Health Manpower Dialectic Physician, Nurse, Physician Assistant PHILIP G. WEILER, MD, MPH
The professional development of physicians, nurses, and physician assistants is examined within the conceptual framework of the dialectic. Some of the problems in health manpower may be generated by the dialectic and can be alleviated by an understanding of the process.
Introduction Most analyses of the present health manpower crisis have played what Kissick1 calls the numbers game. That is, the studies claim we need more of this (i.e., physicians, nurses, physician assistants, etc.) or less of that (i.e., certain specialties) based on "magic" physician to population ratios, economic forecasts, or professional judgment. If some sort of comprehensive approach to the health manpower problem is endeavored, there is little attempt to go beyond the mere connecting of a succession of events and to reveal the underlying plot of the historical development of the health manpower categories. There is little attempt to find a way through the thicket of present events to put things in a historical perspective. The various developmental tracks of physicians, nurses, and physician assistants are usually studied separately, and without studying the interrelations among them and, more importantly, without considering them in the context of organization, specialization, professionalization, and cultural and political changes. This historical myopia fails to focus in on the germane happenings. Predictions and decisions based on such observations usually miss the mark. Examples of such errors are not hard to find: (1) An effort Dr. Weiler is Director, Lexington-Fayette County Health Department, Lexington, Kentucky 40504. He was formerly Associate Professor and Medical Director, Physician Assistant Program, Northeastern University, Boston, Massachusetts. This article was submitted for publication in May, 1972. 858 AJPH AUGUST, 1975, Vol. 65, No. 8
to convert medical corpsmen into practical nurses after World War II did not succeed presumably because the role of men and women was not sufficiently liberalized at this time to accept men in a predominantly female profession.2 (2) The two classic answers to the nursing "shortage" (increasing the supply of nurses and increasing the supply of auxiliary workers) have failed. Although dissatisfied with their professional roles nurses have not been willing to give up any "professional turf"* to auxiliaries.3 (3) The Public Health Service predicted in 1958 that the total supply of doctors would decline from 133 per 100,000 (in 1958) to 127 or 128 per 100,000 population by 1975.4 Instead there was an increase in the ratio to about 150 physicians per 100,000 population by 1970 alone.5 The public demand for and the government response to increasing the number of physicians was obviously underestimated. It is presently estimated that the United States needs about 50,000 more physicians, and a couple of hundred thousand more nurses.5 One of the major components for the alleviation of this "shortage" has been the institution of a new category of health professional, the physician assistant. Unless further insight is gained into the history of health manpower, however, this solution to the problem may prove to be as fruitless as the others. This paper discusses how further insight can be obtained by using a conceptual framework that views manpower development as a dynamic process that can be * "Professional turf" is that area of responsibility and skill considered the exclusive dominion of a particular profession.
related to other pertinent parameters. Thus, more accurate predictions and more effective decisions can be made. The purpose of this paper is to give a historical analysis of the development of these three health manpower categories: the physician, the nurse, and the physician assistant, using the dialectical doctrines. The theory proposed in this paper should serve as a guide for the elucidation of particular contemporary situations in the health manpower field and also act as a source for producing empirical hypotheses.
Dialectic Concept Before proceeding with an elaboration of the dialectic of health manpower development, it is essential that the Hegelian concept of "dialectic" be clarified.4 The dialectic belongs to the philosophical discipline of logic and was originally developed by the Greeks. It refers to the relationship between concepts or ideas. They are dialectically related if: (1) one gives rise to another; (2) they fall into the triad of thesis, antithesis, and synthesis; and (3) the synthesis-concept of each triad becomes a thesis-concept for a new triad (Figure 1). In Hegel's view the realization of freedom was the goal of history and its driving force. Every nation, according to Hegel, is destined to make a contribution to the progress of history at a given time and all others must give way to it at that epoch. In adapting the Hegelian doctrines to the history of the development of health manpower, certain amendments must be made. The dialectical process is portrayed as occurring in the interaction between the practitioners of medicine/nursing using one body of knowledge and set of skills (thesis) and the practitioners of a new body of knowledge and different/superior set of skills (antithesis). This results in the extension of functions to a new group (synthesis) as depicted in Figure 2. To make an instructive analysis of health manpower and to understand why conditions are as they are, one must > Antithesis
Thesis*< TRIAD
Synthesis
A,
O.- Antithesis TRIAD2
Synthes:is
1
TRIAD 3,....n FIGURE 1 Schematic representation of Hegelian dialectical process. * Thesis represents concepts, ideas, classes, or movements.
consider the dialectic process toward professional selfactualization (replacing Hegel's "freedom" as the driving force of the dialectic in my theory). To decrease the fragmentation of professions in the health manpower field, we must decrease the driving force in the dialectic by allowing for professional self-actualization.* Instead of nations (Hegel) coming successively to the fore in the process, specialist/new health categories successively have the limelight in the health manpower dialectic. At the present time physician assistants are in center stage. We will now proceed to confirm some of these theoretical considerations by examining the actual course of historical events and by demonstrating how they are dialectically connected. This will be followed by some policy imperative and interpretive conclusions.
