Robert Moorhead | Breaking New Ground: The Story of Dagmar Berne | Health and History, 10.2

A Quest for Identity, Authority, and Status: The Development of Paediatrics in Australia

Robert G. Evans

In Europe and the United States paediatrics was well entrenched by the end of the nineteenth century, whereas in Australia the specialty only attained legitimacy by the end of the twentieth. Here paediatricians experienced diffi culties in convincing the medical profession and society that children were different to adults and therefore required special care. In seeking a clear identity as specialists for children they were reluctant to distance themselves from their origins in general, predominantly adult, medicine, which, until the 1970s, followed British ideologies in opposing specialisation. There were also local socio–economic factors, adverse market forces, and competition in the field of child health. Even when the problems were largely overcome and new scientific knowledge gave paediatricians authority and status, they were slow to establish an effective professional association. Eventually, however, they achieved their aims with the creation, in 1998, of the Paediatric Division of the Royal Australasian College of Physicians.

Paediatrics, the specialised field of medicine concerned with the care and treatment of children, was late developing in Australia compared with other western countries. It was also late compared with other major specialties here. The specialty barely existed in 1945 and then slowly began to expand. Through the 1970s and 1980s there was a substantial growth of clinical services and in the numbers of paediatricians in hospitals and in private practice. By then one might have considered the specialty well established. However, if an essential characteristic of a medical specialty is the possession of the authority to control its chosen occupational space, including the control of the entry of new members, then it can be argued that paediatrics did not properly arrive in Australia until 1998. This study will examine how paediatrics developed in Australia and the reasons for its lateness—circumstances that throw light on medical specialisation in general.

The processes of specialisation

The processes of specialisation in the profession of medicine began in France and German-speaking countries in the early– nineteenth century. New knowledge in anatomical pathology, in pathophysiology and in microbiology strengthened notions of the specific nature of disease displacing long-held concepts that illnesses were due to generalised disturbances of bodily humours. The nosological organisation of knowledge that followed encouraged specialisation, which became the dominating movement in western medicine through the twentieth century.¹

In his pioneering studies in the 1940s, George Rosen defined a specialty as a field of medical activity oriented around a focus of interest in a particular area of knowledge, which attracted doctors in sufficient numbers to form organised groups. He mainly attributed specialisation to an expansion of scientific knowledge too great to be encompassed by any one person.² More recently, George Weisz has argued that doctors specialised because they wished to expand, rather than to compartmentalise, knowledge. The movement quickened through the twentieth century with the growth of large hospitals in which doctors produced new knowledge based on their empirical observations of the many patients who became accessible to them.³

Rosemary Stevens has acknowledged a role for scientific knowledge in specialisation but has argued that the process was driven by a wider range of forces, stressing the importance of social processes driven by economic, organisational and personal agenda.⁴ Peter Lloyd has declared that a history of the development of the medical profession in Australia must include a consideration of demographic, social, cultural, and economic circumstances, placed in their historical periods, as well as the medical pursuit of power and authority derived from the monopolistic possession of esoteric knowledge.⁵

Sydney Halpern has observed that most accounts of the development of professions have concluded that the major catalysts for their establishment have been intellectual advances and market forces. She believes the same applies to medical specialisation, where expanding medical science equated with intellectual advances. Market forces included the demands of society for skilled medical services and the responses of practitioners—individually and collectively—to satisfy those demands.⁶

Eliot Freidson has written extensively on medical professionalisation and his remarks are pertinent, in part at least to specialisation. A specialty might then be defined as an occupational group that has achieved a dominant position in a particular division of labour, and been granted, by the medical profession and society, a licence or mandate to control its own work, an autonomy vital for professional status.⁷

Status was the result of a value judgement of the society in which the specialty operated: that the members possessed special skills and knowledge, that they embraced high ethical standards, and that their work possessed dignity and importance.⁸ Doctors individually could not create a specialty; they needed collective action through, for instance, a professional association or a college.

The rise of paediatrics

Paediatrics came late to Australia, developing largely in the thirty years following World War II when there was a rapid expansion in scientific knowledge, therapeutics and technology relating to the management of children's disorders. It was also a time of social change and a strengthening of market forces.

In France and Germany the specialty began early in the nineteenth century, a period associated with a general expansion of medical knowledge, when certain physicians developed an interest in diseases peculiar to children.⁹ Late in the nineteenth century another segment of paediatrics arose: in preventive medicine. Governments and doctors established infant welfare and mothercraft services, responding to the growing appreciation of children as individuals and to their importance for national security in countries threatened by high infant mortality rates.¹⁰

Paediatrics was established early in the United States: Sydney Halpern has described three phases of development. From the late 1880s certain doctors defined the discipline and cultivated a special interest in children. Then, from 1900 paediatrics became an independent consulting specialty in private practices and in university teaching hospitals where autonomous paediatric units appeared. In a third phase, from the 1920s, other paediatricians ventured into primary care. They had observed the success of government and philanthropic infant welfare services, established at much the same time as those in Europe, and how they were patronised by both poor and affluent families. They began to offer similar services from their private practices, which they then expanded to provide preventive services for older children. They promoted the health supervision of normal childhood, servicing affl uent, well-educated families who had been encouraged to take an interest in the health of their children by community organisations such as the American Child Health Association. The primary care paediatricians also treated sick children at home and in community hospitals. In the entrepreneurial spirit of the United States medical profession they were responding to a market place that they themselves had created.¹¹ In Britain, however, paediatrics came late, in the 1930s, for reasons to be discussed later because of their relevance to Australian developments.¹²

In Australia, in the colonial period, doctors demonstrated an interest in the disorders of children, publishing articles in contemporary medical journals on their experiences in a strange new country.¹³ In 1861 an editorial article endorsed 'paediatrics,' urging readers to take a special interest in children because they warranted different care to adults.¹⁴ Children's hospitals were established in most of the Australian state capital cities from the 1870s, shortly after those of Britain and the United States. They were attended by doctors with a special interest in children, but not exclusively, for they were also general practitioners or general physicians. As in other countries early paediatricians continued to treat adults, because the future of paediatrics as a viable specialty was uncertain. By 1950 there were only about twenty doctors in Australia who called themselves paediatricians.¹⁵

