Regulating specialties in France during the first half of the twentieth century

Social History of Medicine

Volumn 15, Issue 3, 2002, Pages 457-480

  Weisz, George ^a  

^a MCGILL UNIVERSITY   (Canada)

Author keywords

Dentistry; France; Medical associations; Medical education; Medical profession; Medical specialization; Twentieth century

Indexed keywords

ARTICLE; FRANCE; GOVERNMENT REGULATION; HISTORY; MEDICINE; PROFESSIONAL STANDARD;

FRANCE; GOVERNMENT REGULATION; HISTORY, 20TH CENTURY; PROFESSIONAL ROLE; SPECIALTIES, MEDICAL;

EID: 0036983065     PISSN: 0951631X     EISSN: None     Source Type: Journal    
DOI: 10.1093/shm/15.3.457     Document Type: Review

References (183)

1. G. Weisz, 'The Emergence of Medical Specialization in the Nineteenth Century', Bulletin of the History of Medicine, 77 (2003), forthcoming.
2. G. Weisz, 'Medical Directories and Medical Specialization in France, Britain and the United States', Bulletin of the History of Medicine, 71 (1997), 23-68. The German figures are calculated from the Deutsche Medizinische Kalendar for the appropriate years.
3. G. Weisz, The Development of Medical Specialization in Nineteenth-Century Paris', in A. La Berge and M. Feingold (eds), French Medical Culture in the Nineteenth Century (Amsterdam and Atlanta, 1994), 148-88.
4. On specialization in Britain, see R. Stevens, Medical Practice in England and the Impact of Specialization and State Medicine (New Haven, 1966).
5. Stevens, Medical Practice; Weisz, 'Medical Directories'.
6. This is the argument in P. Guillaume, Le rôle social du médecin depuis deux siècles (1800-1945) (Paris, 1996), pp. 209-10.
7. The only real exception is the UK where specialist regulation was introduced as part of the organization of the National Health Service. But even here, administrative concerns emerged rather late in the game. In Germany, early interest by the government in specialty regulation dissipated in the face of professional hostility to state involvement. The French government virtually ignored the issue except on those rare occasions when specialties, battling for control of a specific domain, attempted to use the legislative process to pursue their aims.
8. Among many other sources, see R. Stevens, American Medicine and the Public Interest (New Haven, 1971; updated edn, Berkeley 1998).
9. Among many other sources, see C. Huerkarnp, Der Aufstieg der Ärzte im 19, Jahrhundert: Vom gelehrten Stand zum professionellen Experten; Das Beispeil Preussens (Göttingen, 1985);
10. M. Ramsey, 'The Politics of Professional Monopoly in Nineteenth-Century Medicine', in G. Geison (ed.), Professions and the French State, 1700-1900 (Philadelphia, 1984), 225-305;
11. H. Herold-Schmidt, 'Ärtzliche Interessenvertretung im Kaiserreich, 1871-1914', in R. Jütte (ed.), Geschichte der deutschen Ärzteschaft (Köln, 1997), 43-96.
12. Weisz, 'The Development of Medical Specialization'.
13. The trade union of surgeons began studying the issue of a special diploma several years before the First World War. Archives Nationales: Archives de l'Ordre des Médecins (henceforth AOM); Circulaire No. 17, 8 June 1944, #3 Lettre de Dr Oberlin au Ministre de la Santé. Also, see Dr Menegaux, 'Le certificat de chirurgien', Bulletin de l'Ordre des Médecins (1947-8), 29-33. This publication appeared sporadically during the war and post-war years and volumes were labelled in unsystematic ways and never included volume numbers. I have chosen to identify these by the year of the volume and, where it seems necessary (because for certain years each issue is paginated separately), the month.
14. On this pre-war state of affairs, see G. Weisz, The Emergence of Modern Universities in France, 1863-1914 (Princeton, 1983), pp. 341-68.
15. On elite careers in France, see G. Weisz, The Medical Mandarins: The French Academy of Medicine in the Nineteenth and Early Twentieth Centuries (New York and Oxford, 1995).
16. These subjects were: surgery, obstetrics, psychiatry, ophthalmology, otorhinolaryngology, electro-radiology, and stomatology. The examinations were competitive examinations (concours) on the model of the ones that had traditionally controlled access to hospital positions.
