Fighting for business: the limits of professional cooperation among American doctors during the First World War.

Fighting for Business: The Limits of Professional Cooperation among American Doctors during the First World War University of Houston, USA. Email: [email protected]

ABSTRACT. The American medical profession participated extensively in preparedness and mobilization for the First World War, with more than one in five doctors voluntarily enlisting in various branches of the Army and Navy Medical Corps. Medical officers were widely valorized for suspending their civilian careers and for sacrificing their professional income while in service. Because of the meager commissions that medical officers received by comparison with fees many doctors earned in established private medical practices, scores of county medical societies implemented organizational solutions to this business problem, with the hopes of removing a significant disincentive to enlistment. In these “practice protection plans,” a civilian doctor promised to take care of the patients of a military doctor, to forward a portion of the fees collected thereby to the family of the military doctor, and to refer these patients to the military doctor upon his return. Despite initial enthusiasm and promotion, these plans ultimately failed to achieve their objectives, leading some medical officers to accuse civilian doctors of being opportunistic, unpatriotic “slackers.” This episode reveals the limits of professional cooperation in American medicine at the time and the need to explain organizational failures in the grand narrative of professionalization during the “Golden Age” of American medicine. KEYWORDS: United States, First World War, private medical practice, medical profession, income, military medicine.

JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES,

Volume 70, Number 2 # The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected] Advance Access publication on February 3, 2014 doi:10.1093/jhmas/jrt073

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JAMES A. SCHAFER Jr.

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I N T RO D U C T I O N URING the final stages of preparedness and early mobilization for the First World War, editorials in popular periodicals and medical journals alerted readers that thousands of doctors would be needed in various branches of the U.S. Army and Navy Medical Corps in support of the war effort. These predictions proved accurate: in the nineteen short months from the U.S. declaration of war in April 1917 to Armistice in November 1918, roughly 32,000 American doctors enlisted as medical officers—what amounted to 22 percent of all licensed doctors nationwide (Figure 1). This unprecedented mobilization of American doctors reflected the scale and felt urgency of this first total war.1 Policy-oriented editorials primarily discussed how to facilitate mobilization and ensure that the remaining health care workforce could meet civilian needs during and after the war.2 Human-interest stories celebrated the brave doctors who voluntarily enlisted and highlighted their personal and professional sacrifices.3 Many of these stories, particularly in the medical press, worried about the financial insecurity of military doctors, who risked their primary source of income by enlisting—namely the fees earned in private medical practice. Although newly enlisted medical officers typically received $2000 –$2400 per year in commission, with

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1. At the declaration of war in April 1917, there were 834 doctors enlisted in the Army Medical Corps and 397 in the Navy Medical Corps; at Armistice, there were 30,591 doctors enlisted in the Army Medical Corps and 2,570 in the Navy Medical Corps, or 33,161 in total (31,930 added since the declaration of war). See Franklin Martin, Digest of the Proceedings of the Council of National Defense During the World War (Washington, DC: United States Government Printing Office, 1934), 510, 630 –31. Percentage participation of the American medical profession was calculated using tally of all legally qualified physicians in the United States and dependencies—or 146,613 for 1918—from the American Medical Directory 6th ed. (Chicago: American Medical Association, 1918), 60. 2. See: “Medical Colleges and Medical Preparedness,” J.A.M.A., 1917, 68, 1127–8; Charles H. Smith, “The Dispensary on a War Basis,” J.A.M.A., 1917, 68, 1772 –3; “Medical Students and Conscription,” J.A.M.A., 1917, 69, 475 –6; “Lack of Physicians,” J.A.M.A., 1917, 69, 482; “Medical Students and the Shortage of Interns,” J.A.M.A., 1917, 69, 571; “The Conscription of Interns,” J.A.M.A., 1917, 69, 652; “Hospital Interns and Medical Students and the Selective Service Act,” J.A.M.A., 1917, 69, 652; Isadore Sandock, “Immediate Action By Conscripted Medical Students,” J.A.M.A., 1917, 69, 751; and “Medical Students, Interns, and the Draft,” J.A.M.A., 1917, 69, 827. 3. Gertrude Seymour, “Medicine Mobilized,” The Survey, April 28, 1917, 87–90; “American Doctors Soon to Be at Front,” New York Times, May 5, 1917, 11; James Morgan, “Soldiers Who Battle Only to Save and Heal,” Boston Daily Globe, June 24, 1917, 44; “Army Must Have 24,000 Physicians,” New York Times, July 30, 1917, 3.

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allowances for quarters, fuel, and light, it was widely acknowledged that this salary failed to compensate for the loss of income from established private practices, particularly in cities.4 What would become of 4. “Our Army of Good Samaritans,” Literary Digest, May 19, 1917, 54, 1505–6; Morgan, “Soldiers Who Battle”; E.C.F., “Doctors for the Army: Enlistment a Difficult Economic Question for Them,” New York Times, July 10, 1917, 11; James B. Morrow, “Thousands of Doctors in War Service: Many Have Large Incomes, But They Have Abandoned Their Practice to Save the Lives of American Soldiers” Boston Daily Globe, November 4, 1917, SM7; “Practices of Reserve Medical Officers in Time of War,” J.A.M.A., 1917, 68, 798; “The Responsibility of the County Society in Preparedness,” J.A.M.A., 1917, 68, 1484–5; “Moving to Another Location after the War,” J.A.M.A., 1917, 68, 1703; “A Tribute to the Doctor,” J.A.M.A., 1917, 69, 46; and “The Roll of Honor,” J.A.M.A., 1917, 69, 843. Salary, compensation, and ratios of military ranks were established in the National Defense Act of 1916: $2000 (lieutenant), $2400 (captain), $3000 (major), $3500 (lieutenant colonel), and $4000 (colonel): “The Medical Officer of the Army [Part] IV,” J.A.M.A., 1917, 68, 1407 –9. Early recruitment established a rank ratio of medical officers at 67.7 percent Lieutenants and


Fig. 1. Graph generated from data tabulated in Franklin H. Martin. The mobilization of American doctors, 1917 – 18. Source: Franklin H. Martin, Digest of the Proceedings of the Council of National Defense During the World War (Washington, DC: U.S.G.P.O., 1934), 630 – 1. Note: The total number of combined medical corps for the U.S. Army included Regular Medical Corps, Medical Corps of the National Guard, Medical Corps of the National Army, and, the largest category, Medical Reserve Corps on active duty. The total number of combined Medical Corps for the U.S. Navy included Regular Medical Corps and the Naval Reserve Force.

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Captains, 23.7 percent Majors, 5.4 percent Lieutenant Colonels, and 3.2 percent Colonels: “Increase in Army Medical Corps,” J.A.M.A., 1916, 67, 446. This ratio was later adjusted slightly after passage of the Owen-Dyer Bill in July 1918, which allowed for a handful of medical officers to be promoted to the ranks of Brigadier General and Major General. There are few systematic studies of the income of American doctors before the 1920s. One early study of Harvard graduates from the classes of 1901 –10 found that income in practice exceeded $2400 per year by the sixth year after graduation: Arthur B. Emmons, The Profession of Medicine: A Collection of Letters from Graduates of the Harvard Medical School (Cambridge, MA: Harvard University Press, 1915), 105. In his study of Chicago doctors, historian Thomas Goebel found that the 63.1 percent of doctors earned more than $3000 annually by 1919: “The Uneven Rewards of Professional Labor: Wealth and Income in the Chicago Professions, 1870–1920,” J. Soc. Hist., 1996, 29, 749 –77, esp. 759. Thus, $2000 –$2400 in commission would have been a pay cut for most established doctors in cities, and perhaps some young elites as well. Rural doctors, however, likely earned less than these commissions offered. 5. From his address given to the 69th Annual Session of the American Medical Association held at Chicago. Reprinted as “Address of General Gorgas” J.A.M.A., 1918, 70, 1932. 6. “Practices of Reserve Medical Officers in Time of War,” J.A.M.A., 1917, 68, 798. J.A.M.A. editors subsequently published more appeals for county societies to consider such plans: “The Mobilization of the Medical Profession,” J.A.M.A., 1917, 68, 1127; “The Responsibility of the County Society in Preparedness,” J.A.M.A., 1917, 68, 1484–5; “Protecting the Practice of the Absent Physician,” J.A.M.A., 1917, 68, 1559; “Protecting the Interests of Absent Physicians,” J.A.M.A., 1917, 69, 126. In addition, J.A.M.A. editors published news of plans already adopted. 7. “Practices of Reserve Medical Officers in Time of War,” J.A.M.A., 1917, 68, 798. For details of the English plans as explained to American doctors, see “How They Protect the Absent Physicians in England,” J.A.M.A., 1917, 68, 1270– 71.


