In the setting of the former areal of Robert Bosch, who was highly interested in alternative medicine such as homeopathy, the conference had the intention to bring especially non-physician healthcare professions to the centre stage. The organisers SYLVELYN HÄHNER-ROMBACH and PIERRE PFÜTSCH (both Stuttgart) emphasised in their introductory remarks the important role of these professionals in providing medical care, which, however, have been neglected in historiography. Recent scholarly accounts and research projects in different parts of the world are tackling this gap – and some of the responsible researchers and representatives of different healthcare professions gathered in Stuttgart to give an overview and discuss the future of this particular field.
The focus of this conference was to investigate conflicts and tensions within (non-)physician healthcare professions and between them and other (non-)medical professions in the struggle for (legal and societal) recognition in the last century. CORINNE DORIA (Paris) explored in her paper the clashes between ophthalmologists and opticians in France, especially during the nineteenth and twentieth centuries. The conflict arose due to the specialisation of both professions and the increased demand for eyeglasses. Subsequently, the market became an important factor in their struggles, as opticians could not “survive” if they could not sell their products, but ophthalmologists claimed that they could produce superior glasses. However, their attempt to take over the market failed due to public protest, and the marketplace remained free. A different dimension in the struggle for recognition and between two professions was explored by KAREN NOLTE (Würzburg), who introduced the audience to the specific gender connotations of giving anaesthesia. In West Germany until the 1950s, nurses applied anaesthetics by dripping the liquid on a mask that patients had to wear before and during surgery. With the replacement of this method by mechanical devices, the role of nurses was questioned and the special field of doctors of anaesthesia created. In this way, nurses’ responsibilities were limited to supposedly feminine tasks such as creating a trustful atmosphere, whereas the technical part was solely carried out by male doctors – a typical gender bias. However, Nolte emphasised that this intended shift took place neither immediately nor simultaneously all over West Germany and many nurses kept their responsible positions for a much longer period especially in rural and small hospitals.
Even today, however, gender bias and the disregard of competencies between different healthcare professions exist. ANDREA BOSCH (Stuttgart), for example, talked about her experience as a midwife in the newly developed midwife-led units in Germany since the late 1990s. With the help of a study, she could show that, compared to obstetrician led clinics, these units not only improved mothers’ and babies’ health, but also reduced the need of medical interventions, increased the choice, control and continuity of care for pregnant women, and were more cost-effective. Obstetricians, however, always raised criticisms as these units could be seen as the first step to an independent profession, which in their opinion had no legitimacy. EILEEN THROWER (Hyden, Kentucky) showed in this context that this struggle between doctors and midwives was neither new nor unique to Germany. The general shift during the nineteenth century from female midwives to male midwives as well as the shift from home to hospital births increased the mortality of mothers and infants, refuting the common belief that science directly enhances the safety during childbirth. The response of authorities in the United States of America was the creation of specialised “nurse-midwives”. However, in Georgia, there was almost no midwifery until the 1970s, and only due to the baby boomer generation this situation changed. Doctors were always sceptical, and some criticised that nurse-midwives would “steal patients” and thus denounced them as “counter-culture”. Nevertheless, nurse-midwives gained prestige, especially among uninsured patients, and thus were able to establish an educational program with their own degrees.
Another healthcare profession that was neglected in historical research is the physical therapist. MAYA GUEZ (Tel Aviv) gave an insight into the development and issues of this particular profession in Israel. Since physicians established a strong lobby in this country, other health professionals have always been hindered in their development and recognition. Therefore, Israel lacked behind the international development and only had five registered physical therapists in the 1950s. From this time onwards, this profession had undergone a slow, but steady development. Their practice, however, remains heavily restricted by the influence of the medical profession until today.
