Staff: The Chalkengr Of Professionalism

Question 1

Profession

Answer 1

An occupation based on specified knowledge and training and regulated standards of performance.

Question 2

Professionalization

Answer 2

A process whereby an occupation achieves the more independent status of a profession.

Question 3

Privileged status of a profession

Answer 3

The combination of these factors produces the privileged status of professions in society. Their status relative to other occupations can be assessed by:
• wealth – higher income, as a result of a better position in the marketplace
• prestige – the esteem in which the group is held by others
•power – the ability to influence decisions and other occupations in the field.

Question 4

Medical profession

Answer 4

Historically, the rise of the medical profession was related to achieving a legal and ideological monopoly. Factors facilitating this process include the scientific background of medical knowledge and organized education.

Question 5

Professional power

Answer 5

As you have seen, Professional power is based on: 
• technical expertise 
• authority 
• Clientele 
• uncertainty 
• relationship to other professions

Question 6

1 What reasons are given as to why nursing has difficulties in developing as a profession?

Answer 6

1 The text gives a variety of reasons for differences in professional development between doctors and nurses, for example:
• lack of independence – nurses are more bound by hierarchy and quasi-military discipline
• lack of autonomy in clinical judgement
• lack of own scientific knowledge and language
• lack of solidarity and syndicalist mode of interest representation
• lack of influence on decision making. Note also that many of the problems are related to the traditional gender role of women in society: nursing is often viewed as women’s work and seen as a domestic service which does not require expert knowledge

Question 7

2What is the professional status of nurses in your country?

Answer 7

2 The status of nursing varies internationally and so do requirements for training, career prospects and payment levels relative to doctors. Different curricula and job entry requirements may even exist within a country between ambulatory care and hospitals. The nurse–doctor ratio varies widely (see Chapter 17) and this is, to some extent, also a reflection of the professional status of nurses. Academically trained nurses are more prevalent in the English-speaking world and in Nordic countries. Strengthening nursing education and professional development is high on the agenda of many countries. Where independent nurse practitioners have been introduced, this has often been seen as a challenge to the medical profession.

Question 8

make notes on the following issues: 1 The contrasting ways in which India, China and what is referred to as the Third World model have sought to integrate western and traditional, indigenous medical systems.

Answer 8

1 India recognized more than one medical system. Practitioners of all systems were at liberty to practise and form professional associations. This was partly driven by social reality and partly a response to nationalist feelings. Professions were encouraged to develop self-regulation. In China, the Maoist state actively sought to integrate traditional medicine with western medicine. Barefoot doctors were trained not only in western medicine but also in acupuncture, herbal therapy and other systems. Hospitals made use of all available systems. The Third World model accepts its inability to control the various local practitioners due to the lack of a strong system of western medicine and, therefore, people’s dependence on indigenous systems

Question 9

Make notes on: 2The source of legitimacy of practitioners.

Answer 9

2 Legitimacy of practitioners and medical systems is derived from the local community’s own traditions or the personal charisma of practitioners. This is essentially a pragmatic, experiential approach rather than one based on political philosophy.

Question 10

Parsons model

Answer 10

Talcott Parsons (1902–79), in 1939. His functionalist view welcomed the notion of professions, seeing the legitimation of professional status as a means of protecting patients from harm. Patients accept the authority of doctors. They trust doctors and expect them to have the highest competence. Therefore knowledge and skills need to be guaranteed by educational standards. To protect the intimate relationship between doctors and patients, the profession needs to be granted an autonomous status, independent from state interference. Professionalism is thought to allow a more flexible response to patients’ needs than tightly controlled health services. As only doctors can judge their peers, they need to have the right to discipline members who violate the code of conduct. Thus professionalism plays a beneficial role by serving both the needs of the individual and of society.

Question 11

Marxist model

Answer 11

In contrast, there have been several critiques that challenge Parsons’ view. In the Marxist view, professions are considered a middle-class privilege, mystifying and stabilizing the power of the ruling class. This was seen as part of a wider struggle between classes for economic, social and political advantages, a struggle that was limited by the mode of production.

Question 12

Freidson

Answer 12

An alternative critique propounded by Elliot Freidson in 1974 emphasized the role of self-interest in the formation of professions. To him, professionalization is similar to trade unionism, a way of increasing the rewards for labour. Doctors have been particularly successful in eliminating their competitors and creating a monopoly. They have managed to keep remuneration high through market closure. And in due course, they have managed to convey the image that only members of the profession can provide services properly. In this view, professionalism is beneficial only at the expense of other occupations and to members who pursue their own interests. This view partly echoed the concerns of the liberal Irish playwright, George Bernard Shaw, in 1911 who suggested that ‘All professions are conspiracies against the laity.’

