epidemiology as an investigative paradigm: the college of general practitioners in the 1950s

Sm. Sci. Med. Vol. 38, No. 2, pp. 317-326. 1994 0277-9536/94 $6.00 + 0.00

Printed in Great Britain. All rights reserved Copyright Q 1994 Pergamon Press Ltd

EPIDEMIOLOGY AS AN INVESTIGATIVE PARADIGM: THE COLLEGE OF GENERAL PRACTITIONERS

IN THE 1950s

THOMAS OSBORNE

Department of Human Sciences, Brunei University, Uxbridge, Middlesex UB8 3PH, England

Abstract-This paper focuses upon the research investigations of the College of General Practitioners in Britain in the 1950s. Beginning with a discussion of Michel Foucault’s concept of ‘pastoral power’, the paper proceeds to analyse the ways in which the College attempted to set up an epidemiological scrutiny of general practices across Britain; from practice by practice observational studies to the first National Morbidity Study. The paper concludes by arguing that the epidemiological paradigm in general practice was beset by particular internal ‘limits’, and was replaced increasingly from the 1960s by an emphasis upon psychotherapeutic approaches.

Key words-general practice, College of General Practitioners, pastoral power, Michel Foucault, epidemiology, country doctor

GENERAL PRACTICE AND PASTORAL POWER

Michel Foucault liked to distinguish a novel form of power that emerged in the sixteenth century, and which, he thought was peculiarly characteristic of the modernity of the West. This he termed ‘pastoral

power’ [l]. What distinguished this kind of power for Foucault was that it was, as he put it, both ‘totalizing’ (concerned with the cultivation of the welfare of the entirety of a population of citizens), and simultaneously ‘individualizing’: “a form of power which does not look after just the whole community but each individual, in particular, during his entire life”

[l, p. 2141. Foucault summed up by saying that “the multiplication of the aims and agents of pastoral power focused the development of knowledge of man around two roles; one, globalizing and quantitative, concerning the population; the other, analytical, concerning the individual” [ 1, p. 2151.

No doubt, as Foucault’s own researches seem to

bear out, medicine has had an important role to play in the evolution of this pastoral power. In The Birth of the Clinic, Foucault laid great emphasis upon the fact that clinical medicine as it emerged towards the end of the eighteenth century, was the “first scientific discourse concerning the individual”; a form of knowledge that was concerned to be both generaliz-

ing yet related fundamentally to the “individual fact” [2]. Yet elsewhere he emphasized that this ‘privatized’ concern for clinical principles and individual examin- ation “cannot be divorced from the concurrent organization of a politics of health, the consideration of disease as a political and economic problem for social collectivities which they must try to resolve as a matter of overall policy” [3]. Similarly, the varieties of public health medicine and collective provision that have developed since the nineteenth century

would seem to testify to medicine’s function in the ‘totalizing’ aspect of pastoral power [4]. This is not to say, of course, that such collectivized forms of medical supervision represent straightforward attempts at ‘social control’, or that medicine functions in these contexts simply as a diabolic extension of the arms of the state. Indeed Foucault himself, by questioning any resolute distinction between ‘privatized’ and ‘socialized’ forms of medicine, sought precisely to cast doubts on the positing of too close a linkage between the activities of pastoral power and the activities of the state per se. Rather, as Foucault argued, health and sickness have tended to be problematized “through the initiatives of multiple social instances, in relation to which the state itself plays various different roles” [3, p. 1671.

Of course, it may well be the case that the concept of pastoral power, whilst being suggestive, is rather too generalized for use in specific and detailed histori- cal instances. Nevertheless it is serviceable in helping us to direct our questioning in a certain way. Rather than assuming that medicine has inevitably embodied ‘real’ instances of pastoral power, it might be more apposite to view the alignment of ‘individualizing’ and ‘totalizing’ functions that Foucault associates with its dissemination as general aspirations-as it were, a pastoral principle-governing the establishment of particular medical rationalities and general problematics. In just such a way, this paper argues, might the recent history of general medical practice be investigated as an instance of a projected pastoral power.

What after all characterizes general practice as a form of expertise if not precisely an aspiration to integrate such individualizing and totalizing functions? In terms of professional status, general practitioners have tended to adhere to an ideal of resolute

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THOMAS OSBORNE

individualism, traditionally resilient to the encroach- ments of central state direction. In short, general practitioners have been concerned to preserve the status of their discipline as an individualizing, ‘clinical’ art; an art centred upon the surgery and the particular case [5, 61. Nevertheless, like it or not, general practitioners have found their vocation increasingly problematized in terms of welfare, and state provision; indeed, they have frequently sought to understand their own activities precisely in such terms [7,8]. In any case, recalling Foucault’s comments concerning the medicine of the eighteenth century, any understanding of the nature of general practice in terms of the opposition between a ‘privatized’ and a ‘socialized’ service would be somewhat misleading [3]. Since the foundation of the NHS, general practice has been by definition integrated into a ‘socialized’ form of intervention, yet general practitioners have famously sought to preserve the ‘privatised’--clinical. individual-status of their en- deavours. Indeed, one might argue that the recent history of general practice can be posed precisely in such terms of an attempted alignment of these two poles of pastoral power--the aspirations to totalization and individualization.