JANE BROOKS (Manchester) opened up the second session, shifting the focus towards the external conditions in which the struggle of healthcare professions for recognition was embedded. In her paper, she showed how nurses from the United Kingdom were expected to expand their roles and tasks in overseas military hospitals to provide better care for the wounded soldiers during the Second World War. This recognition led to conflicts, especially after “war nurses” returned to the motherland, as the medical profession rejected the demands of nurses to take over more responsibilities. Nurses’ role during the war, however, raised their sense of their abilities and many nurses were disappointed. Some even refused to give up their status and recognition after the war – they rebelled against the reinforced gender boundaries. A different influence was enacted by the United Kingdom in their British Mandate Palestine that affected the profession of dentistry. EYAL KATVAN (Ramat Gan) gave an overview how the state tried but failed to regulate this profession during the 1920s. Therefore, the conflict mostly occurred in the legal arena between different qualified and unqualified branches of dentistry in British Mandate Palestine. However, also the immigration of dentists with various diplomas created tensions, as there was no standardised degree. In the end, all groups within the dentistry fought for recognition and denied the competencies of other groups, causing confusion, conflicts, and uncertainties about distinguishing tasks and responsibilities among them.
The cooperation between different medical professions often causes conflicts. As PIERRE PFÜTSCH (Stuttgart) argued, these conflicts can provide an analytical proof of changing mentalities and societal requirements; a fact which he discussed with the example of emergency medical services in Germany. After the initial restriction to non-medical tasks, the advancement in medicine and technologies, such as vehicles, as well as the increase of accidents required that drivers of ambulances had to have a medical training from the 1970s onwards. This change created tension between doctors and the personnel of the emergency medical service that eventually led to a law which, however, failed to provide a clear distinction of tasks and solely enacted a hierarchy between these two medical professions. AARON PFAFF (Stuttgart) provided another perspective of how different parties, like insurance companies and pharmaceutical industries, can hinder or encourage the establishment and recognition of a profession, such as the diabetes advisor. The necessity to educate the patients with the chronic disease of diabetes to accomplish a better treatment was recognised already in the 1920s. However, he showed that it took another 70 years until training courses for advisors were created and this medical profession officially recognised. The final push was given by the pharmaceutical companies who realised the potential profit by reaching out to the patient as a customer, and thus encouraged the widespread education of diabetics to use the new self-measuring devices.
ANDREAS PFEUFFER (Olten) analysed the most recent creation of a new profession that was required in hospitals due to the economic and financial demands of insurance companies: the medical coder. Initially, the doctors’ association was in favour of this new profession, as it would free the doctor from this bureaucratic task. Nevertheless, since its establishment, medical coders came into conflict with physicians, as the former pressured doctors to use the codes and to use them correctly. An important aspect in the development of this profession is that many of the medical coders are former nurses, who changed the job because of their poor working conditions – a fluctuation that threatens the medical services even more due to the already existing shortage of medical personnel in general.
Nevertheless, not only external entities and conditions have an impact on the creation of a health profession, but also struggles within a profession about aims, organisation, and other issues can hamper its development. SYLVELYN HÄHNER-ROMBACH (Stuttgart) turned the discussion to the hesitations and preconception of nurses towards the inclusion of families, especially the mothers, in paediatric hospital wards in Germany. The issue was also based on the fact that until the 1970s nurses had to be unmarried and thus conflicts arose between the two gender models of women. Nevertheless, debates in psychology about the importance of the family for the child and changes in hospitals and the nurse’s role led to a shift in this struggle, and the inclusion of mothers was seen as positive. The knowledge of a child’s social background often increased the effectiveness of treatments, not least as the presence of the family gave the child some stability in a potentially hostile environment. However, the profession of the nurse changed due to this inclusion and it eventually caused a loss of status and recognition. The gender dimension also played an important role in the paper of CHRISTOPH SCHWAMM (Stuttgart), who analysed the entry of men into nursing after 1960 in Germany. After seeing the concept of masculinity as a barrier to take on a feminised job, such as nursing, male nurses were successful in re-masculinising the field. Their societal stand, however, was one of “lesser” or even “subordinate” men. To make male-nursing fit the concept of masculinity at the time, job descriptions particularly emphasised the technical requirements due to technological advances in hospitals that made male nurses indispensable. However, female nurses were against the tendencies to create technological experts, but never criticised the lack of compassion, affection, or caring abilities of their male counterparts. In the end, many male nurses did not worry about masculinity concepts and debates per se and often entered high privileged positions within the field and its associations.