The Development of the Physician's Role The physician in his desire for self-actualization has had to reconcile the roles of scientist (objectivity, detachment) and practitioner (subjectivity, involvement, art). Until modern times this was not very difficult to do because the discrepancy between the two roles was minimal. The dialectic had to wait upon the necessary developments in medical science and technology starting with the bacteriological era in the latter part of the 19th century. At this time, a small differentiation of health manpower began. Fifty or 60 years ago there was still an image, as described by Elling,7 of what could be defined as "the physician." The common denominator of experience was sufficiently large enough among physicians to sustain such an image. Less than 10 per cent of physicians were full-time specialists and they were as numerous as all other trained persons in medicine combined.8 This small differentiation of health categories (mainly physicians, dentists, nurses, and pharmacists) was enough to allow sufficient self-actuali-zation to contain the dialectical process for over half a century. As the advances in medical science and technology accelerated, however, the forces holding "the physician" together began to fall apart. To sustain the role of scientist and decrease the scientist-practitioner dichotomy, the physician had to disengage himself from certain tasks which he perceived as "nonmedical" (i.e., divorced from immediate life and death matters and technicized, that is, involved in a routine set of operations with minimum human judgments). These tasks in the main were "spun off" to nurses who in the beginning were quite receptive. The physician was then able to spend more time with the patient practicing his more scientific (i.e., medical) skills. The physician in his attempt to embrace the role of the scientist (complete knowledge) found it, like the wind, could not be possessed unless he kept narrowing his professional sphere of competence. Levy9 suggests that the * Self-actualization is the need for personal growth and development, worthwhile accomplishments, liberation of creative talents, self-fulfillment, and a need for greater
unity.6 HEALTH MANPOWER DIALECTIC
859
Thesis
Antithesis
Practitioners with one body of knowledge and set of skills
Practitioners of a new body of more relevant knowledge and different/superior set of skills.
Synthesis
Extension of functions to a new group.
FIGURE 2 Hegelian interaction in health manpower. TIME
PHYSICIAN
empirical physician " physiciian with TASKS of Hippocrates physiccal sciences :al scencesCAST OFF scientific physician (germ theory of disease)
A modern physician
training of nurse (Social Science base)
TASKS body of knot wledge and CAST OFF supEerior 5kills/ orgianic approach to cdisease
New
Family function religious function of nurse: family (mother-surrogate) ties "'
collegiate (-
TASKS
__A 4___(Galen theom ry CAST OFF of disease)
Specialists/ 6 research physician. Mechanistic approach to disease
new body of < knowledge and superior skills
NURSE
PHYSICIAN ASSISTANT
-
Formal
Training
(F. Nightingale) Healer role /
Specialists
rofessional
(anesthetists, etc.) healer,
nurse (functional
autonomy)
no autonomy
> SuperspecialiEsts/ < -4 Guilt aboutf Extension of ifunctions leaving patof new group ient care &
decreased time with patient
)Increased - Increased
Specialisation (super-
delegation of
visory roles) Some patient
to aides, etc.
Synthesis 1,...N specialists
Physician Assistant Relieves M.D. of burden of certain functions/provides "out" for nursing progress.
nursing tasks Women's Liber-
ation.
care
M.D. with new functions/
of
nurse (hospital-based)
Synthesis 1,....N Nurse with increased
managerial tasks/more autonomy from physician.
FIGURE 3 Schematic representation of the dialectic of health manpower development.
doctor's dichotomous role generates both guilt (not spending enough time with the patient) and inadequacy (not being a good enough scientist). Partly as a result of this increased discrepancy in the physician's role, and the growing resistance of nurses to do "hand-me-down" tasks, the "balkanization"* of the health manpower pool began in earnest in the 1930s. With each significant advance in medical science or technology that pushed science ahead of the art, further specialization occurred in an attempt to close the gap in order to decrease the guilt and increase the * The analogy is to the formation of the Balkan States in the 1900s with their narrow pursuit of special interest causing territorial fragmentation and conflict.
860 AJPH AUGUST, 1975, Vol. 65, No. 8
adequacy of physicians. Nurses and other health personnel mirrored this fragmentation. Following the lead of ophthalmology (1915), certifying boards were established for otolaryngology (1924), obstetrics and gynecology (1930), dermatology and syphilology (1932), pediatrics (1933), orthopedic surgery, psychiatry and neurology, radiology (1934), urology (1935), pathology and internal medicine (1936), surgery (1937), anesthesiology and plastic surgery (1938), neurological surgery and proctology (1940). At present there are some 52 specialties recognized by the advisory board for medical specialists of the American Medical Association and the number is still growing as the dialectical process continues toward resolution of the dichotomous professional conflict (Figure 3).
As a result of this dialectical process the allied health professions have grown exponentially, trying to absorb the discarded pieces of the physician's "professional turf" as his perceptual set shifts and he moves on to function on a higher scientific level. The physician now composes only one-fifth of all the professionally trained persons in the health field, being outnumbered by more than 2 to 1 by nurses alone.