THE COLLEGE OF GENERAL PRACTITIONERS

Whilst it is true that general practitioners as a body were concerned about the effects of the NHS on their own status as independent contractors, the very fact that, by the 1946 Act, general practice became occu- pationally marginalized from the hospital domain resulted in a kind of de,f&to establishment of general practice as an independent, if not yet homogeneous, discipline embodying a specific vocation. In short, the opportunity-one might say the necessity--arose of turning general practice into a kind of ‘specialty’ in its own right.

It was with the establishment of a research domain adequate to a conception of general practice as a ‘specialty’ that the College of General Practitioners, founded in London in 1952, was originally concerned. The College was conceived by its founders not so much as a political or professional body but as, at least potentially, a kind of academic one-s- tablishing and promoting the boundaries of general practice research [9%12]. The aim was to emancipate general practice from the general sense of long-term neglect under which its proponents felt themselves to have been labouring by founding a research-oriented organization that would be expressive of general practice as a specific discipline in its own right. Two inter-related tasks were implied by this project, and these will be the main subject of this paper. The first was the establishment of a form of organization that would be appropriately fitted to the particular nature of general practice as a domain of knowledge; the second was the establishment of a research paradigm proper to that domain of knowledge itself--a para-

digm that was to be embodied in the 1950s. as we shall see, by collective epidemiological investigation.

A NATURALlSTlC NORM OF KNOWLEDGE

How was general practice to be understood as a particular kind of medical gaze? A certain amount of consensus reigned as to the answer to this question. What everybody agreed upon was that general practice was characterized as a form of expertise. above all. by a kind of ‘naturalized’ status. The general practitioner, so matters were understood, works unhindered; in the surgery, in the home, in the community-away from ‘artificial’ sites of medical attention such as hospitals or health centres. The general practitioner is the first line of defence, seeing disease in its natural state before it becomes, so to speak, ‘immobilized’ by the techniques of diagnosis. More- over, the general practitioner’s tasks are governed by a kind of intuitive knowledge of patients rather than by a ‘scholastic’ hospital-based conceptualization of morbidity [9, 13, 141.

Above all, the general practitioners saw themselves as working within what was essentially understood as a ‘free field’, unhindered by artificial and discontinuous medical structures [cf. 2, p. 381. This free field was to be a socio-medical space, particularly hostile to the refractory effects of medical institutions. Disease could only appear in its pristine state when viewed. so to speak, in its natural domain; that is, in that field of investigation where general practitioners conducted their daily work. What characterized this domain, relative to our discussion of pastoral power, was that it was to be both analytical in its compo- sition-comprising a multitude of individual practitioners, working independently at their clinical tasks-yet totalizing in its nature, that is, in principle. covering the entire expanse of the country, a totalizing surveillance of the population.

If this naturalistic yet comprehensive domain of intervention was to be respected it was essential that the organization of the College should promote rather than hinder or distort the workings of practitioners as individuals. Above all, it was imperative that the rule of the institution was not to be imposed upon the individual practitioner. The purpose of the College was not to direct general practitioners as to how they should practice (education in general practice. for example, should be essentially akin to ap- prenticeship, undertaken only in the practical context of the free field itself) [15. 10. p. 781 but rather---an information-gathering role-to lurk together general practitioners as they currently practiced, and to col- lect information as to the general nature and state of general practice so that they might practice better.

The organizational structure of the College was not designed to direct these collective labours of information-gathering, but to regulate and co-ordinate the information that resulted from the independent efforts of practitioners. College headquarters was to

Epidemiology as an investigative paradigm 319

be a kind of advisory centre regulating the free field of general practice. A College faculty system was devised which was cover the country and provide local points of focus for educational activities and research; local faculties were expected to liaise with their local medical school (faculties were pur- posely sited in proximity to university medical departments in order to facilitate this) and to pass on and receive information from the central headquarters in London. At headquarters, committees would meet to process information and re-distribute results back to the periphery in a kind of circular process of knowledge accumulation distribution and standardiz- ation.

