The Proliferation of Medical Specialisation: A Participatory Account Ian Barry Kern A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy School of Humanities and Languages Faculty of Arts and Social Sciences November 2017 PLEASE TYPE THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Kern First name: Ian Other name/s: Barry Abbreviation for degree as given in the University calendar: PhD School: Humanities and Languages Faculty: Arts & Social Sciences Title: The Proliferation of Medical Specialisation: A Participatory Account Abstract 350 words maximum: (PLEASE TYPE) Of late, the proliferation of medical specialisation has proceeded at a pace that has left the general public, and even some medical practitioners, reeling. In his landmark book, Divide and Conquer, George Weisz argues that medical specialisation originates in the explosion of scientific knowledge, and development of special clinics and hospitals, of the nineteenth century. Contrary to Weisz, this thesis argues that specialization in medical practices has been present since antiquity, and that given supportive social circumstances and multiple knowledge claims, the tendency to proliferation cannot be confined to exclusively modern conditions. At a time when calls to ‘respect the science’ have become insistent, such an argument might seem indecorous; but my experiences as a medical specialist (paediatric surgeon) have inclined me toward a practice-oriented interpretation of the history of specialization. Further, as a participant in the proliferation of medical specialization, factors other than scientific knowledge were frequently decisive. Accordingly, particularly in my efforts to come to terms with the Australian experience (to which end I undertook over 100 interviews with a variety of health practitioners to ascertain their pathways to their chosen professions and their views on specialization), I have focussed on specialisations in action, and the interconnections and contexts of practice, as a way to produce a more balanced and nuanced view of the processes at work. An additional benefit of including the Australian story is that the significance of local factors is brought to the fore, undermining temptations to see developments in Europe, the UK and America as definitive. Further, this thesis discusses drawbacks to proliferation; namely, the tendency to undermine holistic approaches to health care, increased cost to the community, and the inclination to treat because one can rather than one should. The thesis offers some recommendations that might help overcome some of the negative effects of specialisation. 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I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’ Signed ................................................................. Date ................................................................. COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.' Signed ................................................................. Date ................................................................. AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’ Signed ................................................................. Date ................................................................. Figure 1. The Directory of St Vincent’s Clinic, Sydney, Australia—a snapshot of the proliferation of medical specialisation (by permission of St Vincent’s). TABLE OF CONTENTS Acknowledgements i Abbreviations ii Introduction 1 Chapter 1. Practices of Specialisation 13 Chapter 2. Specialisations in Action 32 Chapter 3. Pathways and Participation 92 Chapter 4. Organisational Structures 107 Chapter 5. Special Circumstances: The Australian Rural Scene 142 Chapter 6. Interconnections and Contexts of Practice 165 Chapter 7. Futures and Contingencies 190 Conclusion 205 Bibliography 208 Appendix 1 239 Appendix 2 245 Appendix 3 262 Appendix 4 263 Appendix 5 264 i Acknowledgements I would like to thank the following people, without whom this thesis could not have been written: my supervisory team, Drs Susan Hardy, Anthony Corones and Nick Doumanis, who were always supportive and encouraging; Alice Waugh, who provided indispensable editing assistance and secretarial help; my generous interviewees; the kind librarians, many of whom were complete strangers, who gave freely of their time; and my son-in-law, Jonathon Armstrong, for his help with photography and the appendices. Above all, I am deeply grateful to my wife Vicky for her patience, faith and enthusiasm—without her, I could not have contemplated attempting to write a PhD. ii Abbreviations AAN Australian Association of Neurologists AANMS Australian Association of Nuclear Medical Specialists AAP American Academy of Pediatrics ABMS American Board of Medical Specialties ABS Australian Bureau of Statistics ACC American College of Cardiology ACEM Australasian College of Emergency Medicine ACP Australian College of Paediatrics ACP American College of Physicians ACRRM Australian College of Rural & Remote Medicine ACSP Australian College of Sports Physician A&E Accident and Emergency AGS Australian Geriatric Society AHA American Heart Association AMA Am American Medical Association AMA Australian Medical Association AMC Australian Medical Council AMU Acute Medical Unit AMWAC Australian Medical Workforce Advisory Committee ANZAPNM Australian and New Zealand Association of Physicians of Nuclear Medicine ANZCA Australian and New Zealand College of Anaesthetists ANZICS Australian and New Zealand Intensive Care Society ANZJS Australian and New Zealand Journal of Surgery ANZSNM Australian and New Zealand Society of Nuclear Medicine AOA Australian Orthopaedic Association APA Australian Paediatric Association ARA Australian Rheumatology Association ASA Australian Society of Anaesthetists ASCMO Australasian Society of Career Medical Officers ASEM Australian Society of Emergency Medicine ASIM American Society of Internal Medicine iii ASO Australian Society of Ophthalmologists ASMF Australian Sports Medicine Federation BCGP British College of General Practitioners BMA British Medical Association BMJ British Medical Journal BOA British Orthopaedic Association CAT Computer Assisted Tomography CICM College of Intensive Care Medicine CME Continuing Medical Education COSA Clinical Oncological Society of Australia CRS Colorectal Surgery ENT Ear Nose and Throat ERC Empire Rheumatism Council FIFO Fly In Fly Out FRACS Fellow Royal Australasian College of Surgeons FRANZCO Fellow of the Australian and