Determining forces in Australian paediatrics

The occupational space that paediatricians sought was occupied by others. Up to the 1950s general practitioners provided most of the medical care of children, at home and in their surgeries. By training and experience they were resourceful and accustomed to working without specialist support: they believed that most child care fell within their capabilities.¹⁶Australian paediatricians were not able to enter primary care, like those in the United States, without compromising their status as consultants, who, by long-established custom, treated only patients referred by other doctors. This arrangement followed conventions instituted in Britain in the late 1880s, when medical factions agreed that general practitioners hold a monopoly in primary care, relinquishing patients in public hospitals to specialists.¹⁷

Further competition for paediatricians came from adult physicians who treated difficult clinical problems referred by general practitioners, because paediatricians had been so few in number. Infant welfare nurses potentially provided competition too, offering advice on feeding and mothercraft in publicly-funded clinics in most cities and towns in the country. The nurses were forbidden to diagnose or treat disease, but their availability may have diverted patients from the early paediatricians whose work included dealing with problems of infant behaviour and nutrition.¹⁸

The paediatricians' roles, as honorary medical officers in the children's hospitals—although desirable for the status they conferred—compromised the financial viability of their private practices. Children from families of all social classes, and not just the indigent as the founders intended, began to use the children's hospitals when it became apparent that they provided the best treatment for the seriously-ill (there were few suitable private hospitals). Most children admitted were classified as public patients and the attending doctor was not permitted to raise a fee.¹⁹ Up to the 1960s few paediatric practices treating children exclusively were financially viable.²⁰

It was not only competition which restrained the development of paediatrics in Australia: the specialty lacked a defining image.

The problem existed elsewhere, for example the United States and Europe, but the adverse effects were reduced by the status and authority that the relatively small specialty had acquired. Paediatrics was not a sharply focussed specialty, such as those devoted to a body organ or a disease, but dealt with the multiple disorders of a population group delineated by age, extending from birth to adolescence. Paediatricians everywhere had long been forced to defend the unique nature of children and their need for dedicated health services. Abraham Jacobi (1830– 1919), often described as the father of paediatrics in the US and an icon of humanitarianism, was a powerful advocate for children, in medical, scientific, and political arenas. He was obliged to argue repeatedly that 'children were not miniature men and women.'²¹Australian paediatricians had similar struggles.

Paediatricians, potentially, could offer a wide range of services; the best known being those concerned with the diagnosis and treatment of disease, that is, the internal medicine of childhood. They also believed in the importance of preventive medicine such as infant welfare and immunisation. Infant welfare services were introduced into Australia early in the twentieth century, like other western countries. In the 1920s and 1930s a small number of doctors, from their honorary positions in these services, earned reputations as experts in baby care, and may be described as the nation's pioneer paediatricians.²² Immunisation against infectious diseases like diphtheria and poliomyelitis was of vital interest to paediatricians, but immunisation programmes were the responsibility of government public health departments, local governments, and general practitioners.

The disparate factors that influenced child well-being also shaped the development of paediatrics. Russel Viner noted that complex political and social forces played a greater role in child health than the efforts of the medical profession.²³Halpern remarked that paediatrics was always a specialty allied to social meliorism, even in the United States where the medical profession usually distanced itself from welfare programmes sponsored by governments or charities.²⁴ In contrast, in France, a pioneer in developing preventive child health services, doctors acted as arms of government in monitoring the health status of the population, particularly children, and in policing public health laws.²⁵

In Australia, doctors were often wary of being too close to governments. The thirty years after World War II, when paediatricians were seeking to establish their specialty, was a period when doctors, and their medico–political organisations, were fearful of government intervention in health matters. They were concerned about losing their highly prized independence and threats of nationalisation of the profession.²⁶ One can speculate that the links, however tenuous, between paediatrics and governments, which were often directly involved in infant welfare, school medical services, immunisation, and epidemiological units, may have caused the Australian medical profession to have some suspicions about the development of the specialty.

In western countries, in the early–twentieth century, doctors whose status in medicine was determined by the level of their dedication to medical science, often disparaged paediatrics. The specialty, with its welfare orientation, was deemed unscientific by physicians in the United States and Britain who declared that social welfare and sociology were unrigorous and imprecise disciplines, in contrast to their own fields which, they insisted, were based on sound experimental science.²⁷

There were long-standing views that paediatrics was not worthy of specialty status. In 1910, in the United States, where paediatrics had been widely recognised as a specialty from the 1880s, some physicians still asserted that the discipline was not sufficiently different from other fields of medicine to warrant the creation of a discrete specialty.²⁸ In 1931, in Britain, the editor of the British Medical Journal said the separation of paediatrics from general medicine was too artificial to be altogether good. He admitted infants were an exception, but they, as I shall discuss later, did not constitute a field of scientific interest until the late 1960s. The editor questioned whether the study of the diseases of children posed any challenge 'to a first class mind.'²⁹

A German medical historian and paediatrician, Edouard Seidler, said that paediatrics in his country lacked scientific credibility relative to other areas of medicine. He acknowledged that while separate children's hospitals provided a desirable environment for the patients, their medical staff were isolated from the mainstream of scientific medicine. Paediatricians were not exposed to the rigorous professional competition that had so effectively stimulated the development of internal medicine in large adult teaching hospitals.³⁰

In Australia, a physician who worked in a number of hospitals in Sydney in the early postwar period echoed Seidler's remarks.³¹A paediatrician commented that, up to the 1960s, doctors in the Sydney children's hospital were inferior in intelligence, in scientific attitudes, and in training to those in the major adult hospitals, with some notable exceptions.³²A Melbourne paediatrician noted a similar situation in his city adding that from his observations adult physicians regarded paediatricians as inferior.³³Another, an academic, said that through the 1950s and 60s there were widespread perceptions in medical circles that gifted young doctors wishing to pursue an academic career in internal medicine would not seek positions in children's hospitals because the paediatricians on the staff were not scientific enough.³⁴

The standing of children in society also influenced paediatrics. While western societies labelled children 'the hope of nations,' they were often slow to acknowledge their needs as individuals. Children lacked power, financial resources, and a vote.³⁵ From the oral histories of people who were patients in Australian children's hospitals from the 1940s to 1960s, one can conclude that children and their parents lacked authority to influence their health care, despite the outwardly benevolent atmosphere of the institutions.³⁶According to a Sydney paediatrician, adult physicians described children as merely little adults and working with them unimportant.³⁷ In the competition for the allocation of state resources, submissions from paediatricians had a low priority, there were few sick children compared with sick adults: for every ten hospital beds for adults only one was needed for children.³⁸There were, then, substantial difficulties for paediatricians in their quest to have their specialty accepted.

