Health Professions Network, Chair, Communications Committee

By Alex McEllistrem-Evenson

Fred Donini-Lenhoff is a veritable scholar of allied health. His article “Coming Together, Moving Apart: A History of the Term ‘Allied Health’ in Education, Accreditation, and Practice,” originally published in the Journal of Allied Health in 2008, is the most comprehensive study to date of the evolution of the term “allied health” and its sometimes contentious history. Recently, I had the opportunity to speak with Mr. Donini-Lenhoff about his research, his work with the Health Professions Network (a national allied health organization oriented towards advocacy and collaboration), and his opinions about “allied health” in general.

Although there are a number of journals devoted solely to allied health and health sciences, relatively few scholars have focused on the term “allied health” itself, as you did. What prompted your study?

Ever since I’ve been involved in this area – since 1995 – it’s been very unclear to me and to others what “allied health” actually is. The definition’s morphed and changed over the years, and a lot of groups that formerly had been happy to be called “allied health” were no longer so happy about that. They were “growing up,” in a sense, and felt that the term “allied” was somewhat derogatory, and were seeking a more independent scope of practice or outlook than what they would have had under the moniker “allied health.”

Because allied health is so all-encompassing, it includes many different professions: everything from fields that might require a year or two years of education at a community college on up to a master’s or doctorate, which is becoming more prevalent nowadays. That was another impetus for these professions and organizations to pull away from the term “allied health.” Many believe it’s no longer the best term to describe these fields. The funny thing, though, is that whenever the state or federal government or any other funder uses the term “allied health,” then all these normally non-allied health groups are quick to say “That’s us! We’re allied health!”

You say in your article that the ramifications of the inability to develop a universally agreed-upon definition of allied health are “not just semantic,” that “understanding the genesis and evolution” of the term “can inform the debate among workforce planners, policy makers, and professional associations.” How, specifically? What difference does it make?

It basically gets down to the theme I put in the title, “coming together, moving apart,” or the phrase “if we don’t hang together, we’ll hang separately.” I think for a lot of fields there does need to be recognition that there’s something beyond their small field, something greater than just themselves that they’re a part of, and that would be allied health. Without that identifier, without that unifier, they really could get lost in the shuffle regarding recognition by state and federal agencies when seeking increased funding or changes to practice parameters. The other challenge is understanding and awareness among the public and the crucial K-12 audience—from which future practitioners must be recruited. This has been a key goal and message of the Health Professions Network (HPN), a group I’ve been involved with for a number of years, which provides a forum for collaboration and consensus among disparate allied health groups and professions.

In light of the ongoing debate on health care reform, these groups want to have some say in terms of what’s going to happen in the long run. They want to be sure their field is going to be recognized for funding and to have some awareness at the federal level that they exist. Without that overarching identity of “allied health,” I think a lot of these groups can sort of disappear. They’re stronger together; they have much more strength in numbers versus when they’re trying to do their own thing. At the same time, there are certain fields that have kind of “grown up” and moved beyond allied health – they have been recognized by federal bodies as being more independent.

I don’t want to be a regressive or someone who says “stop right now, no more change, everything has to stay like it is”; I understand there is change and growth and innovation, and those are good things. The same thing has happened to medicine as a whole. One-hundred years ago, you had a very limited number of different kinds of fields, but then over the years as technology developed and things changed and we had more high-tech services and innovations and medicines, we started getting all these other little fields of medicine. Today we have probably 150 or 200 specialties and subspecialties of medicine, depending on your definition.

But physicians are still physicians at root, they all go to medical school for four years, whereas with allied health you have these one- or two-year programs versus a doctoral program, and they’re really apples and oranges. For the smaller groups especially, it’s good for them to be part of allied health. I think it helps them.

You mention at the end of your article that the trend of professions moving “up and out of allied health” is likely to continue and that “in 50 years, it may be as antiquated as ancillary and paramedical are today.” How will that affect workforce issues in general?

If all these fields and professions kind of “grow up”—and basically by “growing up” I mean their education path becomes longer—if that happens, the obvious effect on workforce is that it is going to take longer for students to make it through that program, and they may have higher debt when they finish. These fields have to be very careful when they increase credentials and education requirements because if the potential salaries are not high enough respective to what their student loans and debt are going to be when they get out of college, then people aren’t going to want to get into that field in the first place. From a workforce perspective, it will take that much longer for people to get out of school, so if you have a sudden need for more people in this field, it’s going to take them, say, four years to get out into the workforce instead of two years. They may be better trained when they get out, they may be able to do more things, but again you have to balance the time and the money with the expected reward.

One of the arguments that I’ve heard against increasing education requirements is the potential impact on attracting minorities into a given field. Some minority students are from families that did not have a background of going to college, so for this first-generation college entrant to suddenly go into a doctoral program is that much more challenging. Add to that the issue of loans, and the fact that it’s going to take them more time and money to go into these fields, and this may affect the long-term workforce mix.

I think that’s an issue too – is this trend towards more rigorous educational requirements going to affect not just the workforce as far as a longer “pipeline” time, but is it going to change the kind of people we have coming out of the pipeline? We do want and need more minority practitioners and increased socioeconomic diversity, but if we keep raising the educational bar, that may be less likely to happen.

You’re claiming that increasing credential requirements will make practitioners more qualified but may also result in fewer practitioners overall. What do you think is the best way to negotiate health reform and the increased demand for practitioners that higher rates of coverage would likely place on workforce? What should be done that’s not currently being considered?