these doctors and their families during and after the war? How would the well-known hardships of enlistment affect recruitment of medical officers? These questions captured the attention of the American medical profession, from the rank-and-file to their leaders. As Army Surgeon General William C. Gorgas explained, mobilized doctors not only sacrificed their immediate income, but also faced the possibility of having “to commence all over again” upon their return, as many of their patients would have moved on to the practices of other civilian doctors during the war.5 As early as March 1917, with U.S. entry into the war imminent, his office urged the American Medical Association (AMA) to “bring to the attention of the profession at large the necessity of . . . organizing for the purpose of taking care of the practices of officers of the reserve who respond to the call for service.”6 Such provisions were reportedly being made in England, whereby “should Dr. Jones be called to the colors, the local medical society, through its members, would take care of his practice during his absence. On his relief from active duty, his practice would be returned to him intact.”7 The open letter from the Surgeon

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8. See J.A.M.A. issues from April 14 to July 14, 1917. 9. On the Maryland Plan, see “Punishing Patriotism: A Suggested Method of Meeting this Evil,” Bull. Med. Chir. Fac. Maryland, May 1917, 9, 161 –162. This was later republished in J.A.M.A. and elsewhere in state medical journals. See for example: “The Mobilization of the Medical Profession,” J.A.M.A., 1917, 68, 1127; “Punishing Patriotism: A Suggested Method of Meeting this Evil,” J.A.M.A., 1917, 68, 1131–2; “Punishing Patriotism” Delaware State Med. J., 1917, 8, 1–3; “The Maryland Plan,” Illinois Med. J., 1917, 32, 360 –361; and “Safeguarding Medical Practices of the Doctors Who Enlist,” J. Indiana State Med. Soc., 1917, 10, 196. The Maryland Plan also received newspaper coverage: “400 for Medical Corps; Baltimore Physicians Urged to Join Army and Navy Reserve; Practice Will Be Cared For,” The Sun, March 25, 1917, 16; and “Protects War Doctors; System Devised by State Faculty to be Put in Practice,” The Sun, May 10, 1917, 4.


General’s office first appeared in the Journal of the American Medical Association (J.A.M.A.), and was widely republished in the journals of state medical societies for several months thereafter. Following the Surgeon General’s advice, scores of county medical societies across the United States developed what I shall call “practice protection plans” to safeguard mobilized doctors against the loss of short-term income and long-term business in private medical practice. Over sixty of these county plans were announced in J.A.M.A. alone between March and July 1917, typically appearing in the “Medical News” section or in the new “Medical Mobilization and the War” section.8 Perhaps because they had become so commonplace, J.A.M.A. editors typically included fewer details on plans after the initial ones were announced, and stopped reporting on new plans altogether after July 1917. In contrast, state medical journals continued to discuss the design and fate of these county practice protection plans, and indicate that these plans were even more widespread than reported in J.A.M.A. The following is a case study of county practice protection plans outlined in the state medical journals for twenty-one states (including the District of Columbia). These states comprised a representative sample across the United States by region, population density, and degree of urbanization. At least one county plan was reported in nineteen of the twenty-one states studied (Figure 2). Some of these nineteen states had many county plans, such as Missouri, which claimed more than twenty; other states reported only one or two. Many county plans were drafted by state medical societies for ratification by county medical societies, such as the early and widely reported “Maryland Plan,” in which substitute doctors promised to forward one third of the fees collected to the families of absentee doctors.9 Quite a

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few county medical societies took the organizational initiative themselves, such as the Philadelphia County Medical Society, which passed what became known as “The Philadelphia Idea,” another early plan that was celebrated because of the substantial requirement to forward two thirds of the fees collected from the patients of absentee doctors.10 10. The Philadelphia County Medical Society plan was originally referred to as “The Philadelphia Idea.” See “The Philadelphia Idea,” The Weekly Roster, April 14, 1917, 12, 11. Its rationale was discussed at length in the local medical journal: “Substitutes for Doctors in War Service,” The Weekly Roster, April 14, 1917, 12, 9; “Substitute Care of the Practice of Medical Volunteers,” The Weekly Roster, April 28, 1917, 12, 4; “Caring for the Patients of Other Physicians,” The Weekly Roster, June 2, 1917, 12, 3; “A Suggestion from West Philadelphia,” The Weekly Roster, June 2, 1917, 12, 9; and “Whatsoever Ye Would That Men Do


Fig. 2. Case study of county practice protection plans in the United States, 1917 – 18. Note: The state journal of record was determined from The American Medical Directory, 6th ed. (Chicago: AMA Press, 1918). Some journals functioned as the journal of record for more than one state, such as Northwest Medicine, which covered the states of Oregon, Washington, Idaho, and Utah. The District of Columbia (D.C.) was enumerated as a state in this analysis. Alaska and Hawaii were not yet states in 1918 and were not included in this analysis. States listed in italics were among the 27 states reported to have at least one county practice protection plan in J.A.M.A. from April-July, 1917. There were no further reports of new county plans in J.A.M.A. after July 1917. State medical journals were the only source for reporting on county plans after July 1917.

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Unto You Ye Even So Unto Them,” The Weekly Roster, June 16, 1917, 12, 3. Other Pennsylvania county medical societies modeled their plans on The Philadelphia Idea: “Will Aid Army Doctors,” The Weekly Roster, June 9, 1917, 12, 2 on Pittsburgh; “Doctors Set a Good Example,” The Weekly Roster, June 9, 1917, 12, 6 on Hazelton; “Protecting the Practice of Physicians in the Service,” Pennsylvania Med. J., 1917, 21.3, 3 on Bradford and Lancaster County plans; and “Care of the Practice of Physicians Absent in the Service of Our Country,” Pennsylvania Med. J., 1917, 20, 732, discussed plans throughout the state. 11. Evidence of plans in the ten largest cities: New York City (1)—“Military Surgeons’ Practice to Be Protected,” J.A.M.A., 1917, 68, 1331; New York City (1) and Buffalo (10) were also covered under a larger state effort: “Protecting the Practice of the Absent Physician,” J.A.M.A., 1917, 68, 1632, and New York State J. Med., 1917, 17, 253 – 254; Chicago (2)—“Resolutions by the Chicago Laryngological and Otological Society,” J.A.M.A., 1917, 68, 1269; and “Resolutions Passed by the House of Delegates,” Illinois Med. J., 1917, 31, 414; Philadelphia (3)—see fn. 10; St. Louis (4)—“Care of Practice of Absentee Members,” [Society Proceedings], J. Missouri State Med. Assoc., 1917, 14, 496; Boston (5) had no county or state plan that I could find; Cleveland (6)—“Safeguarding the Interests of Physicians During Military Service,” J.A.M.A., 1917, 69, 49 –51; Baltimore (7) ratified the Maryland Plan—see fn. 9; Pittsburgh (8) adopted The Philadelphia Idea—see fn. 10; and Detroit (9)—“County Society News” J. Michigan State Med. Soc., 1917, 16, 453 –454. 12. See fns. 9 and 10. On the commendation of The Philadelphia Idea, see “Doctors Here Commended,” The Weekly Roster, May 19, 1917, 12, 7.


Generally speaking, county medical societies in and around large cities adopted practice protection plans, likely because urban doctors had more lucrative private practices and stood to lose far more income by enlisting than a rural doctor.11 Practice protection plans in rural counties were less common, though country doctors may not have reported their plans to the editors of state medical journals or perhaps had less formal arrangements. Steeped as they were in patriotic language and professional rhetoric, and signaling the apparent good intentions of their design, early practice protection plans won accolades from the medical press: the Maryland Plan received extensive coverage in J.A.M.A. and widespread re-publication in state medical journals, and The Philadelphia Idea even received commendations from War Department officials and the Council of National Defense (CND).12 Despite all of the fanfare at the outset, reporting indicates that practice protection plans mostly failed or met with mixed results (Figure 3). Within a few months of their establishment, in plans from Pennsylvania to California, enlisted doctors complained that they had received little to no fees from the substitute doctors who had taken on their patients, and high-minded editorials lambasted civilian