The changing scene

According to Andrew Abbott, medical specialties arose in a number of different ways. Some developed when new knowledge or technology produced new work patterns, some when occupational space was vacated, others because the previous tenants lost their grip on the field.³⁹ For aspiring paediatricians in Australia the thirty years following World War II brought important new knowledge and technology. New antimicrobial agents, especially penicillin, become available to cure or control previously untreatable childhood infections. Paediatricians could now actively treat disease instead of being mere passive providers of symptomatic relief: as a result they attained higher status in the medical hierarchy.⁴⁰

New knowledge in physiology and biochemistry enabled paediatricians to safely correct the disturbed metabolic processes associated with many disorders, for example the dehydration of gastroenteritis, severe infections and injuries, and complex surgical procedures. Paediatricians became more effective and their care safer than that of their competitors.

Paediatricians began, for the first time, to treat serious disorders in newborn infants. They improved the survival rate of premature babies and actively treated medical problems such as hyaline membrane disease. They made safer surgery feasible for congenital heart disease and bowel obstructions, for example. Neonatology gave paediatricians a new and uncontested occupational space.

Knowledge that strongly supported the paediatricians' claims came from a better understanding of growth as a discriminating factor between adults and children: children uniquely possessed the potential for growth, not only in physical dimension but also in physiological, intellectual, and emotional functions. Growing individuals needed medical care different from that offered to those in whom growth was complete.⁴¹

With new knowledge, Australian paediatricians could argue that they were well equipped to care for sick children and that adult physicians, however useful they had been in the past, had lost their grip on the field. The proposition created a quandary for paediatricians because they had always been closely aligned with adult physicians, in training, in professional philosophies, and in professional associations. To realise their own identity as specialists for children they would have to distance themselves from their adult colleagues, a difficult and risky move. Part of the problem came from their ties to the ideologies of British internal medicine.

Internal medicine was that field of medicine concerned with the diagnosis and treatment of internal disorders, excluding skin (external) conditions and those requiring surgery.⁴² In Britain and Australia the practitioners called themselves adult physicians or paediatric physicians. From the nineteenth century, and well into the twentieth, British physicians favoured a philosophy of generalism in internal medicine, arguing that the effects of disease were not restricted to any one organ, and that the whole body must be considered in diagnosis and treatment.⁴³They opposed specialism, the course supported in, for example, France, the German-speaking countries, and the United States. In their choice, British physicians refl ected their professed social and cultural background. The ideal physician was an intelligent gentleman, well educated in the classics, a wise man of many parts and broad in vision. Gentlemen did not specialise for it produced cerebral imbalance and a narrow outlook. Specialism was the domain of quacks.⁴⁴

As generalists, British physicians chose to practise 'the art of medicine.' They believed that knowledge and skills acquired from experience and from their predecessors were more valuable than medical science. They trusted their educated and experienced eyes and hands, and while granting science a place, denied that medicine could be reduced to a body of knowledge with precise rules for its implementation. Instruments that produced numerical results, like temperature and blood pressure, threatened the mysterious clinical art. That art was indefinable and therefore inaccessible to criticism. Their elite status could not be challenged.⁴⁵

Australian physicians followed their British counterparts. Up to the early 1970s, they preserved a climate of generalism and opposed specialisation within internal medicine.⁴⁶The ideology made segmentation difficult.

However, after the 1960s advances in knowledge forced paediatricians to admit that the generalist policies conflicted with their desire for their own occupational space in medicine.⁴⁷Individual knowledge alone, however, was insufficient to bring change: a collective approach was needed. There were overseas models to follow. Professional associations that had supported the advance of paediatrics included the German Association for Diseases of Children (formed in 1883),⁴⁸ the American Pediatric Society for consultant and academic paediatricians (1887), and the Academy of Pediatrics for primary care paediatricians (1933).⁴⁹

Professional associations strengthened the bonds between members and facilitated the sharing of knowledge. They drew up the codes of ethics and professional behaviour that were essential to earn the confidence of society that the members were appropriately skilled. They worked in the interests of the people, they possessed integrity, and were therefore fit to control their own field of specialisation.⁵⁰Autonomy was central to specialisation: its bestowal was facilitated if the association was large and well organised.⁵¹

From 1938 to the 1990s the professional association for most Australian paediatricians was the Royal Australasian College of Physicians (RACP), an organisation established predominantly for adult physicians. Paediatricians became members because they were, after all, physicians for children, and there were no suitable alternatives in Australia. Some were members of one or more British associations, because, from the 1930s to the 1950s, aspiring paediatricians went to the United Kingdom to complete their training. They sat for examinations for membership of one of the Royal Colleges of Physicians, usually of London or Edinburgh, which gave them specialist credentials acceptable in Australia. However, from the 1960s, most intending paediatricians prepared for their careers in Australia.

