These are certainly interesting times if you are a health care provider trying to figure out where you stand in the “pecking order” of professional designations. We have a health care system fraught with chronic shortages of physicians. Other health care providers are subject to boom and bust cycles in demand for their services.1 These conditions, along with the pressing need to improve the efficiency of health care delivery, are encouraging innovation in human resources: re-allocations of labour, team care models, and new specialization areas. A recent episode of CBC’s The Current discussed the emergence of one such innovation: the introduction of the Physician Assistant position in Ontario health care settings.
What’s a Physician Assistant? Great question. Add it to the growing list of specializations and sub-specializations that fall under the umbrella of health care providers. The Physician Assistant or “PA” position has been a staple in the military for several decades, but has only very recently been given a place in civilian health care in Canada. According to CAPA, the PAs’ professional organization, a PA works as a “physician extender.” Typical tasks include taking medical histories, ordering and interpreting diagnostic tests, prescribing medications, and assisting in surgery. CAPA President Ian Jones, who was interviewed by The Current, states that the introduction of PAs is a sensible strategy for delivering healthcare more efficiently, and reducing patient wait times.
So what’s the problem here? Doris Grinspun, Executive Director of the Registered Nurses’ Association of Ontario, also appeared on the Current episode, arguing that PAs are inconsistently trained, less trained than RNs, and may potentially compromise care quality.3 In fact both guests define the issue in terms of patient care and patient interests. Regulation of professions, via self-regulation, the state, or some combination of these, is indeed important for protecting public interests in areas that significantly affect their wellbeing. Think, for example, of concerns voiced by some around the unregulated nature of alternative medicine.
The patient-interests based arguments of The Current’s guests are thus not without relevance or merit. However, they obscure the fascinating dynamics of power struggles among established professional groups and “up and comers” competing for legitimacy within a given field. Perspectives that examine conflict, competition and self-interest within and among professions are sometimes designated “neo-Weberian” because they pick up on and extend the work of turn-of-the-century (that’s 20th century) sociologist Max Weber.4 Among his many historical and sociological explorations, Weber took an strong interest in how specialized knowledge brought power and status to the emerging professional class. In other words, he recognized that the idea of “the professional” has what we might call cultural or symbolic worth beyond their defining educational and technical criteria. Professionals have social status; people defer to their authority. This has some cachet, no?
So if we apply this kind of thinking to the discussion on the Physician Assistant accreditation, the opposition expressed by nurses takes on a new dimension. Registered Nurses have historically specialized in similar capacities, so a PA is essentially a new kid on their block, competing with nurses for “ownership” over the bodies of knowledge required to support physicians in various settings. The rarity and breadth of knowledge involved (“expertise”), along with the overall necessity of the services offered, impacts the demand for the work, and the compensation for the work. Simply put here, PAs and RNs may be competing for the same jobs, and they do so by trying to persuade others (including the public) of the legitimacy, importance, and usefulness of what they know.
Turf Wars: Implications for Career Planning
I find these conflicts among professional bodies fascinating in their own right,5 but they can have important consequences for students attempting to establish career paths. Professional turf struggles can translate into competing accreditations, designations, and programs of study that can be bewildering for students entering the field. As provinces and provincial level bodies tend to regulate and license forms of education and work, standards and designations can differ from one end of the country to another, making it difficult for students to move to other provinces with assurance that their credentials will be recognized. In the case of PAs, for example, it’s a graduate-level degree in Manitoba,6 whereas in Ontario a student may enter a PA program after two years in any undergraduate degree program.
Fields in the process of professionalizing – fitness trainers and massage therapists come to mind – can be fraught with risk for those entering them. Credentials with weak or questionable recognition value can make it tough to find work in the chosen field, and the road to such recognition is often long. (Midwifery is a great example of an uphill battle to achieve professional status and recognition.) Emerging fields often can’t promise the same compensation as established fields. Being a “professional” is no guarantee of income or job security.
So if you or someone you know is thinking about career routes, it’s not a bad thing to recognize that a “professional” designation isn’t always a straightforward thing. Some professions like RN, LLB, or CGA (among many others) are well established and well recognized. Where newer and less recognized fields are laying claim to professional status, it is a good idea to do some investigation and determine which programs of study are recognized where. Professionalization generally serves public interests, but it’s important to recognize and remember that professional organizations and professionalizing areas have a stake in selling the public on their legitimacy and credibility.
1 Health Canada (2004). Health human resources: Balancing supply and demand. Health Research Bulletin, 8.
2 Health care provider designations include registered nurses, doctors, licensed practical nurses, registered psychiatric nurses, nursing assistants, nurse practitioners, lab techs, radiation techs, respiratory therapists, psychologists, physiotherapists, and occupational therapists… among others! See Health Canada (2004), above. Also Salhani & Coulter, 2009, The politics of interprofessional working and the struggle for professional autonomy in nursing.
3 More detail on the OARN’s position on PAs is available here.
4 Neo-Weberian or critical accounts of professionals and professionalism take the perspective that many aspects of professional organization and professional regulation are self-serving because they bar entry by competitors. The status of the profession is upheld when its exclusiveness is maintained. Weber didn’t talk about this stuff directly himself, but his work serves as a foundation for it. Weber is best known for his work “The Protestant Ethic and the Spirit of Capitalism,” which looked at (like the title suggests) the historical conditions that led to capitalism being more successful in some places than others (i.e. England and North America). The work famously cites Ben Franklin as an exemplary early capitalist, emphasizing frugality, hard work, and self-control. For a quick and dirty overview, here’s the Wikipedia entry.
5Competition for legitimacy can occur in any professional field. For an interesting account of…well, accountants, see Macdonald, L. & Richardson, A. (2004). Identity, appropriateness and the construction of regulatory space: the formation of the Public Accountant’s Council of Ontario. Accounting, Organizations and Society, 29(5-6), 489-524. It’s a historical overview of competing professional accreditation bodies. And hey, who knew there was a field of academic study called “Critical Accounting?”