The workings of the College Research Committee, the central locus of the College’s activities in the 195Os, illustrate these organizational and research imperatives very well [16]. At the centre there was to be a Research Advisory Committee (composed of members from a whole variety of fields) whose task was to sift through proposals for research (typically concerning small individual projects and collective investigation alike-on the subjects of morbidity, epidemics, conditions of practice and so forth), assess their feasibility and offer advice through what was known as the ‘consolidated comment’ system [IO, pp. 59-73, 171. and put researchers into contact with relevant expert bodies should further advisory assistance be necessary. The Research Committee’s tasks centred on liaising with outside bodies interested in the mapping of the free field (the Ministry of Health, statistical and research organizations and so forth) and on the organization of larger scale research projects. Where necessary, this involved activating the extended technology for the College’s Research Register (a list of practitioners across the country who were prepared to take part in collective investigations of various kinds) in collecting information in the field:

The College research organisation can work both centrally and peripherally. The central organisation will be equipped to cope with the consolidation of clinical records and material from practitioners and their study groups all over the country, and to advise with regard to techniques for the collection and analysis of this material and the necessary controls [ 1 I, p, 13241.

In short, the College’s organization was to take the form of a flexible but well-integrated assemblage of individuals and institutions. fitted perfectly to-because immanent to-the circumstances of the free field itself. According to this organizational schema, nothing is imposed upon researchers beyond their co-operation; within the loose and flexible assemblage of Collegiate institutions they are to have maximum autonomy and individual discretion. They are not asked to change their ways but only to monitor their activities for the academic enlighten- ment of the collectivity. And this very freedom gave the College headquarters a certain purchase on the minutiae of the free field itself. Indeed, very quickly,

the College was to turn itself into a central resource for access to the free field; building up links with the Ministry of Health, the statistics department of Birm- ingham University, the Medical Research Council, the General Registry Office, the Public Health Lab- oratory Service, and a host of medical schools. As an editorial in the second College Research Newsletter was to sum up matters:

The pendulum has started to swing away from the hospital world, the world of departments, the world of the frag- mented man back to the study of the whole man as the varied stress factors of his life may affect him. It may be that the next advances in medicine will come from a fuller understanding of the field in which 20,000 general practitioners are daily at work and means must be found for exploring this clinical material [18].

The actual research technologies made possible by the installation of this ‘ready to hand observer network’ were to be conducted on several registers. Perhaps the most important of these were the activity of practice description and the paradigm of the collective epidemiological investigation of minor morbidity.

PUITING THE PRACTICE INTO WRITING

One of the most immediate striking features of the research activities of the College in the 1950s was the concern with what might be termed the ‘infrastructural’ aspects of practice. Of particular interest for the doctors were various logistical methods and techniques designed to keep continuous the flow of patients in the surgery, to ease the running of the doctor’s task, to ‘free the doctor for doctoring’ according to a model of unimpeded yet ‘natural’ visibility [19,20]. Particularly important amongst such techniques were devices such as rota systems, ancillary services, equipment-rationalization, various systems of recording and record-keeping, appointment systems, forms and paperwork of a great variety of kinds [19,21-251. What is most striking is less the nature of such infrastructural devices themselves so much as the way in which the activity of description relating to such practices and devices became so rapidly a dominant research ethic amongst members of the College. It was as if the labour of describing the existing circumstances of genera1 practice had taken precedence over the pursuit of a novel research paradigm for the discipline; indeed as if the act of description was itself the key research act entailed in general practice.

For instance, in 1956 the Post-Graduate Education Committee of the College reported to the College Council on the subject of research into the area of the “professional accommodation and equipment of family doctors and those intending to enter general practice”. This committee would be concerned with such matters as waiting rooms, dispensaries, consult- ing rooms, but also the administrative problems of record systems, details of charts (temperature,

320 THOMAS OSBORNE

dietetic, intake and output), diet sheets and other kinds of inscriptive apparatus in general practice [ 10, p. 150-1511. Investigations were soon underway. By May of 1957 a pilot scheme relating to eight practices was begun in order to establish a standard method of presentation that could be used in order (in the apt phrase of a memorandum of July 1958) “to put the practice into writing” [26]. This standardized procedure, as outlined by the Practice Equipment and Premises Committee involved details of practice organization, ancillary help, appointment systems, ro- tas. size of rooms, decoration, furnishing, lighting and temperature, ventillation, finances and costs, and the inclusion of architectural plans and photographs. Eventually, it was hoped, enough practice descriptions would be collected to form what would be an advisory dossier available from College headquarters on all aspects of the space of the practice.