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doctors for their unethical behavior.13 The two most publicized plans were no exception either, with the Philadelphia plan failing utterly and the Maryland plan suffering from underenrollment and little interest in ratification from county medical societies outside of 13. On failures in Arkansas, California, Indiana, Maryland, Minnesota, and Pennsylvania, see: “The Absent Doctor’s Practice,” California State J. Med., 1917, 15, 437; “Protect the Physician at the Front,” J. Arkansas Med. Soc., 1917, 14, 81; “Editorial Notes” J. Indiana State Med. Assoc., 1918, 11, 72; “False Patriotism” J. Indiana State Med. Assoc., 1918, 11, 157; “False Patriotism” [same title as previous] J. Indiana State Med. Assoc., 1918, 11, 172–173; “Report of the Council,” Bull. Med. Chir. Fac. Maryland, 1918, 11, 94; “Report of the Hennepin County Medical Society’s Committee on Plan to Serve Interests of Men in the Army, May 27, 1918,” Minnesota Med., 1918, 1, 277–278; “Are You Living Up to Your Agreement?” The Weekly Roster, September 22, 1917, 13, 5; “What Becomes of the Collected Accounts?” The Weekly Roster, January 5, 1918, 13, 4; “Service to Medical Officers in the Army and Navy,” The Weekly Roster, March 2, 1918, 8, 1; and “Has It Accomplished Its Object?” The Weekly Roster, February 1, 1919, 14, 6; and “Have We Kept the Faith?” W.R., April 19, 1919, 14, 6. On mixed results in Illinois, Michigan, Missouri, and Kentucky, see: “The Medical Officer with the National Army” Illinois Med. J., 1918, 33, 46–48; “The Work of the A.M.A. in the World War,” Illinois Med. J., 1918, 34, 57–64; “Introspective,” J. Michigan State Med. Soc., 1917, 16, 414–415; “Editorial Comments,” J. Michigan State Med. Soc., 1917, 16, 448; “Usurpers,” J. Michigan State Med. Soc., 1917, 16, 507; “Secretary’s Report,” J. Michigan State Med. Soc., 1917, 16, 511–514; “County Society News [Bay County]” J. Michigan State Med. Soc., 1919, 18, 36; “John Stayed: Bill Went,” J. Michigan State Med. Soc., 1920, 19, 255–257; “Conserving the Interests of


Fig. 3. The poor results of practice protection plans, 1917 – 20. Note: The results of county plans in a particular state were counted as failures if reporting only mentioned shortcomings or problems, such as poor enrollment of county medical societies, complaints from military doctors about meager fees received, accusations that civilian doctors relocated offices during the war in order to poach patients, or stories of military doctors having inordinate difficulty restarting their practices after the war. Mixed results refers to states which reported some success in county plans, but which also noted problems as listed above. Success refers to states with only positive reporting on plan outcomes.

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Members in Active Service,” J. Missouri State Med. Assoc., 1918, 15, 169; “Report of the Judicial Council,” J. Missouri State Med. Assoc., 1918, 15, 263; “Medical Preparedness in Kentucky” Kentucky Med. J., 1917, 15, 259–260; “County Society Reports” Kentucky Med. J., 1917, 15, 354–358; “Report of the Council” Kentucky Med. J., 1919, 17, 349–355; and [Discussion of the “Report of the Council”], Kentucky Med. J., 1919, 17, 478. Kansas was the only state in this study that had only positive reporting on the outcomes of county practice protection plans (see Figures 2 and 3): “Society Notes—Shawnee County Society,” J. Kansas Med. Soc., 1917, 17, 285; and “Room for All,” J. Kansas Med. Soc., 1918, 18, 225–226. 14. See fn 13. 15. David M. Kennedy, Over Here: The First World War and American Society (New York: Oxford University Press, 1980), 45 –92, 144 –190, Ronald Schaffer, America in the Great War: The Rise of the War Welfare State (New York: Oxford University Press, 1991), Nancy Gentile Ford, The Great War and America: Civil-Military Relations During World War I (Westport, CT: Praeger Security International, 2008), and Christopher Capozzola, Uncle Sam Wants You: World War I and the Making of the Modern American Citizen (New York: Oxford University Press, 2008). 16. Carol R. Byerly, Fever of War: The Influenza Epidemic in the U.S. Army during World War I (New York: New York University Press, 2005), 14– 68; Mary C. Gillett, The Army Medical Department, 1917 –1941 (Washington, DC: Center of Military History, 2009).


Baltimore and the suburbs of Washington, DC.14 The following analyzes the rise and fall of practice protection plans and the larger implications of these erstwhile plans for our understanding of the early twentieth century medical profession. In line with growing scholarly emphasis on the effects of preparedness and mobilization on the home front, this article assesses the broader issue of how well the American medical profession withstood the social, political, and economic pressures of the First World War.15 As in many other matters of pressing concern to the medical profession, the AMA and its constituent city, county, and state medical societies coordinated the recruitment drive for Army and Navy medical officers, and to good effect.16 In this regard, the AMA and the medical profession appear to have held up well during the war, leveraging prewar organizational momentum to strengthen internal cohesion and to further enhance the status and legitimacy of the profession in the eyes of the federal government and the public. However, the general failure of practice protection plans reveals the limits of professional cooperation and the persistence of individualism in the earlytwentieth-century medical marketplace—important details that are missed if one only reads the sanguine assessments of the AMA or CND, rather than the more sober editorials of local and state medical journals or the correspondence of frustrated military doctors.

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17. For early work on medical professionalization that focused on institutional reform and professional cooperation, see: Joseph Kett, The Formation of the American Medical Profession: The Role of Institutions 1760– 1860 (New Haven: Yale University Press, 1968); James G. Burrow, Organized Medicine in the Progressive Era: The Move Toward Monopoly (Baltimore: Johns Hopkins University Press, 1977); Gerald E. Markowitz and David Rosner, “Doctors in Crisis: Medical Education and Medical Reform During the Progressive Era, 1895–1915,” in Health Care in America: Essays in Social History, ed. Susan Reverby and David Rosner (Philadelphia: Temple University Press, 1979), 185 –205; Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982); Rosen, The Structure of American Medical Practice; Barbara G. Rosenkrantz, “The Search for Professional Order in Nineteenth Century American Medicine,” in Sickness and Health in America: Readings in the History of Medicine and Public Health, ed. Judith W. Leavitt and R. Numbers, 2nd ed. (Madison: University of Wisconsin Press, 1985), 219232; William G. Rothstein, American Medical Schools and the Practice of Medicine: A History (New York: Oxford University Press, 1987); Ronald Numbers, “The Fall and Rise of the American Medical Profession,” in Sickness and Health in America: Readings in the History of Medicine and Public Health, ed. Judith Walzer Leavitt and Ronald Numbers, 3rd ed. (Madison: University of Wisconsin Press, 1997), 225 –36. 18. See, for example: Thomas Goebel, “American Medicine and the ‘Organizational Synthesis’: Chicago Physicians and the Business of Medicine, 1900–1920,” Bull. Hist. Med., 1994, 68, 639 –63; Thomas Goebel, “The Uneven Rewards of Professional Labor: Wealth and Income in the Chicago Professions, 1870–1920,” J. Soc. Hist., 1996, 29, 749 –77; Donald L. Madison, “Preserving Individualism in the Organizational Society: ‘Cooperation’ and American Medical Practice, 1900–1920,” Bull. Hist. Med., 1996, 70, 442 –83; Christopher Crenner, “Organizational Reform and Professional Dissent in the Careers of Richard Cabot and Ernest Amory Codman, 1900–1920,” J. Hist. Med. Allied Sci., 2001, 56, 211 –37; Allan M. Brandt and Martha Gardner, “The Golden Age of Medicine?” in Companion to Medicine


Using the example of failed practice protection plans during the First World War, this article adds to a growing body of scholarship— what might be termed “the new history of medical professionalization”—that revises the grand historical narrative of the American medical profession written primarily in the 1970s and 1980s. Although earlier histories rightly focused on identifying the origins and consequences of the “social transformation of American medicine,” they overestimated professional cohesion outside of support for a narrow set of (highly significant) institutional and regulatory reforms.17 That doctors at times privileged economic self-interest to the detriment of collective goals is not surprising, but the consequences of individualism for the structure of the medical marketplace and for the evolution of medical careers remain poorly understood. More recent scholarship has begun to consider the limits of professional cooperation, and indicates that what emerged from the era of medical professionalization was by no means a unified corporation of homogenous professionals, but rather a tenuous alliance of disparate professional subgroups with distinct economic interests, political motivations, and social identifications.18 Internal divisions most often

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manifested in the conduct of private medical practice, as illustrated by the limits of professional cooperation during the First World War, when doctors fought for business. P R I VAT E M E D I CA L P R AC T I C E A N D M E D I CA L M O B I L I Z AT I O N

in the Twentieth Century, ed. Roger Cooter and John Pickstone (London; New York: Routledge, 2003), 21 –37; “Transforming American Medicine: A Twenty-Year Retrospective on The Social Transformation of American Medicine,” spec. issue of J. Health Polit. Policy Law, August/October 2004, 29; and James A. Schafer, Jr., The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900–1940 (New Brunswick: Rutgers University Press, 2014). 19. Rosen, The Structure of American Medical Practice, 37 –117, and Schafer, The Business of Private Medical Practice, 15– 38. 20. Schafer, The Business of Private Medical Practice, 39 –70. 21. Rothstein, American Medical Schools, 96, table 5.3.