The Development of the Nurse's Role We now turn to the development of nursing which can be analyzed by the same dialectical pattern. Nursing as a profession had an identity struggle (professional versus family duty) right from the very beginning. It first arose to satisfy a fundamental need in all families for care of its sick members. The dominating influence in nursing in these early stages was the religious one, which still plays an important role today. The nurse assumed the dual role of healer and mother surrogate.' ° These roles were present in peaceful coexistence from the earliest times until the latter part of the 19th century, which marked the starting of the bacteriological era and the Women's Rights Movement. At this time difficulties and contradictions developed within the context of the dialectic. In progressing toward self-actualization, the nurse's professional role became inextricably entangled in the struggle for self-actualization of her feminine role. It is seldom recognized, however, how closely developments in nursing paralleled those of women's status in general. The first evidence that any organized group of women were nurses is in the Christian Era' 1 when women's status was significantly improved. Nursing became one of the few acceptable outlets for women's self-actualization drives. The roles of mother surrogate and religionist predominated over the healer role. At this stage the nurse was supposed to give succorance to her children (patients) and complete deference to her husband (physician). It is not surprising then that the "physician-husband" should turn to the nurse-mother as the first nonphysician health worker. While physicians resented woman as a colleague, they nontheless valued her as an aide. Florence Nightingale's establishment of the first school of nursing at St. Thomas' Hospital, England, in 1860 was a "foot in the door" event. Up until this time few people thought nurses (i.e., females) should have or even needed any training, much less formal education. Once introduced, however, the idea (of education) spread rapidly. Nursing was carried along with the general feminist movement both for the education of women and toward professional status. A number of colleges for women were founded in the United States in the mid-19th century and shortly thereafter, women were accepted for the first time into universities by Case Western Reserve in Cleveland and Tulane in New Orleans (1887 and 1888). Others soon followed. Nurses began receiving more education and developing increased specialization, to enhance their independent role (healer role). They were no longer content to blithely accept the "hand-me-down" functions of the
physician but attempted to develop equal status and functional autonomy by establishing collegiate programs. In 1909 when there were already 1,105 hospital-based diploma schools of nursing,' 2 nursing's developing dialectic force led to the establishment of the first collegiate school of nursing at the University of Minnesota. However, the collegiate schools, which now number over 120, increased the gap between the healer and mother surrogate images. Although Florence Nightingale did much to improve the image and competence of nurses and eliminated some of the servile and demeaning aspects of the occupation which existed prior to her time, she failed to recognize the dialectic. She was providing for more education for nurses but not for any more independence of thought which the education produced. Her training emphasized motherly duties, "communion with God," and complete submission ("Let us not question so much. We are not more likely to be right than they (physicians) are").' 3She made clear that she did not want to "rock the boat" with a "new order" of nursing in relation to physicians. The religious component, as nourished by Florence Nightingale, persists today as revealed by the fact that, in one survey, one-third of the nurses interviewed considered nursing to be a "'calling."'I4 This adds to the role confusion by emphasizing the mother/family duties of nursing. The fact that the nursing movement became involved in the general feminine class struggle is exemplified by Elizabeth Blackwell. She was a strong nurse-activist and demonstrated leadership in the suffragette movement and later in the women's liberation movement which immediately followed the industrial revolution in the mid-19th century.' 5 As a result of involvement in this struggle, not only was the Nightingale mentor of nursing, the physician, being challenged now but the sexual class system, as attacked by the feminists, was pulling the mother surrogate "rug" from under the nursing profession. The desire for independence from the physician was also causing the nurse to be drawn further away from the patient where the physician ruled. The nurse, therefore, has struggled into the decade of the 1970s burdened by the residue of what have become several conflicting positions: (1) subordination to the physician; (2) confinement to the hospital base (analogous with women in the home) where 63 per cent are presently employed; (3) diminished role as healer (because of decreasing patient contact: i.e., nurse doesn't nurse but sees that the patient is nursed); (4) emphasis on role as mother surrogate (which is now in conflict with the role of the liberated woman); and (5) increased education and independence. These positions are pulling nursing in opposite directions. Either direction seems to lead to a Scylla or Charybdis. One direction is the equal-but-separate direction stimulated by the increased emphasis on education and by the feminist movement. This direction leads to a concept of nursing which searches for a professional identity and functional autonomy, eliminates subordination to the physician, and demands peer status in patient care. The HEALTH MANPOWER DIALECTIC
861
Hegelian contradiction in this concept of nursing is that to achieve these aims in hospital settings nursing is focusing on the psychosocial dimensions of patient care, neglecting the physical sciences, and becoming more managerial in function. The technical skills of nursing which are the components of the discrete tasks designed to help and comfort patients undergoing a therapeutic program are deemphasized. As a result of this the nursing profession is put in the position of no longer actually practicing nursing. The equal-but-separate idea was almost reached with the public health nurse in the community, but at the expense of lower professional status, as it has been with women doctors in Russia who do not enjoy high status professionally but who do have autonomy. The other direction is the together-but-subordinate direction which follows along traditional lines. This direction leads to a concept of nursing which is very task-oriented and usually hospital-based with no functional autonomy. The nurse is in a dependent role, carrying out the physician's orders, which requires a minimum of background knowledge. While this role provides the nurse with direct patient contact and emphasizes actual nursing practice, it is even more of a block to self-actualization than the other direction. With a task approach there is little opportunity for intellectual development for one who has been drilled in the importance of increased education for the nurse. Her feelings of a subordinate role to the physician perpetuates a gulf which forces the nurse to work more closely with aides and attendants than with physicians in the care of patients. In professional nursing's struggle for self-actualization, the nurse has been working under "conditions of economic depression, environmental deprivation and role confusion (which) are endemic to much of American nursing" (p. 26 in Reference 3). In their struggle, nurses must overcome both the sex barrier and the class barrier of the health pyramid with the physician on top. As a result of such a struggle, over 285,000 nurses-almost one-third of all registered nurses-have given up the struggle and are not practicing their profession. There is also a high turnover rate of nurses in many hospitals. Thus, these developments have brought nursing into a professional cul-de-sac. The Hegelian type of interaction that is occurring has produced the synthesis, the physician assistant. This "out" was recognized as the best hope for the nursing profession by the National Commission for the Study of Nursing and Nursing Education.3 However, the synthesis is not without problems of its own.
Russian feldshers, described by Sidel' 6 and Field' 7 were active in the 1700s. In addition, in Russia where 75 per cent of physicians are women there would seem to be less of a conflict due to sex prejudice. The feldshers act as primary care practitioners in rural areas and in urban areas they are dependent on the physician. In Fox and Cramer's' 8 study of the assistant medical officer (physician assistant) in the Belgian Congo, most of the nurses (religious nuns) were still at an early stage in the dialectic in comparison to those in American and were not in any way in conflict with physicians or the physician assistant concept. For these reasons, therefore, the delegation of physician functions to assistants in less developed countries has not been as conflict-laden as in the United States. In the United States the physician assistant program began in 1965 when increased consumer pressure for medical services coinciding with the development of Medicare caused a sharp rise in the physician's guilt index. In order to see patients in a satisfying way he had to disengage himself from certain functions previously considered exclusively the physician's (i.e., history taking, physical examination, diagnosis, and treatment initiation). The performance of these functions within certain limits was delegated to physician assistants. The first program was started at Duke University and from the very beginning emphasized male recruitment (especially ex-military corpsmen). Therefore, although the nurse needed this "out," the physicians (only 7 per cent female) chose to use males when their "professional turf" was involved, citing the nursing "shortage" as a reason for not using women. However, the "shortage" in nursing is not well documented (there are 15,000 more nurses now than are needed by some estimates)3 and if one exists at all it may not be due to a lack of facilities or graduates as with physicians but due to the large numbers of nonpracticing nurses. Ironically, this is a result of the nursing dilemma which the physician assistant role could potentially solve. In addition to the physician preference for male assistants, the nurse's ambivalence toward dependence on the physician and her need for functional autonomy have also inhibited her acceptance of the physician assistant role as an "out" for her dilemma. Even though there are several nurse practitioner programs in operation, organized nursing is opposed to any large scale training of nurses as nurse practitioners or physician assistants.