Question 13

Illich

Answer 13

More recently, the Austrian theologian Ivan Illich (1974) criticized professionalism as a way of colonizing other sectors of social life (medical imperialism) and disguising the fact that doctors produce ill health (iatrogenesis). In his view, professionalism does more harm than good. Doctors don’t just provide health services but attempt to take control over other aspects of life. Examples of medical expansion include the medicalization of childbirth, disabilities, problems of ageing and death. An increasing number of social problems have been handed over to the medical profession, thereby extending its authority to define what is good or wrong and barring other professions and lay people from dealing with health problems. Medical expansion is seen as a threat as it weakens individual abilities to cope with illness and hides away pain and death, which are natural parts of life.

Question 14

1 Write down four key arguments in favour of and four against independent status of doctors.

Answer 14

For 
Trust 
Defence of individual 
Peer control 
Flexibility

Against 
Middle class monopoly 
Medical expansion 
Dominated by self-interest 
Lack of accountability

Question 15

2 Contrast briefly the different views and compare them with your own experience in health services.

Answer 15

2 Though medical expansion has clearly occurred, Illich’s generalizing view of the role of experts has been criticized as exaggerated and misleading (Strong 1979). On the other hand, the functionalist view, which had developed among the early writers, appears to be naive in not taking account of the self-interest of the medical profession. Friedson’s view has incorporated the aspect of self-interest and given an explanation of professional power, which has been widely acknowledged.

Question 16

Think of the status and power of doctors in your country.
• Has it changed in recent years?
• What challenges have there been to medical knowledge?
• Have challenges been mounted by other professionals working in health care?

Answer 16

You are more than likely to have noted that the status and power of doctors has changed in recent years. These changes, which represent threats to traditional medical interests, can also be seen as opportunities for changing the way health services are conceived and delivered. 1 Managerialism – the growing importance of managers and management processes in health care. Decisions on resource allocation are no longer left to professional autonomy. Doctors are being made increasingly accountable to those paying for health services. (See the article by Relman in Chapter 2.) 2 Lay knowledge and self-help movements – consumers have become better informed and may develop into experts in dealing with particular health problems, thereby challenging professional knowledge (see Chapter 10). 3 Boundary disputes – while there is medical expansion there are also challenges from other professions taking over tasks formerly performed by doctors. For example, think of the increasing number of medicines sold without prescription by pharmacists. Nurse practitioners performing tasks formerly reserved to doctors are often seen as challenge. Think also of psychologists or social workers dealing with drug addicts who, it was once thought, should be exclusively treated by doctors. 4 Medical pluralism – the profession is increasingly divided. The interests of doctors in primary care may conflict with those in secondary and tertiary care. Subgroups within the profession challenge traditional views. Growing specialization makes it difficult to represent the interests of all doctors. For example, in many countries instead of a single organization representing all surgeons, there are several subspecialties with potentially opposing views. 5 Effectiveness in question – the issue of the extent to which medical interventions are effective has gained public attention. Many treatments have only little effect on outcomes but are promoted with professional authority. The public is increasingly aware of the limits of medicine and is becoming more critical towards medical knowledge. 6 Ideological opposition – doctors face opposition from other groups in society, such as other professions, social movements or parties who try to challenge the ideological monopoly of the profession. Examples include social movements fighting for consumer rights in medicine, feminist groups challenging the role of medicine in childbirth, and religious groups challenging the medical definition of death and criteria for organ transplantation. 7 More general problems are those of a loss of faith in experts and public institutions and the contracting role of the state, which in some countries is taking less responsibility for health care and for protecting professional status.

Question 17

Ambulatory care

Answer 17

Health care provided to patients without admitting them to hospital, such as general practice, outpatient clinics and day care.

Question 18

Max Weber

Answer 18

In 1947 the German sociologist, Max Weber, suggested the concept of the ‘ideal type’, an abstract model of a complex real phenomenon which highlights its most salient features. Note that ‘ideal’ is not meant in the sense of desirable (or normative) but in the sense of a pure, abstract construct. An ideal type description of a profession would have the following characteristics:
• a ‘craft’ tradition – a specific body of knowledge and skills, requiring an advanced training
• a syndicalist mode of interest representation – similar to trade unions but with ambitions to gain control of the means of production
• a code of ethics – peer control through a strict code of rules
• legal monopoly – government regulates entry to the profession by law and specif ies requirements for training and qualifications, thereby restricting activities of other occupations in the field
• ideological monopoly – a means of enabling the profession to dominate the views on its subject and to make it widely accepted. These are the values, attitudes and beliefs underlying a profession’s way of achieving and maintaining privileged status. Ideology is used to justify and legitimize professional status and gives its members a sense of importance and cohesiveness. Professional ideology has evolved over time and during this process the views held by the profession have also become shared and internalized by the public.

Question 19

Ideal type

Answer 19

A hypothetical model of a complex real phenomenon which emphasizes its most salient features.