A Simultaneous Need for Independence and Solidarity Places Professions in Precarious Position
By Alex McEllistrem-Evenson
Ask ten people to define “allied health,” and you are likely to receive ten different answers. While the category is still most commonly defined by exclusion, as those in health care fields who are not physicians or nurses, a variety of usages proliferate. For some, the term encompasses all health professionals, “allied” to support patient health. Alternatively, many view it with a degree of disdain, as an almost-derogatory concept which elides the significant differences in skill and training required by various professions traditionally lumped together. Two things, however, upon which just about everyone with experience and interest in “allied health,” “health sciences,” or any of the more than 70 individual professions which the American Medical Association places under this umbrella can agree are that the concept itself has occupied contentious and shifting territory for decades, and that “allied health” plays a significant role in many health workforce issues and challenges.
For decades, allied health as a singular category has been regarded as anything but, viewed (ironically) as being fragmented and relatively unstable when compared to “stalwarts” such as medicine and nursing. At root, however, this apparent multiplicity is the result of a double-bind which plays itself out in numerous and complex ways. Interestingly, it may also serve as a useful microcosm for assessing the health workforce landscape as a whole.
The most detailed account to date of the history of the definition and usage of the term “allied health” was published in 2008 in the Journal of Allied Health. Fred Donini-Lenhoff’s article, “Coming Together, Moving Apart” clearly tracks the origins of “allied health” as well as the manner in which the term has moved in and out of vogue.
Although Donini-Lenhoff traces the term back to the 1930s, it first surfaced in a legal sense with the passage of the federal Allied Health Professions Personnel Training Act of 1966. According to the Association of Schools of Allied Health Professions (ASAHP), “the passage of this legislation brought about a new and radical concept of unifying all the various disciplines that comprise allied health into academic units with a single administration”; however, the actual language of the Act only defined “allied health training” programs as those “in the digital technology, optometric technology, and dental hygiene” fields, adding that the Act also applies to “any of such other of the allied health technical or professional curriculums [which] prepare the student to work as a technician in a health occupation.” This broad context establishes allied health, for legal intents and purposes, as a sort of “catch-all” for new and emerging professions, a role the category still occupies today.
A Double Bind
It is principally because of allied health’s traditional role as a “catch-all” that the double bind mentioned above becomes apparent. For a given profession, the benefits of being grouped together under a single category are clear: “recognition and funding,” states Dr. Lacheeta McPherson, president of the Board of Directors for the Commission on Accreditation of Allied Health Education Programs (CAAHEP). “It gives us a greater voice at the federal level.”
For health professions which are new and emerging, and for ones which serve a “niche” function and are by necessity comparatively small in size, a greater voice is crucial. Workforce development initiatives, awareness campaigns, and more which are essential to maintaining the stability of a given profession and satisfying important needs in the health care system are funded from a finite set of government funds. In order to be able to compete for those funds, smaller and less-established professions must be heard and recognized to the same extent that their more readily visible counterparts are. In a very real sense, organizations which accredit education programs in allied health fields and those which advocate for allied health professions ensure the stability and healthy growth of their member professions.
Despite this, there is a natural impulse within any profession to be autonomous, to be recognized on the basis of the merits, functions, and skill set which are endemic to a particular profession and which emerge from a unique course of study or training path. This impulse equates “independence” with “growth,” and as a result there has been a noteworthy trend of member professions taking steps to leave the various umbrellas of “allied health” and similar categories. To the extent that professional autonomy and strength in numbers are mutually exclusive concepts, member professions find themselves in a double bind.
Donini-Lenhoff states that “having reached a critical mass of public/governmental awareness and number of practitioners…they begin to ‘brand’ themselves as an independent health profession, not an allied health profession, which to some connotes a secondary, subsidiary, and dependent relationship to physicians and medicine.” He cites physical therapy, occupational therapy, and clinical laboratory science – all of which have moved to a post-baccalaureate degree requirement for practitioners – as example professions in this regard.
