[The position of medical specialists in the Netherlands (1890-1920].

At the end of the nineteenth century medical specialists came to the fore. In the larger cities they started to establish so-called dispensaries--clinics, not attached to hospitals--for medical aid of the poor. In this specialists differed from general practitioners, the GPs. With these dispensaries the specialists emphasized their own specific knowledge and skills in the treatment of patients with complaints in the field of their specialization. So, the specialists created an infrastructure which met the patients' specific requirements. Patients and municipal corporations were enthusiastic about it. The specialists needed the support, since the Dutch Medical Association [the Nederlandsche Maatschappij tot bevordering der Geneeskunst (NMG)] gave them no support at all. The most important group within the NMG, the GPs, felt that specialization threatened their sources of income and challenged their competence. Circa 1900 the GP was THE doctor for all categories of patients. Specialists, clearly recognisable by patients, disturbed this traditional structure. The NMG reacted on this new phenomenon of specialization either passively, or repressively. In theory the Association resigned itself to specialization as an inescapable result of the increased knowledge and more advanced technology. In practice, however, it was very reluctant in accepting it. There was no fundamental discussion about specialization within the Association. Recognition of a specialism depended mainly on the extent to which it threatened the practice of the GP. Within the NMG the most significant result of the differentiation of the medical profession was an internal struggle. This struggle escalated when in 1902 the Association introduced a 'National Health Service' system. On the one side, this policy created possibilities of taking action against those sections of other insurers for medical aid of the poor, on the other hand of taking repressive action against specialists. It follows that local branches could, among other things, exclude certain specialisms from the collective national health contracts, and introduce a doctor's referral for the national health patients. However, specialists depended on the national health patients to establish their claim on professional skill. This was not only based on greater knowledge than the GP's, but a specialist had also more experience. Until 1920 specialists needed a large number of national health patients to build up their experience. Until 1920 specialists needed a large number of national health patients to build up their experience. That made the introduction of the doctor's referral a threat to specialists. The introduction of a collective cashing in of the national health fees was another part of the policy of the NMG. It not only consumed time and energy, but also caused a lot of conflicts between the local GPs and the specialists. Thus the attention was diverted from the national health struggle, and replaced bij an internal 'struggle' between GPs and specialists.