The Development of the Physician Assistant Role
Conclusions
The physician assistant is seen as in juxtaposition between the dialectic process of the physician and the nurse (Figure 3). The development of health manpower categories such as physician assistants in other countries has been different than in the United States. In most other countries where the need for medical services has been intense, physician assistants have developed concomitantly with the medical and nursing profession or even before nursing. The
Health manpower development in the United States for the physician, nurse, and physician assistant can be considered as a dialectical process toward the self-actualization of the professions. In attempting to resolve their conflicting drives the nursing and medical professions have fragmented into specialties and superspecialties. The process is now focused on the concept of the synthesis of the physician assistant.
862 AJPH AUGUST, 1975, Vol. 65, No. 8
The dialectical process is perpetuated because of the old concepts of professionalism which set up artificial barriers based on sex, college degrees, licensure, and cultural roles. If these barriers cannot be overcome the resulting dialectic will continue to produce further fragmentation and more problems in the delivery of health care. In order to help alleviate the problem it seems evident that the following changes must take place: 1. "Professional turf" must be relinquished with true delegation of responsibility. If someone can perform a task well it is nonsense not to give the person responsibility for that task. Unless this is done there is really no division of labor in the true sense as described by Adam Smith and its proposed benefits will remain illusionary. This has been demonstrated by assistants, the assignment of duties to aides, attendants, and orderlies. In spite of the proliferation of such personnel, the manpower dilemma has worsened because professionals have not really relinquished any of their "professional turf." 2. Nurses as well as other allied health professionals need to participate more in the decision-making process in health care delivery. As the movement for consumers', minority's, and women's rights has emphasized, the middle class-oriented health society must accept more peer relationships. This is exemplified in the attempts of some community institutions, group practices, and health centers which are organizing on a peer model. This is especially evident in the free clinic movement. 3. The method and level of education should be changed to make it commensurate with the expected level of performance. To increase one without the other only makes professional self-actualization less tenable. At present most physicians and nurses are being overtrained and mistrained for what they are expected to do. The educational system must also be more egalitarian in its approach if the first two objectives are to be accomplished. Unless the dynamics of health manpower are considered and some attempt is made to resolve the dialectic, the numbers game of increasing physicians, nurses, and physician assistants with the attitude of "damned be him that first cries hold enough"'' 9 will only waste our time and
resources as the health manpower crisis continues to deteriorate.
References 1. Kissick, W. L. Forecasting Health Manpower Needs: The 'Numbers Game' is Obsolete. Hospitals 41:18-47, 1967. 2. Greenfield, H. Allied Health Manpower: Trends and Prospects. Columbia University Press, New York, 1969. 3. National Commission for the Study of Nursing and Nursing Education. An Abstract for Action. McGrawHill Book Company, New York, 1970. 4. Somers, H., and Somers, A. Doctors, Patients, and Health Insurance. The Brookings Institution, Washington, DC, 1961. 5. The Carnegie Commission on Higher Education. Higher Education and the Nation's Health. McGraw-Hill Book Company, New York, 1970. 6. Maslow, A. J. Motivation and Personality, pp. 199-234. Harper and Row, New York, 1954. 7. Elling, R. The Shifting Power Structure in Health. Milbank Mem. Fund Q. 46:119-143, 1968. 8. Magraw, R., and Magraw, D. Ferment in Medicine, p. 166. W. B. Saunders Company, Philadelphia, 1966. 9. Levy, L. Factors Which Facilitate or Impede Transfer of Medical Functions from Physicians to Paramedical Personnel. J. Health Hum. Behav. 7:50-54, 1966. 10. Bayly, M. Clinical Medical Discoveries. Garden City Press, Ltd., Great Britain, 1961. 11. Lottie, D. C. Anesthesia: From Nurse Work to Specialty. In Patients, Physicians, and Illness, edited by Jaco, E. G., pp. 405-412. Free Press, Glencoe, IL, 1958. 12. Jensen, D. History and Trends of Professional Nursing, p. 63. C. V. Mosby Company, St. Louis, 1959. 13. Nightingale, F. Florence Nightingale to Her Nurses. Macmillan and Company, London, 1914. 14. Corwin, R., and Loves, M. Nursing and Other Health Professions. In Handbook of Medical Sociology, Ch. 11. Prentice-Hall, Englewood Cliffs, NJ, 1963. 15. Firestone, S. The Dialectic of Sex. William Morrow and Company, Inc., New York, 1970. 16. Sidel, V. Feldshers and Feldersherism. N. Engl. J. Med. 278:187-192, 1968. 17. Field, M. Soviet Socialized Medicine. Free Press, New York, 1967. 18. Fox, R., and Cramer, W. The Emerging Physician. Hoover Institution Studies, vol. 19. Stanford University, Stanford, CA, 1968. 19. Shakespeare, W. Macbeth, V, VII.
Don't miss APHA's 103rd Annual Meeting 'Health and Work in America" to be held Nov. 16-20. 1975. Chicago Use special forms in this issue for advance registration, housing. and job placement service. Convention highlights appear on page 900; Preliminary Program pp. P1-P33.
