John F. Roatch Global Lecture Series - PowerPoint Presentation

Slide1

John F.

Roatch

Global Lecture Series

22 February 2013

THE IMPLICATIONS OF MARGINALITY IN THE MEDICAL PROFESSION: THE CASE OF ALTERNATIVE MEDICINE

Professor Mike Saks

Provost and Chief Executive

University Campus Suffolk

Slide2

RELATED EXPERIENCE

Dean of Faculty of Health and Community Studies, De Montfort University, UK

Chair of the Research Council for Complementary Medicine

Adviser to government and professions on health and social care in the UK

Recipient of major international funding for

health

projects in North America and Europe

President of the International Sociological Research Committee on Professional Groups

Author of thirteen books on professions, health and social care.

Slide3

THE IMPLICATIONS OF MARGINALITY

IN

THE

MEDICAL

PROFESSION: THE CASE

OF ALTERNATIVE MEDICINE

Marginality in the Professions

Marginality and the Medical Profession

The Case of Alternative Medicine

Slide4

1. MARGINALITY IN

THE

PROFESSIONS

Slide5

THE MYTH

OF SIMILARITY IN THE PROFESSIONS

It

is often assumed that professions are

similarly based

– when there are considerable differences in how they are constituted and their position in society.

The notion of professions as communities of equals is a myth both in a single profession and

in

terms of the relationship between

professions – on which this presentation focuses.

Slide6

DEFINING PROFESIONS

Professions

are defined

in terms

of exclusionary social closure – based on legal boundaries creating ranks of insiders (vs. outsiders) with associated

privileges.

However, it is recognised that professions have different forms of social

closure. Some

occupations, moreover, have not effected full social closure and are in the process of

professionalizing

– governed by voluntary rather than statutory regulation.

Slide7

MARGINALITY AND

THE PROFESSIONS

The category of ‘

marginalized

professions’ and their relationship with dominant professions highlights the pecking order within professions. These have a less well accepted standing, typically reflected in different levels of income, status and power.

‘Marginal professions’ in contrast are professionally-aspiring occupations outside the state-supported orthodox division of

labour.

Slide8

THE

IMPLICATIONS OF MARGINALITY IN THE PROFESSIONS

The

marginal nature of

professional

groups

can

have many

implications,

not least

for

social inequalities

–

from patterns of geographical dispersal

of practitioners to

the number of practitioners

in

particular fields.

This issue becomes more politically charged if the position of marginal professions or

marginalized professions

does not

relate

s

o much to their expertise

and the significance of the knowledge base for the wider society, but

rather

to interest-based politics.

Slide9

2. MARGINALITY AND THE MEDICAL PROFESSION

Slide10

MARGINALITY IN HEALTH

CARE

The differentiation

within professional groups

and its impact, especially in terms of social inequalities, is now

illustrated with reference to health care.

This

then builds

into

the major

case study

of the marginalized field of alternative medicine.

Slide11

CATEGORISING HEALTH PROFESSIONS

Orthodox health professions

are

divided

by Turner (1995) into

the following

hierarchical categories:

The dominant medical profession which stands at the pinnacle of orthodox health care in modern industrial societies.

Limited health professions (

eg

dentists and opticians) which restrict themselves to particular parts of the body.

Subordinated health professions (

eg

nurses and midwives)

in the orthodox division of labour.

Slide12

THE

IMPLICATIONS OF MARGINALITY

This is a fluid

categorisation

– given, for example, the recent dilution of medical professional power related to the rise of corporatism and

consumerism.

Nonetheless, these differences

have significant implications in areas such

as:

The way knowledge is used in the division of labour (

eg

through referral structures)

The quality of

entrants

to particular

health professions

in the pecking

order

A

ccess

to

care through

the

public

sector or insurance support.

Slide13

THE POLITICS OF

HEALTH MARGINALITY

The political debate about the reasons for marginality in the professions is also reflected

in the health arena

(Saks

2003):

At one end of the spectrum, the medical profession is

seen as being placed

on a

lofty pedestal

as a result of

possessing complex/esoteric expertise of vital importance to the public.

