DEPROFESSIONALIZATION: Anew approach to professionalization!

INTRODUCTION

The demographic development, the shift in the health problem situation, the continuing medical and technical progress, the rising care demands of those receiving services, and the increase in health care expenditure that has been caused by the complex ensemble of these factors are increasingly responsible for this shift towards “deprofessionalization”.^1,2

Professions are a special type of occupation^3,4 that is the subject of extensive research in the specialized sociology of occupations and professions. The constitutive characteristics of a profession are is a debated issue and is something focused on in its own respect within each variation of the theory of professions¹. Professions are considered for the most part to be relatively autonomous and science-based expert occupations in the service sector that provide special services for society and their own special clientele within a certain field of problems relevant to society, thereby following a specific logic of conduct^5,6. They are characterized by power and influence as well as privileged opportunities of qualification, employment, and control, and they therefore often enjoy a distinctive social esteem. A central characteristic that marks professions in their classic form, and therefore also the medical profession is their relatively high degree of occupational "autonomy". Health professionals and others need to work together to devise innovative ways of delivering effective health care.^7,8

The concept of “deprofessionalisation” is a revolutionary approach towards delivering health care where the doctor holds his unique position in the field of health care by encouraging participation of a new cadre of health workers such as the community health workers, the multipurpose workers and the practitioners of indigenous medicine etc who with relatively little training form an integral part of the health teams and it also provides a wide field for the doctor to take up new roles in serving the community. Hence this approach acts like a helping hand towards the tasks that need to be performed by limited number of health care personnel available⁹. Hence the aim of this paper is to explore the concept of deprofessionalisation which could integrate to form the missing link to professionalism in its own context.

PROFESSIONAL AUTONOMY

Professional autonomy, or the ability to control the conditions of one's work, is an outcome of a trust relationship established between a profession and the society. It is important to recognize that professional autonomy which extends well beyond the professional-patient relationship and originates in social and political relationships within the society. Autonomy is a privilege and allows the professional to have greater influence over the everyday terms of his or her work than comparable freedoms available to other workers.^10-14

It reflects deference to the profession by others in the community based on the field's demonstration of specialized knowledge, integrity, and altruistic orientation. This is where deprofessionalisation plays a new role of enlightening this as an approach to professionalism where people from other sectors are trained to play a prominent role in the delivery of health care.¹⁴

Types of professional autonomy:

Freidson says that there is an additional extensive independence from governmental instances and from the market. Professional autonomy, however, also includes having control over the profession's scientific knowledge, meaning its production and conveyance as well as its application and evaluation in practice.

Freidson et al, a preeminent sociologist of the professions, defined 2 types of professional autonomy:

1. Technical autonomy is the “right to use discretion and judgment in the performance of work. In general, society gives the professions wide, but not total, independence in terms of technical autonomy.

2. Socioeconomic autonomy is the ability of the worker to ascertain and allocate the economic resources needed to complete his or her work. Bureaucracies have increasingly limited the socioeconomic autonomy of professionals in recent years. This change is related to the increasing costs of health care, public perceptions of insularity of the professions.

There are 2 major sources of social force acting to restrain and redirect professional autonomy: threats from outside the profession and weaknesses within the profession itself. The external threats to autonomy are domination, rationalization, and deprofessionalization.¹⁵

PROFESSIONAL DOMINANCE

From the end of World War II until the early 1980s, organized medicine dominated the organization and delivery of health care. Professional domination is the control by a profession of all aspects of its work, that of other occupations, and in certain situations that of its clientele and the society. During the period of greatest political power (1945–1960), medicine controlled the education system of other health care providers, determined the scope of practice for these occupations, and controlled the workplace for many health care occupations. Health care occupations that did not accept the dominance of medicine were labelled “quack” fields and were subjected to enormous pressure by organized medicine to cease their patient care activities.^16-20

Rationalization of Deprofessionalisation

Rationalization, a sociological theory developed by Weber in the 19th century, describes the historical movement of people to organize society by developing formal rules, responsibilities, and hierarchies defining acceptable behaviors and relationships, culminating in a bureaucracy. Freidson et al defined rationalization as the “pervasive use of reason, sustained where possible by measurement, to gain the end of functional efficiency. At first intended to increase access to health care, the goals of these organizations have shifted to cost containment as the cost of health care has grown rapidly. ^{15, 21 , 22}

