ideas was that women were perceived as mentally and morally weak and fragile. These assumptions were used to justify the allocation of an inferior social status of women. The division of labour between men and women was seen as being pre-determined by nature: men produced and women reproduced.
Interestingly, though women were actively excluded from medical practice, the wording of the 1858 Medical Act did not specifically exclude women from becoming a registered medical practitioner. Indeed, the Act stipulated that a person could practice medicine if they possessed a British University degree or a licentiate membership or fellowship in one of the medical corporations. It should be no surprise to learn then that women managed to break into the profession, though not without some difficulty. The first, Elizabeth Blackwell, gained a medical qualification in the USA in 1849. On returning to England, she subsequently obtained a diploma from the Irish College of Physicians. This enabled her to gain admittance onto the medical register in 1858. In typical gentleman club style the GMC at once changed their rules so that in future women with a foreign degree could not be included on the medical register. Despite experiencing considerable social hostility, Blackwell gave lectures and encouraged other women to become doctors. She inspired Elizabeth Garrett, who in 1865 became the first women to qualify in Britain after studying at the Society of Apothecaries, which was the only medical corporation that did not specifically exclude women. She subsequently helped other women lobby for equality and eventually in 1899 an Act of Parliament removed all remaining legal barriers to women training as doctors. However, social and cultural barriers would persist for several generations. For instance in the 1890s William Osler jokingly told his students that humankind could be divided into three categories – men, women and women physicians (Moldow 1987).
Women and the Modern Medical Profession
Women who wished to practice medicine during the first part of the twentieth century faced were actively encouraged by family and friends to be nurses. Nursing was seen to be a more suitable occupation for a woman (Riska and Wegar 1993). The fact of the matter was that female medical students were actively kept in the minority through an informal quota system (roughly 10% of medical school places). It was not until after the 1968 Todd report on medical education that women would enter medical school in greater numbers. In contemporary times, women are now in the majority as the proportion of women entering medical school has risen to almost 55% (McManus 1997). Indeed, in 2001 3,355 women from the UK were given places at UK medical schools compared to 2,320 men (Carvel 2002). This trend is expected to continue and seems to reflect broader social changes in regards to traditional perceptions surrounding the appropriate position of women in the public sphere in general, and health care and medicine in particular. Recent figures show that the percentage of female hospital consultants has grown from 16% to 22% (Department of Health 2001). This trend indicates that medicine’s traditional male bias has been slowly disappearing over the last several decades. Inequalities between the sexes remain. Not only are they less women consultants than men, but women are also unevenly distributed across the medical specialists. With the majority being in paediatrics (38%) and the minority surgery (6%) (Department of Health 2001). Providing a full historical exploration of the topic of modern medicine’s gender imbalance is not the purpose of this topic. However, it is important to note that there has been a change in the general social perception of which individuals are appropriate to practice medicine. For this highlights, first, the culturally and historically embedded nature of the organisation of medical practice and regulation, and second, that it is possible for social inequalities to be successfully challenged. Even those that at a particular point in time are perceived by society as ‘natural’. Indeed, the central argument of this topic has been that the particular form of medical regulation in the UK with the establishment of the 1858 Medical Act – i.e. medical self-regulation – was not a natural consequence of the nature of medical expertise, but rather was very much a product of its time.
Medical Science, the Principle of Self-Regulation and the Doctrine of clinical Autonomy
At first sight there does seem to be a logical consistency between the scientific foundations of modern medical expertise, the principle of medical self-regulation and the doctrine of clinical autonomy. Patients want doctors to possess the freedom to decide the best course of treatment for them (i.e. clinical freedom). While it can be argued that the esoteric nature of medical knowledge means only a doctor’s peers can be said to be sufficiently qualified to judge the quality of her work (i.e. medical self-regulation). Yet the rational scientific basis of modern medical knowledge means it is open to codification, routinization and cross-site comparison and evaluation by outsiders. A point that will be discussed in more detail in subsequent topics. Additionally, even if one admits that there is an inherent indeterminacy present when clinical decisions are made in complex practice situations, it does not necessarily follow that a particular course of action lies beyond the moral evaluation of an outsider, or even the patient themselves for that matter. Regardless of the persuasiveness of arguments in support of medical self-regulation in particular and clinical autonomy in general, the possession of an esoteric knowledge base alone does not necessarily lead to a ‘closed shop’ approach to medical regulation, as was established by the 1858 Medical Act. Indeed, this topic has focused upon how the process by which the principle of medical autonomy became institutionalised in the form of the GMC took place within a broader social and political context. This supported the development of an occupational culture within medicine built upon paternalistic practices during doctor-patient encounters and occupational elitism in the professional-public relationship. In short, the particular form medical regulation took with the introduction of the 1858 Medical Act (i.e. self-regulation) reflected an elitist model of ‘club government’ characteristic of the organisation of the state in the Nineteenth century (Moran 2004). The patterning of medical regulation on the Victorian gentleman’s club reflected doctor’s individualistic image of themselves ‘as autonomous, self sufficient practitioners with personal responsibility for their patients’ (Davies, 2004: 59). An emphasis on voluntary compliance and self-regulation has historically been a common feature of the government of social elites in the United Kingdom. The informal ‘old boy network’ of the gentleman’s club stressed informal and unwritten gentleman’s agreements and emphasised self-discipline (Baggott 2004). The direct control of fellow members was seen to be distasteful and ungentlemanly, as well as largely unnecessary. Relatively few ‘bad apples’ were expected to exist. How could such people get into the club in the first place?