17. A list of Parisian hospital physicians in the leading medical directory of the period, Guide Rosenwald of 1920, lists the vast majority as specialists of one sort or another.
18. On this process, see Weisz, 'Development of Medical Specialization', pp. 148-88.
19. The decree is reprinted in Paris méd., 14 (1914), 719-25.
20. On the wider context of this reform, see P. Camot, 'Les nouveaux décrêts rektifs à l'Agrégation ... ', Paris méd., 14 (1914), 731-2.
21. See, for instance, the many reports on the teaching of the different specialties in Congrès des Praticiens, 2 vols. (Paris, 1907).
22. Medical journals also sought to educate GPs in specialist knowledge. See the series of articles by Dr Boudin throughout Concours méd., 32 (1910) entitled 'Le médecin de campagne et l'exercise de la spé cialité'.
23. Also J.-L. Faure, 'L'enseignement de la chirurgie', Pressa méd., 27 (1919), 401-3.
24. 'Reportage médical', Concours méd., 31 (1909), 620.
25. A good survey of such courses before the First World War is the series by P. Carnot, 'Rapport sur l'organisation des enseignements de perfectionnement dans les Facultés de Médecine', Paris méd., 14 (1914), 146-47, 177-83, 249-53.
26. For example, H. Besnier, 'A quoi sert le diplôme de médecin-légiste', Presse méd., 20 (1912), 1369-70.
27. On these programmes more generally, see Carnot, 'Rapport sur l'organisation', pp. 180, 249-50.
28. This situation did not change in later years. 'Association des diplômés de l'Institut d'Hygiène de l'Université de Paris', Paris méd., 84 (1932), 615.
29. 'Special Commission for Surveillance of Outcome of Nervous arid Mental Disease in Soldiers', JAMA, 70 (1918), 1554.
30. This was 37 per cent, as compared to 35 per cent 15 years before. On the reasons for this stability, see G. Weisz, 'Mapping Medical Specialization in Paris in the Nineteenth and Twentieth Centuries', Social History of Medicine, 7 (1994), 177-211.
31. The figure in the largest provincial cities was 46 per cent in 1935, compared to 12 per cent in 1905. On the growth in the number of specialists more generally, see Weisz, 'Mapping Medical Specialization'.
32. Syndicats were established for spa physicians in 1896; oculists in 1905; electro-radiologists, ORL, and stomatologists in 1907; urologists in 1913; biologists (pathologists and bacteriologists) in 1924; surgeons in 1925; dermatologist-venereologists in 1929; gynaecologists in 1930; pneumologists (including TB) in 1931.
33. Tout-Paris: Annuaire de la société parisienne, 1921 (Paris, 1921), pp. 724-35.
34. G. Liriossier, 'Libres propos: Médecins spécialistes', Paris méd., 42 (1921), 271-2. Perhaps as a result of such medical reactions, the directory in 1939 divided medical specialists into a relatively modest 60 categories.
35. Guillaume, Le rôle social du médecin, p. 201.
36. D. Evleth, 'Vichy France arid the Continuity of Medical Nationalism', Social History of Medicine, 8 (1995), 95-116.
37. T. B. Smith, 'The Social Transformation of Hospitals and the Rise of Medical Insurance in France, 1914-1943', The Historical Journal, 41 (1998), 1055-87.
38. In 1919, the Municipal Council of Paris discussed the creation of posts for ophthalmologists and stomatologists for the schools of Paris. Note in Prese méd., 27 (1919), 375.
39. See the many issues discussed in the series of articles, 'Applications du tarif des pensionés de guerre', in the issues of Médecin syndicalist of 1923 and 1924.
40. For a retrospective view, see Dr Caillaud, 'Le C2 et les spécialistes', Concours méd., 70 (1948), 515-16.
41. A major dispute was provoked in the council of the Union des Syndicats Médicaux when the President published an article suggesting that specialists agree to a reduction in their fees. 'Tarifs des spé cialistes', Méd. synd., 8 (1926), 364-5.
