In December, 2023, the Sydney Morning Herald, The Age and 60 Minutes ran stories condemning podiatric surgeons on the basis that they can “perform surgery without having a medical degree”, that they can “pick up a knife with only a podiatry or science degree if they complete training at institutions that are not accredited by the Australian Medical Council”.
The article, and the reader responses to the article display some common strong themes:
- That only medical doctors should use the title ‘doctor’.
- The only accrediting body for the practice of surgery should be the Australasian College of Surgeons.
- The foot is complex, and therefore only orthopaedic surgeons have the expertise to understand how to perform foot surgery.
- People who perform surgery should have a full system of knowledge of the entire body which can only come from having studied medicine for around a decade.
As a sociologist, a health services researcher, I have been studying and writing about health professional boundaries with interest over the past 25 years or so. I am also a former Chair of Academic Board at an Australian University and have a professional interest, and work, in the professional accreditation and registration space.
My colleague, Alan Borthwick, completed his PhD on the evolution of podiatric surgeons in the UK. If you would like to read more about the fascinating history of the development of podiatric surgeons, you can read more of Alan’s excellent work here. Together we recently published a book The Allied Health Professions: A Sociological Perspective, which explores the history and sociology of the allied health workforce – which inevitably explores the role of the medical profession in shaping the current roles and professional boundaries of the health workforce.
The purpose of this article is not to support or refute the concept of podiatric surgeons, but to use this powerfully emotive topic to consider society’s assumptions about the nature of ‘health work’ and who is the rightful owner of particular tasks and titles.
The reaction of the public and of health professionals to the emergence of podiatric surgeons provides a striking illustration of deeply-rooted societal perceptions and biases regarding ‘truth’ and ‘ownership’ in healthcare roles. The perceived audacity of the somewhat humble and often maligned podiatrist to take on not just the medical profession but orthopaedic surgeons is an interesting and somewhat contentious story.
This issue is particularly timely because of the current national review of scopes of health care practice that essentially explores ways to ensure that health practitioners work to their full scope of practice. A Queensland Health Ministerial Taskforce performed a similar review for allied health nearly a decade ago and found that there were substantial opportunities to increase the efficiency and effectiveness of the workforce by removing barriers that stopped allied health working to their full scope of practice.
More than 100 relatively simple changes to practice were identified that would improve patient flow, reduce emergency or elective surgery waiting times – some of which included changes to professional boundaries (such as non-medical prescribing). Several involved no change in scope of practice but instead the removal of historic, restrictive practices that prevented allied health professionals from working to their full scope of practice, such as being able to order radiographs or make direct referrals to other practitioners.
In addition, most health professions are currently experiencing substantial global workforce shortages, resulting in delays in emergency and elective admissions to hospital, as well as barriers to accessing other health services. Historically, workforce shortages resulting from outbreaks of disease or war have been one of the largest drivers of workforce change (discussed more in this article). Indeed, the early need and opportunities for podiatrists to undertake minor surgery arose during WWII.
In essence, the key points that are illustrated by the backlash to podiatric surgeons (and other contentious role boundary issues such as non-medical prescribing, physician assistants, nurse practitioners, consultant and extended scope allied health professionals, and allied health assistants) is the extent to which we assume that the professional role boundaries within health workforce are a universal and irrevocable, when in reality:
- All professions are socially constructed and have evolved to meet the needs of society, and reflect the norms, values and power structures of that society.
- The current structure of the health workforce in western societies has been shaped under medical hegemony.
- We assume that the current paradigm is normative but it is constantly evolving. Historically, health tasks have been allocated (or taken) according to power and prestige.
- Since the formation of the modern health system (around a century ago) sophisticated clinical governance and professional regulatory systems have evolved, coupled with the development of high quality evidence and education systems that mean that a lot of tasks that have been subsumed by a specific profession on an historic basis, can and are now be safely delegated to other workers.
- Task-shifting between professions has seen a proliferation of questions around “who does it better”, which should, instead, be replaced by “can [alternative workforce] perform the task safely and effectively”.
That is not to say that all health tasks should be reduced to competencies and dissociated from a profession. Obviously, relevant training, governance (including regulation) and philosophies / approaches to care are important contexts for the delivery of healthcare work. However, as a society, we rarely unpack our assumptions about healthcare work to consider whether alternative approaches may safely improve health care accessibility for our communities.