On the other, medicine is

seen

as self-interestedly establishing its own exalted position in society at the expense of other health

professions/occupations.

Slide14

MARGINAL HEALTH PROFESSIONS

Despite

the hierarchies,

even

marginalized

health professions have official recognition and legitimation and a variety of associated benefits, such as protection of title, which has often been linked to enhanced income, status and

power.

This marks out orthodox health professions from marginal health professions which largely stand outside formal state-endorsed frameworks

and are

based on

the categorisation by Turner (1995) of ‘exclusion

’ rather than ‘subordination’ or ‘limitation’ in the health care division of

labour.

Slide15

FURTHER MARGINALIZATION

Such marginal professions include aspiring health professions within the orthodox

health

care division of labour

striving

to

professionalize.

The excluded also

include occupations such as

those in alternative medicine

that are not yet fully

professionalized with statutory

underwriting, but

have

some form of voluntary

self-regulation.

It

is these variations from orthodox medicine which

have

the greatest implications for

the health groups concerned and the wider public.

Slide16

3. THE CASE OF ALTERNATIVE MEDICINE

Slide17

(a) THE DEFINITION OF ALTERNATIVE MEDICINE

Slide18

DEFINING ALTERNATIVE MEDICINE

Alternative medicine in the West is defined

here in terms of its lack of power relative to

orthodox health care:

Orthodox Health Care

Health care underwritten by the state

At present based on biomedical dominance

Focused heavily on drugs and surgery.

Alternative Medicine

Not widely supported by the state

Largely subordinated to biomedicine

Covers a great diversity of approaches, from

acupuncture to reflexology.

Slide19

TYPES OF ALTERNATIVE MEDICINE

Acupuncture

Aromatherapy

Ayurveda

Biofeedback

Chiropractic

Crystal therapy

Healing

Herbalism

Homeopathy

Iridology

Massage

Naturopathy

Osteopathy

Reflexology

Shiatsu

Yoga

Slide20

Acupuncture

Slide21

ALTERNATIVE MEDICINE AND POLITICS

In terms of the approach to professions based

on the concept of social closure, the marginal

position of alternative medicine is viewed as

part of a political process creating insiders and

outsiders.

Importantly, it is not seen simply as those

therapies that lack available scientific

evidence in terms of efficacy and effectiveness

compared to orthodox medicine – which in

itself may be contentious.

.

Slide22

KEY POINTS ABOUT THE DEFINITION

In terms of this definition, it therefore follows

that:

Alternative medicine is not based on the

intrinsic characteristics of such therapies,

but their political marginality

Depending on the balance of power, the

orthodoxy of one period can become the

unorthodoxy of another, and vice versa.

Slide23

(b) ALTERNATIVE MEDICINE IN THE UK

Slide24

PRE-INDUSTRAL HEALTH CARE IN THE UK

Pre-industrial health care in the UK was

historically characterized by:

A comparatively undifferentiated field

The absence of a national, enforceable

legal monopoly of medicine

Difficulties in distinguishing practitioners:

- Theories/practice

- Training

- Status/repute.

Slide25

THE CREATION OF A MEDICAL PROFESSION IN THE UK

From the early nineteenth century, political

power was used to create the medical

profession through:

A lobby for a unified profession, led by the Provincial Medical and Surgical Association (later the British Medical Association)

A successful campaign to professionalize

medicine, increasingly sustained by the state by the ‘medical-Ministry alliance’

Attacks by the emerging profession on rival health groups, through the medical media.

Slide26

THE DEVELOPMENT OF THE MEDICAL PROFESSION IN THE UK

The rise of biomedicine was underwritten by

the 1858 Medical Registration Act and

subsequent legislation which led to:

Differentiation from rival practitioners

Reinforcement of medical dominance with:

- An ever wider state market shelter

- Growing paradigmatic unity

- Advances in medicine

Subordinated health professions

A highly privileged professional position in terms of income, status and power.

Slide27

PROFESSIONALIZATION AS A POLITICAL PROCESS IN THE UK

It is claimed that the process of differentiation

that began in the latter part of the nineteenth

century in the UK was political rather than

scientifically functional/justifiable at that time

because, amongst other things:

Medicine was classificatory (vs. curative)

Aseptic techniques had not been introduced

Anaesthesia was not standard in operations

Hospitals were seen as gateways to death.