In the early twentieth century, private practice remained the cornerstone of medical careers and livelihoods in America. Despite the growth of hospitals as centers for clinical education and surgical care, doctors devoted most of their time to private practice. Even specialists, who associated more closely with hospitals than general practitioners (GPs), sought to translate internships and clinical appointments into lucrative office practice outside of the hospital.19 As many popular advice manuals warned, though, it took time to build a successful private practice, with the early years yielding little in the way of income as young doctors “waited for patients” while developing a reputation and establishing networks for referrals.20 To make matters worse, in the years leading up to the First World War, the medical marketplace remained overcrowded, as the effects of new medical school reform and medical licensing reform had only just begun to relieve the glut of medical graduates and alternative healers. As late as 1906, for example, attrition rates in the first ten years of practice commonly reached 1 in 5 doctors, even among graduates of elite medical schools, such as Johns Hopkins.21 Under these conditions, older and more established doctors were particularly reluctant to leave their private practices in order to voluntarily enlist as medical officers for the war. Although the families of conscripts, in general, endured great financial hardships during and after the war, J.A.M.A. editors claimed that volunteer doctors had more to lose than the average draftee:

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In a published letter to the editors of J.A.M.A., Dr. E. W. McBratney of St. Louis tried to justify why refusal to enlist must be understood as a rational business decision rather than as a cowardly act: Does the average physician who has not volunteered his services to his country consider himself a disgrace? Absolutely not. The psychology of a physician’s practice is vastly different from that of any other profession, business, trade, or occupation. A customer buys his goods of a certain wholesale or retail house because the firm has always done a square business. A railroad switchman, when he changes location, presents his credentials from the last road he worked for. Not so the physician. His practice is held by his personality, and when he goes to war, his practice goes elsewhere . . . One of the principal reasons why the army is so short of medical officers is that physicians realize that their work of five, ten, or fifteen years, in building up a practice, will be lost when they return, and that they, men of middle age, will have to start at the bottom again, in competition with younger men.23

Other mid-career doctors agreed, though some correspondents concealed their full names in publication, perhaps for fear of approbations from a judgmental public or from colleagues who had already enlisted. For example, as one doctor “E.C.F.” explained in a letter to the Editor of The New York Times in July 1917, “there are many of us between 30 and 40, our most valuable period, who are ready and willing to enter service, but cannot because of domestic and financial obligations.” As E.C.F. explained of doctors who enlisted: 22. “The Responsibility of the County Society in Preparedness,” J.A.M.A., 1917, 68, 1484–5, quotation on 1484. 23. E. W. McBratney, “Disgracing the Medical Profession,” J.A.M.A., 1917, 69, 664. These sentiments were echoed in editorials published in state medical journals as well. See, for example: “Patriotism and Dollars,” J. Med. Assoc. Georgia, 1917, 7, 35 –36; “Drafting Doctors,” Illinois Med. J., 1917, 32, 205 – 206; and Joseph Colt Bloodgood, “Medical Preparedness in the Great Drive for Democracy,” J. Florida Med. Assoc., 1917, 4, 63 –69.


The sacrifice a physician makes in leaving his practice for a protracted period of time is unique. The bookkeeper, the clerk, the artisan, the clergyman, the merchant can be guaranteed his position on his return. The merchant, the banker, the farmer, the lawyer can arrange with another, or with his partner, to look after his business during his absence. But the physician’s practice—his “business”—is different; there is a personal relationship between a physician and his patient that makes the transference of the patient from one practitioner to another almost, but not quite, impossible.22

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In a crowded and competitive medical marketplace, the doctor who enlisted stood to lose the cornerstone of his career and livelihood— his private practice. A number of factors, however, compelled thousands of doctors, young and old, to enlist in spite of well-known risks to private medical practices. For the first time in American military history, the majority of soldiers were conscripted. As the size of the military increased dramatically following passage of the Selective Service Act of 1917, so too did the likelihood of being drafted. Initially, only men aged 21 to 30 years were drafted, though it was later expanded to 18 to 45 years in 1918.25 Early on in mobilization, there was no guarantee that a drafted doctor (or hospital intern or medical student) would be able to transfer from the regular forces to a branch of the Medical Corps, at least not without a few months of military service while the transfer request was processed.26 Given the hazards of regular military 24. E.C.F., “Doctors for the Army: Enlistment a Difficult Economic Question for Them,” New York Times, July 10, 1917, 11. “Two-fifths of their market value” refers to the difference between commission as a lieutenant and what E.C.F. regarded as average income earned in private practice. Other editorialists published in state medical journals bemoaned the meager pay, arguing that it would hinder enlistment, particularly of established city doctors: “The Other Side,” J. Iowa State Med. Soc., 1917, 7, 311 –312. 25. See John Whiteclay Chambers, To Raise an Army: The Draft Comes to Modern America (New York: Free Press, 1987), 73 –178, and Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore: Johns Hopkins University Press, 2001), 9–19. Targets for the size of the military increased as the War dragged on, from one million planned to over 3.9 million by the Armistice. See Martin, Digest of the Proceedings, 629. 26. See: “Position of Physician Under the Selective Conscription,” J.A.M.A., 1917, 68, 1992; R. V. Baker, “Medical Students and the Draft,” J.A.M.A., 1917, 69, 228; “Physicians Who Are Conscripted,” J.A.M.A., 1917, 69, 289; “Conscripted Medical Students,” J.A.M.A., 1917, 69, 290; “Medical Students and Conscription,” J.A.M.A., 1917, 69, 475 – 6; “Medical Students and Conscription,” J.A.M.A., 1917, 69, 570 –1; “Medical Students and the Draft,” J.A.M.A., 1917, 69, 649– 50; “Medical Students and Conscription—Our Figures Questioned,” J.A.M.A., 1917, 69, 650; “The Disposal of Drafted Medical Students,


Practically every one is given a First Lieutenant’s commission, ($2,000 per annum) whether he be a graduate of one or ten years’ standing. The average man of over 30 has dependents, leases, mortgages, or insurance, commensurate to his present income. How can he, even by material sacrifice of these obligations, clothe and feed himself and support his family on the above income? A physician’s practice is his assets. If the Government commandeers the assets of its citizens it pays them market price for those assets, but the medical man is expected to contribute his assets at an average of two-fifths of their market value in many cases.24

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Pharmacists, and Physicians,” J.A.M.A., 1917, 69, 652; and “Medical Students and the Draft,” J.A.M.A., 1917, 69, 735. Procedures for the exemption of medical students and interns from regular military service were formalized by mid-September 1917: “Exemption of Medical Students and Interns,” J.A.M.A., 1917, 69, 917. 27. With every expansion of the American Expeditionary Forces, editorialists warned that unless enough doctors enlisted to serve the needs of the larger military, the medical profession would have to endure a selective draft of its members, like that in England: “Draft of Physicians in England,” J.A.M.A., 1917, 68, 1483; “The Duty of the Medical Profession,” J.A.M.A., 1917, 68, 1556–7; Herbert B. Wilcox, “Drafting Physicians,” J.A.M.A., 1917, 69, 934; “Richard Derby, “A Selective Draft of Physicians Based on Classification,” J.A.M.A., 1917, 69, 1023.


service, it was relatively easy for the AMA to convince many draft age doctors to voluntarily enlist in the various branches of the Medical Corps, as the horrors of trench warfare were well known. Although the CND considered pushing for a special draft for doctors at various points during the war, the AMA-coordinated enlistment drive prevented this from happening, much to the pride of AMA leaders.27 Besides fearing the draft, many doctors, especially those older than draft age, enlisted in order to satisfy patriotic urges. This motivation took two forms: on the one hand, doctors might enlist in order to feel patriotic or to fulfill a desire to help suffering soldiers; on the other hand, some doctors no doubt enlisted to avoid being labeled as unpatriotic slackers or cowardly pacifists. The pull of patriotism could be found in the titles of many misty-eyed articles that valorized military doctors, especially in the popular press of the time: “American Doctors Soon To Be At The Front j First United States Uniforms To Be Seen In France Will Be Those Of Medical Corps j Some To Go Within AWeek”—The New York Times, May 5, 1917; “Our Army Of Good Samaritans”—The Literary Digest, May 19, 1917; “Soldiers Who Battle Only To Save And Heal j American Doctors, The Real Vanguard Of Our Army, Already Are Joining Their English And French Colleagues In A War Against The Invisible Foe, Who Has Been More Terrible In The Past Than Any Army With Banners—A Race Between The Science Of Killing And The Science Of Saving”—The Boston Daily Globe, June 24, 1917. Early press coverage generally centered on the leadership of the AMA and CND in meeting recruitment goals and in organizing base hospitals for early deployment. Unlike such reportage of mobilization success stories, early human-interest stories instead sang the praises of famous American