Case in Point: Respiratory Therapy
For some professions, however, the concept of becoming a freestanding accreditor is simply not feasible. “Some professions are just too small to operate on their own,” remarks Dr. Tom Smalling, Executive Director of the Committee on Accreditation for Respiratory Care (CoARC). “It takes a lot [of resources]: there’s a large financial investment. You’ve got to have your own insurance, for example, to cover legal costs. You’ve got to have the financial resources to have staff to do a number of those things [associated with accreditation services]. Some allied health professions don’t have that ability.”
On the other hand, a number of other professions do. Since November 2008, Smalling has been instrumental in carrying out the decision of CoARC’s board of directors to move the respiratory therapy profession out of the umbrella of CAAHEP, the organization which has accredited respiratory therapy education programs (along with education programs for other allied health professions) since it was established in 1994. The transfer will be complete in early November 2009.
The rationale behind this decision is fairly clear. “We strongly felt that we wanted to make sure that we were the ones who would determine the standards for respiratory care and quality,” states Smalling. “Currently, the members of CAAHEP’s Board of Directors are the final deciders. We only had one of our board members, one respiratory therapist, on that board.” Smalling also cites CoARC’s experience, based on the fact that that day-to-day accreditation services for respiratory therapy have been conducted by CoARC and its predecessor organization for nearly 40 years.
For McPherson, however, the “strength in numbers” argument takes precedence. “We are so fragmented in our voice,” she states. “You hear about the nursing shortage all the time. There is even a greater workforce shortage in allied health. But you never hear that, you never hear about the big companies picking up the gauntlet like they did for nursing and putting on a national campaign for allied health. And part of that’s because we’re our own worst enemy when it comes to having a common voice.”
“I can appreciate that professions want to go off,” she continues. They feel like they have a little more control when they do so. But they tend to lose a voice when they do that. I have a bias for CAAHEP because it really is the only forum where twenty different organizations can come together and actually speak in one voice about the same problems, even though they are different, they still have the same problems. Independent professionals that have their own stand-alone accrediting body still face the same issues that all the other allied health programs face but they lack the opportunity to share those issues and talk about some best practices. It becomes inbred if you will that they can’t see outside of the possibilities because of the fact that they are so ingrained on their profession and not from a more global perspective.”
Smalling is quick to disagree with McPherson’s claims. “Being a CoA [a Committee on Accreditation under the CAAHEP Board of Directors], the world we [CoARC] knew under CAAHEP was CAAHEP – that was the world. That was the box we lived in. We collaborated with other CoAs and we went to the CAAHEP meetings. But when you’re in that group, and perhaps a majority of those in that group are CoAs that are less experienced than you are, you get less and less out of the collaborative process.”
“Prior to our board’s vote to separate,” states Smalling, “we had contacted professions who had separated from CAAHEP and asked them for their input. All three of the groups that I spoke with had said that they made the right decision.” In Smalling’s view, a more important question has to do with the nature of a given collaborative relationship rather than the simple existence of one. “Going to CHEA [Council for Higher Education Accreditation] and ASPA [Association of Specialized and Professional Accreditors] meetings now, we are not just collaborating with specialized and professional accreditors, we’re collaborating with the regional, national, faith-based accreditors. Getting involved with CHEA and ASPA, we know much more about what’s going on in the national arena. We are more involved with what’s going on at the federal level than we would have ever been.”
“Where the Rubber Meets the Road”
While there’s an obvious and clear separation when a profession leaves the umbrella of CAAHEP or a similar formal allied health organization, it is difficult to pinpoint what must occur in order for a profession to leave the umbrella of “allied health.” Is the “neat little package” of autonomous management that McPherson refers to ever really attainable, or is it more or less an illusion? In either case, what are the larger ramifications?
Smalling brushes aside any suggestion that respiratory therapy is leaving allied health behind: “There’s always been that view,” he states, “talking about the death of allied health. You know, we’re doing the same thing we always have. We are allied health. We’re part of a larger set of health care professions. We’re certainly not as autonomous as nursing or medicine and perhaps some of the other health professions like physical therapy. We are very closely tied to our physicians. We consider ourselves a physician extender in many areas.”