Slide28

THE INCREASING MARGINALITY OF ALTERNATIVE MEDICINE IN THE UK

Nonetheless, with the rise of orthodox

medicine came the growing marginality of

a

lternative medicine, as indicated by:

Common Law rights, but no state legitimacy

Restrictions on claims to treat conditions

Medical ethics restricting collaboration

Intensified attacks in the medical journals

Informal medical colleague controls

Stifling the professionalization of alternative medicine.

This led to a fall in use of alternative medicine

and the numbers of alternative practitioners

by the mid-twentieth century in the UK.

Slide29

THE EMERGENCE OF A COUNTER CULTURE

However, there was growing public demand

for alternative medicine from the late

1960s/early 1970s. This was linked in the UK

to the development of a medical counter

culture based on:

Increasing awareness of the limits to

medicine and the availability of alternatives

A response to medical depersonalization

and disempowerment

A desire by consumers to exercise greater

control over their own health care.

Slide30

THE PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE UK

These trends are an important context to the

professionalization of alternative medicine in

the UK. This has been accentuated by the

following political pressures:

Growing medical incorporation of alternative medicine

Disaffection with orthodox medicine

Greater receptivity of government to the professionalization of alternative medicine

House of Lords Select Committee support

Lobbying for alternative medicine (

eg

Prince Charles).

Slide31

Slide32

THE RECENT RESURGENCE OF INTEREST IN ALTERNATIVE MEDICINE IN THE UK

The development of this counter culture was

the spur to the resurgence of interest in

alternative medicine in the UK by the

beginning of the new millennium with:

More than 1/7 of the population using alternative medicine

60k+ alternative medicine practitioners in existence

Increasing employment of alternative medicine in the National Health Service by medical and non-medical practitioners.

Slide33

THE GROWING PROFESSIONALIZATION

OF ALTERNATIVE MEDICINE IN THE UK

In consequence, there has been an increased

move to professionalize alternative medicine:

Alternative medicine has increasingly been based on education/training

Ever more alternative medical practitioners like acupuncturists have voluntary regulation

The General Osteopathic Council and the

General Chiropractic Council were

established in the 1990s with statutory regulation

Increasing numbers of alternative therapists are qualified health professionals.

Slide34

THE FUTURE OF PROFESSIONALIZATION

OF ALTERNATIVE MEDICINE IN THE UK

Although there have been obstacles to

professionalization in the past, this is now

becoming more of a direction in the UK.

This was addressed by the 2007 White Paper

on

Trust, Assurance and Safety – The

Regulation of Health Professionals in the 21st

Century

. This proposed, amongst other things:

Ensuring regulation for alternative medicine proportionate

to the risks and benefits

Statutory regulation for certain groups (

eg

psychotherapists and counsellors).

Slide35

THE STEERING GROUP FOR ALTERNATIVE

MEDICINE

T

he 2007 White Paper led to a Steering Group

exploring the regulation of acupuncture, herbal

medicine and Traditional Chinese

M

edicine.

This reported to Ministers in 2008 on the

statutory regulation of these groups – and

prompted a consultation with key parties in

2009, the results of which were fed back in

February 2011.

The consultation showed, amongst other things,

that most respondents preferred statutory to

voluntary regulation to protect the public in

these fields and to enhance practice quality.

Slide36

THE FUTURE PROSPECTS FOR

ALTERNATIVE MEDICINE AS A

MARGINAL FIELD IN THE UK

The future prospects for professionalization

in the UK, though, are not that rosy:

The Government is planning to statutorily

regulate herbal and traditional medicine

practitioners because of EU licensing issues

Acupuncture, which has long lobbied for statutory regulation, does not look like it will be allowed to move in this direction at present

The position is limited by current attacks on alternative medicine as non-scientific.

