SOC 574 The Health Professions

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SOC 574 The Health Professions

• James G. Anderson, Ph.D.
• Purdue University

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Professionalization of an Occupation

• Making the occupation a full-time pursuit
• Linking training to schools and colleges and
  gaining control of professional education
  training
• Establishing strong national and state
  professional associations
• Obtaining a legal monopoly over a sphere of work
  by expanding the scope of practice
• Developing a code of ethics that regulates
  professional behavior
• Shaping the public image of the profession

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Parameters of a Profession

• Entry into the profession/curricula controlled by
  the profession
• Profession is the guardian of its specialized
  knowledge and skills
• Credentialing Occupational
  degrees Certification Licensing

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Parameters of a Profession Cognitive
Characteristics

• Specialized knowledge, skills, mode of reasoning
• Learning specialized skills through an extended
  process of education, training and socialization
• Post-baccalaureate degree for entry level into
  the profession

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IndicatorsCognitive Characteristics

• Post-baccalaureate degree required for entry into
  the profession
• Entry level degree (e.g., DPT, PharmD, AuD, etc.)
• Profession controls professional education
• Profession sets standards and accredits
  professional education programs

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Parameters of a Profession Autonomy and
Collective Self-Control

• Technical autonomy
• Control over services, resources
• Direct access to patients/clients
• Self-control based on socialization of attitudes,
  beliefs, practice patterns
• Informal control by peers
• Professional associations exercise control by
  licensing

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IndicatorsAutonomy

• State licensure laws
• Control over board certification
• Ability to exclude competitors from practice
• Percent of professionals in independent practice
  compared to organizational practice
• Profession has direct access to patients
• Profession sets fees and rates of payment
• Direct third-party reimbursement

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Parameters of a Profession Value Components
Service, Commitment, Calling

• Code of ethics
• Fiduciary relationship with clients
• Making the welfare of the client the first
  consideration
• Conception of the larger ends and purposes that
  professional work serves
• Commitment to a higher level of competence

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IndicatorsOrganizational Cohesion

• Homogeneity of membership in the profession
• Membership commitment (e.g., members who join
  the professional association)
• Membership stability over time (e.g., lifetime
  members)
• Overlap of membership with other professional
  associations

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IndicatorsRelational Cohesion

• Competing professional associations
• Membership in the major professional association
• Major professional association includes other
  organizations within the profession
• Establishment and circulation of professional
  journals

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Parameters of a Profession Value Components
Service, Commitment, Calling

• Do no harm to patients
• Confidentiality
• Code of professional ethics

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Licensing Professions

• Licensing protects the public from
  incompetence/charlatans
• Licensing also creates a professional monopoly
  for services

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Process by Which Occupations Evolve into
Professions
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Competition

• Clinical psychologists (PhDs) versus
  Psychiatrists (MDs)
• Optometrists versus Opthamologists (MDs)
• Nurse Midwives versus OBGYNs (MDs)
• Sociologists versus Social Workers, Marriage and
  Family Therapists, and Professional Counselors

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Public Prestige Ratings for Health Care
Occupations
Occupation Rating
Dentists 96
Osteopaths 96
Lawyers/Judges 93
Physicians/Surgeons 92
Pharmacists 82
Social Scientists 81
Optometrists 79
Veterinarians 78
Secretaries 61
Therapists/Healers 58
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Public Prestige Ratings for Health Care
Occupations
Occupation Rating
Mail Carriers 53
Student Nurses 51
Medical/Dental Technicians 48
RNs 46
Postal Clerks 44
Opticians 39
Dieticians/Nutritionists 39
Policeman 39
Physician Office Attendants 38

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Public Prestige Ratings for Health Care
Occupations
Occupation Rating
Plumbers/Pipe-fitters 34
Machinists 33
Bus Drivers 24
LPNs 22
Carpenters 19
Hospital Attendants 13




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Critical Elements in Achieving professional Status

• Unified national organization
• Integrated state and national professional
  organizations
• Accreditation of professional education
• Use of studies and other activities to enhance
  the professions public image
• Legislation to support changes in scope of
  practice and entry to the profession

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Optometry

• Since 1898 optometry has benefited from a strong
  national organization, the AOA
• From 1940 state and national associations have
  worked for legislation to ensure favorable
  reimbursement rates
• National Board of Examiners in Optometry was
  created in 1951
• The 1965 Medicare Act included Optometrists as
  qualified providers

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Optometry

• By 1989 all 50 states and DC had passed
  legislation to allow optometrists to employ
  pharmaceutical agents
• Currently 49 states all optometrists to treat
  glaucoma
• Optometrists are gaining the right to perform
  laser procedures.

