Shaping institution-based specialism: early twentieth-century economic organization of medicine.

This paper focuses on structural development of institution-based medical specialism in the USA in the first third of the twentieth century. It examines organizational ideas of key reformers and specialty leaders and it examines corresponding characteristics of the institutions they built. The structural characteristics which they incorporated into medical care embodied forms of economic organization of the time. Leaders (variously) explained their reform activities in terms of scientific, professional, and/or economic development of medicine. The first section describes a form of specialization within academic medical centres as a vertical functional division of labour which divided medical work into procedures performed by a range of personnel. This division of labour and its required management changed the work of doctors and nurses and required a multiplication of 'auxiliary' hospital staff, as shown in the second section. The final section demonstrates how the departmental structure within academic medical centres provided a necessary institutional framework for vertical specialism. The literature has emphasized the fact that an industrial model was only partly implemented in medical care at the time. Nevertheless, the (industrial) characteristics identified had a significant impact on fundamental structures of twentieth-century medicine.