Slide37

(c) ALTERNATIVE MEDICINE IN THE USA

Slide38

PRE-INDUSTRIAL HEALTH CARE

IN THE USA

Pre-industrial health care in the USA was

similarly characterized as in the UK by:

Great eclecticism, especially given the

anti-corporatist resistance to monopolies

The co-existence of a spectrum of practitioners from herbalists to homeopaths

Difficulties in distinguishing ‘regular’ and ‘irregular’ practitioners in terms of remedies, education and other factors.

Slide39

THE CREATION OF A MEDICAL PROFESSION IN THE USA

In the less unified system in the USA, state

medical licensing systematically emerged in

the early twentieth century – some five

decades after medical professionalization in

the UK. The formation of the medical

profession largely resulted from:

Lobbying from the increasingly influential American Medical Association

Careful political positioning to ride the waves of the anti-monopolistic culture

Attacks by the emerging profession on alternative health groups as ‘quackery’.

Slide40

THE DEVELOPMENT OF THE MEDICAL PROFESSION IN THE USA

In the USA the rise of biomedicine was

underwritten by a

de jure

monopoly

(legally

bounded) rather than a

de facto

monopoly as

in the UK (with protection of title but where

anyone can practice under the Common Law).

This led to differentiation from rivals and

m

arket privileges in the USA – and the

reinforcement of medical dominance with:

Growing biomedical unity

Ever greater specialism in medicine

C

reation of subordinate health professions.

Slide41

PROFESSIONALIZATION AS A POLITICAL PROCESS

The claim that the process of differentiation

in the early twentieth century in the USA

was political rather than scientifically

justifiable is less convincing than in the UK

as the move to professionalization came fifty

years later.

At this time the scientific underpinnings of

biomedicine in the USA were stronger. Even

s

o, medicine could still not be considered to

be rigorously founded at this time – with

controlled studies only just starting and doubts

over the general competence of medical

practitioners.

Slide42

THE INCREASING MARGINALITY OF

ALTERNATIVE MEDICINE IN THE USA

Despite this, as in the UK, with the rise of

orthodox medicine came the increasing

marginality of alternative medicine

in the

distinctive USA context in particular as:

It became illegal for the unlicensed to practice without their own licensing board

There were tough legal powers against those practising without a license

There were attacks on alternative therapists and other medical controls existed.

This also led to a decline in alternative medicine

by the mid-twentieth century – even if by the

1950s osteopaths were licensed in most states.

Slide43

THE RISE OF A COUNTER CULTURE

Nonetheless, there was similarly growing

public demand for alternative medicine from

the late 1960s/early 1970s in the USA linked to

the development of a medical counter culture.

This was exemplified in the USA by, amongst

o

ther things, the Boston Women’s Health

Collective and the ping-pong diplomacy that

excited interest in acupuncture.

This gave alternative medicine impetus in

the

USA in

the

back half of the twentieth

century,

with a medically incorporationist

culture

contrasting with the UK – linked to the more laissez-faire climate and more limited risk of legitimation of outsiders.

.

Slide44

Slide45

THE PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE USA

As in the UK, these trends are a key context

to the professionalization of alternative

medicine in the USA. This has been

accentuated in the USA by the following

political pressures, amongst others:

Growing medical incorporation of alternative medicine (

eg

with the establishment of the American Holistic Medical Association)

On-going public disaffection with orthodox medicine

Greater receptivity of local/federal government to alternative medicine

Lobbying for specific alternative therapies.

Slide46

THE RESURGENCE OF INTEREST IN ALTERNATIVE MEDICINE IN THE USA

In the USA the resurgence of interest in

a

lternative

m

edicine seems to have gone

further and faster than in the UK. This

i

s indicated by the fact that by the beginning

of the twenty-first century in the USA:

An increasing percentage (42%) of Americans reported using alternative medicine

Out of pocket expenditure on alternative medicine had reached $27 billion

More than 35% of physicians practiced at least one alternative therapy.

Slide47

THE GROWING PROFESSIONALIZATION

OF ALTERNATIVE MEDICINE IN THE USA

In consequence, as in the UK, there has been

a further move to professionalize alternative

medicine, as exemplified by the following:

There are a myriad of associations representing the alternative

therapists, with licensing typically based on graduation from accredited schools (

eg

in

naturotherapy

)

Chiropractic, for long the bane of the American Medical Association, has gained widespread state licensure, as well as the right to reimbursement under Medicare and Medicaid.