In the final paper, GEERTJE BOSCHMA (Vancouver) employed a generational analysis to discuss the views and application of electroconvulsive therapy in the Netherlands since 1939. After its rejection as dangerous and unscientific, the debate slowly changed: the treatment became more acceptable as part of biological psychiatry, not least due to the use of anaesthesia. Nevertheless, as the activism against electroconvulsive therapy remained strong, politicians questioned the responsible physicians and psychiatrists. Therefore, the continued use of this therapy due to practical and medical reasons caused a shift to research-based justifications of the psychiatrists themselves and to the people, which eventually led to an increase of clinical and public confidence since the 2010s.
In the final discussion, the organisers concluded that this conference aimed to examine if the analysis of conflicts allows revealing mentalities and disclosing dynamics of historical change in this field. It was discussed that this analytical approach broadens the perspective on medicalisation and opens up areas for comparison between different countries and continents and for future research. Furthermore, the role of pharmaceutical companies and technological change cannot be neglected in the analysis of healthcare and its professions. However, patients need to remain the focal point of historical research, as they, for example, had the agency to dispel a conflict within and between medical professions. This conference brought together many researchers from this field from all over the world, covering a wide range of topics and possible ways to investigate the struggle of (non-)physician healthcare professions. In this way, it was not only a summary of work in progress but also emphasised the potential of getting “off the beaten tracks” within the social history of medicine. However, the focus of the conference was limited to Western medicine and was unable to incorporate, for example, the different developments in Central-Eastern Europe or developing countries. Nevertheless, all papers were able to give an insight in the mentalities, power relations, exchanged ideas, external constraints, and the players, which determined the conflict, development, and recognition of a healthcare profession during the twentieth century.
Conference Overview:
Session 1: Interprofessional Conflicts
Chair: Robert Jütte
Corinne Doria (Paris): “Eyes on me”. Ophthalmologists, opticians and the medical professionalization process in the France ‘fin de siècle’
Karen Nolte (Würzburg): The debate on 'nurse anaesthetists’ in West-Germany in the 1950s
Andrea Bosch (Stuttgart): Midwife-led Units in Germany
Eileen Thrower (Hyden, Kentucky): Inter-Professional Symbiosis: An Oral History of the Relationships Among Midwifery, Nursing, and Medicine in Georgia
Maya Guez (Tel Aviv): Physical therapists and their medical diagnostic abilities for back pathologies
Session 2: Conflicts due to Changed Conditions
Chair: Martin Dinges, Sylvelyn Hähner-Rombach
Jane Brooks (Manchester): Negotiating nursing in the Second World War: Extended roles and new work of British Army nurses
Eyal Katvan (Ramat Gan): Toothless Law: The Regulation of Dentistry in British Mandate Palestine
Pierre Pfütsch (Stuttgart): Emergency Medical Services in Germany: The Conflictual Development of a Professional Field
Aaron Pfaff (Stuttgart): Advisors or Assistants – The Formation of Diabetes Educators in Germany
Andreas Pfeuffer (Olten): 14 medical coders tell their story. A new hospital profession in the area of tension between economic and professional orientations
Session 3: Conflicts Within Profession
Chair: Pierre Pfütsch
Sylvelyn Hähner-Rombach (Stuttgart): Mothers on Hospital Wards for Children: Conflicts in Paediatric Nursing in Germany
Christoph Schwamm (Stuttgart): “Every male nurse must withdraw from basic care" Masculinities in West German nursing organizations 1960 –1975
Geertje Boschma (Vancouver): Negotiating Electroconvulsive Therapy (ECT) in Dutch psychiatry: Cultural and intraprofessional tension over biological psychiatry in the Netherlands, 1970-2010