Advocacy and Community: The Social Roles of Physicians in the Last 1000 Years. Part I in a 3-Part Series.

Karen E. Geraghty, PhD (c), Matthew K. Wynia, MD, MPH

In This Article

The Rise of Hospitals and Universities

As the population of Europe expanded, the growth of urban centers and the increasing wealth of the citizenry led to demand for new services. During this time, the emergence of hospitals and the development of the first European universities laid the groundwork to redefine both the environment of and the educational qualifications for medical practice, although it would be another half millennium before the 2 institutions truly complemented each other in the formation and dissemination of medical knowledge.

The first organizational shift - the emergence of hospitals - occurred as a result of the increasing political and social power of the Church, in the context of the belief that illness bespoke both spiritual and humoral imbalance. Thus, caring for the aging and sick merged with religious objectives, and hospitals as charity institutions were developed under the direction of religious orders charged with both the physical and spiritual care of those in need. The number of hospitals grew rapidly across Europe, most notably in the 12th century. The majority of these institutions were monastic, under the direction of the Benedictine Order, which alone is credited with having founded more than 2000 charitable infirmaries.[6,7] Well before the emergence of "public health" as a recognizable concern, these early religious hospitals already made tangible what would become a recurring tension for physicians, arising from the often unmet and conflicting expectations that medical practitioners would care for those in need while also helping to remove the morally unbalanced (the ill) from the rest of society.

The rise of hospitals coincided with the establishment of universities as centers for specialized learning and accreditation. This second organizational shift took place from the 13th through 16th centuries, as new universities established themselves as sources of professional qualification. Although physicians and healers had been organized into various guilds in previous centuries, a university diploma conveyed greater status and privilege, and universities soon became the best venue to secure access to the most sought-after patients in the aristocracy and upper classes.[8]

With the emergence of universities in Europe, medicine began to be recognized as a profession based on formal education, a standardized curriculum, and legal regulation. In some regions, physicians were required to pass examinations before beginning practice. Untrained physicians were subject to prosecution and fines, and state licensing became common. Despite increasing educational requirements and the institution of strict licensing regulations, however, university-trained medical doctors constituted only a small number of practicing healers, with very few available to service the general public. In large urban areas, there was often only 1 MD per 5000 people. The medical doctorate required years of study and for most was prohibitively expensive to pursue. For practical reasons, therefore, the bulk of medical services continued to be offered to society by an array of healers from midwives and apothecaries to local parish priests. Hospitals and charity institutions continued to service the poor, usually without benefit of university-trained physicians.[9]

But it was not long before university-trained physicians, despite their primary service to the well-to-do, were also called upon to serve larger communities. The 13th century saw efforts to bring qualified physicians to the general public come to fruition with the development of a system of community-based physicians, hired by towns and contracted to provide health services to the local population. In northern Italy, such physicians were paid with a stipend and property, and citizenship was conferred if necessary. Pressing this development were the plagues that began to decimate the European population in the 14th century. In response, local communities at this time began to assume more control over the interests of public health, and towns began to establish public health committees to coordinate quarantines and regulations to control the spread of pestilence. Thus, activities once belonging to the domain of church-sponsored institutions, such as keeping records of the deceased and listing the causes of death, shifted to the state.