Similarly, a glance at successive editions of the journal The Practitioner (a journal with, at that time, close associations with the College) discloses that the activity of putting one’s practice into writing was far from being a marginal exercise in the 1950s. The Practitioner was, in the 1950s a journal of clinical medicine, taking for its quarterly theme a topic of particular medical research. In the 1950s the theme of general practice research did not relate to diagnostic innovations and so on so much as to the study of the space of the practice premises. A special edition on ‘General Practice Today and Tomorrow’, for example [27] contained as well as a series of photographs of exemplary practice premises, articles relating to the ‘The Doctor’s Surgery’, ‘The General Practitioner’s Premises’, ‘Organization of Group Practice’ and other related themes. Meanwhile in the following years, in an issue of the journal devoted to ‘Advances in Treatment’, the section on general practice passed quickly over the question of advances in diagnosis and treatment and concentrated almost entirely on what was termed the ‘way of life’ of general practice-which was then laboriously de- scribed-since it was in this domain that “the greatest advances have taken place in general practice over the last two or three years” [28].

It would be misleading to see this infrastructural research ethic, however, as a retreat from the pursuit of a homogeneous research paradigm for general practice; or for instance, as reflecting an obsession with concrete conditions at the expense of establish- ing wider objectives for general practice. In fact what was being recognized here was that the essence of general practice lay in the details, in the minutiae of the practitioner’s habits and conduct. If general practice was to become a truly pastoral discipline, its nationwide organization would have to be correlated at the lowest level with a power that reached down through the minutest capilleries of practice existence. General practice would have to become a discipline characterized by an almost calculated mundanity. In general practice, it was precisely at the most mun-

dane, un-remarkable, yet compulsively detailed level of existence-that of small-scale facets of organization and minor technical innovations--that the ‘leading edge’ of power would necessarily reside.

THE SURGERY AND THE HOME

It would clearly be an absurdity, however. to deduce from this concern for detail and minutiae some kind of sinister disciplinary vocation on the part of general practice; after all, power---as some sociol- ogists may need reminding-is not the same thing as discipline. What was at stake was rather a kind of technico-paternalist vocation; mixing ideals of observational exactitude with those of a paternalistic ethic of moral guidance. We can ask, in this context, what kind of practice it was that constituted the ideal medical space?

Above all, what was sought was a well-regulated internal environment, which includes a kind of atmosphere (both physical and emotional), allowing for maximum visibility and freedom of movement; the absence of all obstacles that might divide the world of the sick from the gaze of the doctor. Anything that allows free flow of movement~~albcit very carefully regulated (via appointment systems. electric-buzzer calling devices, receptionists and so on)- will be deployed so long as these are not allowed to come into contradiction with the discretion and autonomy of the individual doctor. The surgery has to be constructed as a space that is ‘scientific’ in so far as it is geared rationally to the art of observing patients. according to an ethic of perfect order and complete visibility. Yet the condition of such visibility will itself entail that the surgery should be a kind of ‘natural’ space where the individual can appear without distor- tion. As such the surgery must present itself at once as the locus of order and technical cllicicncy and simultaneously as a homely, affective space [29],

As a combination of both a scientific and an affective-emotional (though not a psychiatric) space. the general practitioner’s surgery came into a relation of natural homology with the space of the family home. This homology has. first of all. the condition that both arc naturalistic types of domain -distinct from more artificial sites of family observation. Hence the denigration of child guidance clinics and other alien sites of family intervention:

schools. climca and other social services outside the family wll have a large share in the national life. but they cannot take the place of the influence of the family environment

1301.

Of course, there can be no substitute for actual observation in the family space. And who is better qualified to observe this space than the family doctor himself who has such natural access there? For:

In the domestic warmth of the kitchen. in the snug atmosphere of the surgery. there are so many more opportunities for this kind of instruction than in the cold comfort of the


clinic; where, be the health visitor never so neat, the nurses never so charming, the voluntary helpers never so motherly, intimacy and the consequent will-to-learn are hard to gener- ate [3l].

Secondly, aside from having in common a certain distinctiveness from other more artificial spaces of observation, both home and surgery are nevertheless, in a sense, ‘medical’ domains, having as their point of mutual intersection, the family. In both home and surgery, it is of paramount importance to maintain a carefully adjusted and monitored internal environment [32-351. Great pains are to be taken with minute descriptions of ventilation, fresh air supply, air temperature and so forth in order to ensure the least submission to respiratory infections and to maintain the optimum atmosphere (physical and emotional). The desire for a systematic regulation of the interior space of the home demands attention, in parallel to the concerns in the surgery with logistical regulation, to the functions of rooms and the maintenance of constant visibility over offspring [30, p. 441. Above all, this discourse centred on the ideal surgery and home instances a fundamental anxiety concerned with minor morbidity-especially that of children- as a constantly potential, if hitherto generally hidden, threat to the physicomoral integrity of the population.