42. The issue did not disappear. See F. Decourt, 'Un omnipraticien ne serait-il qu'un "demi-médecin": IV- spécialisation n'est pas études "supérieur" mais études "fragmentaires"', Concours méd., 66 (1944), 189-90.
43. See, for instance, 'Question 53: criterium du spécialiste', Méd. synd., 5 (1923), 375;
44. and the long quote from a judgement by the Commission Supérieure de Surveillance des soins gratuits aux Mutilés, reproduced in Médecin de France, 37 (1931), 915.
45. 'Belgium: Diplomas for Specialists', JAMA, 99 (1933), 1706.
46. In 1928, there were specialist trade unions representing biologists, surgeons, electro-radiologists, ophthalmologists, otorhinolaryngologists, spa physicians, stomatologists, and urologists. Together they had about 2,300 members. G. Renori, 'Le statut des médecins spécialistes', Méd. synd., 9 (1927), 274-80, especially pp. 277-8;
47. 'Liste des syndicats médicaux', Méd. synd., 10 (1928), 564.
48. Two issues that proved especially thorny were whether members of national specialist syndicats also had to belong, and pay dues to the local general syndicats; and what kind of voting rights, if any, did specialist representatives have on the administrative councils.
49. This was the Groupement des syndicats des spécialistes. 'Le statut des spécialistes', Méd. synd., 9 (1927), 167-9.
50. The best discussion of the intricacies of medical trade unionism during this period is Guillaume, Le rôle social.
51. But also, see B. Vergez, Le Monde des médecins au XXe siècle (Paris, 1996), pp. 236-46.
52. See the collection of reports and discussions grouped under the heading 'Les médecins spécialisés et L'Union des syndicats médicaux', Méd. synd., 9 (1927), 270-88.
53. Ibid., especially p. 276.
54. I b i d.
55. Ibid., pp. 282-5.
56. 'Notre revue', Revue internationale de médecine professionnelle et sociale, 1 (1928), 1-3.
57. In 1934, for instance, the annual meeting of the APIM voted unanimously that diagnosis and prescription of glasses should be under the control of doctors rather than opticians. 'L'Association professionnelle internationale des médecins', Paris, méd., 94 (1934), 479.
58. F. Decourt, 'Association professionnelle internationale des médecins: La spécialisation en médecine et les spécialistes', Méd. synd., 10 (1928), 518-57.
59. The article was reprinted in Revue interantionale de médecine professionnelle et sociale, 4 (1931), 10-44.
60. Dr Vuilleumier, 'Les médecins spécialistes', Rev. inter, méd. prof. soc., 1 (1928), 30-7.
61. Discussion in Dr Vuilleumier, 'Les médecins spécialistes', Rev. inter, méd. prof. soc., 1 (1928), ibid., pp. 38-41.
62. See also F. Decourt, 'Causeries professionnelle: de k multiplication dangereuse des catégories de "spécialistes" en médecines', Rev. inter, de méd. prof. soc., 11 (1938), 7-12.
63. See, for example, 'Définition et qualification du médecin spécialisée', Méd. Fr., 37 (1931), 834-5. Foreign examples were riot just positive.
64. Decourt, in 1938, used the result of a second survey he had prepared to warn the Confederation that unless appropriate steps were taken France could easily end up with 20-25 specialties as was the case in most of the countries in his survey. Méd. Fr., 44 (1938), 714.
65. J. Couturat, 'Les dermatologistes en face de l'exercise illégal ou commercial de la médecine', Presse méd., 43 (1935), 1309.
66. On the history of French dentistry, see F. Vidal et al., Histoire d'un diplôme, 1699-1892; du l'expert pour les dents an docteur en chirurgie dentaire (Paris, 1993);
67. R. Boissier, L'évolution de l'art dentaire (Paris, 1927)
68. and C. Godin, L'évolution de l'art dentaire: L'École Dentaire son histoire, son action, son avenir (Paris, 1901).
69. This issue generated a huge polemical literature. See, for example, T. Raynal, Rapport sur la réforme de l'enseignement et la refonte du statut professionnel de l'art dentaire en France (Paris, 1923).
70. For a similar, although less intense version, of the same controversy in the USA, see N. Gevitz, 'Autonomous Profession or Medical Specialty: The Stomatological Movement and American Dentistry', Bulletin of the History of Mediane, 62 (1988), 407-28.