The health workforce is social construct
On the 8th day, God created doctors.
In actual fact, the health professions in the UK, Australia, New Zealand, Canada and Ireland (and many other countries) all largely evolved under similar models of medical dominance that were established during the mid-19th century. Most of the published, English-speaking literature on the structure and organisation of the health professions arose from the UK model, however each country’s heath system diverged slightly in terms of their funding models and systems of organising health work. This has influenced the roles of some of the professions, and systems of power of those professions.
The western medical model is one perspective… that is not universally adopted
Health workers have always had status in society because of the important role they play, but the model of health care delivery that we see in Australia—and other high-income countries—is largely unique to high income countries.
For example, the Western medical model is a relatively new introduction in China, and much of Asia. From 1949 until the 1970s, the People’s Republic of China predominantly employed locally trained practitioners who supported and delivered public health and health promotion support, with basic medical care delivered by barefoot doctors who were locally trained to provide basic health care needs. The Western medical model was explicitly rejected by Mao Zedong in the post-war era due to its focus on individual curative models as opposed to population health and prevention; China does not formally train or recognise allied health professions, for instance.
In our book The Allied Health Professions: A Sociological Perspective, we describe the impact that different cultures have had on the introduction of the health professions. For example, the Western medical model is underpinned by philosophies of personal freedom and autonomy which is at odds with ‘collective identity’ cultures. For instance, occupational therapists working in Arabic countries using client-centred, goal-directed activities found that these values clashed with Islamic paradigms focused on fatalism and family responsibilities.
Most tasks can safely be performed by anyone who is appropriately trained and credentialed to perform that task and with appropriate support
Once upon a time, in the days before evidence-based practice (pre-1990), professionalism was associated with tacit, or ‘indeterminate’ knowledge that came with knowing the job and spending a lot of time in a role.
The introduction of evidence-based practice, clinical guidelines, standardisation of training and education from around the mid-1990s (yes… that recently) means that a lot of tasks and roles can be—and have been—codified, documented, and given away to another person or practitioner. Competency based training and the ability to give away roles, for instance through transdisciplinary practice and the principles of delegation, use this approach.
In fact, an efficient workforce will ensure that the qualifications of the worker are equivalent to the level of risk and complexity of the task being performed, as outlined in this article on principles to ensure health workforce flexibility. With appropriate training, support, supervision—within a safe clinical governance framework, and supported by appropriate regulation—most tasks can be reallocated. For example, this article discusses the research evidence on non-medical prescribing, and in this article we explore the normative frameworks that reinforce the perception of medical ownership of tasks like prescribing.
Not all task reallocation between health practitioners is as contentious as prescribing and surgery. As this example of rural generalist allied health practitioners demonstrates, there is a great deal of overlap between the roles of many health practitioners—with some careful negotiation, tasks can safely and effectively be re-allocated across different professional groups to better meet the needs of patients.
The ownership of both prescribing and surgery by the medical profession can be traced back to the late 19th century.
This is not to refute the importance of tacit or ‘indeterminate’ knowledge that comes from years of training or experience, which all professions develop over time. This is the clinical intuition and expertise, as well as contextual knowledge, that professionals develop as they master their subject area through practise. Professions are also bound together by a professional culture and philosophies that guide their practise. However, that does not mean that tasks cannot and should not be performed by more than one kind of worker.
Ownership over particular tasks is largely based on historic negotiations between different occupational groups, and become reinforced within social structures and norms. For example, in rural areas in Nigeria, bone fractures have historically been treated by “bone setters” who have no formal training in orthopaedics but inherited the role from their ancestors or as an “inheritance from God”. These workers hold a great deal of status in the communities in which they work because of the importance of the work they perform, their accessibility, and because of social norms. Their lack of formal training means that the outcomes are often varied. Consequently, some traditional bone setters have received formal training by orthopaedists as a way to standardise practice and reduce complications in fracture management (and because of an acute shortage of orthopaedists).
Modern systems of regulation need to recognise expertise rather than support professional role boundaries
The topic of the Fairfax story cited in our introduction, and the reader comments, illustrate the unquestionable position of power and dominance that the medical profession holds in Australian society.