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28. “Our Army of Good Samaritans,” Literary Digest, May 19, 1917, 1505, James B. Morrow, “Thousands of Doctors in War Service,” Boston Daily Globe, November 4, 1917, and Samuel Hopkins Adams, “Uncle Sam, M.D.,” Collier’s, September 21, 1918, 6. 29. Ibid. On the push for reform of rank and pay for medical officers, see: “The OwenDyer Bill for Increased Rank,” J.A.M.A., 1918, 70, 539; “Legislation for Increased Rank for Medical Officers,” J.A.M.A., 1918, 70, 926; “Medical Features of the Army Appropriation Bill,” J.A.M.A., 1918, 71, 45; “Increased Rank for Medical Officers: Remarks of United States Senators Preliminary to Passage of Amendment Granting Increased Rank,” J.A.M.A., 1918, 71, 46; and “Increased Rank for Medical Officers,” J.A.M.A., 1918, 71, 199. 30. “The War Service of the Medical Profession,” J.A.M.A., 1918, 70, 1649–1732. 31. C.P.F., “Making Good in the Medical Reserve Corps,” Pennsylvania Med. J., 1918, 21, 528.


doctors who enlisted. Among those singled out for special acclaim were Dr. William H. Welch, Professor and founding Dean of Johns Hopkins School of Medicine, and Dr. George Emerson Brewer, a renowned New York surgeon with “one of the largest professional incomes in the country”—both of whom enlisted and deployed early in the war. Despite their illustrious civilian careers, Drs. Welch and Brewer only received commissions as Majors in the U.S. Army Medical Corps.28 Extreme examples circulated about other famous doctors whose incomes were reduced from $50,000 or more in private practice to $3000 or less as a medical officer, and whose great responsibilities in civilian life were replaced by the indignities of low rank under the command of younger Army officers outside of the medical corps. Toward the end of the war, stories like these inspired a successful campaign to increase the rank of senior medical officers and to raise the commissions of all medical officers.29 In all of its wartime efforts, the AMA fanned the patriotic flames alight nationwide. In their regular coverage of mobilization and war service, J.A.M.A. editors frequently published lists of newly commissioned doctors, and, even a comprehensive “honor roll” of state and county medical societies with exemplary state and county enlistment rates.30 States with high enlistment rates, such as Pennsylvania, praised their members. As one fervent doctor put it during an enlistment drive in May 1918: “surely Pennsylvania will hold her own as the Keystone State in medicine, and carry on the torch lit by John Morgan, and the old commonwealth will without question, on the day that the peace is signed, look with pride on her sons of Aesculapius, who have unostentatiously upheld her hands.”31 Both in deeds and words, tens of thousands of doctors answered the call of the AMA,

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32. “Patriotic Rally and Reception,” The Weekly Roster, November 3, 1917, 13, 5; “Northern Medical Drill Corps,” The Weekly Roster, January 12, 1918, 13, 1; and “Patriotic Meeting Extraordinary” The Weekly Roster, April 6, 1918, 13, 8. 33. “Doctor, Why Hang Back?” J. Indiana State Med. Soc., 1918, 11, 240. 34. “The Duty of the Medical Profession in This War,” J.A.M.A., 1917, 68, 1626– 7. 35. “Our Country’s Call,” J.A.M.A., 1918, 70, 1162. Similar appeals were made in “The Call for Medical Officers,” J.A.M.A., 1918, 70, 1228.


not only by enlisting, but also in demonstrations of support and military readiness. For example, Philadelphia doctors organized patriotic rallies and even formed “voluntary” drill corps whereby doctors who awaited deployment could become acquainted with military procedures and training exercises.32 In other words, opportunities abounded for doctors to play the part of the dutiful soldier. But patriotism and volunteerism took a coercive form as well. In states with low enlistment rates, like Indiana, state medical journal editors penned lengthy rebukes of the alleged ulterior motives of doctors, particularly younger unenlisted doctors, who were assumed to be “holding back” either out of cowardice or out of selfish business interests.33 Not only were draft age doctors were threatened with regular military service if they did apply for commissions as medical officers, but older doctors were hectored as well. Even as early as June 1917, J.A.M.A. editors warned—“Let there be no slackers!”—further arguing that “the obligation has come to us. Let us lay aside our individual interests, forget our personal desires and professional ambitions, and with one accord proceed in the execution of duty that lies before us.”34 By April 1918, the AMA set a very high age limit for voluntary enlistment, one well above draft age: “the time has come for deeds, not words; for action, not promises; for accomplishment, not prophecy. The time has come for every medical man under 55 years of age, who is physically qualified, to consider seriously for himself the question of his duty to his Government.”35 In other words, only the very oldest members of the medical profession were spared from scrutiny if they remained on the home front. At a time when Congress passed the Espionage Act of 1917 and the Sedition Act of 1918, censoring the publication of critical literature and abrogating the civil liberties of dissenters and pacifists, there was enormous pressure to demonstrate one’s loyalty to the war

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36. Kennedy, Over Here, 45 –92, 144 –190. Schaffer, America in the Great War, 3–63. Capozzola, Uncle Sam Wants You. Ford, The Great War and America, 50–70. See also Susan Zeiger, “She Didn’t Raise Her Boy to Be a Slacker: Motherhood, Conscription, and the Culture of the First World War,” Feminist Studies, 1996, 22, 6–39. 37. Beth Linker, War’s Waste: Rehabilitation in World War I America (Chicago; London: University of Chicago Press, 2011), 10 –60. 38. Charles H. Mayo, “War’s Influence on Medicine,” J.A.M.A., 1917, 68, 1673–7. 39. Dr. Edwin Martin’s remarks were widely reprinted. See, for example, “No Slackers Allowed,” J. Kansas State Med. Soc., 1918, 18, 143. 40. It is difficult to quantify the relative participation of draft age doctors versus doctors older than draft age in medical mobilization at the national level. From a case study of the Philadelphia doctors who enlisted during the war, two thirds of Philadelphia doctors under 30 years of age (the draft age until Spring 1918) enlisted for commissions as medical officers. But older Philadelphia doctors also enlisted at fairly high rates—roughly one in five above age 30 enlisted; altogether, older doctors comprised the sixty percent of Philadelphia’s medical officers. Data not shown. The general impression in the medical press was that younger doctors were not enlisting at sufficient rates.


effort—to prove that one was not a “slacker.”36 Even wounded soldiers were expected to return to the front after convalescence, and disabled veterans were expected to work after returning to the home front in order to receive their pensions.37 Expectations were very high for doctors as well. As Dr. Charles H. Mayo asserted in his Presidential Address to the AMA’s annual meeting in New York City in June 1917: “medical men, your country needs you now and always. You must remember that the state is permanent and does not exist for the good of the individual, but that the individual exists for the good of the state.”38 One year later, patriotic appeals for more doctors gave way to threats. As Dr. Edward Martin, Chairman of Committee on States Activities of the CND, put it to state recruiters of medical officers in early 1918: “We believe that any man who . . . refuses to go into service will find hell a more comfortable place. So you have them [in your state]. We are after them. Our honor is involved. Our duty is to get them, and you will do it.”39 Coercive volunteerism emerged in medicine just as in so many areas of life on the home front. Between the risk of being drafted into the regular military for younger doctors and the risk of being labeled an opportunist, slacker, or worse for doctors of all ages, there was tremendous pressure on doctors to “voluntarily” enlist as medical officers.40 Under these circumstances, more than 30,000 doctors of all ages, from fresh out of medical school to nearing retirement, left their private practices during the war for posts ranging from cantonments and casualty clearing

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T H E R I S E A N D FA L L O F P R AC T I C E P ROT E C T I O N P L A N S

With the business disincentives to voluntary enlistment well known in advance of U.S. declaration of war, leaders in the medical preparedness and mobilization movements pursued two strategies for recruitment. The first was to put a positive career spin on service as a medical officer, particularly for young doctors. As one recruitment bulletin put it to California doctors: “Thus far there has been proportionately a much larger enrollment among the older physicians than among the younger. And yet no physician who has graduated within the last four years should content himself with other than the most substantial reasons against enrollment . . . It affords sure promise of action, valuable experience and training, and danger to inspire any man’s best courage.”41 Pitches like this one then enumerated the opportunities for developing a surgical specialty through war work, particularly for medical officers deployed closer to the front lines. As a further inducement, a Lieutenant’s commission in the M.R.C. ($2000) generally exceeded the returns expected from the first five or so years of private practice even for elite city doctors, and thus removed (or at least delayed) the immediate financial stress upon a young doctor hanging a first shingle after medical school. The second strategy for encouraging enlistment was to promote the establishment of practice protection plans, which were geared mostly toward mid- to late-career doctor with established practices. With so many older doctors needed in the ranks of the M.R.C., both 41. “Military Medical Needs,” California State J. Med., 1917, 7, 230 – 231. See also: “An Opportunity for the Younger Man,” J.A.M.A., 1917, 68, 1048; “The Immediate Need of Young Men for the Regular Medical Corps,” J.A.M.A., 1917, 68, 1265; and “The Regular Medical Corps—An Opportunity,” J.A.M.A., 1918, 70, 1160.


stations near the front, to base and evacuation hospitals well behind the front, to military training camps at home. Thousands more doctors staffed local examining boards for draftees, which also demanded time away from private practice. The potential disruption to the medical marketplace was real, and doctors were being asked to place national and professional goals above business self-interest for an uncertain length of time and with uncertain consequences for their individual private medical practices.