71. Syndicat général des médecins stomatologistes français, 'Lettre ouverte au corps médical', Paris méd., 62 (1926), 18.
72. P. Boudin, 'Mouvement syndicale de l'année', Concours méd., 50 (1928), 3198-9.
73. A good summary of the various attempts at reform is M. Mordagne, 'La qualification des spécialistes', Presse méd., 46 (1938), 1517-18.
74. 'Une note de M. le professeur Balthazard à l'Académie de Médecine', Méd. Fr., 36 (1930), 155-7.
75. 'Candidature du syndicat des gynécologues', Méd. Fr., 38 (1932), 205, 280.
76. See the protests in Presse méd., 41 (1933), 509, 967.
77. Mordagne, 'La qualification des spécialistes', p. 1517, for explicit links between this holism and opposition to specialization.
78. On holism in France more generally, G. Weisz, 'A Moment of Synthesis: Holism in Interwar France', in C. Lawrence arid G. Weisz (eds), Greater than the Parts: Holism in Biomedicine 1920-1950 (Oxford, 1998), 68-93.
79. 'Commission de droit syndicale', Méd. Fr., 38 (1932), 202-5.
80. G. Roussy, 'Réforme des études médicales', Presse méd., 40 (1932), 1807-9,
81. and Presse méd., 41 (1933), 571.
82. 'Commission de l'enseignement', Méd. Fr., 39 (1933), 271-3.
83. For the debate arid its conclusions, see 'Commission de l'enseignement', Méd. Fr., 39 (1933), ibid., pp. 357-78.
84. 'Certificat de spécialités', Méd. Fr., 39 (1933), 644-8.
85. Paris méd. 90 (1933), p. 403.
86. Discussion is in 'Etudes et certificats de spécialités', Méd. Fr., 39 (1933), 966-72;
87. 'Brevet de chirugien', Méd. Fr., 40 (1934), 186-95.
88. 'Enseignement des spécialités', Méd. Fr., 40 (1934), 27-9;
89. 'Assemblée générale de la Confédé ration des syndicats médicaux français, 15-17 dec. 1933', Méd. Fr., 40 (1934), 165-85.
90. G. Roussy, 'La réforme des concours d'Agrégation des Facultés de médecine', Presse méd., 42 (1934), 1545-9.
91. Secretary general's comments, Méd. Fr., 43 (1937), 148;
92. Dr Béliard, untitled report, Méd. Fr., 43 (1937), ibid., pp. 149-54.
93. Dr Béliard, untitled report, Méd. Fr., 43 (1937), Ibid., p. 152;
94. Méd. Fr., 45 (1939), 414.
95. 'Qualification des specialists', Méd. Fr., 44 (1938), 161-9.
96. 'Proposition de loi', Méd. Fr., 44 (1938), 288-93.
97. The controversy had always been about whether dentists currently in practice would have the right to transform dentistry degrees into the MD. 'La qualification du spécialiste', Méd. Fr., 44 (1938), 586-9.
98. The discussions are in 'Certificats de spécialités', Méd. Fr., 44 (1938), 706-25.
99. The possibility of obtaining a specialist certificate before obtaining the MD was mainly directed at hospital interns who would be getting an intense training in specialty hospital wards and who did riot normally graduate until after the completion of the internship. 'Qualification du spécialiste', Méd. Fr., 45 (1939), 268.
100. In this version, the Confederation recognized only seven specialties: surgery, ophthalmology, otorhiriolaryrigology, stomatology, electro-radiology, neuro-psychiatry, laboratory biology.
101. Mordagne, 'La qualification des spécialistes', pp. 1517-18.
102. 'La qualification du spécialiste', Méd. Fr., 44 (1938), 931-7, p. 932. The article is unsigned but was certainly written by Paul Cibrie, Secretary General of the Confederation.
103. 'Accord interconfédéral sur l'intégration de l'art dentaire dans le doctorat en médecine', Méd. Fr., 44 (1938), 937-9;
104. 'Il n'y aura pas de Docteurs-Dentistes', Méd. Fr., 45 (1939), 225-6. In the post-war period, the attempt at unification was abandoned but the battle between the two professions in no way abated. Dentists, however, gradually began to win the battle. The Code of Deontology, promulgated in 1947, specified that stomatologists were under the jurisdiction, not of the Ordre des Médecins, but of the Ordre des Chirurgiens-dentistes. Although never enforced, this issue was a source of irritation for stomatologists.