The RACP was established in 1938 by senior physicians, mostly consultants in private practices and honoraries at the leading teaching hospitals. They wished to create 'a body of some standing to organise and supervise the postgraduate study of internal medicine—a college would possess greater dignity and achieve a higher status in the eyes of the medical profession and lay public than an association.'⁵²The RACP was modelled on the Royal College of Physicians, London (RCP), an elite body in British medicine from its establishment in 1516. The Australian College sought similar status. It purchased one of the oldest mansions in Sydney, an imposing building in Macquarie Street, the favoured address of medical consultants. It was built in 1848 for the newspaper publisher John Fairfax, later becoming the Warrigal Club for gentleman pastoralists.⁵³The building fitted Geoffrey Millerson's description of an elite association headquarters, 'a suitable (London) address in certain streets or squares … a house with a sense of age and quiet dignity.' There was also a Royal Charter, a symbol of high social status implying supremacy in a particular field and a strong record of public service. It meant respectability and a strict control of entrance standards and professional conduct.⁵⁴Other symbols of status were the armorial bearings, a classical motto and the presidential robes.⁵⁵

The college membership was at first on two levels: fellows and members. The foundation fellows were 'men of distinction in medicine.' New fellows were elected by existing fellows, taking into account 'their standing in the college, their contributions to literature and science, their academic honours and public appointments, the length of tenure of membership, and their professional eminence.'⁵⁶There were twelve paediatricians amongst the 191 Australian foundation fellows; more were elected from time to time. Members were admitted after satisfying the Board of Censors of their competence in internal medicine, usually by examination. Paediatricians became members from the first examination in 1938, when six passed out of a total of forty-one candidates.

Paediatricians had little influence on college matters, partly because they were greatly outnumbered by adult physicians. Few held positions of authority. Fellows elected the governing body, the council, which appointed the president and the executive committee. It was not until 1955 that a paediatrician, Dr. Lorimer Dods was elected to the council; for the next ten years he was alone amongst twenty adult physicians. Dods was nominated for president in 1964 but received few votes, although he was then one of the best-known figures in Australian paediatrics and professor of child health at the University of Sydney.⁵⁷ Perhaps the councillors considered it inappropriate that a paediatrician, a person perceived to be of inferior status, lead the college.

Up to the late 1950s, paediatricians were too few in number to seriously consider establishing their own professional organisation. Then, having decided that the RACP was not able to meet their needs, they moved to create an association with status and authority in medicine and society. Those attributes come, Judy Sadler declares, to organisations that control the three systems of production in medicine. The production of medical care provided the economic basis for the specialty. The production of new knowledge enhanced intellectual status and authority. The third, the production of new specialists was the major activity around which a specialty was organised.⁵⁸

Australian paediatricians gained status in patient care when they began to utilise the scientific knowledge that came after World War II. They produced new knowledge to a modest degree, some conducting clinical research in consulting rooms and the children's hospitals. The Clinical Research Unit of the Royal Children's Hospital, Melbourne, engaged in clinical and laboratory research from 1948, but formal institutional research was rare until the 1980s. The delay was not critical, other specialties were similarly placed. It was, however, in the third system of production that Australian paediatricians were handicapped. Up to the late 1990s they did not fully control entry to their specialty: that was in the hands of the RACP through the examination for membership (called fellowship after 1978).

From 1938 to 1965 there was only one form of the examination, covering the field of general medicine, for both paediatric and adult medicine candidates. It was usually attempted at the end of training, after four to six years of hospital experience. There were no prerequisites, except three years must have passed from graduation. In contrast, for surgical training the Royal Australasian College of Surgeons (RACS) had rigid criteria for training, in operating theatres, wards, and outpatient departments. Physicians thought differently. The chief censor of the RACP declared that the surgical regime was excessively prescriptive; for physicians experience was less measurable and more subtly obtained.⁵⁹

The MRACP examination was a daunting, adversarial experience for all candidates. Only about 30 percent of all those who sat the exam passed—a small percentage considering the long period spent in training in selective posts. The censors expected candidates to have knowledge more detailed than that required for the Bachelor of Medicine examination, but not necessarily that of an experienced physician. All were expected to have a general acquaintance with children's diseases.⁶⁰Some knowledge of the history of medicine was required (but probably rarely tested), a relic of the tradition of physician as cultured gentleman.

The written part of the examination assessed a candidate's knowledge of medical science and the principles of internal medicine, with which a paediatrician might reasonably have been expected to be familiar. However, the questions became excessively adult-oriented when the medical science relating to childhood progressively diverged from that of adults.⁶¹Those who passed the first part then undertook tests of clinical skills. They were held in adult hospitals with adult patients. In this section the censors expected candidates to demonstrate their competence in the art of medicine, that 'judgement and clinical sense which could only come from clinical experience under the guidance of a well-qualified physician.'⁶²The assessments were conducted by adult physicians, who whatever their standing elsewhere, were not 'well-qualified' in childhood disorders. A senior paediatrician judged the examination to be unfair for paediatric candidates, based on his own experience in 1948 and that of many others later. He said the censors had no knowledge of the differences between adult and child physiology and pathology, and little awareness of advances in paediatrics.⁶³

Paediatric trainees gave high priority to passing the examination because it determined their professional future, but the pressures distorted their training. They were expected to study childhood medicine, but also had to be prepared to demonstrate a knowledge of disorders of little relevance to their future careers. For adult experience they attended ward rounds and clinics in adult hospitals. The quality and quantity of work they offered the children's hospitals were diminished.⁶⁴Many potential paediatricians were deterred because they believed that they would have difficulties passing the examination from a position in a children's hospital. They went to work in general hospitals to gain experience with adult patients, where some of them were induced to follow an alternative career in adult medicine, which was in an exciting stage of development. Doctors who may have contributed much to paediatrics were lost to the specialty.⁶⁵

Despite the difficulties, many aspiring paediatricians passed the MRACP examination. However, by the early 1960s it was apparent that an examination in general medicine did not test the knowledge and skills required of paediatric consultants. They needed to show a mastery of growth and development, of the biochemistry, physiology, pathology, and pharmacology of childhood, of the emotional and behavioural problems of children and of new areas in neonatology and genetics. For adult physicians the MRACP was an unquestioned benchmark of a competent consultant: paediatricians needed their own criterion. One option was to establish a new college, another to create a self-determining group within the RACP, like certain subspecialties had done within the RACS.