MINOR MORBIDITY AND PASTORAL POWER

If there was a ‘conceptual persona’ that was constitutive of the art of general practice in the 1950s then this was not to be-as was to be the case by the mid- 1960s-the psychotherapist or psychoanalyst but the supposed master of minor morbidity, the country doctor [3&38]. This ideal persona actually took on a ‘concrete’ form in the person of Dr William Pickles, who was duly to become the first President of the College of General Practitioners. Pickles com- bined two exemplary characteristics proper to the country practitioner; an intimate-literally ‘pastoral’-familiarity with the home lives and personal characteristics of his patients, and a research orien- tation into the minor epidemics of the countryside. The image of the country doctor is above all that of a generalist; because he finds that, far from the major sites of medical endeavour, he has to do everything himself (minor surgery, dispensing, preventive medicine, giving friendly advice and so forth) [39] and because his expertise is not confined to strictly bio- medical pursuits. In the countryside patients are simple folk with ways of their own which have to be-paternalistically, indulgently-understood;

patients are in fact more or less equivalent to children in the countryside [38, p. 2011. But the practitioner does not put this pastoral familiarity to psychiatric uses; rather this personal knowledge is deployed in the investigation, above all, of minor morbidity.

It was Pickles who provided the model for this kind of knowledge in his Epidemiology in a Country Prac-

tice [40], a seminal moment in general practice mythology. In that work, Pickles disclosed the methods he had evolved for mapping the “natural history of disease” in the countryside. By the use of charts marking off in squares the days on which people in the practice contracted particular epidemics, a visual picture could be built up that revealed the time-intervals between contractions of the infection; hence allowing calculation of the typical incubation period of the disease, the period when it is at its most infectious, the length of its stay in the community, its juxtaposition with other infections. Using his personal knowledge of patients, their re- lationships and whereabouts, Pickles was able to provide detailed accounts of the course of the infection, its sources and the geography of its dissemination. This kind of investigation depended for its efficacy upon the existence of a closed community of known individuals as the site of investigation:

Wensleydale in early days must have been as much a closed community as those herds of mice which experimental epidemiologists find so useful in studying the ways of epidemics [40, p. 141.

In Pickles’s work, the cause of an epidemic entering the community will be typically either some outside, foreign connection in the village (gypsies, a visit by a villager to a large town) or a carnivalesque social occasion, with all its attendant dangers (“There are now cinemas, and there are, of course, concerts, whist-drives, and dances. . .“). The most important crucible of infection, however, was the school, even though, fortunately in the case of Pickles’s Wensley- dale; “the headmaster is epidemiologically minded and alive to the dangers of the school helping an epidemic around the countryside” [40, p. 211.

Would not the kind of intimate knowledge pos- sessed by the likes of Pickles be even more powerful, of even greater utility, if it could be related on a systematic basis to the whole country? Might one not envisage the generalization of this paradigm-the localized pastoralism of Pickles’s work-beyond its analytic functions in local village communities onto the totalizing level of the population itself? In spite of certain necessary departures from the model, the Epidemic Observation Unit of the College of General Practitioners represented just such an attempt to put such investigations onto a nationwide basis; to establish the project of a natural history of disease as a collective endeavour at the level of the national population.

COLLECTIVE EPIDEMIOLOGICAL INVESTIGATION

The conditions that interested the general practitioners associated with the College were characterized by their invisibility to the established sites of medicine; conditions, for example, infrequently-because either too rare at the level of the individual practice, or too minor in importance-to be seen

322 THOMAS OSBORNE

within the walls of the hospital, conditions of which the full clinical picture or the typical course of infection remained unclear; epidemic winter vomiting, pyrexia of unknown origin (shere fever), influ- enza, measles, mesenteria, lymphadenitis, various respiratory conditions. The purpose of the Unit was to make visible, by use of technological forms, an infection which, taken case by case, would have remained obscure; to describe both the ‘picture’ of the disease (characteristic signs and symptoms) thus making diagnosis more reliable, and its natural course both in the individual and the community (incubation period, typical rate of spread and so on)

[411. The College envisioned the tracking of such mor-

bidity as fundamentally a collective endeavour. In order to make these forms of minor epidemic morbidity more visible an institutional apparatus needed to be set up through which practitioners could alert one another to outbreaks and, in turn, report their find- ings. This collective research technology came to consist of an advisory function at centre and periphery, and a ‘warning system’ with the College’s Re- search Newsletter (and, later, a publication entitled, enigmatically enough. Between Ourselves) serving as the means of communication between them. Mem- bership of this research network consisted of all those on the Research Register of the College (by 1954 there were 380 names on this register) [42]. A practitioner who, on the basis perhaps of the observation of just a few cases, suspected that he had the dim outline of an epidemic appearing in his practice would notify the director of the Observation Unit at the College. Next, a ‘yellow warning’ would be sent out to inform all those on the research register to be on the lookout for similar cases and. should any appear, to inform the originator of the warning. Should the outbreak be of special interest ‘red warning’ would be sent to all members of the Research Register. Finally, a ‘purple warning’ would inform those interested that a full report of the outbreak would be published in the forthcoming Research Nm~sletter [43]. The case of epidemic winter vomiting provides a good illustration both of the workings of the Observation Unit. and of what it was able to make visible. This condition is an example of an affliction rarely seen anywhere but in general practice; moreover its clinical picture is unclear, being a kind of vague concatenation of symptoms with few dis- tinguishing physical signs present:

What is known about this disease has largely come from localized outbreaks in closed communities such as schools, hospitals etc. One aim was to study the disease as it appeared in general practice with special reference to its seasonal incidence and its spread from one locality to another [44].