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42. These plans were mentioned in the national medical press: “Will Conserve Practices of Medical Officers” J.A.M.A., 1917, 68, 1270; “Protecting the Practice of the Absent Physician” J.A.M.A, 1917, 68, 1828; and “Safeguarding the Interests of Physicians During Military Service” J.A.M.A., 1917, 69, 49. On Gorgas and the AMA, see fns. 5 and 6. 43. On organizational solutions in this period, see Louis Galambos, “The Emerging Organizational Synthesis in Modern American History,” Bus. Hist. Rev., 1970, 44, 279 –90, and Louis Galambos, “Technology, Political Economy, and Professionalization: Central Themes of the Organizational Synthesis,” Business History Review, 1983, 57, 473 –391. 44. Rothstein, American Medical Schools, 143, table 7.2. 45. See fn. 17.


for leadership of younger medical officers and to meet the recruitment targets of the CND, it is not hard to understand why Army Surgeon General Gorgas and the AMA promoted these plans as early as March 1917; at least two practice protection plans—of the Indianapolis Medical Society in Indiana and the Atlantic County Medical Society in New Jersey—were adopted even before the formal declaration of war.42 Medical leaders had good reason to expect that organizational solutions could solve the problem of lost income for enlisted doctors with fallow private practices.43 After all, as has been well studied by historians, professional cooperation had produced a dramatic transformation of American medical institutions in the decades leading up to the First World War—from medical schools to state licensing boards to hospitals. In every case, hard-earned reforms were accomplished through the cooperation of like-minded doctors in pressing their agenda. By the beginning of the First World War, the achievements of professional cooperation were undeniable: overcrowding in the profession had been curtailed as tougher licensing laws and more rigorous medical education had already begun to reduce the number of medical schools and annual medical graduates from 160 schools and 5747 graduates in 1904 to 96 schools and 3536 graduates in 1915.44 Institutional reform not only promoted the Progressive Era goal of protecting public safety—in this case by forcing the closure of diploma mills and ensuring higher minimum training for doctors— but institutional reform also elevated the income and status of the medical profession as a whole.45 Professional cooperation to achieve institutional reform also extended to military medicine in this period. After the sanitary and public health failures during Spanish American War and subsequent Cuban occupation, the AMA and its allies in the Army Medical

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46. J. T. H. Connor, “‘Before the World in Concealed Disgrace’: Physicians, Professionalization and the 1898 Cuban Campaign of the Spanish American War,” in Medicine and Modern Warfare, ed. Roger Cooter, Mark Harrison, and Steve Sturdy (Amsterdam: Rodopi, 1999), 29–58. Vincent J. Cirillo, Bullets and Bacilli: The Spanish-American War and Military Medicine (New Brunswick, NJ: Rutgers University Press, 2003), 91 –135. Richard V. N. Ginn, The History of the U.S. Army Medical Service Corps (Washington DC: U.S.G.P.O., 1997), 20–27. Gillett, The Army Medical Department, 318 –326. 47. Martin, Digest of the Proceedings, 44 –49.


Department lobbied Congress to fund the organizational reform of military medicine. They finally succeeded with passage of the Army Medical Reorganizational Bill of 1908, which secured higher rank and pay for medical officers, authorized a larger standing Medical Corps, and established the Army Medical Reserve Corps, which comprised civilian doctors who could be mobilized during wartime. Subsequent provisions in the National Defense Act of 1916 ensured a minimum ratio of seven medical officers per 1000 troops and provided more legal authority for the Army to mobilize reserve medical officers.46 After the outbreak of the First World War in Europe in 1914, especially after it became clear that American involvement was imminent by 1916, the AMA also took charge of the medical preparedness movement. Beginning with the first meeting of the ad hoc Committee of American Physicians for Medical Preparedness in April 1916, medical leaders from the AMA and other national medical organizations, like the Red Cross, met regularly with leading physicians and surgeons, hospital administrators, and surgeons-general of the Army, Navy, and Public Health Service in order to prepare for medical support of the war effort. In early 1917, this ad hoc committee was absorbed by the General Medical Board of the Advisory Commission to the Council of National Defense, which coordinated the enlistment of medical officers with the AMA and the establishment of base hospital units with the American Red Cross. The organization of base hospitals began so early that six units were able to deploy immediately after the American declaration of war, which gave medical officers the distinction of having been the first of the American Expeditionary Forces to reach France.47 In the wake of these organizational achievements (in civilian as well as military medical institutions), medical leaders assumed that almost any reform could be accomplished through top – down coordination and professional cooperation. This explains why Surgeon

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48. “County Society Reports,” Kentucky Med. J., 1917, 15, 354 –358. Other state medical journals depicted medical commissions as adequate for young or rural doctors: “Medical Men for the Army,” Illinois Med. J., 1917, 31, 350; “Who Should Go?” J. Kansas Med. Soc., 1917, 17, 191 –192; “Young Physicians, Your Opportunity,” J. Arkansas Med. Soc., 1917, 14, 138; “Young Physicians, Your Opportunity,” J. Florida Med. Assoc., 1917, 4, 188; and “Young Physicians, Your Opportunity,” J. Iowa State Med. Soc., 1917, 7, 422. 49. [News of the El Paso County Medical Society], Texas State J. Med., 1917, 13, 129.


General Gorgas, J.A.M.A. editors, and the General Medical Board (GMB) lent their full-throated support to practice protection plans announced in Spring 1917, as medical mobilization kicked into full swing. Although these plans captured the interest of the county and state medical societies across the United States, with scores of counties ratifying plans in three short months, there were signs of early trouble—signs that cooperation to protect the practices of military doctors would not match the cooperation used to strengthen licensing laws, lobby for drug regulation, or reform medical schools and hospitals. For starters, many counties objected to the idea that commissioned medical officers needed special protection. For rural doctors in many states, such as the members of the Lyon County Medical Society in western Kentucky, the commissions of medical officers amounted to princely sums that exceeded returns from country practice; for doctors in these circumstances, practice protection plans seemed “unwise.”48 Other rural doctors, such as members of the Scott County Medical Society in the boot heel region of Missouri, argued that “caring for the practice of members gone to war is impractical” and instead passed a resolution that “the government pay a salary sufficient to sustain the families of those who have gone to war.” This position rejected the assumption that the medical profession should make collective sacrifices to compensate for an underfunded medical mobilization. Other state medical journals reported that some county medical societies, such as the El Paso County Medical Society in west Texas, refused to meet to ratify proposed practice protection plans, further adding that “no hope was held out that they would ever meet.”49 The organizational solution to lost business in private medical practice failed to account for local conditions, and was met with apathy and even outspoken resistance in many rural counties. Even in states where county plans were ratified, some members had low expectations from the beginning. For example, just a few

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50. “The Physician in Military Service,” J. Indiana State Med. Assoc., 1917, 10, 369. 51. Madison, “Preserving Individualism in the Organizational Society.” Crenner, “Organizational Reform and Professional Dissent.” David T. Beito, “The ‘Lodge Practice Evil’ Reconsidered: Medical Care through Fraternal Societies, 1900–1930,” J. Urban Hist., 1997, 23, 569 – 600. Schafer, The Business of Private Medical Practice, 63 –67. 52. McBratney, “Disgracing the Medical Profession,” 664. 53. “The Absent Doctor’s Practice” California State J. Med., 1917, 15, 437. “Editorial Notes” J. Indiana State Med. Soc., 1918, 11, 72. “False Patriotism” J. Indiana State Med. Soc., 1918, 11, 172 –173. “Has It Accomplished Its Object?” The Weekly Roster, February 1, 1919, 14, 6.


short months after the first plans were implemented in Indiana, one doctor wondered what would compel the substitute doctor to return patients to the absentee doctor upon his return, as the “former outsider—now a real insider—will retain quite firmly the hold he has secured in that community.”50 In the business of private medical practice, many doctors regarded patients as rightfully earned clientele in a cutthroat, competitive marketplace. Why should the substitute doctor return another doctor’s patients after caring for them over a period of months, let alone a year or more as the war dragged on? Such a notion ran counter to the very idea unfettered access to the marketplace, a principle that rank-and-file doctors jealously protected during this period, at least for licensed graduates of orthodox medical schools.51 Furthermore, as Dr. E. W. McBratney of St. Louis noted it in his letter to the J.A.M.A. editors in August 1917: “Does anyone imagine that the average doctor feels that the pittance he receives for his night’s service is so out of proportion to the services rendered that he must needs [sic] hurry to find some one to divide [it] with?”52 His colleagues must have been more hopeful, though, as the St. Louis Medical Society passed a one-half plan just one month after Dr. McBratney’s invective appeared in print. Early doubts and suspicions were later confirmed, though, as there were widespread reports of angry medical officers having received little or no fees from substitutes after months away from their private practices. Editors in state medical journals often excerpted or published these letters in full in an effort to shame their colleagues into honoring their promises.53 Part of the problem was administrative. How frequently were substitute doctors to remit to the family of the absentee doctor? If the absentee doctor didn’t notify anyone or arrange for a substitute doctor, how were the de facto substitutes