105. Dr Hennion, 'Syndicat national des médecins stomatologistes qualifiés', Méd. Fr., 60 (1954), 7923-5.
106. On the resolution of this battle in favour of dentists in recent years, see Vidai et al., Histoire d'une diplôme.
107. 'Statut général des spécialités', Bull. de l'Ordre des Médecins (June 1941), 95-8
108. and 'Statut général des spécialités', Bull. de l'Ordre des Médecins (1941), ibid., p. 42.
109. Obstetrics-gynaecology and dermatology-venereology were the two new categories.
110. There were 22 specialist categories of this sort and no doctor was allowed to practise more than two.
111. I summarize very superficially many pages of rather inconclusive discussions from the minutes of the Conseil Supérieur de l'Ordre des Médecins from mid-March to mid-December of 1941 in the AOM. Donna Evelth is currently preparing a detailed study of the many projects discussed by this council and the various ideological tendencies represented within it.
112. Brief notes on the Ordre in Presse méd., 52 (1943), 174, 239.
113. 'Ecole de Chirurgie', Bull de l'Ordre des Médecins (August 1942), 142-3;
114. AOM, Circulaire no. 17, 8 June 1944, 'Projet d'enseignement de la Chirugie'.
115. These were: surgery, phthisiology, dermato-venereology, ORL, and ophthalmology. AOM, Circulaire no. 17, July 1942.
116. AOM, Circulaire no. 7, 19 April 1944.
117. F. Decourt, 'Un omni-praticien ne serait-il qu'un demi-médecin', Concours méd., 66 (1944), 274-5.
118. The author claimed that the Ordre was dominated by elite specialists. On the composition of the Ordre at this time, see B. Vergez, 'Internes et anciens internes des hôpitaux de Paris' (unpublished thesis, Institut des Études Politiques, 1995), p. 373.
119. The council did in fact intervene on several occasions when an administrative body decided that some specialties did not merit the high fees specialists usually received. For a case involving the Veteran's Administration, see AOM, Circulaire no. 3, 3 January 1944.
120. AOM, Circulaire no. 7, 19 April 1944.
121. AOM, Circulaire no. 20, 12 June 1944.
122. This factor was openly discussed in 'De la qualification des spécialistes: rapport de Dr. Carlotti', Bull. de l'Ordre des Médecins (1946-7), 77-87, p. 77.
123. Also the brief editorial note, 'Qualifications des spécialistes', Méd. Fr., 52 (1946), 593.
124. While surgery, radiology, biology, stomatology, ophthalmology, ORL, and gynaecology-obstetrics could only be practised as exclusive specialties, dermato-venereology, neurology, urology and phtisiology could be exclusive specialties or competencies combined with general practice. (Obstetrics, by itself, could also be a competence.) Up to two competencies could be combined with general medicine.
125. 'De la qualification des spécialistes. . . Carlotti', pp. 77-87.
126. In a report adopted in April 1947, Dr Carlotti claimed that the proposal 'n' a pas soulevé d'objections majeures de la part du Corps médical', in 'Définition du médecin spécialiste: rapport du Dr. Carlotti', Bull. de l'Ordre des Médecins (1947), 231-3, p. 231.
127. 'n' a pas soulevé d'objections majeures de la part du Corps médical', Bull. de l'Ordre des Médecins (1947),Ibid., p. 233.
128. Menegaux, 'Le certificat de chirurgien", p. 30.
129. 'Arrête du 23 Août 1947', Méd. Fr., 53 (1947), 1225-7.
130. For the ministerial explanation of this measure, see 'Lettre du Ministère de la Sarité Publique", Méd. Fr., 53 (1947), ibid., pp. 1228-30.
131. For a brief summary of the discussion of the national council of the Ordre, Bull. de l'Ordre dus Médecins (1947), 10.