One thing that should be looked at workforce-wise—and this is sort of happening with physicians now—is the issue of retraining or reentry into a field or practice. In medicine, some physicians may choose to drop out of medicine for a number of years to have kids and raise a family or to pursue other things, but then after they do that how do they re-enter practice? What kind of test do they have to do, or what kind of recertification? There’s no real process to do that.

Another thing for all physicians and health practitioners is this issue of movement into a different field. Say you decide you want to be an ophthalmologist, and you do that for ten years, and one day you realize you’re not happy with that because it feels like the same thing every day. And let’s say your real heart’s desire is to move into primary care. Can you really do that? You’ve already gone through all of these hoops – you’ve done your residency, board certification, etcetera, and now you’re kind of strait-jacketed and there’s no way to expand into a different area. So I think that retraining has to come into it.

That’s really true for the allied health folks as well, because if you’ve done a two-year program and there’s some special program that you could go into and take an additional two years to get a higher-level credential, that’s something we should look at. Not just taking the students coming in and making them into what we need, but also looking at the people who are already out there in the workforce and figuring out how we can build on their education and experience and bump them up to another level. “Career ladder” is a term, but I’ve also heard the term “career lattice,” which I think is a nice image because it’s not necessarily going up, it may be going sideways or jumping diagonally.

I think we need to be more innovative and have different kinds of programs. It takes a lot of involvement from state and federal bodies and hospitals, employers, etcetera. I heard something interesting on Chicago Public Radio a couple of months ago. They were talking about a hospital in the Chicago area that was training employees who wanted to move into clinical positions, janitors and housecleaning and cafeteria staff, to have them learn about health professions and do some on-the-job training and get certified. That’s a real basic-level thing, these people wouldn’t become physicians through this type of program, of course, but the hope is that they could do some clinical work, medical-assisting kinds of jobs, and I thought that was pretty neat. That’s the kind of thing we have to do – realign and reinvigorate the workforce we have now. The bright side of the current economic situation is that a lot of people are interested in getting into health care careers that might not have been five or ten years ago. I think there’s a real good market out there and we’ve just got to get them aware of what allied health is and of all the different opportunities and to get them into the right programs.

You mention that a common argument in favor of “allied health” is that there’s “strength in numbers.” Maybe this is just the English major in me, but the rhetoric of the “strength in numbers” argument implies that there’s a battle to be won and that it’s being fought between various professions. Do you have any sense of what this battle is for and who’s engaged in it?

To use a military term, I guess it is sort of a battle for the hearts and minds of the people. And maybe it’s for wallets too, as far as the federal and state funding aspect goes. Again, it’s this issue of awareness – the hearts and minds of the federal lobbyists and the lawmakers and executive branch. And also the awareness of the general public out there; what these people are doing and how important they are to the system, to keep the federal and state largesse running. I’m thinking also of the hearts and minds of the K-12 population, making sure that there’s awareness of these fields, making sure that students won’t just think of medicine and nursing and if they can’t get into that or if they’re not interested in that, they’ll just drop health care entirely without realizing that there’s all these other health fields out there that they can get into: anesthesiologist assisting, respiratory care, sleep technology, or even attractive fields without clinical contact—health information management, for example.

How has your study been received? What have you learned?

I didn’t hear much negative feedback; I think people sort of recognize that things are changing in allied health and that the term is losing favor somewhat. A colleague of mine who writes for the Association of Schools of Allied Health Professions (ASAHP) newsletter, Stephen Collier, PhD, discussed in one of his articles [see page 5] an informal study he did looking at the names of schools of allied health throughout the country. He found that a lot of the schools over the past decade had changed from “School of Allied Health” to “School of Health Sciences” or something similar that took out the term “allied health.”

I don’t think my position was very controversial, I was just reflecting what was happening with education and how the fields are maturing. The problem is that there’s no other term that really fits or works. When it was formed in 1995, the HPN intentionally excluded the term “allied” even though they really are an allied health professions group, but maybe that’ll be what will happen in the future, the word “allied” will totally disappear and it’ll be looked upon like the terms “ancillary,” “auxiliary,” or “paramedical” are today.

It’s clear, researching “allied health” on HRSA’s web site, that they feel it is a problem that “allied health” has traditionally been defined by exclusion – according to what it is not.

I guess the feeling is that the term isn’t perfect but it’s the best we have now. In a way, there’s more important fish to fry. Then again, names are important. Nowadays people really latch onto a term or phrase or word and that’s why English majors like myself have a real important role to play. What you call yourself does matter: A rose by any other name might actually stink. Many people just read headlines or titles rather than articles or books because they don’t have time for anything else. So if you send out something that says “allied health” or if you send out something that says “health professions,” you’re going to get two totally different responses.

It’s important, but at the same time you have to go with the flow and see where change takes us. It may dissipate, but maybe the term will just become “health professions” and that’ll be everybody.

The fact that the word “allied” is the problematic thing is sort of telling, I think. This culture of competition in our health care system seems like until that is addressed on some fundamental level, someone is always going to lose.

I think that’s true. What we have to do in health care is to keep the focus where it belongs—on the patient, and on improving quality of care. The Chinese curse, “May you live in interesting times,” was never more true than it is today. On the bright side, there is incredible opportunity today to make real and lasting changes in how health care is delivered. From electronic health records and the patient-centered medical home model to an increased focus on wellness and patient education, there’s no shortage of promising practices. With growing recognition in the importance of interdisciplinary care, with highly skilled teams of practitioners working in unison, some of these concerns about who’s “allied health” and who’s not may go away. No matter what they’re called, or how they’re classified, or where they work, every worker in health care has a critical role to play. Again, that’s the beauty of a group like the HPN, which brings together diverse fields to take action on the overarching issues facing all health professionals—and all patients.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.