HEALTH MANPOWER DIALECTIC
863
The professional development of physicians, nurses, and physician assistants is examined within the conceptual framework of the dialectic. Some of the problems in health manpower may be generated by the dialectic and can be alleviated by an understanding of the process.
Introduction Most analyses of the present health manpower crisis have played what Kissick1 calls the numbers game. That is, the studies claim we need more of this (i.e., physicians, nurses, physician assistants, etc.) or less of that (i.e., certain specialties) based on "magic" physician to population ratios, economic forecasts, or professional judgment. If some sort of comprehensive approach to the health manpower problem is endeavored, there is little attempt to go beyond the mere connecting of a succession of events and to reveal the underlying plot of the historical development of the health manpower categories. There is little attempt to find a way through the thicket of present events to put things in a historical perspective. The various developmental tracks of physicians, nurses, and physician assistants are usually studied separately, and without studying the interrelations among them and, more importantly, without considering them in the context of organization, specialization, professionalization, and cultural and political changes. This historical myopia fails to focus in on the germane happenings. Predictions and decisions based on such observations usually miss the mark. Examples of such errors are not hard to find: (1) An effort Dr. Weiler is Director, Lexington-Fayette County Health Department, Lexington, Kentucky 40504. He was formerly Associate Professor and Medical Director, Physician Assistant Program, Northeastern University, Boston, Massachusetts. This article was submitted for publication in May, 1972. 858 AJPH AUGUST, 1975, Vol. 65, No. 8
to convert medical corpsmen into practical nurses after World War II did not succeed presumably because the role of men and women was not sufficiently liberalized at this time to accept men in a predominantly female profession.2 (2) The two classic answers to the nursing "shortage" (increasing the supply of nurses and increasing the supply of auxiliary workers) have failed. Although dissatisfied with their professional roles nurses have not been willing to give up any "professional turf"* to auxiliaries.3 (3) The Public Health Service predicted in 1958 that the total supply of doctors would decline from 133 per 100,000 (in 1958) to 127 or 128 per 100,000 population by 1975.4 Instead there was an increase in the ratio to about 150 physicians per 100,000 population by 1970 alone.5 The public demand for and the government response to increasing the number of physicians was obviously underestimated. It is presently estimated that the United States needs about 50,000 more physicians, and a couple of hundred thousand more nurses.5 One of the major components for the alleviation of this "shortage" has been the institution of a new category of health professional, the physician assistant. Unless further insight is gained into the history of health manpower, however, this solution to the problem may prove to be as fruitless as the others. This paper discusses how further insight can be obtained by using a conceptual framework that views manpower development as a dynamic process that can be * "Professional turf" is that area of responsibility and skill considered the exclusive dominion of a particular profession.
related to other pertinent parameters. Thus, more accurate predictions and more effective decisions can be made. The purpose of this paper is to give a historical analysis of the development of these three health manpower categories: the physician, the nurse, and the physician assistant, using the dialectical doctrines. The theory proposed in this paper should serve as a guide for the elucidation of particular contemporary situations in the health manpower field and also act as a source for producing empirical hypotheses.
Dialectic Concept Before proceeding with an elaboration of the dialectic of health manpower development, it is essential that the Hegelian concept of "dialectic" be clarified.4 The dialectic belongs to the philosophical discipline of logic and was originally developed by the Greeks. It refers to the relationship between concepts or ideas. They are dialectically related if: (1) one gives rise to another; (2) they fall into the triad of thesis, antithesis, and synthesis; and (3) the synthesis-concept of each triad becomes a thesis-concept for a new triad (Figure 1). In Hegel's view the realization of freedom was the goal of history and its driving force. Every nation, according to Hegel, is destined to make a contribution to the progress of history at a given time and all others must give way to it at that epoch. In adapting the Hegelian doctrines to the history of the development of health manpower, certain amendments must be made. The dialectical process is portrayed as occurring in the interaction between the practitioners of medicine/nursing using one body of knowledge and set of skills (thesis) and the practitioners of a new body of knowledge and different/superior set of skills (antithesis). This results in the extension of functions to a new group (synthesis) as depicted in Figure 2. To make an instructive analysis of health manpower and to understand why conditions are as they are, one must > Antithesis
Thesis*< TRIAD
Synthesis
A,
O.- Antithesis TRIAD2
Synthes:is
1
TRIAD 3,....n FIGURE 1 Schematic representation of Hegelian dialectical process. * Thesis represents concepts, ideas, classes, or movements.
consider the dialectic process toward professional selfactualization (replacing Hegel's "freedom" as the driving force of the dialectic in my theory). To decrease the fragmentation of professions in the health manpower field, we must decrease the driving force in the dialectic by allowing for professional self-actualization.* Instead of nations (Hegel) coming successively to the fore in the process, specialist/new health categories successively have the limelight in the health manpower dialectic. At the present time physician assistants are in center stage. We will now proceed to confirm some of these theoretical considerations by examining the actual course of historical events and by demonstrating how they are dialectically connected. This will be followed by some policy imperative and interpretive conclusions.
