Let me explain first that I’m not insinuating that professional standards are declining, rather that the professions themselves are losing territory. Let me explain.
In England for instance over the last decade we have seen the introduction of ‘nurse practitioners’ into health centres. Despite the addition of the important-sounding title of practitioner to the more mundane nurse these are in fact simply nurses with a few months extra training. They then take over some of the duties of the doctor. If you visit our doctors’ surgery these days you only get to see the doctor if it’s something ‘serious’. That decision is made by a receptionist with no medical qualifications at all.
I learned recently that you have similar positions in the US, a ‘family health doctor’ who in fact isn’t a doctor at all.
In teaching in the UK we have the same thing. Teaching-assistants without qualifications who are being asked increasingly by the State to take on the duties of real teachers and give lessons themselves without the support of a teacher. My wife was a teacher until recently and has watched many qualified teachers being laid off and replaced by teaching-assistants who are of course far cheaper to employ.
Are there similar situations in other professions or am I simply being alarmist?
To comment on your specific examples, Nurse Practitioners in the U.S. do not work like you describe. They (and Physicians Assistants - don’t ask anyone to explain the difference) are highly educated professionals. It typically requires a 4 year Bachelors degree in nursing followed by a 2 - 4 year Masters degree in advanced practice nursing. They are trained to handle the bulk of common medical needs but they also work under the (loose) supervision of a doctor for anything that is out of their area of expertise.
I believe that they are a welcome enhancement to the U.S. medical system. Nurse Practitioners work in regular doctor’s offices and hospitals but they also work in places like pharmacies and even large workplaces where you would rarely find a full MD. They are usually available on demand and much cheaper than a regular doctor and they specialize in hands-on patient care. They aren’t allowed to do anything that they aren’t qualified for but their experience in hands-on care often makes them at least as qualified as doctors, if not moreso, to treat the majority of common problems.
Teaching is a different story at least at the college level. The U.S. has countless great colleges and universities with many notable and even famous professors. Students enroll in the well-known schools hoping to be able to freely exchange ideas with some of the great minds of the world. About that, they probably aren’t going to have easy access to very many of them. Many classes, at least at the lower levels, are taught by graduate students that have about as much teaching experience as your typical 22 year old college graduate. Some of them are very good and others have anger management issues and can barely speak English. Most of the actual professors have better things to do like going to committee meetings and writing papers and grant proposals (which is their real job when you get down to it). A few of them like teaching and do a great job with everyone but it takes real effort to have an interaction with many of them.
The number of physicians in the U.S. has been steadily increasing for as long as records have been kept of their number. This has been offset somewhat by two things. First, the population of the U.S. has been increasing by about the same proportion as the number of physicians has been increasing. Second, the average age of Americans is increasing. When that happens, the number of physicians needed increases each year for the same size population. There has been no attempt to decrease the number of physicians in the U.S. In fact, there has been a continuous attempt to increase it by increasing the number of places at medical schools in the U.S. and a fair amount of recruiting doctors trained at medical schools outside the U.S.
So we have just as many physicians per person as we always have had. The increase in the average age means that the number of doctor visits has been increasing. To make up for this, there has been an increase in people called physician assistants and nurse practitioners whose job is to take care of the more routine doctor visits. I don’t know of any statistics showing that this harms the overall health of the population.
If you want to increase the number of physicians in the U.S. faster than it’s increasing now, you have to do one of two things. First, you can increase the number of American medical schools and places at existing medical schools. Second, you recruit foreign doctors faster than they now are being recruited.
My primary care provider is a nurse practitioner, and I’m fine with that. I don’t know what the limits are of her expertise or ability… but I do trust that she knows. And if something comes up that’s beyond her limits, she’ll refer me to someone better qualified. For everything that’s come up so far, though? If you can have a job done equally well by an expensive MD or by a cheap NP, why not have it done by the NP? And at that, she doesn’t even do all of the work herself, either. The really routine stuff like getting my height and weight was done by a medical technician (at least, I think that was the title), who may not have had any post-secondary education at all. Again, why waste the qualified person’s time with such minutia?