Australian paediatricians had already established, in 1950, a modest professional association, the Australian Paediatric Association (APA), similar to the British Paediatric Association. The aims of both were limited: to promote fellowship and to share knowledge on clinical and scientific matters.⁶⁶Membership of the APA was by election and did not confer any professional credentials.

In 1954, the APA (from 1978, the Australian College of Paediatrics, or ACP) formally conceded that paediatricians could achieve little in the RACP. Members voted 'to establish an Australian Board of Paediatrics to examine the qualifications of men [sic] desiring to practise paediatrics as a specialty, and if necessary conduct examinations and grant certificates to those who met the standards successfully.'⁶⁷

It soon became apparent that some members lacked enthusiasm for such a move. They believed that their small organisation could not afford the expense of conducting a national examination for only a small number of candidates. The APA had only 150 members in 1965 while the RACP had over one thousand, with sixty to eighty candidates attempting each examination.⁶⁸ In 1965, in the first examination when paediatric candidates were identifiable (there were paediatric questions) there were fifteen aspiring paediatricians; in the next year only nine.⁶⁹ Many paediatricians, despite their examination experiences, were loyal to the RACP and were reluctant to relinquish the prestige and security of a large established college for the uncertainty of a new, untested organisation.⁷⁰ Rosemary Stevens has observed similar sentiments associated with the creation of new specialties from old, the schism creating deep anxieties in those who separated.⁷¹

The APA acquired neither the essential material resources nor the status that Freidson has declared is vital for the success of a professional association.⁷² It did not have a permanent secretariat or its own accommodation until 1970, when it rented a small single-storey terrace building in an undistinguished street near the Melbourne children's hospital, a marked contrast to the RACP mansion. The APA was not well organised, partly because the constitution frustrated decision making: policies could only be adopted at annual general meetings.⁷³The situations supported Abbott's view that a professional association that was not well organised was disadvantaged in seeking occupational space.⁷⁴

After much procrastination, the APA abandoned plans for a new college and approached the RACP, which reluctantly conceded that the examination for MRACP was not suitable for paediatricians.⁷⁵This was not the only reason for the concession: the RACP Council wanted to avoid dividing internal medicine, should paediatricians leave, as they had threatened to do.⁷⁶ In the early 1960s, a joint RACP/APA committee began to develop a new examination. In 1965 the written paper included questions for paediatric candidates and there were children in the clinical examination. A paediatrician was invited to be an acting Censor. The paediatric content of the examination progressively increased. By the 1980s it was completely child-oriented and there was a full complement of paediatric censors.⁷⁷

In due course Australian paediatricians acquired a form of independence. The ACP was disbanded in 1998 and the RACP was restructured with separate divisions for paediatrics and adult medicine. Paediatricians had played a large part in creating change, but there was also, at the time, a shift in RACP policies. With expanding knowledge, adult physicians were narrowing their areas of interest, generalism within internal medicine was dislodged by specialism and segmentation accepted as inevitable.⁷⁸ Subspecialties such as cardiology, gastroenterology, and endocrinology were legitimised within the college.⁷⁹The changes came much later than in the United States, where, for example, the American Neurological Association appeared in 1875, and the American Gastroenterological Association in 1897.⁸⁰

There were also forces in Australian society outside medicine that favoured specialisation, which was, as Weisz has observed, a self-evident necessity for medicine as it was for other fields of endeavour in industrial countries in the twentieth century.⁸¹ People were more knowledgeable about health and beginning to appreciate that specialists could offer higher levels of skills than general practitioners.⁸² From the 1970s more parents could afford to consult paediatricians because the Commonwealth health scheme, Medibank, provided increased financial assistance for patients attending consultant physicians and paediatricians.⁸³ Paediatrics became financially as well as professionally viable.

Australian paediatricians had followed their British counterparts. Paediatrics appeared in the United Kingdom in the 1930s, and for long was dependent for professional credentials on associations dedicated to generalism, the RCP and other Royal Colleges of Physicians, although some attempted to accommodate, in a limited way, paediatric needs.⁸⁴British paediatricians eventually decided, with reluctance, that the situation was unsatisfactory, and that, contrary to the course followed in Australia, they would separate themselves from their adult medicine associations. In 1996 they formed the Royal College of Paediatrics and Child Health (RCPCH).⁸⁵

Other specialties

Paediatrics in Australia lagged well behind other major specialties in the country: the surgical disciplines being distinct examples. From the colonial period many doctors engaged in surgery, and from their ranks certain elite surgeons emerged—their status derived largely from their depth of training or experience and their appointments as senior honorary medical officers at the major teaching hospitals. In 1927 they established the Royal Australasian College of Surgeons (RACS) despite the opposition of the British Medical Association (Australian branches), which feared that such a move would divide and weaken the medical profession, a widely-held anxiety affecting medical specialisation in this country, up to the 1960s.⁸⁶The RACS became a large powerful organisation, aspiring to influence all the systems of production in surgery. However, it was soon faced with threats of segmentation itself.⁸⁷

Ophthalmology was one of the first specialties established in Australia, in the late–nineteenth century, supporting the hypothesis that a clearly defined and narrow focus of interest facilitated specialisation. Ophthalmology applied special examination techniques, surgical procedures, and intricate instruments to a single organ system. There was virtually no competition from other sections of medicine. Professional associations formed early: the Melbourne Ophthalmic Society in 1899, and a Sydney counterpart in 1910. A national body, the Australian Ophthalmological Society, was formed in 1938, and soon became an effective medical collective. Diplomas in ophthalmology, which provided specialist credentials adequate at the time, were available from institutions in Britain, and, after World War II, from certain Australian universities. In the late 1950s ophthalmologists began to plan for a national college to confer academic and professional status, to improve their position in medical politics and to control training and grant credentials. The Royal Australasian College of Ophthalmologists (RACO) was established in 1969 despite the RACS having earlier established a fellowship qualification in ophthalmology, hoping to retain control over all the surgical groups. A compromise was reached; in the 1980s, the RACO and the RCS agreed to award joint qualifications to eye specialists. The surgeons retained the ophthalmologists within their number, and the eye specialists kept their independence.⁸⁸Members of both organisations negotiated from positions of professional strength, unlike the paediatricians who were hampered by their relative weakness in internal medicine.