This issue is somewhat peculiar to Australian society because, for instance, in the United Kingdom and the United States podiatric surgeons are recognised members of the health care team. Podiatric surgeons were first introduced in England in 1983 and received general NHS funding and approval in 1993. Neither the US nor the UK requires podiatric surgeons to hold a medical degree, or to be accredited by the country’s medical regulatory board.
Podiatric surgeons spend several years studying the foot and lower limb (which is a complex mechanical structure) as opposed to dedicated orthopaedic surgeon foot and ankle training which, according to this article averages 12 weeks (this is an older publication, but the only paper that quantified the actual length of training over several programs).
The proliferation of “who does it better?” research
A by-product of contested professional boundaries is the proliferation of “who does it better” research.
This research generally tends to ask the question “does a [non-doctor] achieve better outcomes than a medical doctor for the same procedure?” Inevitably, the outcomes of the published research can be predicted by the profession of the author of the publication. For example, the who does it better research comparing the outcomes of podiatric versus orthopaedic foot and ankle surgery shows strong confirmation bias according to the profession of the authors (each reinforcing their own professional standing). Interestingly, there is no published data suggesting that “the other profession” does it [anything] better.
Perhaps disappointingly, the recent media articles drew heavily on “anecdata” (a range of good stories that prove their point in the absence of published evidence).
Who does it better research only tends to be undertaken when there is a (real or perceived) power differential between occupational groups, or when the occupational groups are competing for the same patients, and therefore funding.
Instead of “who does it better”, focus on patient-centred models of care
Intra-professional turf wars, or conflicts between different types of healthcare professionals over their roles and responsibilities, can unfortunately lead to a loss of focus on the most important aspect of healthcare: the patient.
No health practitioner should be performing high risk procedures without adequate training, supervision, regulation and clinical governance to support that role. There should never be systematic differences in the outcomes of any procedure on the basis of the professional title of the practitioner alone. Systematic differences in outcomes will be a byproduct of training, experience, governance or differences in patient populations – all of which are modifiable factors.
As systematic task reallocation between professions become increasingly entrenched, who does it better is being replaced by who does it cheaper but as effectively, such as this recent systematic review on the cost effectiveness of physician assistants.
Health regulators should be closely monitoring the safety and effectiveness of the workforces they regulate. Health funders and policy makers have an obligation to ensure that the most effective workforce is allocated to perform appropriate tasks based on proportionate risks and cost effectiveness.
Health work roles and professional role boundaries are constantly evolving
The discussion of professional role boundaries is particularly topical globally.
Our society assumes that health professional roles are relatively stable and static. However, the health workforce is constantly evolving in response to new population needs, notably new technologies, and supply and demand issues. We discuss the dynamic nature of health professional boundaries in some detail in this paper. Some of the greatest influences on health worker roles are outbreak of disease and war.
COVID-19 led to a rapid reconfiguring of the workforce in several ways: rapid role redesign to move allied health professionals from chronic disease management to acute care; the introduction of new roles in public health; changing hospital procedures and flows to accommodate the changing patient load and de-prioritising elective surgery; and the system-wide shift to online modes of health care delivery.
World-wide shortages of most health professions coupled with long waiting lists and increasing costs of delivering services are calling for new models of service delivery—and the reallocation of tasks to different workers.
Conclusion: A call for open dialogue on professional role boundaries
The question of “Who owns healthcare work?” opens up a broader discussion about the future of healthcare.
It calls for an open dialogue among professionals, policy-makers, educators, and patients to adapt to the changing landscape. By embracing flexibility, collaboration, and a patient-centred approach, we can redefine professional boundaries in a way that respects the expertise of each profession while prioritising the health and well-being of patients.
Review our ongoing scope of practice coverage here. | Join us on 22 February 2024 for our seminar ”The Power Play in Healthcare: Who Really Holds the Scalpel? “, a thought-provoking, challenging, call-to-action for the health professions, policy makers, employers, service users and funders to secure sustainable, efficient and equitable access to safe and effective health services. Our expert panel of presenters, Professor Susan Nancarrow, Professor Alan Borthwick OBE and Dr Anne-Louise Carlton, will lead an informative discussion exploring scope of practice at the legislative, professional and service levels, examining international and interdisciplinary variations in responses changing role boundaries. Register for this engaging and informative event today, as spaces are limited.