Over the winter of 1954 approximately 1300 cases

had been reported in 120 local outbreaks involving 120 general practitioners. As a result of the pooling of their observations. the College was able to draw up

both a clearer symptomatic picture of the illness itself, differentiating it more finely from other apparently similar conditions, and to trace the geographical distribution of an epidemic in the community that would have otherwise remained invisible to the medical gaze [44, p. 281.

As writers in the College journal and elsewhere pointed out, the significance of this kind of investigation was its focus on the collective facts of morhid-

it?! as opposed to mortality [45]. Previously, the analysis of notifiable infectious diseases had represented the only systematic medical confrontation with morbidity in the living population. Not that the concern with morbidity was exclusive to the Epidemic Observation Unit of the College of General Prac- titioners: other institutions such as the Ministry of Pensions and National Insurance had also been concerned with mapping this field; although none had hitherto attempted to do so across the entire free field of the nation itself. But this was indeed the ambitious project which the College had (in fact. since its very inception) been envisaging. A College Records Unit had been set up to supervise the setting up of a constant monitoring of morbidity occurring in the

national population:

to carry out a constant and continuous watch on the illnesses of the community through the eyes of an observer- group of perhaps a hundred practitioners. In many ways this watch will resemble that kept on the weather by the Meteorological Ofice, where n+orts from numerous field workers are coordinated and translated quickly into information valuable to us all. It will be our task, with whatever help we may receive. to bring the sources of t’dmily illnesses to the surface, to measure their effects and to take steps to prevent spread or further recrudescence.

Whilst the Records Unit of the College itself-&when it was tinally set up in 1957%was actually to be far more concerned with the methods of data collection than with extensive investigations per se, such a nationwide investigation was, nevertheless, to be undertaken.

THE NATIONAL MORBIDITY SURVEY

Like the College’s epidemiological work, the Na- tional Morbidity Survey, undertaken as a joint ven- ture between the General Register Office and the College’s research network, was intended as a contri- bution to the project of the mapping of the “natural history of disease” at the level of the general population [46]. Moreover, the ambitious nature of this project should not be underestimated; for it was hoped that such investigations would ultimately lay the groundwork for a new science, one not centred on morbid anatomy, the lesion or the microbe; but a morbid mapping of the free held. And thus would necessarily entail a novel system of medical nomenclature and taxonomy more appropriate to the world of general practice. As Pickles had put it:

A nomenclature which is based on morbid anatomy or on


the presence of infecting organisms finds little place in the records of general practice [47].

Such a new taxonomy specific to the demands of general practice would be one resultant of collective investigation [IS, p. 21. But finding the actual means of conceptually and practically codifying morbidity was not simply a question of collating at College headquarters the entirety of haphazard information collected by general practitioners in the field. For it soon became clear that the domain of evidence and investigation in general practice was simply too diffuse, simply too many forms of classification were possible.

This problem of the incommensurability of classifi- cations had already been encountered by the Re- search Advisory Committee of the College when considering applications for research studies coming from the faculties. Going through the material collected as part of the College’s ‘consolidated comments’ system, whereby genera1 practitioners at College headquarters would monitor the research proposals and strategies for practitioners in the field, one quickly perceives that the problem in the 1950s was less one of sub-standard research proposals but rather one of a lack of stable diagnostic standards altogether. Although a host of individual practitioners had mapped the profiles of morbidity in their practices all that had emerged was, far from a continuous picture of disease in the population, a mass of confusing, if impressive heterogeneity. One research proposal, for example, drew the comment:

I always wish that GPs who are interested in this kind of work would use the same classification so that their figures were comparable. Truly he will get something out of it himself but how much more could be obtained if his results could be compared with those of other similar observers?

[4gl.

But how was such a uniform system of classification to be devised? The research decisions taken in prep- aration for the National Morbidity Study and some of the studies-under the broad shadow of the Mor- bidity Study-show up the difficulties encountered by all those who wished to enact the strange marriage between the science of statistics and the art of the individual that general practice conceived itself to be.