Orthopaedics gained early a strong position in surgery and the RACS. From the second decade of the twentieth century certain general surgeons, many of them Fellows of the RACS, began to concentrate on bone and joint work. In 1937 they created the Australian Orthopaedic Association (AOA), while retaining their links with the RACS. They soon became the largest craft group in the college and established, within its structure, a Board of Orthopaedic Surgery, with which they controlled the training and entry of new specialists to their field.⁸⁹

Gynaecologists were recognised as specialists by 1900 in Australia. With the creation of the RACS in 1927 they had to decide whether their future should lie with surgeons, or with obstetricians. Many had ties to the Royal College of Obstetricians and Gynaecologists, London (RCOG) because they went to the UK for training and to gain a specialist qualification. To meet the demands for an Australian examination, which arose after the war, the RCOG established an Australian Regional Council in 1948. This body, however, continued to reflect British practices and standards. Control remained in London. The situation eventually became intolerable to Australian obstetricians and gynaecologists, who formed the Royal Australasian College of Obstetricians and Gynaecologists (RACOG) in 1979, despite the reluctance of some to break the traditional ties with Britain. Like paediatrics, the question of control of entry played an important part in the creation of a specialty⁹⁰

Dermatology was not a surgical specialty, but developed, in the late–nineteenth century, out of general medicine. In Australia dermatologists held university diplomas from British, and later Australian, universities. Although the field was separate from internal medicine, a number of its prominent practitioners were members of the RACP, having passed the examination in general medicine. To them and other elite members of the medical profession, the possession of a mere diploma lacked the status associated with membership of one of the Royal Colleges. There were parallels in paediatrics. Many Australian paediatricians acquired the Diploma of Child Health, London, (DCH) but it was not the mark of specialist consultant. In 1964 the RACP proposed creating a division of dermatology similar to the one developed later for paediatrics. However, the dermatologists could see that the ability to control their own occupational field would be compromised, and in 1966, amid allegations that the RACP was intent on undermining their specialty, they set up an Australian College of Dermatology.⁹¹

Conclusions

For a long while paediatricians in Australia lacked the strength and decisiveness shown by other medical groups in their quest for specialty organisation. It was only during the 1990s that paediatrics became a legitimate specialty in Australia, if one takes as a benchmark of successful medical specialisation the control of all three systems of production, especially the control of the entry of new members. Some paediatricians, however, remained concerned that they still did not have a professional association that they themselves controlled. They feared that at some time in the future the paediatric division of the RACP could be overwhelmed by the much larger adult division.⁹²

Despite these views most paediatricians now accept that they have created an organisation that endows their specialty with authority and status in medicine, and in Australian society. Paediatricians are equal in status to their adult physician colleagues—a paediatrician recently held the office of president of the RACP, ruling over both adult and child health divisions.⁹³Paediatricians no longer have to argue that children are not little adults.

Notes

^1. W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), 45, 130.

^2. G. Rosen, “Whither Specialization,” in Medicine and Society Contemporary Medical Problems in Historical Perspective (Philadelphia: The American Philosophical Society, 1971), 196–219.

^3. George Weisz, “The Emergence of Medical Specialization in the Nineteenth Century,” Bulletin of the History of Medicine 77 (2003): 536–75.

^4. Rosemary Stevens, Medical Practice in Modern England: The Impact of Specialization on State Medicine (New Haven: Yale University Press, 1966), 3, 6.

^5. Peter J. Lloyd, “A Social History of Medicine: Medical Professionalisation in New South Wales, 1788–1950,” (PhD thesis, University of NSW, 1993), 8.

^6. Sydney A. Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1980 (Berkeley: University of California Press, 1988), 28.

^7. Eliot Freidson, Profession of Medicine: a Study of the Sociology of Applied Knowledge (New York: Dodd Mead, 1970), 37 ,48, 181, 186–8

^8. Ibid., 181, 186–8.

^9. Bynum, Science and the Practice of Medicine, 95–109.

^10. Angel Ballabriga, “One Century of Pediatrics in Europe,” and Robert Laplace, “French Pediatrics,” in History of Pediatrics 1850–1950, edited by Burford L. Nichols, Angel Ballabriga, and Norman Kretchmer (New York: Raven Press, 1991), 9–10, 39–41.

^11.Halpern, 80–109, 149.

^12. John A. Davis, “British Pediatrics,” in History of Pediatrics 1850–1950, 31–7.

^13. Articles on children's diseases, injuries, nutrition and other topics are listed in Sheila Simpson and Ann Tovel, introduction Brian Gandevia, “A Bibliography of Australian Paediatrics 1846 to 1900,” Parts I, II, III, Australian Paediatric Journal 14 (1978), 21–765–101; Australian Paediatric Journal 15 (1979), 20–32.

^14. Editorial, “An Hospital for Sick Children,” Australian Medical Journal 6 (1861): 31–8.

^15. Lorimer Dods, Notes for an address, 7 August 1960, Dods papers, P172, Series 3, Item 1, University of Sydney Archives.

^16. B. Gandevia, “A History of General Practice in Australia,” Medical Journal of

Australia 2 (1973): 381–5.

^17. Stevens, Medical Practice in Modern England, 31–3.

^18. Claire Isbister (paediatrician, Sydney), interview, Blackheath, 3 March 1998; E. J. R. Rossiter, “Paediatrics in a Country Area,” Australian Paediatric Journal 4 (1968): 240–4.

^19. Honorary medical officers claimed that patients in the children's hospitals were classified as public patients, and not private or intermediate, for ideological reasons. Patient classification and means testing, and their adverse effects on paediatric practice are referred to in, for example, Peter Yule, The Royal Children's Hospital: A History of Faith Science and Love (Sydney: Halstead Press, 1999), 303, 304; Also, see RAHC, Sydney, Medical staff minutes, 18 August 1944, 2 November 1945, and 8 May 1953, RAHC Archives, Sydney (no file number); BMA, Hospital Committee minutes, 24 February 1955, 24 May 1955, 24 November 1955, 23 October 1956, AMA Collection, Mitchell Library, Sydney.