132. Carlotti in discussion, 'De la qualification des spécialistes', Bull. de l'Ordre des Médecins (1946-7), 74;
133. 'Rapport de Dr. Carlotti', p. 86. In response to a request from the Ministry of Youth, the Ordre agreed to a competency 'medico-sportive' for the 200 or so doctors who had public functions in this area;
134. Rapport de Dr. Carlotti, ibid., p. 209.
135. These decisions did riot put an end to vigorous debate and campaigning around these issues. See Dr Demarque, 'L'homéopathie est-elle une spécialité?', Concours méd., 70 (1948), 358-9.
136. Carlotti, 'De la qualification des spécialistes", p. 79.
137. 'Conseil national", Bull. de l'Ordre des Médecins (1947-8), 241-2.
138. Ophthalmology and ORL, however, could be combined into a single practice.
139. Although combining competencies with general practice was permitted, the specialist trade unions still considered exclusive practice as the norm for specialists. The Groupement des syndicats nationaux des médecins spécialisée excluded as member groups the syndicats of neurologists and gastro-enterologists which admitted members who combined their specialty with general practice. Dr Courtois, 'Quelques problèmes qui se posent au spécialites', Méd. Fr., 60 (1954), 7901-5, p. 7902. Eventually physicians practising a competency exclusively came to be considered a special category. To complicate matters still further, it turned out that it was possible to combine competencies (psychiatry and neurology, ORL and ophthalmology), and a specialty (like surgery) with a competence (like urology or gynaecology). Finally, there was constant pressure to add new competencies. In 1958, rheumatology joined the list of competencies.
140. These were published throughout Bull. de l'Ordre des Médecins of 1947-8.
141. Dr Hude, 'L'avenir de la radiologie', Concours méd., 71 (1949), 1025-6.
142. 'Qualification des spécialistes: état des travaux', Bull. de l'Ordre des Médecins (1948-9), 9-10. By 1949, the figure had reached 7,000.
143. R. Garaud, 'Toujours à propos des spécialisations'. Concours méd., 71 (1949), 449-50.
144. C. Blondel, 'Qualification des spécialistes', Bull. de l'Ordre des Médecins (1955), 6-9. It was not until 1958 that certificates formally became the fundamental prerequisite for specialization and even then important exceptions remained.
145. Courtois, 'Quelques problèmes qui se posent au spécialités', p. 7901.
146. J. R. Debray, 'Étude de la répartition des médecins en France en 1953', Bull. de l'Ordre des Médecins (1954), 36-44.
147. Dr Durand, 'La spécialisation', Concours méd., 80 (1958), 3095-3106, p. 3105.
148. An initial decision to this effect was taken by the Ordre in 1950, 'Séance du 9 juillet (après-midi)', Méd. Fr., 56 (1950), 3673-5. It took some years for this decision to come into effect.
149. 'Information et documentation: pédiatrie', Méd. Fr., 64 (1958), 1954-6.
150. Durarid, 'La spécialisation', pp. 3095-106.
151. For protests about this situation, see Dr Kreis, 'Bruits de pot fêlé dans la symphonie des spécialisations', Concours méd., 72 (1950), 1537-44.
152. J. Mignon, 'Organisation professionelle: les praticiens devant le problème de la spécialisation', Concours méd., 70 (1948), 2053-4.
153. 'Qualification des spécialistes', Méd. Fr., 55 (1949), 2872-3.
154. P. Douriez, 'Tout ne va pas pour le mieux en matière de la qualification des spécialistes', Concours méd., 79 (1957), 57-60, p. 58.
155. P. Douriez, 'Comment se trouvent rétablie la dualité des qualifications des spécialistes', Concours méd., 71 (1949), 2541-5.
156. 'Circulaire N. 63 SS du 4 avril 1950', Méd. Fr., 56 (1950), 3529-30.
157. A decree of 29 July 1957 tried to realign the social insurance regulations to follow those of the Ordre, Bull. de l'Ordre des Médecins (1957), 251-2.
158. P. Douriez, 'Actualité professionnelle: pour l'inté grité du diplôme', Concours méd., 73 (1951), 1409-11;
159. 'Le certificat d'études spéciales n'est plus exigé des radiologistes hospitalières', Concours méd., 80 (1958), 2043.
