Professionalism & the Health Professions

1. Professionalism & the Health Professions Frederic W. Hafferty Ph.D. Professor University of Minnesota School of Medicine–Duluth December 1o, 2009 Warwick Medical School The University of Warwick fhaffert@d.umn.edu

2. Minnesota

3. Duluth, MN

4. Opening Day of Shipping May, 2009

5. December 2009

6. All Politics is Local: Professionalism as a Zero Sum Game Frederic W. Hafferty Ph.D. Professor University of Minnesota School of Medicine–Duluth December 1o, 2009 Warwick Medical School The University of Warwick fhaffert@d.umn.edu

7. Two Key Articles for Me Baldwin, D. C. Jr. Territoriality and power in the health professions. Journal of Interprofessional Care21, 97-107 (2007). Neal, M. & Morgan, J. The professionalization of everyone? A comparative study of the development of the professions in the United Kingdom and Germany. European Sociological Review 16, 9-26 (2000).

8. U.S. Congressman Tip O’NeilSpeaker of the House 1978-1987

9. A Recent New York Times RSS Feed

10. The Article

11. And Yet Another…Modern Day Profession

12. Emergent Professions Health care executives (Netherlands) Community psychologists (France) Doctor’s assistant (Poland) ELSA (Netherlands) Genetic counsellor (France) Infant pedagogue (Germany) Software engineering (U.S., Canada, U.K.) Kindergarten teachers (Israel) Human resources management (U.S.)

13. Ever More Emergent Professions Forestry (Canada) Respiratory care (U.S.) Companion animal ethology (South Africa) Veterinary technicians (U.S.) Peace counseling (U.S.) Operating department practitioner (U.K.) Speech & hearing therapy (Canada) Psychotherapist (Austria) Interactive media design (Netherlands)

14. More Image consultancy (U.K.) Public diplomacy (U.S.) Family therapy (India) Liaison interpreting (Lithuania) Eco-auditors (EU) Public relations (Malaysia) Online journalists (Netherlands) Nonprofit management (U.S.) Systems engineering (Slovenia)

15. Still More Sign pathology (language) (U.S.) Educational developmentalist (New Zealand) Multifunction project management (Sweden) Color consultants (France)

16. Nothing New Under the SunAbraham Flexner & Howard Becker Revisited Flexner, A. Is social work a profession? Research on Social Work Practice 11, 152-165 (1915). Becker, H. Some Problems of Professionalization. Adult Education 6, 101-105 (1956).

17. SO WHAT DO WE DO? How do we deal with this muddlement of meaning?

18. WE REJOICE

19. WE SHOULD EMBRACE AMBIGUITY

20. WE SHOULD USE THE OCCASION TO DIALOGUE

21. BABEL IS GOOD

22. THE NATURE OF PROFESSION It is not a thing. There is no one right definition [where one group knows what it is and other groups need to be better informed]. Instead, profession is a conversation – a social dynamic -- and the outcome of social relations. In turn, professionalism is a social movement – unfolding over time as different occupational groups interact with each other and with the public.

23. So What Does This Have to Do With Issues of Interprofessionalism? It is background – it serves as a frame for what I planned to talk about. BUT It also leaves less time to talk to you about my trips through interprofessional training at the U of MN, and through the MN State Legislature.

24. University of Minnesota

25. The Minnesota State Legislature

26. Quote “The health licensing subcommittee is the least partisan and yet the most conflict ridden of the subcommittees and a place where you get all kinds of fights of jurisdiction that cross party lines.”

27. Abbott, A. The System of Professions: An Essay on the Division of Expert Labor (University of Chicago Press, Chicago, IL, 1988).

