THE DOCTOR'S VIEW CLINICAL AND GOVERNMENTAL RATIONALITIES IN TWENTIETH-CENTURY GENERAL MEDICAL PRACTICE Thesis submitted for the degree of Doctor of Philosophy by THOMAS OSBORNE Department of Human Sciences Brunel University June 1991 BRUNEL UNIVERSITY, UXBRIDGE: DEPARTMENT OF HUMAN SCIENCES THOMAS OSBORNE JUNE 1991 TITLE: 'The Doctor's View: Clinical and Governmental Rationalitiesin Twentieth Century General Medical Practice' (Thesis submitted for the degree of Doctor of Philosophy.) This thesis traces endeavours in the twentieth century to provide the 'intellectual' foundations for general medical practice as an independent, autonomous clinical discipline. The empirical focus of the study is upon the application of psychological and 'person-centred' approaches to general practice; above all, in the work of Michael Balint, and the Royal College of General Practitioners in the post-war period. The thesis is guided by two predominant theoretical concerns. First, to highlight the complex strategies and the wide range of means and resources that have been required to give substance to the claim that general practice is 'by nature' a person-centred endeavour. Second, to consider - and to question certain influential approaches to medical power in general, and to the social consequences of 'emancipatory' - person-centred - forms of medicine in particular. Specifically, the 'power/knowledge' approach to medical sociology is contested both with regard to its empirical findings and in relation to its basis in the work of Michel Foucault (of whose writings on clinical medicine an alternative evaluation is offered). CONTENTS Preface Page 1 PART ONE: METHODOLOGY AND CLINICAL MEDICINE 1. On the Tasks of a 'History of the Present' 6 2. 'Anti-Medicine' 20 3. Michel Foucault and Clinical Medicine 38 4. Epistemology, Organisation, Government 59 PART TWO:JAMES MACKENZIE AND THE RE-INVENTION OF THE CLINIC 5. Medical Instruments and Clinical Principles 78 6. Mackenzie: Epistemology, Organisation, Government 92 PART THREE: THE TAXONOMICAL PROJECT 7. The College of General Practitioners 115 8. Technologies of the Free Field 140 9. Family Studies and Minor Morbidity 160 10. Country Practice and Collective Investigation 173 11. The Limitations of Taxonomy 190 PART FOUR: BALINTISM 12. Anti-Medicine and Psychoanalysis 216 13. Balintism and General Practice 244 14. The Governmental Consciousness of Balintism 278 PART FIVE: THE REGIME OF SELF-SURVEILLANCE 15. From Taxonomy to Pedagogy 299 16. Collegiate Patterns of Organisation and Research 326 17. Operationalising the Regime of Self-Surveillance 353 18. The Governmental Consciousness of the Regime of Self-Surveillance 388 Conclusion 417 Notes 446 Acknowledgements 479 1 PREFACE The study which follows is intended neither as a narrative history of general practice nor as a history of ideas about general practice. Its empirical concern is more specific than either of these. Focusing upon the twentieth century and above all the post-war period, it seeks to analyse some of the ways in which general practitioners have sought to autonomise their discipline by giving it an 'intellectual' basis. If the 'general practitioner' (or equivalent) has long existed as a professional label then nevertheless notions of what unifies the general practitioner's activities have undergone a degree of mutation. 1 It is these 'models' of general practice - physiological, epidemiological, psychological - which will be investigated here. As such, the purpose behind the study is partly of a 'methodological' order. The study seeks to show that what counts in evolving a coherent model of general practice is not just the provision of a 'representation' of the general practitioner's activities but a construction on several levels. One has to align, for example, the way the profession is organised with the way it produces knowledge; one has to address the question of the social 'telos' of the discipline itself. And these requirements impose limits upon what can and what cannot 2 be said in and about general practice. As we shall see, we are also concerned with 'limits' at a wider level. For general practice also appears in this study as a kind of 'social laboratory' for wider tendencies that characterise the nature of our 'present'. Most important here has been evidence of a mutation towards a mode of governance based less on anonymous rules and bureaucratic resources than one which is concerned to utilise the qualities of persons. In characterising general practice as being exemplary of modern 'technologies of subjectivity' we shall also have recourse to some of the works and insights of Michel Foucault and some of his followers.2 But this endeavour clearly involves some omissions which, in a narrative history of general practice, would clearly be important if not unforgivable. Little is said for example about the role of the general practitioner in the maternity service; certainly, a long-standing area of dispute. This is simply because this theme has not played an important role in the project of autonomising general practice as an independent intellectual discipline. Other themes are also omitted; there is little mention of medical 'politics' (cf. the discussions in Dobson 1971 and Forsyth 1966), nor of relations between general practitioners and the hospital service (Honigsbaum 1979; and, for a work, which focuses upon a similar theme of a 'split' in the medical profession, Horner 1922). 