“CoARC was a founding member of CAAHEP,” he clarifies. “We helped develop standards and policies [related to outcomes assessment] that were put into place and we had a large number of programs. When you look at the 16 or 17 committees on accreditation within CAAHEP, a lot of them don’t have the 40 years of experience that we have. A lot of them are fairly new, and CAAHEP is a great venue for that type of group.”
While CAAHEP may be an ideal organization for new professions and committees on accreditation, most CAAHEP committees are actually quite experienced. According to Kathy Megivern, Executive Director of CAAHEP, “eleven [of the 17 CoAs] are anywhere from 25 to 49 years old. A couple others were doing recognition before they joined CAAHEP. The only professions that are truly ‘new’ to accreditation are Polysomnographic Technologists, Surgical Assistants (which is part of a CoA that goes back to 1970), Personal Fitness Trainers, and the most recent one, Lactation Consultants, just approved in April 2009.”
For McPherson, CAAHEP – and by extension, allied health as a whole – is more than an incubator for professions. “From my perspective,” she states, “it’s important that we know that we’re not going to meet the health care demands at the current rates of education putting out the number of graduates that we currently do. There is a place for the technician, there’s a place for the technologist, the therapist, there’s a place for the advanced practitioner, all the way up the line. But it’s imperative that the professions figure that out.”
“An example of that,” McPherson states, “is Physical Therapist Assistants (PTAs). The physical therapists (PTs) have a limited relationship with PTAs. I went to a forum about five years ago and we were talking about the difference between PTAs and PTs. At that point, PTs had to have a master’s degree, minimum – now it’s gone up to a doctorate. We asked this panel of PTs ‘if you had a PTA come in and apply to your program, say they were a practicing PTA, they went ahead and got their bachelor’s degree, they went ahead and got their master’s degree and they’re applying to your doctorate program for physical therapy, would you see that as being an advantage for them to be a PTA?’ Their answer was ‘why would it? Absolutely not. There’s nothing that a PT and a PTA have in common.’”
“Frankly, that’s ludicrous. If you go to the hospitals and see who’s actually working with patients, if you go to the rehab centers and see who is actually working day-to-day with the patient, those organizations can’t afford a staff full of PTs. They’re going to hire PTA’s, and frankly that’s where the rubber meets the road. Why is there a shortage of physical therapists? One of the reasons might be because you have to have a doctorate now to become a physical therapist and there aren’t as many people who want to get a doctorate in physical therapy. So that ‘degree creep’ will impact the shortages.”
The Larger Picture
Although issues of personnel shortage, degree creep, and limited funding become most noticeably intermingled in allied health, these apply to other areas of health workforce as well. The double-bind, in this regard, is perhaps best understood as a side effect of a health care landscape which may be more accurately described as competitive rather than collaborative. It is here where allied health, due to its necessarily diverse and amalgamated nature, can provide health care at large with concrete and progressive solutions.
“There is a place for everybody in this huge game of health care,” asserts McPherson. “I think the people who set the rules have to recognize that they’re in the role for all levels of health care. We have to get off the wagon of saying ‘I’m better than you because I’ve got a doctorate, I’m better than you because I’ve got a bachelor’s degree.’ There’s a role for everybody and we have to define what those roles are. We need to have better-defined career lattices, so that there are opportunities for people to start off, if you will, with on-the-job training or with a certificate or an associate degree from a community college as a base” and then move from there according to interest and demand.
“We find ourselves fighting amongst ourselves whether it’s on the professional level or even if it’s on the educational level because we think one program or one profession is better than another,” McPherson concludes. “The fact of the matter is, we’re all in this together and we’re going to have to have somebody to take care of mom and dad in the bigger scheme. The only way we can do that is through collaborative efforts. Collaboration in sharing skills and ideas, collaboration in sharing faculty and resources, collaboration in sharing of programs, collaboration in understanding that there are different levels of a profession – from the technician all the way up to the doctorate. We have to recognize and respect those possibilities and the role that they play. Everybody has a role.”