Slide48

THE FUTURE OF PROFESSIONALIZATION

OF ALTERNATIVE MEDICINE IN THE USA

The professionalization of alternative

medicine is now therefore becoming even

more common in the USA, as in the UK.

This is accentuated by the establishment of the National Center for Complementary and Alternative Medicine in 1998 as part of the National Institutes of Health by the federal government to fund alternative medical research – with a $128m pa budget in 2012 that adds greater legitimacy to alternative medicine.

Slide49

THE FUTURE PROSPECTS FOR

ALTERNATIVE MEDICINE AS A

MARGINALIZED FIELD IN THE USA

The future prospects for alternative medicine

professionalization in the USA, as in the UK,

though, do have limits which highlight its

on-going marginality:

The degree of licensing varies for specific therapies from state to state – with medical control in some states

J

ust as

in

the UK,

the largest use of such

therapies continues

to be through

self-help

The position is restricted by on-going attacks on alternative medicine as ‘cultism’

.

Slide50

(d) A WIDER PERSPECTIVE ON ALTERNATIVE MEDICINE

IN THE UK AND THE USA

Slide51

THE RELUCTANCE OF ALTERNATIVE PRACTITIONERS TO PROFESSIONALIZE FURTHER

For all the developments in alternative medical

p

rofessionalization in the UK and USA, such

therapists have often been reluctant

professionalizers:

There was a considerable delay in forming voluntary/statutory organizations

There are many outlying alternative therapists, even in professionalizing areas

Some alternative practitioners continue to resist professionalization.

Slide52

THE INDEPENDENCE OF ALTERNATIVE THERAPISTS

This is partly explained by the independence

of alternative practitioners who often:

Work in private practice

Operate outside state structures

Dislike bureaucracy and hierarchy

Regard individualism as sacrosanct

See a free spirit as essential to practice

Hold egalitarian philosophies

Do not collaborate within/across disciplines.

The term ‘herding cats’ has been applied to

alternative therapists as this has undermined

t

heir unity in the politics of professionalization.

Slide53

BROADER SYSTEMS OF POWER

However, the main reason for the limits to

professionalizing alternative medicine seems

t

o relate to the impact of broader systems of

power, for example:

The mainly negative response to the resurgence of alternative medicine by orthodox medicine

The interlinked rejection by local/national government of certain individual therapy interest in gaining professional standing

The pressures bought by other interest groups (

eg

the pharmaceutical industry and the private health insurers).

Slide54

THE IMPACT IN A MARGINAL AREA

As with the marginalized health professions discussed earlier, this situation has impacted on alternative medicine through, for instance:

The way knowledge is used in the division of labour

– including through

referral

structures

The quality of entrants to particular

fields of alternative medicine

Access to

alternative medicine care

through the public sector or insurance support.

Slide55

ALTERNATIVE MEDICINE AS

SELF-HELP

It has also

impacted in the

UK

and the USA

on the use of alternative medicine as self-

help by:

Limiting the range of consciousness

about alternative medicine

Increasing the use of alternative medicine as self-help where there is an absence of professionalized practitioners.

Slide56

(e) THE IMPLICATIONS OF ONGOING MARGINALITY FOR ALTERNATIVE MEDICINE IN THE UK AND THE USA

Slide57

BENEFITS OF THE

PROFESSIONALIZATION OF

ALTERNATIVE MEDICINE

The potential benefits to the public and

practitioners of decreasing marginalization

of alternative medicine through increased

professionalization include:

Stronger educational base

Certified knowledge/expertise

Evidence-based practice

Codes of ethics

Protection of the public

Increased public access

Security of practitioners

Enhanced income, status and power.

Slide58

COSTS OF THE FURTHER

PROFESSIONALIZATION OF

ALTERNATIVE MEDICINE

There are also potential downsides too that

need to be acknowledged from the viewpoint

of alternative medicine:

Distancing from the client

Constraints on the scope of practice

More limited client accountability and responsiveness

Potential economic costs

Dangers of professional tribalism

Barriers to integrated working

Lack of a sufficient evidence base in terms of safety, efficacy and effectiveness.