The Development of the Physician's Role The physician in his desire for self-actualization has had to reconcile the roles of scientist (objectivity, detachment) and practitioner (subjectivity, involvement, art). Until modern times this was not very difficult to do because the discrepancy between the two roles was minimal. The dialectic had to wait upon the necessary developments in medical science and technology starting with the bacteriological era in the latter part of the 19th century. At this time, a small differentiation of health manpower began. Fifty or 60 years ago there was still an image, as described by Elling,7 of what could be defined as "the physician." The common denominator of experience was sufficiently large enough among physicians to sustain such an image. Less than 10 per cent of physicians were full-time specialists and they were as numerous as all other trained persons in medicine combined.8 This small differentiation of health categories (mainly physicians, dentists, nurses, and pharmacists) was enough to allow sufficient self-actuali-zation to contain the dialectical process for over half a century. As the advances in medical science and technology accelerated, however, the forces holding "the physician" together began to fall apart. To sustain the role of scientist and decrease the scientist-practitioner dichotomy, the physician had to disengage himself from certain tasks which he perceived as "nonmedical" (i.e., divorced from immediate life and death matters and technicized, that is, involved in a routine set of operations with minimum human judgments). These tasks in the main were "spun off" to nurses who in the beginning were quite receptive. The physician was then able to spend more time with the patient practicing his more scientific (i.e., medical) skills. The physician in his attempt to embrace the role of the scientist (complete knowledge) found it, like the wind, could not be possessed unless he kept narrowing his professional sphere of competence. Levy9 suggests that the * Self-actualization is the need for personal growth and development, worthwhile accomplishments, liberation of creative talents, self-fulfillment, and a need for greater
unity.6 HEALTH MANPOWER DIALECTIC
859
Thesis
Antithesis
Practitioners with one body of knowledge and set of skills
Practitioners of a new body of more relevant knowledge and different/superior set of skills.
Synthesis
Extension of functions to a new group.
FIGURE 2 Hegelian interaction in health manpower. TIME
PHYSICIAN
empirical physician " physiciian with TASKS of Hippocrates physiccal sciences :al scencesCAST OFF scientific physician (germ theory of disease)
A modern physician
training of nurse (Social Science base)
TASKS body of knot wledge and CAST OFF supEerior 5kills/ orgianic approach to cdisease
New
Family function religious function of nurse: family (mother-surrogate) ties "'
collegiate (-
TASKS
__A 4___(Galen theom ry CAST OFF of disease)
Specialists/ 6 research physician. Mechanistic approach to disease
new body of < knowledge and superior skills
NURSE
PHYSICIAN ASSISTANT
-
Formal
Training
(F. Nightingale) Healer role /
Specialists
rofessional
(anesthetists, etc.) healer,
nurse (functional
autonomy)
no autonomy
> SuperspecialiEsts/ < -4 Guilt aboutf Extension of ifunctions leaving patof new group ient care &
decreased time with patient
)Increased - Increased
Specialisation (super-
delegation of
visory roles) Some patient
to aides, etc.
Synthesis 1,...N specialists
Physician Assistant Relieves M.D. of burden of certain functions/provides "out" for nursing progress.
nursing tasks Women's Liber-
ation.
care
M.D. with new functions/
of
nurse (hospital-based)
Synthesis 1,....N Nurse with increased
managerial tasks/more autonomy from physician.
FIGURE 3 Schematic representation of the dialectic of health manpower development.
doctor's dichotomous role generates both guilt (not spending enough time with the patient) and inadequacy (not being a good enough scientist). Partly as a result of this increased discrepancy in the physician's role, and the growing resistance of nurses to do "hand-me-down" tasks, the "balkanization"* of the health manpower pool began in earnest in the 1930s. With each significant advance in medical science or technology that pushed science ahead of the art, further specialization occurred in an attempt to close the gap in order to decrease the guilt and increase the * The analogy is to the formation of the Balkan States in the 1900s with their narrow pursuit of special interest causing territorial fragmentation and conflict.
860 AJPH AUGUST, 1975, Vol. 65, No. 8
adequacy of physicians. Nurses and other health personnel mirrored this fragmentation. Following the lead of ophthalmology (1915), certifying boards were established for otolaryngology (1924), obstetrics and gynecology (1930), dermatology and syphilology (1932), pediatrics (1933), orthopedic surgery, psychiatry and neurology, radiology (1934), urology (1935), pathology and internal medicine (1936), surgery (1937), anesthesiology and plastic surgery (1938), neurological surgery and proctology (1940). At present there are some 52 specialties recognized by the advisory board for medical specialists of the American Medical Association and the number is still growing as the dialectical process continues toward resolution of the dichotomous professional conflict (Figure 3).
As a result of this dialectical process the allied health professions have grown exponentially, trying to absorb the discarded pieces of the physician's "professional turf" as his perceptual set shifts and he moves on to function on a higher scientific level. The physician now composes only one-fifth of all the professionally trained persons in the health field, being outnumbered by more than 2 to 1 by nurses alone.