^20. D. G. Hamilton, paediatrician, correspondence, 24 February 1998 and April 1998; D. G. Hamilton, interview, Sydney, 24 February 1998; J. H. Colebatch, paediatrician, interview, Melbourne, 30 August 1999.

^21. Russel Viner, “Politics, Power and Paediatrics,” Lancet 353 (1999): 232–4; Peter C. English, “ 'Not Miniature Men and Women,' Abraham Jacobi's Vision of a New Specialty a Century Ago,” in Children and Health Care: Moral and Social Issues, edited by Loretta M. Kopelman and John C. Moskop (Dordrecht: Kulwer Academic Publishers, 1989), 247–8.

^22. Examples: Lysbeth Cohen, Dr. Margaret Harper (Sydney: Wentworth Books, 1971); Neville Hicks and Elisabeth Leopold, “Mayo, Helen Mary,” Australian Dictionary of Biography, 1891–1938 (Canberra: Australian National University) 10: 166, 167; John Pearn, “Dr. Jefferis Turner, Brisbane,” in Focus and Innovation: A History of Paediatric Education in Queensland (Brisbane: University of Queensland Press, 1986), 258, 489; Patricia Grimshaw, “Dr. Kate Campbell,” in 200 Australian Women, edited by Heather Radi (Sydney: Women's Redress Press, 1988), 208–9.

^23. Viner, “Politics, Power and Paediatrics.”

^24. Halpern, 10.

^25. Alisa Klaus, Every Child a Lion: The Origins of Infant Health Policy in the United States and France, 1890–1920 (Ithaca: Cornell University Press, 1993), 44–5, 283–4.

^26. Anne Crichton, Slowly Taking Control: Australian Governments and Health Care Provision 1788–1988 (Sydney: Allen and Unwin, 1990), 74.

^27. Halpern, 10–1.

^28. Ibid., 73.

^29. Editorial, British Medical Journal 2 (1931): 176–7.

^30. E. Seidler, “An Historical Survey of Children's Hospitals,” in The Hospital in History, edited by L. Granshaw and R. Porter, (London: Routledge, 1990), 181–297.

^31. R. M. Mills, interview, Newcastle, 24 May 1998, and 24 June 1998.

^32. Hamilton, interview.

^33. H. E. Williams (paediatrician, Melbourne), correspondence, 14 January 1995; H. E. Williams, telephone interview, 19 October 1998.

^34. John Beveridge (professor of paediatrics), interview, Sydney, 22 August 1998.

^35. Deborah Dwork, “Childhood” in Companion Encyclopedia of the History of Medicine, edited by W. F. Bynum and Roy Porter, (London: Routledge, 1993) 1072– 91.

^36. R. G. Evans, “Paediatrics in New South Wales 1945 to 1965,” (PhD thesis, University of Newcastle, NSW, 2000), 231–86; http://www. Newcastle.edu.au/services/library/adt (accessed 1 February 2007), 2002.

^37. W. Grigor (paediatrician), interview, Sydney, 13 August 1998.

^38. H. H. Schlink, The Hospital Problem of the Metropolitan and Suburban Areas of Sydney, (Sydney: 1940), pamphlet in History of Medicine Library, RACP, Sydney.

^39. Andrew Abbott, The System of Professions: An Essay on the Division of Expert

Labour (Chicago: University of Chicago Press, 1988), 3.

^40. Andrew Abbott, “Status and Status Strain in the Professions,” in American Journal of Sociology 86 (1981): 819–35.

^41. Evans, thesis, 101–27.

^42. A. L. Bloomfield, “Origin of the Term 'Internal Medicine,'” Journal of the American Medical Association 169 (1959): 1628–9.

^43.C. Lawrence, “Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850–1914,” Journal of Contemporary History 20 (1985): 503–20.

^44. Ibid.

^45. Ibid.

^46. Josephine C. Wiseman, To Follow Knowledge: A History of Examinations, Continuing Education and Specialist Affiliations of the Royal Australasian College of Physicians (Sydney: RACP, 1988), 21 (cardiology); 105 (neurology);51 (gastroenterology).

^47. Evans, thesis, 101–27.

^48. Nichols et al., History of Pediatrics 1850–1950, 25.

^49. Halpern, 25, 80.

^50. Rosen, 209; Geoffrey Millerson, The Qualifying Associations: A Study in Professionalisation (London: Routledge and Megan Paul, 1964), 112–4.

^51. Abbott, The System of Professions, 82.

^52. Association of Physicians of Australasia, Minutes, General meeting, 21 January 1930; Council, 3 May 1931, 3 May 1936, and 8 May 1936, RACP Archives, Sydney.

^53. Ronald Winton, Why the Pomegranate? A History of the Royal Australasian College of Physicians (Sydney: RACP, 1988), 63–74.

^54. Millerson, The Qualifying Associations, 192, 89–91.

^55. Winton, Why the Pomegranate?, 23–7.

^56. RACP, Articles of Association, 32—7; Association of Physicians Council, 16 June 1937, Executive, 16 June 1937, RACP Council and Executive, September 1945 with lists of office bearers, fellows, and members from foundation to 1943, RACP Archives.

^57. RACP Council minutes, 21 October 1963; 10 and 11 May 1955; APA, Annual Report 1961/62, RACP Archives.

^58. Judy Sadler, “Ideologies of 'Art' and 'Science' in Medicine,” in The Dynamics of Science and Technology: Social Values, Technical Norms and Scientific Criteria in the Development of Knowledge, edited by Wolfgang Hrohn, Edwin T. Layton, and Peter Weingart, (Dordrecht: D. Reidel Publishing, 1978), 177–215.

^59. RACP Council, Report of Chief Censor, 10 October 1952, RACP Archives.

^60. RACP, Examination for Membership: Notes for the Guidance of Candidates (Sydney: RACP, 1939), RACP Archives.