The Morbidity Study was intended to measure simply the amount of sickness encountered in the national population:

to provide data of value to the medical research worker, the sociologist, the administrator and, by no means least, to the general practitioner himself [46, p. 11.

This data was collected from the clinical records of 106 practices in England and Wales between May 1955 and April 1956, and was analysed by statistical coders at the General Register Office. What was actually revealed was less the morbidity profile of the national community than the limitations of the paradigm of collective investigation itself. In any case, several problems manifested themselves.

The main problem concerned the classification of diagnoses. Unlike the hospital case, where a diagnosis could be entered when the patient was discharged, in general practice a diagnosis had to be entered at each encounter. This meant that, since diagnoses were liable to change and since patients were liable to attend the surgery more than once during the one- year period of data-collection for the study. the unit of analysis could not be the patient per se; thus eliminating from the analysis one of the elements most closely associated with general practice as a vocation. Both the chronic patient with an underlying condition manifested as a series of different conditions was obscured, as was the ‘troublesome neu- rotic’ (important because known to be so common, yet for whom a firm diagnosis suitable for statistical classification was rarely straightforwardly possible) [47,46. p. 411.

But a more serious problem related to the sheer volume of diagnoses that appeared in the survey itself; over 500,000 in fact (by way of comparison, Sauvages’ famous classification of 1763 in his Nosolo- giu M&o&a had turned up a mere 2,400 different diseases). But this was less a problem of the prolifer- ation of different diseases than the result of the fact that-individual discretion in modes of clinical practice being paramount-ach doctor was allowed to use the terminology that suited him best. What was effectively at stake was the question as to whether doctors should be ‘disciplined’ into using a coherent and pre-set classificatory system, agreed upon prior to the investigation itself; a disciplining that would seem to be at odds with the nature of general practice as an art of the individual. But even were this ethically feasible, the difficulty remained that there was simply no way to find absolute agreement on the diagnosis of the kinds of conditions found in genera1 practice. A pilot study relating to the national morbidity investigation, conducted by the College Re- search Committee had already indicated the difficulties of applying strict diagnostic categories to conditions--composed largely of vague ‘symn- tomcomplexes’ rather than clearly defined diseases as such+ncountered in general practice. Only 55% of diagnoses by the I2 doctors studied could be labelled as ‘firm’ (though in fact only 70% of these would later be proven to be accurate); and 30% of diagnoses would found to be initially only ‘tentative’

]491. Aside from these diagnostic difficulties, doubts

were also to emerge concerning the clinical use-value of such research. Volume III of the Morbidity Study, which was produced by the College itself, was concerned with translating the statistics derived from the observation of practitioners back into a recognizable clinical language to be of use to practicing doctors [46, 1962, p. v]. In fact, as the introduction to the volume acknowledged, what was perhaps most striking about the study was less the information it gave concerning the prevalence and incidence of morbidity

324 THOMAS OSBORNE

in the national community than the way in which it revealed that statistical results were themselves largely dependent on the clinical predelictions of the doctor concerned [46, p. 21. Indeed, it became increasingly evident that disease taxonomies were largely the cmstructs of medical expertise:

Doctors who make a special study of a disease always find more cases in their subject than the disinterested worker [46. p. 36.47, p. 1291.

But, more radically, writers began increasingly to

point out the lack of relevance of the statistical

project as a whole to the aspirations of general

practice knowledge. Already in 1955, one delegate to a conference of College faculty chairmen had pointed out that:

all the work written or discussed had concerned individual disease. Yet the particular role of the GP was to follow the same patient through many diseases. We should, in our researches, concern ourselves more with the patient [51].

This was a theme that was to be taken up increasingly towards the end of the 1950s as a certain sense of disillusion set in about the epidemiological vocation in general practice. In particular, it came to be felt increasingly that the general practitioner’s role was more than just medico-scientific:

In this age of the specialist the general practitioner is the specialist in domiciliary medicine and, to my mind is the specialist in treating porienf.r as human beings-and such a calling demands personal qualities besides medical qualifica- tions [52].

Yet such a calling-the inclusion of the concern with the patient as an individual-within the epidemiology of general practice was to prove ultimately inconsist- ent, in spite of various attempts to develop appropriate classificatory systems more sensitive to the individual experience of illness [53]. In fact, it was only with the abandonment of the epidemiological problematic as the guiding rationality of research at the College and its replacement with a psychotherapeutic rationality-in which the work of the psychoanalyst Michael Balint was to assume a certain importance-that a confrontation with the patient’s individual experience of illness become a coherent possibility.

COLLECTIVE INVESTIGATION, PSYCHOTHERAPEUTICS AND PASTORAL POWER

What were the limitations-in the sense not of

‘errors’ but of inherent limits-of the paradigm of collective epidemiological investigation? Perhaps we can single out two.