With teaching assistants, I’m not sure whether you’re referring to the elementary, high school, or college level. At the college level, it might help to remember that, even though the TAs have probably had no training in education, neither, most likely, have the big-name professors themselves. Most professors are hired with no consideration whatsoever given to their teaching ability. And those few who are hired for their teaching ability will indeed be teaching classes.
At the elementary or high school level, teaching assistants still have a role. If you give me a choice between a class of 25 students all by myself, or 30 students with the help of a minimally-trained assistant, I’ll take the 30 and assistant every time. I might even make the same choice for 20 solo vs. 30 with aid: That means, for instance, that if I have one particular student who’s causing problems, I can assign the aide to deal with that one, while I continue to teach the other 29. Or, while the students are working on classwork, we can both circulate through the room and answer questions. Half the questions are going to just be “Can I use the bathroom”, anyway, and worst-case, if a student has a question the aide can’t handle, they can always bump it up to me. And given the disparity in pay, it might be cheaper to hire the aide, as well.
Is this merely an argument about titles and degrees? I don’t care if I’m treated by an MD or NP or PA if they can do the job, and they are all professionals anyway. What is the ‘losing territory’ part? Are the traditional professions due some kind of market ownership that exempts them from competition from equivalent services?
Some significant fraction of what the professionals do can be done by any competent, reasonably intelligent, reasonably skillful person with access to the internet.
Another significant fraction of what the professionals do can be done by any competent, reasonably intelligent, reasonably skillful person with some training in the profession.
It’s an inevitable effect of a literate population.
The whole health care area has been characterized by a truly massive increase in the number of different types of professionals being trained in the last several decades.
Their is a big move in the US in dentistry to have the equivalent of nurse practitioner in the dental field so you dont need full out dentists. These “near dentists” could do more than just clean teeth but also do things like fillings and pull teeth. This would help with the big problem of lack of dentists in many areas.
Well, as a consumer, I certainly hope the professions are undermined.
They are self interested organisations that exist primarily for the benefit their members, their prime motivation is to preserve the pay and privileges of those at the top and they do this by rationing the numbers allowed to enter at the bottom. They are supposed to guarantee standards, but it is left to them to decide what they are.
Where professions are regulated by government, they effectively entrusted to run major public services. The NHS in the UK is like that, dominated by the medical profession. The organisation and delivery of a health service at a national level is a different and much broader set of objectives than the narrow career interests of doctors.
Aneurin Bevan, the Minister of Health in 1948 had to fight doggedly in face of huge opposition from the doctors to get National Health System established. He said he ‘had to stuff their mouth full of gold’ to get their agreement. The dominance of doctors professional interests over the national interest in providing a universal health care system is still very apparent in the NHS to this day and it remains riven with conflicts of interest and has resulted in a highly politicised organisation.
On the other hand, professional structures seem to be a model that is proliferating. In the UK, it is no longer possible to hire what was known as a plumber. You know, a guy who deals with water and gas pipes? They have diversified. They are central heating professionals, drainage consultants, ventilation specialists. They have to pass exams every couple of years organisations that behave like a professional body, regulating who can enter the business, endorsing skills and maintaining the income of the practitioners. Quite a lot of other areas or work are also adopting this model.
Professionalism in its most positive sense suggests maintaining ‘standards’. This is a good thing, sadly it often degenerates into simple job protectionism. Great if you are inside, receiving the benefits of a regular stream of well paid work. Not so good if you are a consumer who has to pay high charges or someone who has to deal with barriers to entry that profession establishes to restrict entry. However even the essential role maintaining of standards is open to question. In the UK we have had scandals involving homocidal GPs and surgeons who perform unnecessary or botched operations on large numbers of patients over many years. That has opened to question how these criminals were allowed to get away with their crimes for so long? They don’t kick out the bad apples as much as they should.
The whole business of professions seems quite archaic.