^61. APA/ACP subcommittee (with RACP representatives) “Report on Higher Qualifications in Paediatrics,” 8 March 1963, Box 3, APA/ACP files, RACPArchives.

^62. RACP Council, Reports of the Chief Censor, 10 October 1952, RACP Archives.

^63. Williams, interview.

^64. J. S. Yu (paediatrician, previously Chief Executive Officer, RAHC), interview, Sydney, 11 August 1998.

^65. Ibid.; see also, APA subcommittee on “Higher Qualification in Paediatrics.”

^66. Lorimer Dods, “As It Was In the Beginning,” Australian Paediatric Journal 4 (1968): 204–8.

^67. APAAnnual Report 1954–55, Executive minutes, 8 April 1954, APA/ACP files, Box 1, RACP Archives.

^68. Dods papers.

^69. RACP Council minutes, 16 September 1965, May 1966, RACP Archives.

^70. J. H. Colebatch, W. Grigor, D. G. Hamilton, interviews.

^71. Stevens, 341.

^72. Freidson, 181, 186–8.

^73. Norman Wettenhall, “Some Thoughts on the APA,” June 1960, The Wettenhall papers, APA/ACP Box 10, APA/ACP files, RACPArchives. After 1977 the management of the APA (ACP from 1978) was vested in a management committee. D.G. Hamilton, A History of the Australian College of Paediatrics 1950–1980 (Melbourne: ACP, 1990), 31–32.

^74. Abbott, The System of Professions, 82.

^75. APA/ACP, “Report on Higher Qualifications.”

^76. RACP Council, October 1961, letter from APA to RACP, RACP archives; APA/ ACP, copy of letter from APA Executive to RACP, 21 May 1963, Box 3, APA/ACP file, RAHC Archives.

^77. W.J. Benson, “The History of the College Examinations,” in Josephine C. Wiseman, To Follow Knowledge: A History of Examinations, Continuing Education and Specialist Affiliations of the Royal Australasian College of Physicians (Sydney: RACP, 1988), 1–6.

^78. RACP Council, October 1966, RACP Archives.

^79. Wiseman, To Follow Knowledge, 21 (cardiology); 105 (neurology); 51 (gastroenterology).

^80. Jan Goldstein, “Psychiatry,” and Christopher C. Booth, “Clinical Research,” in Companion Encyclopedia, 1365, 210.

^81. Weisz, “The Emergence of Medical Specialisation.”

^82. C.R.B. Blackburn, “The Growth of Specialism in Australia During Fifty Years and its Significance for the Future,” Medical Journal of Australia 1 (1951): 20–4; Freidson, Profession of Medicine, 21.

^83.J.C.H. Dewdney, Australian Health Services (Sydney: John Wiley, 1972), 70.

^84. British Paediatric Association, “Careers in Paediatrics,” Archives of Disease in Childhood 39 (1964): 421–5.

^85. Bernard Volman, The Royal College of Paediatrics and Child Health at the Millenium (London: RCPCH, 2000).

^86. Blackburn, “The Growth of Specialism in Australia.” See also, Editorial, Medical Journal of Australia 2 (1944): 191, 192.

^87. Julian Smith, The History of the Royal Australasian College of Surgeons 1920– 1935, (Melbourne: RACS, no date).

^88. Ronald Winton, New Lamps for Old: A History of the Royal Australasian College of Ophthalmologists, (Melbourne: RACO, 1992).

^89.Hugh Barry, The History of the Australian Orthopaedic Association, (Sydney: AOA, 1983).

^90.Ian A. McDonald, Ian Cope, and Frank M.C. Forster, Per Ardua: The Royal Australasian College of Obstetricians and Gynaecologists, 1929–1979 (Melbourne: RACOG, 1981).

^91. Tessa Milne, From Clique to College: A History of the Foundation of The Australasian College of Dermatologists (Melbourne: Blackwell Science, 1999).

^92. H. E. Williams, W. Grigor, interviews and correspondence.

^93. See, for instance, Report of the outgoing President of the RACP, Dr. Jill Sewell (paediatrician), and Report of the Chair of the Paediatric Division, RACP News 25, no.4, (2006).

Why is History Important for Physicians and Medicine?

Robert G. Evans

As a paediatric physician my interest in the history of medicine came from an involvement in planning regional paediatric services and from trying to understand the tortuous and painful development of the specialty. I had the benefits of having occupied vantage points in four children's hospitals and two paediatric units in general hospitals. I met many of the people who had created Australian paediatrics and heard of their efforts to convince medicine and society that child health was a legitimate field for a medical specialty. I have watched authority change in public hospitals in Australia, moving centrally, from medical staff associations, to hospital boards and their professional administrators, to regional boards, to government departments of health. I have watched increasing specialisation in medicine, and the intertwining of all these processes.	61
I resolved to write a history of the development of paediatrics in Newcastle, NSW, and, having read something of medical historiography, decided on an academic approach I entered a post-graduate research degree programme in the history department of the University of Newcastle. The local history expanded and, with the sympathetic support and encouragement of my supervisors, emerged five years later as a PhD thesis on a history of paediatrics in NSW.	62
From these experiences one might argue that a physician/historian, an insider, a participant observer, guided by academic principles relating to evidence, interpretation and analysis, is in a privileged position to be able to offer a history that is a useful and valid interpretation of medical events, institutional evolution, or the achievements of participants. That history, if successful, should provide a special insight into how and why a segment of medicine developed at a particular time and place.	63
A history of medicine may offer a lesson from the past—a message to present or future practitioners that is more than just an interesting narrative. My own historical exercises provide an argument that unless Australian paediatricians carefully guard their heritage, so painfully won in the middle of the twentieth century, their specialty may be lost again in the unfeeling fields of internal medicine and its even more threatening subspecialties.	64
A motivation for a physician/historian may well be personal: a desire, in the words of the defenders of oral history, to make sense of the past, to undertake a life review and perhaps to justify a career choice.	65
Whatever else they might bring, historical research and writing provide very satisfying ways, in retirement, of continuing an involvement in the professional matters which have absorbed one for many decades.	66

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