Specialization without the Hospital: The Case of British Sports Medicine

Specialization in medicine acts to normalize categories of health and sickness that, once constructed, can appear to be obvious and rational divisions of the body, of disease, or of populations. While the earliest work on this topic, George Rosen's sociologically informed The specialization of medicine (1944), highlighted the role of medical theory in specialty formation, historians of medicine since the 1940s have overwhelmingly argued that medical specialization is better characterized as an economic, social or political process.1 In Britain, specialization, particularly in connection with the foundation of specialist hospitals, was also a strategic approach taken by doctors competing in a vigorous medical marketplace where the advantages of professional advancement through a hospital consultancy post were monopolized by a tiny urban elite.2 George Weisz's recent work on specialization also dismisses the idea that conceptual models drove specialization.3 Yet he recognizes that medical theory did play a role in the internal justifications for specialisms—in other words, such justifications were used to vindicate specialization in certain areas, rather than explaining why specialization occurred. The turn away from holism in medicine allowed diseases to be located in specific organs, tissues or cells, and so the division of medicine into specialties based on body region and disease categories seemed a rational response to the needs of practitioners working (and learning) in a field where knowledge appeared to increase year after year.4 Reconsideration of specialization in France also demonstrates that the form of specialties is dictated by the “current state of knowledge, techniques, [and] institutions” while other influences drive the process of specialization.5 So while the external motivations for specialization—economic competition, the needs of rational management and health-care policy, and other social contexts—varied over the nineteenth and twentieth centuries, the internal justifications tended to focus on reductive understandings of disease causation. In the twentieth century these explanations were supplemented by a focus on technological and treatment innovations.6 In this context, sports medicine is an extremely unpromising field to convert into a medical specialism. Sports medicine is a holistic practice, covering everything from gross musculo-skeletal injuries to dietary advice to genetic testing. It has virtually no unique diseases or injuries (one can get tennis elbow cleaning floors) nor any unique treatment modalities or technologies. Another way to define a specialism is to claim that the patient, rather than the disease or the treatment, is in some way special. Paediatrics and geriatric medicine are justified on the grounds that the very old and the very young are different from the “normal” body public.7 Obstetrics and gynaecology are at least in part based on the understanding that women's bodies are deviant.8 While sports medicine could not identify its patients conclusively by age or gender, in the late 1940s and early 1950s sports medicine practitioners laid claim to expert knowledge based on the athletic body, which was figured as quantitatively different from the body public.9 The athlete was a discrete clinical object, a distinct patient group for two reasons, one biomedical and one social. Physiologically athletes could appear quite different from the “norms” of human life; they could have enlarged hearts, extremely low resting pulse rates, delayed menses, and so on. All these physiological features could mistakenly be interpreted as pathologies by inexperienced doctors. Secondly, the demands of athletes differed from those of non-athletes. They (allegedly) required a faster return to high levels of activity, and thus fuller functional repair, and they moved in the partly closed world of sport where they had to live by a different set of rules. They might be unable to take certain drugs at certain times in the competitive season, and their treatments and rehabilitation had to be negotiated through other professional groups, such as trainers, team coaches and so on. When the British Association of Sport (and Exercise) Medicine (hereafter BAS(E)M) was formed in 1952, it aimed to become the “authoritative body on every medical aspect of athletics and exercise”. 10 “Athletics and exercise” quickly became interpreted to mean elite and professional sport, and very little of the BAS(E)M's work in the 1950s and 1960s focused on school or community sports, or exercise for health or leisure. At the Association's first provincial meeting, in Loughborough in 1961, the theme was “Are athletes different? ”, a question comprehensively answered with “yes” by all the papers delivered.11 Meanwhile the executive committee of the BAS(E)M remained committed to sports medicine as an area of expertise, not a formal specialism. Sports medicine was robustly interdisciplinary, multi-practitioner, largely voluntary, and regulated through experience and enthusiasm.12 (It was, after all, an advantage for a sports doctor to have been an athlete him- or herself, a requirement of personal experience as a patient not applied to any other medical specialism.) The first hints that this was to change appeared in the 1970s, and then with force in the 1980s and 1990s as the leadership of the BAS(E)M began actively to campaign for the formal recognition of sports medicine as a specialty in the UK, with a distinct career path and consultant positions. Sport and exercise medicine was approved as a medical specialty in the UK on 21 February 2005, entering the official register of specialties, the Specialist Order, seven months later. For nearly thirty years the leading medical organization representing sports medicine practitioners had seen no need (at least according to statements in their public records) for this sort of state-sanctioned specialization. This article will discuss the events in the 1970s and 1980s that turned a multi-disciplinary, elite, athlete-focused and experience-based model of expertise into the formalized, academic, diploma-led medical specialty that now extends into community sports and public health. As most previous studies of specialty formation have shown, a web of interrelated causes can be credited with the shift in vision within sports medicine from the 1970s. Some of these causes are economic, some social, and others political. But what makes the story of sports medicine's specialization particularly novel is the explicit way in which the internal justification for the specialty—the athletic body—became deeply problematic because of changes in the cultural and socio-political context in Britain. An increasing demand for, and consumption of, sports and exercise services combined with a new public health focus on “lifestyle” to create government-backed interest in the relationship between leisure habits and health.13 In particular, exercise became a possible cure for some of the emergent diseases of civilization, while at the same time being a cause of fresh injury and disability.14 A sports medicine which was based only on elite or professional sport would fail to capitalize on these movements, and could be at risk of marginalization. British sports medicine practitioners needed to reclaim the body public as part of their patient group, and did so by adding “and exercise” to the definition of their area of expertise. In doing this they also embraced the need for specialism as a necessary part of the process of protecting an endangered area of expertise. In this article I will outline two examples of the external influences which created the pressure to specialize. First, the Sports Council's sports injuries clinic scheme of the 1970s, which highlighted all the vulnerabilities of a sports medicine based on definitions of the 1950s and 1960s; second, the economic and professional pressures of insurance and medical representation, which became particularly problematic in the 1980s. As these external factors drove the process of specialization in sports medicine, so the internal justification for the specialty also had to shift. A strong rhetoric was produced describing exercise as a drug, which should be undertaken only with expert guidance; an appeal was made for patients’ right as consumers—that is, the right of everyone, regardless of their ability to pay—to access specialist sports medicine services; and an argument was made about the need to protect patients from “quacks”. 15