The Development of the Nurse's Role We now turn to the development of nursing which can be analyzed by the same dialectical pattern. Nursing as a profession had an identity struggle (professional versus family duty) right from the very beginning. It first arose to satisfy a fundamental need in all families for care of its sick members. The dominating influence in nursing in these early stages was the religious one, which still plays an important role today. The nurse assumed the dual role of healer and mother surrogate.' ° These roles were present in peaceful coexistence from the earliest times until the latter part of the 19th century, which marked the starting of the bacteriological era and the Women's Rights Movement. At this time difficulties and contradictions developed within the context of the dialectic. In progressing toward self-actualization, the nurse's professional role became inextricably entangled in the struggle for self-actualization of her feminine role. It is seldom recognized, however, how closely developments in nursing paralleled those of women's status in general. The first evidence that any organized group of women were nurses is in the Christian Era' 1 when women's status was significantly improved. Nursing became one of the few acceptable outlets for women's self-actualization drives. The roles of mother surrogate and religionist predominated over the healer role. At this stage the nurse was supposed to give succorance to her children (patients) and complete deference to her husband (physician). It is not surprising then that the "physician-husband" should turn to the nurse-mother as the first nonphysician health worker. While physicians resented woman as a colleague, they nontheless valued her as an aide. Florence Nightingale's establishment of the first school of nursing at St. Thomas' Hospital, England, in 1860 was a "foot in the door" event. Up until this time few people thought nurses (i.e., females) should have or even needed any training, much less formal education. Once introduced, however, the idea (of education) spread rapidly. Nursing was carried along with the general feminist movement both for the education of women and toward professional status. A number of colleges for women were founded in the United States in the mid-19th century and shortly thereafter, women were accepted for the first time into universities by Case Western Reserve in Cleveland and Tulane in New Orleans (1887 and 1888). Others soon followed. Nurses began receiving more education and developing increased specialization, to enhance their independent role (healer role). They were no longer content to blithely accept the "hand-me-down" functions of the
physician but attempted to develop equal status and functional autonomy by establishing collegiate programs. In 1909 when there were already 1,105 hospital-based diploma schools of nursing,' 2 nursing's developing dialectic force led to the establishment of the first collegiate school of nursing at the University of Minnesota. However, the collegiate schools, which now number over 120, increased the gap between the healer and mother surrogate images. Although Florence Nightingale did much to improve the image and competence of nurses and eliminated some of the servile and demeaning aspects of the occupation which existed prior to her time, she failed to recognize the dialectic. She was providing for more education for nurses but not for any more independence of thought which the education produced. Her training emphasized motherly duties, "communion with God," and complete submission ("Let us not question so much. We are not more likely to be right than they (physicians) are").' 3She made clear that she did not want to "rock the boat" with a "new order" of nursing in relation to physicians. The religious component, as nourished by Florence Nightingale, persists today as revealed by the fact that, in one survey, one-third of the nurses interviewed considered nursing to be a "'calling."'I4 This adds to the role confusion by emphasizing the mother/family duties of nursing. The fact that the nursing movement became involved in the general feminine class struggle is exemplified by Elizabeth Blackwell. She was a strong nurse-activist and demonstrated leadership in the suffragette movement and later in the women's liberation movement which immediately followed the industrial revolution in the mid-19th century.' 5 As a result of involvement in this struggle, not only was the Nightingale mentor of nursing, the physician, being challenged now but the sexual class system, as attacked by the feminists, was pulling the mother surrogate "rug" from under the nursing profession. The desire for independence from the physician was also causing the nurse to be drawn further away from the patient where the physician ruled. The nurse, therefore, has struggled into the decade of the 1970s burdened by the residue of what have become several conflicting positions: (1) subordination to the physician; (2) confinement to the hospital base (analogous with women in the home) where 63 per cent are presently employed; (3) diminished role as healer (because of decreasing patient contact: i.e., nurse doesn't nurse but sees that the patient is nursed); (4) emphasis on role as mother surrogate (which is now in conflict with the role of the liberated woman); and (5) increased education and independence. These positions are pulling nursing in opposite directions. Either direction seems to lead to a Scylla or Charybdis. One direction is the equal-but-separate direction stimulated by the increased emphasis on education and by the feminist movement. This direction leads to a concept of nursing which searches for a professional identity and functional autonomy, eliminates subordination to the physician, and demands peer status in patient care. The HEALTH MANPOWER DIALECTIC
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Hegelian contradiction in this concept of nursing is that to achieve these aims in hospital settings nursing is focusing on the psychosocial dimensions of patient care, neglecting the physical sciences, and becoming more managerial in function. The technical skills of nursing which are the components of the discrete tasks designed to help and comfort patients undergoing a therapeutic program are deemphasized. As a result of this the nursing profession is put in the position of no longer actually practicing nursing. The equal-but-separate idea was almost reached with the public health nurse in the community, but at the expense of lower professional status, as it has been with women doctors in Russia who do not enjoy high status professionally but who do have autonomy. The other direction is the together-but-subordinate direction which follows along traditional lines. This direction leads to a concept of nursing which is very task-oriented and usually hospital-based with no functional autonomy. The nurse is in a dependent role, carrying out the physician's orders, which requires a minimum of background knowledge. While this role provides the nurse with direct patient contact and emphasizes actual nursing practice, it is even more of a block to self-actualization than the other direction. With a task approach there is little opportunity for intellectual development for one who has been drilled in the importance of increased education for the nurse. Her feelings of a subordinate role to the physician perpetuates a gulf which forces the nurse to work more closely with aides and attendants than with physicians in the care of patients. In professional nursing's struggle for self-actualization, the nurse has been working under "conditions of economic depression, environmental deprivation and role confusion (which) are endemic to much of American nursing" (p. 26 in Reference 3). In their struggle, nurses must overcome both the sex barrier and the class barrier of the health pyramid with the physician on top. As a result of such a struggle, over 285,000 nurses-almost one-third of all registered nurses-have given up the struggle and are not practicing their profession. There is also a high turnover rate of nurses in many hospitals. Thus, these developments have brought nursing into a professional cul-de-sac. The Hegelian type of interaction that is occurring has produced the synthesis, the physician assistant. This "out" was recognized as the best hope for the nursing profession by the National Commission for the Study of Nursing and Nursing Education.3 However, the synthesis is not without problems of its own.
Russian feldshers, described by Sidel' 6 and Field' 7 were active in the 1700s. In addition, in Russia where 75 per cent of physicians are women there would seem to be less of a conflict due to sex prejudice. The feldshers act as primary care practitioners in rural areas and in urban areas they are dependent on the physician. In Fox and Cramer's' 8 study of the assistant medical officer (physician assistant) in the Belgian Congo, most of the nurses (religious nuns) were still at an early stage in the dialectic in comparison to those in American and were not in any way in conflict with physicians or the physician assistant concept. For these reasons, therefore, the delegation of physician functions to assistants in less developed countries has not been as conflict-laden as in the United States. In the United States the physician assistant program began in 1965 when increased consumer pressure for medical services coinciding with the development of Medicare caused a sharp rise in the physician's guilt index. In order to see patients in a satisfying way he had to disengage himself from certain functions previously considered exclusively the physician's (i.e., history taking, physical examination, diagnosis, and treatment initiation). The performance of these functions within certain limits was delegated to physician assistants. The first program was started at Duke University and from the very beginning emphasized male recruitment (especially ex-military corpsmen). Therefore, although the nurse needed this "out," the physicians (only 7 per cent female) chose to use males when their "professional turf" was involved, citing the nursing "shortage" as a reason for not using women. However, the "shortage" in nursing is not well documented (there are 15,000 more nurses now than are needed by some estimates)3 and if one exists at all it may not be due to a lack of facilities or graduates as with physicians but due to the large numbers of nonpracticing nurses. Ironically, this is a result of the nursing dilemma which the physician assistant role could potentially solve. In addition to the physician preference for male assistants, the nurse's ambivalence toward dependence on the physician and her need for functional autonomy have also inhibited her acceptance of the physician assistant role as an "out" for her dilemma. Even though there are several nurse practitioner programs in operation, organized nursing is opposed to any large scale training of nurses as nurse practitioners or physician assistants.