Family medicine in the U.S. is a specialty requiring an M.D. degree, three years of residency training and board certification (my father was among the first to be board-certified). Then there are subsequent CME/performance improvement activities required.
As noted, NPs here have a lot more training than the OP suggests.
aldiboronti, do you mean something different by “family health doctor” than what is usually meant by the term “family doctor” in the U.S.? You claim that there is something called a family health doctor (a term that isn’t usually used, as far as I know) that’s not a kind of doctor at all. What do you mean? Please return to this thread and explain what you’re talking about.
The market economy does not get along with legally protected guilds. Legal considerations for the market in reasonably priced healthcare are being made out of necessity.
All of the legal requirements for becoming a licensed medical provider are not there for quality. They are there to keep members’ salaries higher. No different from unionization. There are a lot of terrible doctors out there who go on doctoring with no oversight from professional or legal bodies. They simply don’t care. Same with teachers. There are some really bad teachers who go on teaching with little to no oversight. It’s not about quality, so do not be afraid. As a healthcare consumer, the best indicators of quality are the same as with any other service, professionalism(no pun intended), good reviews, etc. A medical degree itself does not buy credibility for many folks, hopefully.
This is largely nonsense. The AMA deliberately held down the number of medical school places for many years until the early 1990s, fearing a “glut” of doctors that would drive down wages. In fact, we got the opposite, which is why we import so many physicians - and yet we require foreign physicians to recertify even if they are licensed to practice in countries with similarly high medical standards.
My physicist-friends insist chemists will eventually be replaced by physicists, and metallurgists by materials scientists. That was in the '80s. Nowhere near, I would say.
Really Not All That Bright, could you explain carefully why you think that my post was “largely nonsense”? What you have written doesn’t really contradict what I wrote at all. It’s about other things than what I wrote. Please go through my post sentence by sentence. Restate what I wrote. Tell me what’s actually true about that issue. Show me specifically why each claim that I made was incorrect. Talking about issues quite different from what someone talked about and then claiming that this shows that their statements are largely nonsense doesn’t advance the conversation.
The professions are entrenched and expanding. I have taught overseas for twenty years, but do not have the licenses and credentials needed to teach in the US. In Texas, interior decorators have to pass an educational requirement and a test and are licensed by the state. Only two states allow dental practitioners, leading to low-quality dental care.
The wonderful world of IT is an interesting example.
It never really had a professional structure. Technology and the skillsets required changed so fast. it made it very difficult for any professional association to get established. What did happen was that companies who supply equipment or software created their own set of ‘certifications’ that purported to confirm that an individual had the necessary skills to use their product.
They soon found out that getting people to study many hours for certifications was a really good way of selling more product. A fully certified Cisco expert working for a customer is not going to recommend any product from another company. Same with Microsoft and all the other big companies. Moreover, the certifications expire after a couple of years, so you have to pay more and renew them. Worse, most certifications amount to computerised multi-choice tests: is the answer A,B,C or D?
This has led to a class of IT worker who simply accumulates certifications and they use various memory techniques to do this. Real world problem solving is not tested. There is no guarantee a fully certified person can fix anything, but they are fully equipped to recommend additional purchases of equipment. Certifications become an extension of a supplying companies marketing strategy. There are hundreds of these certifications and they confer all kinds of career titles often using the word practitioner or professional. Many are not one exam, but a whole series of them and tuition (from certified trainers) is another revenue earner.
Just like regulated professions, this sort of authority to authenticate skills is very flawed. It does not really act in the interest of the consumer.
I guess there are examples out there where skills and experience are impartially authenticated, taught and maintained. There are some very expensive items of equipment out there and some critical services. They have to be in safe hands.
This is false. See this 2005 USA Today article describing how “For the past quarter-century, the American Medical Association and other industry groups have predicted a glut of doctors and worked to limit the number of new physicians. In 1994, the Journal of the American Medical Association predicted a surplus of 165,000 doctors by 2000.”