28. MN State Licensing Subcommittee

29. Current licensing Legislation Being Considered

30. EHF 1226 (Thao) - Licensure and practice limitations established for an oral health practitioner, fees established, and rulemaking required. • This bill creates a new mid-level dental professional known as an “oral health practitioner” who is authorized to perform certain types of complex procedures in setting serving low-income, uninsured or areas with dental shortages as well as supervising dental assistants. [The version that was ultimately enacted into law changed the name of the new practitioner class to “Advanced Dental Therapists.”] • The proposal was strongly supported by community clinics, MnSCU, disability groups, Children’s Defense Fund, Minnesota Council of Health Plans, Minnesota Hospital Association, and a wide variety of organizations that advocate on behalf of the poor. • The proposal was adamantly opposed by the Minnesota Dental Association, who used radio and newspaper advertising to attack the bill.

31. HF 677 (Thao) - Body art procedures and establishments regulated. • This bill creates a licensure system for body art establishments [tattoo parlors] and body art technicians [tattoo artists.] • The bill is supported by Memorial Blood Centers and the American Red Cross, who are concerned about the rising proportion of the population who have tattoos. The policy of the American Red Cross to require a 12-month waiting period (to screen for Hepatitis) in any state that does not regulate tattoo parlors. Additionally, outside of Hennepin County, tattoo parlors are subject to little oversight. • Tattoo artists testified against the bill and were strongly opposed to several elements including the requirement to work for 200 hours as an apprentice (regardless of how many years an artist has been in business), minimum standards for equipment, instruments and supplies, and the annual licensing fees and penalties.

32. HF 1668 (Murphy, E.) - Advanced practice registered nurses practice requirements modified. • This is a bill to modify the existing scope of practice for advanced practice registered nurses (APRNs). Most significantly, the bill removes the requirement that APRNs practice within the context of a written collaborative management agreement with a licensed physician for certain delegated services, prescribing authority, and clinical settings (e.g. certified registered nurse anesthetists). • The bill was supported by the Minnesota Nurses Association (but see below) and the Minnesota Hospital Association. • The bill was opposed by the Minnesota Medical Association, the Minnesota Society of Anesthesiologists, the Minnesota Psychiatrists Association, and the Minnesota Academy of Family Physicians. In a last minute reversal, the Minnesota Association of Nurse Anesthetists also came out against the bill (because it would be more restrictive than their current authority).

33. HF 1860 (Ruud) - Lasers, intense pulsed light devices, and radio frequency devices regulated. • This is a bill to create a new licensure standard for the use of ablative treatments, including lasers, intense pulsed light, or radio frequency devices expected or intended to remove, burn, or vaporize live skin. The bill creates new supervision and training requirements for all non-physicians and clarifies that a physician who delegates authority to provide laser services have the expertise in providing those services him or herself. • The bill was supported by the Minnesota Dermatologic Society and the Minnesota Medical Association. It was also supported by the state medical societies for Plastic Surgery, Otolaryngology, and Ophthalmology. • The bill was opposed by the Minnesota Association for Aesthetic Safety, Permanent Choice Laser Hair Removal (a local business), and Radiance Medspa (a local business).

34. HF 2273 (Thao) - Dental professional licensure provided. • Not to be confused with the dental therapists bill, this bill created stricter regulatory requirements for dental assistants– changing their regulatory system from a registration to licensure. Most significantly, the bill restricts the dispensing of tooth whitening and bleaching agents. • The bill never even received a hearing in the House but was strongly supported by the Senate because of concerns about tooth whitening “stalls” selling services to teenagers in shopping malls. The bill was supported by the Minnesota Board of Dentistry and the Minnesota Dental Assistants Association. • The bill did not have opposition from any organized group, but there was great concern among House Members that it had never even been vetted.

35. Summary Interprofessional relations – at least in the U.S. – often is a zero sum game. It is not unusual for groups to have jurisdictional disputes stretching back decades What unfolds on the legislative floor [and spills out onto the airwaves and newspapers] has a direct bearing on what takes place within the university with respect to interprofessional education.

36. Factors Facilitating & Hindering Interprofessional Education • FACILITATING • Concerns about patient safety • Improved access to care • Improved outcomes • Growing collaboration among educators • Workforce changes • Changing values among healthcare professionals • HIDNERING • Different calendars, levels • Dense, packed curricula • Academic finance & reward systems • Assessment issues • Unprepared faculty • Deeply entrenched cultural differences professional roles