The Development of the Physician Assistant Role
Conclusions
The physician assistant is seen as in juxtaposition between the dialectic process of the physician and the nurse (Figure 3). The development of health manpower categories such as physician assistants in other countries has been different than in the United States. In most other countries where the need for medical services has been intense, physician assistants have developed concomitantly with the medical and nursing profession or even before nursing. The
Health manpower development in the United States for the physician, nurse, and physician assistant can be considered as a dialectical process toward the self-actualization of the professions. In attempting to resolve their conflicting drives the nursing and medical professions have fragmented into specialties and superspecialties. The process is now focused on the concept of the synthesis of the physician assistant.
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The dialectical process is perpetuated because of the old concepts of professionalism which set up artificial barriers based on sex, college degrees, licensure, and cultural roles. If these barriers cannot be overcome the resulting dialectic will continue to produce further fragmentation and more problems in the delivery of health care. In order to help alleviate the problem it seems evident that the following changes must take place: 1. "Professional turf" must be relinquished with true delegation of responsibility. If someone can perform a task well it is nonsense not to give the person responsibility for that task. Unless this is done there is really no division of labor in the true sense as described by Adam Smith and its proposed benefits will remain illusionary. This has been demonstrated by assistants, the assignment of duties to aides, attendants, and orderlies. In spite of the proliferation of such personnel, the manpower dilemma has worsened because professionals have not really relinquished any of their "professional turf." 2. Nurses as well as other allied health professionals need to participate more in the decision-making process in health care delivery. As the movement for consumers', minority's, and women's rights has emphasized, the middle class-oriented health society must accept more peer relationships. This is exemplified in the attempts of some community institutions, group practices, and health centers which are organizing on a peer model. This is especially evident in the free clinic movement. 3. The method and level of education should be changed to make it commensurate with the expected level of performance. To increase one without the other only makes professional self-actualization less tenable. At present most physicians and nurses are being overtrained and mistrained for what they are expected to do. The educational system must also be more egalitarian in its approach if the first two objectives are to be accomplished. Unless the dynamics of health manpower are considered and some attempt is made to resolve the dialectic, the numbers game of increasing physicians, nurses, and physician assistants with the attitude of "damned be him that first cries hold enough"'' 9 will only waste our time and
resources as the health manpower crisis continues to deteriorate.
References 1. Kissick, W. L. Forecasting Health Manpower Needs: The 'Numbers Game' is Obsolete. Hospitals 41:18-47, 1967. 2. Greenfield, H. Allied Health Manpower: Trends and Prospects. Columbia University Press, New York, 1969. 3. National Commission for the Study of Nursing and Nursing Education. An Abstract for Action. McGrawHill Book Company, New York, 1970. 4. Somers, H., and Somers, A. Doctors, Patients, and Health Insurance. The Brookings Institution, Washington, DC, 1961. 5. The Carnegie Commission on Higher Education. Higher Education and the Nation's Health. McGraw-Hill Book Company, New York, 1970. 6. Maslow, A. J. Motivation and Personality, pp. 199-234. Harper and Row, New York, 1954. 7. Elling, R. The Shifting Power Structure in Health. Milbank Mem. Fund Q. 46:119-143, 1968. 8. Magraw, R., and Magraw, D. Ferment in Medicine, p. 166. W. B. Saunders Company, Philadelphia, 1966. 9. Levy, L. Factors Which Facilitate or Impede Transfer of Medical Functions from Physicians to Paramedical Personnel. J. Health Hum. Behav. 7:50-54, 1966. 10. Bayly, M. Clinical Medical Discoveries. Garden City Press, Ltd., Great Britain, 1961. 11. Lottie, D. C. Anesthesia: From Nurse Work to Specialty. In Patients, Physicians, and Illness, edited by Jaco, E. G., pp. 405-412. Free Press, Glencoe, IL, 1958. 12. Jensen, D. History and Trends of Professional Nursing, p. 63. C. V. Mosby Company, St. Louis, 1959. 13. Nightingale, F. Florence Nightingale to Her Nurses. Macmillan and Company, London, 1914. 14. Corwin, R., and Loves, M. Nursing and Other Health Professions. In Handbook of Medical Sociology, Ch. 11. Prentice-Hall, Englewood Cliffs, NJ, 1963. 15. Firestone, S. The Dialectic of Sex. William Morrow and Company, Inc., New York, 1970. 16. Sidel, V. Feldshers and Feldersherism. N. Engl. J. Med. 278:187-192, 1968. 17. Field, M. Soviet Socialized Medicine. Free Press, New York, 1967. 18. Fox, R., and Cramer, W. The Emerging Physician. Hoover Institution Studies, vol. 19. Stanford University, Stanford, CA, 1968. 19. Shakespeare, W. Macbeth, V, VII.
Don't miss APHA's 103rd Annual Meeting 'Health and Work in America" to be held Nov. 16-20. 1975. Chicago Use special forms in this issue for advance registration, housing. and job placement service. Convention highlights appear on page 900; Preliminary Program pp. P1-P33.
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