3 If the empirical focus of the study is a narrow one it is because the primary object of interest here is not the progression of a narrative but what might be termed the end-point of a series. Following some of the methodological stipulations of Georges Canguilhem, the study is analogous to a 'recursive' history which, so to speak, has its starting point and condition of possibility only with where the study itself ends (Canguilhem 1988: 1- 23; Canguilhem 1968: 9-23). This 'recursive origin' is provided by 'person-centred' medicine; that form of discourse which seeks to promote an ever-greater sensitivity to the 'ideographic' dimensions of doctoring (cf. Armstrong 1979). In what follows the focus of investigation will be oriented towards the rules of formation of the medical vocabulary of the emancipation of the person in just one medical field, general practice; a discipline which has sought repeatedly over the past seventy years or so to take up the old mantle of the 'clinic' whilst consistently setting itself the task of treating the 'patient' - and, later, the 'person' as opposed to the 'disease'; of treating the living individual rather than the inert corpse' 3 The study performs this task on the basis of an 'inventory of differences'; an investigation of models of general practice that have existed prior to this 'person-centred' paradigm which today amounts to a kind of obligatory 'infrastructure' of thought in relation to medicine. 4 This 'recursive' interest was instrumental in determining the 'data-base' of the study. Aside from considerations of the influential work of James Mackenzie (Part 2) and of Michael Balint (Part 4) the empirical focus is upon the labours of the (Royal) College of General Practitioners (founded, 1952) to institute a patient-centred general practice. Parts 3 and 5 of this study are indeed effectively 'reviews of the literature' associated with this organisation. Yet we have not written the history of the College itself (for which, Fry et al. 1983). Rather, our interest was determined by the different ways in which the College has set itself the task of establishing general practice as an independent clinical discipline around the theme of the 'person-centred' dimensions of the general practitioner's tasks (Parry & Parry 1976: 217). The history of the College also afforded an exemplary site of investigation for a study which would be concerned with the ways in which intellectual endeavours depend upon a particular kind of organisational 'technology'. Epistemological statements - even in such a 'common sense' discipline as general practice - are always dependent upon an organisational infrastructure through which their emergence becomes possible.4 The main empirical 'body' of the study is prefaced in Part 1 by some considerations - relating above all to Michel Foucault's work Birth of the Clinic - which should serve to put the present study into a wide theoretical and methodological perspective. 5 PART ONE METHODOLOGY AND CLINICAL MEDICINE 6 CHAPTER ONE ON THE TASKS OF A 'HISTORY OF THE PRESENT' 1. The History of the Present and the Project of Recuperation This study should be conceived as belonging to that order of investigation that Michel Foucault has called the 'history of the present'. This term should serve to draw attention to the particular kind of problem addressed by the study as well as to the approach employed in addressing this problem. 1.i. The notion that there could be such a thing as a 'history of the present' gained its specificity, claims Foucault, with Kant's essay Was 1st AufklWring of 1784 (Rabinow ed. 1986: 32-50; Foucault 1986: 88-96). Considering Kant's text, Foucault argues that the notion of Enlightenment (AufklVrung) - that general project (more or less incarnated by the 'enthusiasm' for the French revolution) of the universal progress of reason in the service of human happiness, emancipation and freedom - should be understood as being inseparable from the 7 problematisation and questioning of the phenomenon of the 'present' moment. As Foucault notes, the question of 'enlightenment'