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54. A number of county medical societies and state medical journal editors complained of these administrative problems. See, for example: “The Absent Doctor’s Practice” California State J. Med., 1917, 15, 437; and “Report of the Council,” Md State Med J, 1918, 11, 94. 55. “False Patriotism,” J. Indiana State Med. Assoc., 1918, 11, 172 –173. Emphasis added. 56. [William Taylor to Emily Taylor], October 18, 1918, Jones and Taylor Family Papers, Historical Society of Pennsylvania, 2037, Box 9, Typed Copies of Letters to Family (World War I) August 25 –October 31, 1918.


supposed to know that a new patient came from the practice of an absentee doctor?54 In the haste of mobilization, these details had been overlooked in many counties. As time wore on, and many plans continued to falter, state medical journal editors and letter-writing medical officers assumed selfishness, rather than absentmindedness, as the true motivation behind the actions of stay-at-home doctors. One Indiana Captain in the M.R.C. complained about the “false patriotism” of his colleagues, as he had only received two dollars over his first six months of deployment, despite having an $8000 per year “cash practice” and belonging to a county medical society that had ratified a one-third plan. The Captain, whose name was withheld in publication, dared his civilian competitors to declare their true intentions: “Instead of hiding behind this false front, pretended patriotism, that they may loot the practice that we have left behind . . . let them come out with at least an honest statement and pass resolutions that they will do all in their power to take the practice of the men who have good to the defense of the country in her hour of need.”55 Dr. William Taylor, a fifty-seven-year-old Philadelphia surgeon commissioned as a Captain in the M.R.C., was even more acerbic in private letters written from his base hospital in Le Tre´port, France. He named specific colleagues he claimed had stayed behind in order to steal patients from his $10,000 per year private practice, even alleging that one Quaker pacifist colleague, Dr. Eves, was “very willing for everyone else to join the army while he makes money hand over fist.”56 Other military doctors aired such personal grievances in public, leading to a libel suit in one such dispute between Dr. Percy W. Roberts, a New York doctor and Captain in the M.R.C., and his substitute, Dr. George Barrie, whom Roberts alleged was “exploiting” his patients in his absence. Dr. Barrie brought a suit for $100,000 in damages on the grounds of injury to his reputation. Although Barrie

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57. “Sues Surgeon for $100,000 j Capt. Roberts, Vanderbilt Doctor, Made Defendant by Dr. Barrie,” New York Times, April 11, 1919, 5. “Gets 6 Cents Damages j Doctor Says Doctor Neglected Practice While He Was At War,” New York Times, January 15, 1921, 6. 58. “The Conservation of the Practices and Interests of the Members of the Michigan State Medical Society Who Enter the Medical Services of the United States Army and Navy,” J. Michigan State Med. Soc., 1917, 16, 257. 59. “Introspective,” J. Michigan State Med. Soc., 1917, 16, 414 –415. “Editorial Comments,” J. Michigan State Med. Soc., 1917, 16, 448. 60. “Special Meeting of the Council, Held in Grand Rapids November 7, 1917,” J. Michigan State Med. Soc., 1917, 16, 511 –514.


eventually won the libel suit, the jury awarded him just 6 cents in damages, suggesting public sympathy for medical officers.57 Even in states that reported some success from their county practice protection plans, there is evidence to suggest that rosy assessments functioned more as propaganda than as factual accounting. For example, in Michigan, at an emergency meeting in May 1917, the state medical society developed a different sort of practice protection plan for ratification by counties. Instead of having substitute doctors forward a portion of fees collected, county medical societies were to establish Patriotic Committees charged with collecting a special assessment of $5 from every civilian member, regardless of whether they were looking after the patients of another doctor. The collected funds were to provide for the families of medical officers in need during the war.58 The Patriotic Fund got off to a shaky start, though, with only eleven counties having established Patriotic Committees by September 1917, of which only six had sent money to the state fund. Members of some county societies even questioned the legality of the special assessment.59 By November 1917, a few more counties had joined, though the Fund had received only $2170 in assessments, some $9910 short of the anticipated remittance based on membership. With 621 members having received commissions by that point in the war, the average supplement to the families of medical officers would have been a paltry $3.49 in total.60 Even though the state medical society tried to put a good face on it, the Vice Chairman of the Council confessed that the effort to run the Patriotic Fund at the state level “was doomed to meet with defeat” given the varied responses from different counties, with some supportive, such as Wayne County around Detroit, and some “who refused altogether.” As a result, the Council handed over administration of funds to the individual counties that had elected to participate, confessing that the plan for the

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61. “Annual Report of the Council,” J. Michigan State Med. Soc., 1918, 17, 265. 62. “John Stayed: Bill Went,” J. Michigan State Med. Soc., 1920, 19, 255 –257. 63. See, for example, the controversy surrounding the Philadelphia Medical Club presidential election in 1918, in which the results were initially rejected because the winner was accused of “pro-Germanism” before the War: “Medical Club is in Turmoil Over Election,” Public Ledger, January 28, 1918; and “Copy of the Letter Sent to the Board of Governors and Board of Directors of the Medical Club of Philadelphia,” The Weekly Roster, February 2, 1918, 13, 7. 64. See, for example: “Patriotism not Confined to Those Who Go To War,” J. Indiana State Med. Assoc., 1917, 10, 292 and “Correspondence,” J. Missouri State Med. Assoc., 1917, 15, 28. 65. Detailed to Philadelphia doctors in “Volunteer Medical Service Corps,” The Weekly Roster, May 11, 1918, 13, 7.


state fund “had been afflicted with War Hysteria, and with consequent over-anxiety concerning the families of our members who were to enter the Army Medical Service.”61 For this reason, the Michigan county plans had mixed results at best (see Figure 2), and the state journal ran stories of doctors who had great difficulty reestablishing practices and careers after returning home.62 Although they might not have been shamed into forwarding more (or any) of their fees to military doctors, substitute doctors—and civilian doctors in general—came under increasing scrutiny not just from military doctors, but also from medical leaders and the public at large during the war. Doctors were not immune to being charged as slackers, dissenters, and German sympathizers.63 With complaints from military doctors about unmet promises in practice protection plans and the larger wartime malaise in America, many civilian doctors were eager to deflect suspicion, especially doctors who were infirm or otherwise unable to enlist as medical officers.64 Perhaps recognizing the need to involve more of the civilian medical workforce in the war effort, the CND established the Volunteer Medical Service Corps (VMSC) in early 1918. The VMSC recruited civilian doctors, who “because of overage, physical disability, dependents and essential home needs were not eligible for service in the Medical Reserve Corps of the Army or Navy.”65 These included women doctors who were ineligible for military service. Members of the VMSC participated in various wartime domestic public health campaigns, and were expressly “authorized” to wear the insignia of their affiliation with the VMSC. By the time the VMSC disbanded on April 1, 1919, it had received more than 70,000 membership applications from civilian

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66. Ibid. See also: “Council of National Defense,” The Weekly Roster, September 21, 1918, 14, 5; “Volunteer Medical Service Corps,” The Weekly Roster, April 1, 1919, 14, 3; Martin, Digest of the Proceedings, 498 –510. 67. “The Volunteer Medical Service Corps,” The Weekly Roster, October 5, 1918, 14, 7. 68. “Making Our Association 100 Per Cent American,” J. Missouri State Med. Assoc., 1918, 15, 331. “County Medical Societies and the War,” J. Missouri State Med. Assoc., 1918, 15, 331 – 332; “Rescinded,” J. Missouri State Med. Assoc., 1918, 15, 363. 69. Martin, Digest of the Proceedings, 498 –510. 70. “Have We Kept the Faith?” The Weekly Roster, April 19, 1919, 14, 6—republished from the Lancaster County Medical Society Bulletin.