First of all, this rationality failed to bring about an alignment between the means by which the profession was to govern its own activities, and the means by which it objectivised and governed the objects of its concerns. As regards self-government, the College was established on the basis of allowing the practitioners involved in research activities the maximum

flexibility in pursuing their tasks-most notably, in terms of letting them preserve their own habits of classification in their research. This flexibility was not a form of institutional ‘cowardice’ on the part of the College-a failure to impose its requirements on individual practitioners in the field. Rather, such flexibility represented, one might say, an integral aspect of the concern for clinical ‘truth’ at this time. The gaze of the practitioner had, above all, to be sensitive to singularity-overarching guidelines and systems of classification would thus have distorted the emergence of clinical truth. Yet. since the conse- quence of this flexibility was an array of disparate and discontinuous results, this concession to the clinical freedom of practitioners worked against the generul- ization of the epidemiological paradigm into a totalizing clinical gaze capable, as was the aspiration of the College, of monitoring the entire space of the general practice population in Britain. In short. to revert to Foucault’s terminology as regards pastoral power, the ‘individualizing’ imperative of the epidemiological paradigm came into a kind of objective ‘contradiction’ with its aspiration to ‘totalization’

[541. A second limitation was related again to the pro-

posed status of general practice as a discipline concerned with the individual. For the paradigm of epidemiological investigation failed to feed back no- ticeably on everyday clinical practice in the surgery; in this sense, it failed to achieve the status of a properly ‘clinical’ form of knowledge. No guide for action in the surgery in relation to patients could be said to have derived from the form of knowledge proper to epidemiological investigation. Above all. it was unclear how this work connected to the government of subjectivity. How did the knowledge gener- ated in the collective study of minor morbidity connect to that truly ‘pastoral’ side of practice, the treatment of patients in the surgery-their guidance, supervision, regulation? Indeed, as we have seen, some practitioners argued that the epidemiological paradigm actually came to obscure the individual experience of illness that the general practitioners saw as being a constitutive interest of their daily labours.

As a general research rationality. the paradigm of collective investigation declined in significance from about the middle of the 1960s as it began to be replaced at he College by an emphasis, derived from the field of psychotherapy and psychoanalysis, on ‘person-centred medicine’. This psychotherapeutic ideal was not just an attempt to ‘humanize’ general practice in making it more sensitive as a discipline to the needs of the patient as a person. It might be better represented, if more cumbersomely. as an alternative means of aligning the twin aspirations of ‘totalization’ and ‘individualization’ proper to general practice as a potential embodiment of pastoral power.

Person-centred medicine is arguably of greater interest in terms of its conceptualization of the practitioner than it is in its famous concern for the patient


[%I. The persona of the practitioner acts in person- centred medicine, so to speak, as a ‘relay’ between the two concerns of individualization and totalization. According to the psychotherapeutic model, the practitioner conducts ‘research’ upon his own personality. The liberty of the individual practitioner is pre- served-he is still free to practice as he pleases. All that is important is that he should become a master of his own style of practice. But such a norm of knowledge was capable of a certain generalization in so far as what is ‘general’ about it relates less to specific forms of knowledge (pertaining to each individual practitioner) so much as to the fact of each doctor’s observation of self. Moreover, person- centred medicine retains a kind of feedback principle between research and everyday practice; in form of knowledge since clearly the doctor’s research into his own self has consequences for the way in which he conducts his practice.

The adoption of a person-centred model for general practice had consequences for the ways in which the College chose to organize its activities and structure itself. This was not a question of the imposition by the College of a straightforwardly psychoanalytic model of practice [56]. Rather what was promoted was an emphasis more generally upon developing the doctor’s reflexive powers of self. To this end, the College turned the principle focus of its activities

away from the domain of ‘research’ per se toward an emphasis upon the provision of postgraduate education for practitioners. The aim was to establish a nationwide system of ‘vocational training’ whereby the personalities of doctors were to be fitted for the particular-ideographic-circumstances of general practice. Of key import here was the inculcation of the values of continuing education; the need to be aware continually of one’s particularities, skills and limitations as an individual doctor. All the key themes, salient at the College in the 1970s and 198Os, of audit, ‘quality’, self-assessment and so forth were to be linked to this clinical concern to monitor oneself and be reflexive in order to use oneself in helping one’s patients to maturity and autonomy.

With the coming of person-centred medicine, a subjectivizing surveillance of self was substituted for an objectivizing surveillance of morbid populations; and simultaneously, a collectivizing medical rationality with occasional moral overtones was replaced by a vertitably salvationist ideology of expertise.

Acknowledgements-My thanks to Judith Blake, David Owen, Nikolas Rose and two anonymous referees of this journal for their helpful comments.

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epidemiology as an investigative paradigm: the college of general practitioners in the 1950s

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