Economic changes in health care, health system reorganization and, more recently, the rise of the Internet and other sources of publicly available health information were leading to a “deprofessionalization” of the health care professions.^21-24 To some, the changes wrought by managed care have caused a “proletarianization” of health care professionals by large capitalistic organizations. Ritzer and Walczak et al defined deprofessionalization as the “decline in the possession, or perception that the professions possess altruism, autonomy, authority over clients, general systematic knowledge, distinctive occupational culture, and community and legal recognition.”²⁵

It is evident that care of good quality should be delivered at the lowest possible cost. This might include delivery of care by a less trained person than heretofore, or by someone with limited but focused training. Sharing of skills is a more sensible subject for discussion than transfer of tasks. We review a number of studies which show the effectiveness of inter-professional substitution in various care settings, and also the effectiveness of substitution by those other than health professionals.^26,27

In summary, rationalization affects professional autonomy by organizing professional work into systems that can be controlled by policies and managers. This reorganization has been used most often to limit socioeconomic autonomy in order to ensure high-quality, cost-effective care.^21-25

Future and Challenges to Deprofessionalisation

The commodification and industrialization of health care and weakening of its ethical foundations are among the main forces threatening to deprofessionalise the practice of medicine. To overcome these challenges, an honest and introspective review of the goals of medicine and an affirmation of the ethical values of medicine are needed in order to reinstate the unique role of medicine and also be able to accept this new approach. It is a way of rethinking professionalism. It is commonly agreed that professional practitioners face new challenges in the contemporary environment. These challenges have the potential to radically alter the nature of professionalism and professional practice when many other are also taking part in the health care sectors.^15,26

The contemporary environment of globalization carries with it economic, political, social and cultural changes which impact directly on professional practice (Pugh & Gould, 2000).²⁷

The challenges faced by the practitioners against deprofessionalism are;

a) Complex and uncertain environments.

b) Need to provide value-based service in an increasingly technocratised environment -

c) To maintain position and credibility in an environment calling for increased accountability and transparency.

There has been a long-standing debate about the benefits and disadvantages of pursuing a model of elite professionalism and being equated with traditional professions such as medicine and law. A glance at a recently published Australian undergraduate social work text (Chenoweth & McAuliffe, 2005) provides some insight into current thinking about professionalism^25-28. Camilleri argues that 'Professionals' are necessary. Consumers of services recognize the value and expertise of the professional'. Professionalism, it has been argued, implies the acquisition of some form of specialism: knowledge and skills that are not possessed by untrained workers.

The reality of living in a small community means that all members perform multiple roles. Such role multiplicity in the rural practice context means a fusion of personal and professional lives. According to Mellow, professionalism is an urban concept and ' rural life problematizes the notion of professionalism.' Doctors, through their technical expertise, heightened ethical sensitivity and growing awareness of the relevant ethical issues, can rejuvenate the concept of medicine as a moral community, and reinstate medical professionalism as one of the cornerstones of a stable and civilized society.^{15, 26-28.}

In a deprofessionalised approach sometimes other staff extends their boundaries into the province of what would usually be the 'territory' of the social worker. This blurring can have positive outcomes, where staff work with their strengths and acknowledge each other's specific expertise, but it can create additional stresses. Role blurring and the experience of dual and multiple roles is not necessarily a 'bad thing', but can be constructed as both a challenge and as a positive experience for the worker and community members. It is maintained that rural contexts pose unique challenges for practitioners in constructing professional identity and the need for active negotiation with clients about roles in small communities.²⁹

Advantages Of Considering This Approach Of Deprofessionalism

Within their scope of practice, and to professionally act on that judgment .

The goal will be explicated through the achievement of five major objectives:

a) Demonstrating professionalism.

b) Achieving direct patient access to health care services.

c) Use of evidence-based practice.

d) Attaining entry-level education with the doctor. 

e) Degree becoming the practitioner of choice.^28,29

CONCLUSION

'The Professionalization of Helping', where the history of the profession is detailed and the suggestion made that the current state may be one of 'deprofessionalisation'. This approach can thus provide health care to more people as compared that which could have been provided through the professional approach by the doctors. The involvement of health workers or the community health workers add to the number of health care personnel that can provide health care services and also provides socio-economic upliftment to the people from other sectors willing to extend their helping hands in the field of health care delivery system. This approach has been facing various challenges since the past, but has made several contributions in this field of work whenever in need.