Slide59

A GLOBAL PERSPECTIVE

These costs and benefits should be seen in a global perspective in so far as other world systems (

eg

in Asia) have reversed the pecking order in the West – including in Canada and Western Europe as a whole.

This means that the relatively recently established orthodoxy of biomedicine is seen as more of a marginal practice as compared with other therapies that are considered alternative medicine in the West.

This is well exemplified in the East by the cases of China (where Traditional Chinese Medicine prevails) and India (where

Ayurvedic

Medicine is more of a force).

Slide60

SOCIETAL VARIATIONS

This is not to say that there are not societal variations in alternative medicine as a marginalized therapy in the West, for example:

I

n the USA practices like prayer, herbalism and meditation dominate

In Canada chiropractic is the most popular type of alternative medicine

In the UK therapies such as acupuncture and herbalism prevail

In France homeopathy is the most broadly employed therapy

In the Netherlands spiritual healing is the most widely used alternative therapy.

Slide61

KEY QUESTIONS

However, these comparisons should make us

think in the West very carefully in our own

society in a recessionary world about:

The alternative therapies that have the

strongest evidence base

Their cost-effectiveness relative to orthodoxy

The methods that we use to form the

evidence base (quantitative vs. qualitative)

The extent to which voluntary vs. statutory regulation is desirable in particular cases

How far the practice is restricted to medicine

To what extent the self-help use of alternative therapy should be limited.

The quality and cost of health in the UK, USA

and elsewhere hinges on these questions.

Slide62

POLITICAL ISSUES

To concretise this in the USA – not least with the implementation of the 2010 Affordable Care Act – there are some key political issues about the alternatives in an increasingly harsh financial climate in terms of individual rights:

Which alternative therapies should be paid for through Medicare/Medicaid or private health insurers or customers at the point of access?

What should be the threshold criteria of eligibility for federal/state/private health insurer funding of the alternatives?

What are the implications of marginalization of alternative medicine for health care delivery in this context?

Slide63

SELECTED REFERENCES

Kuhlmann

, E. and Saks, M. (

eds

)

(2008)

Rethinking

Professional Governance

, Policy

Press

Saks, M. and

Allsop

, J. (

eds

)

(2013)

Researching

Health

, Sage,

2nd edition

Allsop

, J & Saks, M. (

eds

)

(2002)

Regulating the Health Professions

,

Sage

Saks

, M.

(2003)

Orthodox

and Alternative Medicine: Politics, Professionalization and Health Care

,

Sage

Slide64

SEE ALSO...

 

Kellner

, M., Wellman, B.,

Pescosolido

, B. and Saks, M. (

eds

) (2003)

Complementary and Alternative Medicine: Challenge and Change

,

Routledge

.

Saks

, M. (1995)

Professions and the Public Interest

,

Routledge

.

Saks, M. (2000) “Medicine and the Counter Culture”, in

Cooter

, R. and

Pickstone

, J. (

eds

)

Medicine in the Twentieth Century,

Harwood Academic Publishers.

Saks

, M. (2006) “The Alternatives to Medicine”, in

Gabe

, J., Kelleher, D. and Williams, G. (

eds

)

Challenging Medicine,

Routledge

.

Slide65

AND…

Saks

, M. (2010) “

Analyzing

the Professions: The Case for the Neo-

Weberian

Approach.”

Comparative Sociology

, 9: 887-915.

Saks, M. (

2013

forthcoming) “Marginalized Health Professions”, in Stevens, F. (

ed

)

Encyclopaedia of Health, Illness

Behavior

and Society

, Wiley-Blackwell.

Saks, M. and

Kuhlmann

, E. (2006) ‘Introduction: Professions, Social Inclusion and Citizenship’,

Knowledge, Work and Society

, 4 (1): 9-20.

Turner, B. S. (1995)

Medical Power and Social Knowledge

, 2nd edition, Sage

.

Slide66

Thank you for listening.

Any questions?