doctors, 56,540 of which had been processed and coded before Armistice Day on November 11, 1918.66 Besides patriotism, one major reason why so many American doctors joined the VMSC was to avoid suspicion by medical colleagues, both overseas and on the home front. The fact that the VMSC publicly discouraged the coercion of doctors to join the VMSC or the military indicates that such coercion existed. As one VMSC circular warned: “Our committeemen are especially urged against favoring any movement that would threaten to impair a medical man’s standing in his local, state, or national society because he refused to enroll in the Army or Navy, or the Volunteer Medical Corps.”67 In fact, the Missouri State Medical Association tried just that in Fall 1918, proposing termination of the state medical society membership of any doctor who refused to enlist as a medical officer or join the VMSC; the Central Governing Board of the VMSC in Washington later rejected the idea.68 Given attempts to use the VMSC for the purposes of coercion and intimidation, it is little wonder that physicians who joined the VMSC demanded to receive their insignia in a timely fashion.69 By wearing the VMSC insignia, a doctor lifted suspicions—of cowardice or of opportunism—as to why he remained behind on the home front. With the armistice in late 1918 and the acceleration of medical demobilization by early 1919, medical editors made last appeals to their readers to honor defunct practice protection plans. Again, threats featured prominently. For example, medical journal editors in various Pennsylvania counties warned substitute doctors “would it not be wise to make a settlement now, before the boys get home?”70 For those who were delinquent by virtue of “crookedness,” the editor of the Bulletin of Lancaster County Medical Society in Pennsylvania threatened: “If a person thinks he is playing a game of this nature that

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Resolved, That the Indiana State Medical Association condemns the unpatriotic and unprincipled action of those physicians who have entered new communities during the war and established themselves in practice at the expense of medical men absent in the service of the country; and be it further Resolved, That this Association recommend to its County Societies the exclusion from membership of all practitioners of medicine who have sought, by changing their locations, to profit by the patriotism of physicians who went to war.73

Although there was no further discussion of this resolution or its enforcement in the Journal of the Indiana State Medical Society, the gesture reveals that disappointment and anger surrounding the misconduct of county practice protection plans during the war lingered for at least a year. Eventually, with demobilization and the return of military doctors to civilian practice, the failures of practice-protection plans during the war slowly faded from public and professional memory. Early 71. Ibid. 72. For example, see: “Usurpers,” J. Michigan State Med. Soc., 1917, 16, 507; and “An Unfair Advantage,” J. Med. Assoc. Georgia, 1918, 11, 254—originally published in J. Tennessee State Med. Assoc. 73. “Minutes of the House of Delegates,” J. Indiana State Med. Assoc., 1919, 12, 280. On relocation as poaching, see: “Editorial Notes,” J. Indiana State Med. Assoc., 1918, 11, 282; and “Plain Facts,” J. Indiana State Med. Assoc., 1918, 11, 309 –311.


he can conceal, we would advise him to go slow. Soldiers, we believe, are not used to questioning things because they deal with real men, but once a slacker crops up, it is our opinion that they would go to the limit in exposing and punishing him. We hope they will reserve this soldierly qualification for home use and at the same time we hope they will never have occasion to use it in this connection.”71 Journal editors in Indiana took the shaming of allegedly delinquent substitute doctors to even greater lengths. Like other state medical societies, editorialists condemned civilian doctors who changed practice locations during the war, alleging that such removals were deliberate poaching in the unprotected territory of absentee doctors.72 Incensed by low participation in practice protection plans and evidence of rampant office relocation during the war, the medical leadership in Indiana succeeded in passing the following resolution at its September 1919 meeting:

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P R I VAT E M E D I CA L P R AC T I C E A N D T H E L I M I T S O F P RO F E S S I O N A L CO O P E R AT I O N

If we limit our exploration of American medicine during the First World War to the official publications of the AMA and the CND, then evidence abounds to support the historical narrative of professional cooperation in American medicine, both on the home front and overseas. Such cooperation also conforms to grand narratives in the historiography of the Progressive Era, in which professionals with scientific authority teamed up with government officials to achieve organizational reforms in the interest of public safety and business 74. For example, in Philadelphia, where the county practice protection plan failed utterly, the College of Physicians of Philadelphia sponsored a series of lectures on military medical progress and its domestic applications: Meyer Wiener, “The Army School of Ophthalmology,” Trans. Coll. Physicians Phila., 1919, 41, 61 –6; Harris P. Mosher, “Observations on Otolaryngology in the War,” Trans. Coll. Physicians Phila., 1919, 41, 67 –92; John H. Gibbon, “Advancement in the Treatment of Wounds and Infections Resulting from the War,” Trans. Coll. Physicians Phila., 1919, 41, 93 –6; and Merritte W. Ireland, “The Achievement of the Army Medical Department in the World War in Light of General Medical Progress,” Trans. Coll. Physicians Phila., 1921, 43, 394 –414. 75. Alfred Crosby, America’s Forgotten Pandemic: The Influenza of 1918, new ed. (New York: Cambridge University Press, 2003). Byerly, Fever of War. 76. Martin, Digest of the Proceedings, 498 –510.


assessments of the medical profession during the war focused instead on the notable successes of organization and planning, from medical preparedness and rapid medical mobilization, to the effective operation of base hospitals, to the efforts of the VMSC to combat the outbreak of the Spanish Influenza Pandemic on the home front in 1918.74 In particular, the response of civilian doctors to the flu likely restored some of the lost trust of their military counterparts, as civilian doctors had to encounter the worst outbreak of the flu in recorded history, all the while having more than a fifth of doctors unavailable because of military service.75 Throughout the final days of the war and during demobilization, President Woodrow Wilson and U.S. Public Health Service Surgeon-General Rupert Blue personally thanked Dr. Franklin Martin, chairman of the General Medical Board of the Advisory Commission to the CND, for the work of the VMSC during the war and for the effective organization of the medical profession during the war.76 The First World War, it seems, was destined to be memorialized as a victory in the professionalization of American medicine.

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77. See fn. 43. See also Brian Balogh, “Reorganizing the Organizational Synthesis: Federal-Professional Relations in Modern America,” Studies in American Political Development, 1991, 5, 119 – 172, and Louis Galambos, “Recasting the Organizational Synthesis: Structure and Process in the Twentieth and Twenty-First Centuries,” Bus. Hist. Rev., 2005, 79, 1– 38. 78. Donald L. Madison and Thomas R. Konrad, “Large Medical Group-practice Organizations and Employed Physicians: A Relationship in Transition,” Milbank Q., 1988, 66, 240–82. 79. Madison, “Preserving Individualism in the Organizational Society,” 480 –1. 80. Christopher Crenner, “Organizational Reform and Professional Dissent.” Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill, NC: University of North Carolina Press, 2001).


efficiency—what a generation of historians have referred to as the emergence of “the organizational society” or “the administrative state” in the early twentieth century.77 From afar, American medicine during the era of professionalization and institutional reform fits nicely into this broader historical narrative of the later nineteenth and early twentieth centuries. But if we drill down deeper, to the business of private medical practice on the ground level, the picture becomes more complex. Instead, what we find is a strong individualist streak, which in part reflected the small business mentality of doctors in solo private practice, still the dominant form of medical practice until the rise of large group practices and managed care in the 1980s.78 Rather than following contemporary trends in American business toward incorporation into ever-larger firms that promised economy of scale, vertical integration, and bureaucratic efficiency directed by scientific management, doctors in private medical practice in the early twentieth century remained, as historian Donald Madison once observed, “the exception.” He continued: “Forgoing the search for modernization, they preached instead a kind of antimoderism that would be protective of dominant small-business and artisan values held by the majority of medical practitioners.”79 Examples abound of individualism among private practitioners at that time, from reluctance to endorse prepaid specialty clinics in the 1910s, to opposition to government subsidy of compulsory health insurance for industrial workers in the late 1910s, to opposition (at least at first) to early voluntary private health insurance plans during the Great Depression.80 In every instance, belief in the right to unrestricted access to patients in the medical marketplace trumped appeals to greater health care efficiency and equity promised by some corporate reforms of private practice. Individualism among ordinary doctors even led the AMA—the

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AC K N OW L E D G M E N T S

Special thanks to Professor Joseph Allen Pratt and the NEH-Cullen Professorship of History and Business at the University of Houston for generous financial support of this project.

81. Madison, “Preserving Individualism in the Organizational Society.”


paragon of organizational medicine and professional cooperation—to support political positions that privileged individualism at the expense of professional cooperation. Returning to the example of county practice protection plans during the First World War, at first glance, these plans had all of the features of the top– down organization and professional cooperation in American medicine that had characterized institutional reform of medical schools, state licensing boards, and hospitals, not to mention medical mobilization. However, upon closer inspection of state and local medical journals and of professional correspondence during and after the war, not only did the plans fail to meet their goals, but their founders failed to appreciate the sentiments of the rank-and-file doctors in the medical marketplace. Although nonelite doctors could support institutional reforms that limited oversupply in the marketplace, such as licensing law reform, these same doctors on the home front during the war had difficulty adhering to practice-protection plans that required sending hard-earned fees to competitors, patriotic pressures be damned. Cooperation may have been the buzzword of the American medical profession in this period, but it definitely had its limits in private medical practice.81 The goal of the “new history of medical professionalization,” as I see it, is to rewrite the grand narrative of medical professionalization by taking these limits into fuller account. The first step in this revision is to return our attention to the business of private medical practice.

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Remembering the first doctors worldwide who offered their lives fighting Ebola virus epidemic.

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Fighting words: new medical terms from the Persian Gulf War.

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