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Physical Therapy

• Physical therapists in the U.S. created a
  professional association in 1920 that became the
  APTA in 1946
• The educational requirements have been gradually
  upgraded from a certificate to a BS in the
  1950s. In the 1980 some programs began offering
  graduate degrees including the DPT degree
• In 1983 APTA became the accrediting body in place
  of the AMA

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Physical Therapy

• By 2002 there were about 60 accredited DPT
  programs and 85 MPT programs in the U.S.
• The APTA is lobbying state legislatures and the
  federal government to change Medicare to allow
  patients direct access to PTs instead of through
  medical referrals.
• To date 39 states allow patients direct access to
  PTs for evaluation and some level of treatment

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Podiatry

• By 1940 podiatrists needed a doctorate in
  podiatric medical education to take the licensing
  exam in many states.
• Today podiatrists enjoy a broad scope of practice
  in treating foot and ankle problems
• The APMA Council on Podiatric Medical Education
  accredits podiatric medical schools and residency
  programs

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Podiatry

• Podiatrists were defined as physicians in the
  1965 Medicare Act. But Medicaid defines them as
  optional services
• The Balanced Budget Act of 1997 stated that
  podiatrists should be paid equally to medical
  doctors providing the same service.

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Audiology

• Audiology has three major national associations
• American SpeechLanguage-Hearing Association
  (ASHA)
• American Academy of Audiology (AAA)
• Academy of Dispensing Audiologists (ADA)

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Audiology

• Only 15-20 states have strong audiology
  associations. Some states have two associations
• ASHA affiliated organizations are dominated by
  concerns of speech-language pathologists, the
  dominant profession in ASHA.
• There is little agreement over which organization
  should accredit degree programs. An
  ASHA-affiliated organization accredits degree
  programs and certifies competency of
  audiologists.

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Audiology

• In 2003 the Accreditation Commission on Audiology
  Education (ACAE) was created representing the
  AAA, ADA and direcvtors of AuD programs
• Federal legislation in 1998 allows federal
  employees to obtain care from an audiologisxt
  without a physicians referral
• Audiology is lobbying for an amendment to
  Medicare to authorize audiologists to provide
  services to beneficiaries without a physician
  refferal

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Dangers in Licensing ProfessionsCulture
dominated by professionals

• Monopoly.
• The public relinquishes control.
• Medicalization -Professionals determine needs.
• Conflicts of interest. Needs/interests of
  patient vs. profit for professionals Misdiagnosis,
  over prescription, unnecessary surgery

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Dangers in Licensing ProfessionsCreates
Professional Dominance

• Legitimizes monopoly.
• Limits competition through licensing boards
  dominated by members of the profession.
• Enhances professionals prestige, authority,
  income
• Inadequate self-regulation
• Resistance to change - Limited experimentation
  and innovation.
• Higher direct costs to consumers.
• Services unavailable to poor, those who cant
  pay.

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Dangers in Licensing ProfessionsAttempts in
state legislatures to license

• Auctioneers
• Well diggers
• Home improvement contractors
• Pet groomers
• Electrologists
• Sex therapists
• RV repairmen
• Appraisers
• Tattoo artists
• Lightening rod salesmen

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Solutions to the Problems Created by the
Licensing Professions

• Courts have struck down state laws prohibiting
  professional advertising.
• Certification is an alternative to licensing to
  protect against fraud and deception.
• Separation of diagnosis from services.
• Second opinions allow consumers to comparison
  shop.

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How Serious is the Problem of Fraudulent
Physicians?

• 1/50 or 10,000 practicing medicine with
  fraudulent credentials.
• 1982-1984 Medicare payments. 8.5 million sent
  to 271 unlicensed doctors in Florida.
• 60 of the patients of fake MDs are elderly.

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Who are likely to become bogus doctors/nurses?

• Chiropractors
• Pharmacists
• Nurses
• Physician Assistants
• Nurse Practitioners
• Medics

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How do Bogus Doctors Obtain their Credentials?

• Some obtain forged medical degrees and become
  licensed.
• Some open clinics/apply to hospitals where
  documents arent checked.
• Assume the name of a living or dead or retired
  physicians.
• Purchase fake credentials form phony universities
• Graduates from foreign medical schools.

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How can Bogus Doctors be Detected?

• National practitioner clearing house lists
  disciplinary actions against physicians.
• Some licensing agencies fingerprint applicants
  and perform background checks.
• Laws can make it a felony to pose as an MD.
• Provide state medical licensing boards with more
  investigators.