160. Discussion in Bull de l'Ordre des Médecins (1955), 150-1.
161. The three administrative modifications of the regulatory basis of specialization that had been introduced in 1947 and 1948 were promulgated in 1952, 1955, and 1957. On the complex legal difficulties provoked by the system, see H. Meillet, 'La procédure de la qualification des spécialistes devra-t-elle être modifiée?', Concours méd., 74 (1952), 2817-19;
162. and J. Mignon, 'Qualifications des spécialistes ou qualifications des consultants', Concours méd., 77 (1955), 1351-3;
163. Douriez, 'Tout ne va pas pour le mieux en matière de la qualification des spécialistes', pp. 57-9,
164. and idem, 'Le quatrième régime de qualification des spécialistes a vu le jour', Concours méd., 79 (1957), 403-4.
165. For a few examples, see R. Jodin, 'Pour une spécialité de médecine interne', Concours méd., 70 (1948), 17-19;
166. Dr Kreiss, 'A Propos de la spécialisation surveillée', Concours méd. ,71 (1949), 145-7;
167. R. Durand, 'Défense du praticien', Concours méd. ,71 (1949), ibid., 1665-6;
168. R. Salins and F. Michaud, 'Pour un dialogue constructif entre omnipraticiens et spécialistes', Concours méd., 80 (1958), 3223-7. Those justifying disparities in fees tended to alternate between the older argument that it was necessary to compensate doctors who were drastically limiting the number of patients they could see, and a newer one in which higher fees were the reward for special education and greater 'perfection' of the procedures they performed. Specialists also argued (and GPs denied) that the expenses of specialty practice were greater and that consultations were longer. No documentation was ever offered in support of this claim.
169. Dr Caillaud, 'Le C2 et les spécialistes', pp. 515-16.
170. The first was bemoaned by Kreiss, 'A Propos', p. 445.
171. The second was mentioned by several speakers in the account of 'Colloque tenu à L'Abbeye de Royaument, 22 oct. 1960', Presse méd., 69 (1961), 264-6.
172. On the earlier opposition of Paris interns to specialty diplomas that did not distinguish interns from non-interns, see Comité des internes en exercise des Hôpitaux de Paris, 'L'internat des hôpitaux de Paris et la création de nouveaux diplômes de spécialité', J. des praticiens, 63 (1949), 189.
173. The complexity of this issue is underlined by the fact that the latter statement is followed immediately by another, (Syndicat national des médecins des Hôpitaux libre, 'A propos de la qualification des chirurgiens et spécialiste', J. des praticiens, 63 (1949), ibid., pp. 189-90), complaining that many of those who interned outside of the official Paris hospitals (especially those in the suburbs) were being denied qualifications as surgeons.
174. Mignon, 'Organisation professionnelle', pp. 1852-3;
175. Courtois, 'Quelques problemes', p. 7902.
176. 'Les internes et la qualifications des spécialités', Concours méd., 77 (1955), 2789-90.
177. Kreiss, 'A Propos', pp. 446-7.
178. His comments are in 'Colloque tenu à L'Abbeye de Royaument', p. 264.
179. Caisse Nationale de l'Assurance Maladies des Travailleurs Salaries, Le secteur libéral des professions de santéen 1982 vol. 1, Démographic (Paris, 1983), p. 12.
180. Full-time specialists comprised 77 per cent of the American profession in 1969. See, Stevens, American Medicine, p. 181.
181. P. Hassenteufel, Les Médecins face à l'État: un comparaison européene (Paris, 1997), p. 212. The figures do not imply any real functional differences between the USA and other countries. They rather reflect the fact that primary care fields like family medicine have specialist status in the USA; they also reflect American tolerance for specialists who continue in general practice. But they do suggest the extent to which the logic of specialization has permeated the American medical system.
182. J.-P. Carlotti and H. Lafitte, 'De la qualification des médecins spécialistes', in Ordre National des Médecins, Premier Congrès International de Morale Médicale: Paris, octobre 1955, 1, Rapports (Paris, 1955), 35-40.
183. On this Congress, see G. Weisz, 'The Origins of Medical Ethics in France: The International Congress of Morale Médicale of 1955", in G. Weisz (ed.), Social Science Perspectives on Medical Ethics (Dordecht, 1990), 145-62.