The role of governmentality in the establishment, maintenance and demise of professional jurisdictions: the case of geriatric medicine

Accessibility in health professions education: The Flexner Report and barriers to diversity in American physical therapy

Health professionals do not reflect the broader racial/ethnic diversity of the United States. Historical barriers to accessing health professions education have played a major role in initiating and perpetuating these disparities. Sociologists of professions have highlighted the role of educational reform in professions' efforts to enhance their status, but have overlooked the central role of government bodies in facilitating or impeding these strategies. The Flexner Report (1910) enhanced the status of medicine, but only after state medical boards adopted its recommendations, leading to the closure of half of the nation's medical schools and limiting opportunities for marginalized populations to enter the medical profession. Physical therapy leaders have espoused Flexner's precepts in seeking to advance their field's professionalization. In doing so, they consistently overlooked the more insidious impacts of Flexnerian approaches on student and practitioner diversity. This article examines how physical therapy's Flexnerian ambitions disrupted its parallel efforts to increase the field's racial/ethnic diversity. I argue that physical therapy leaders' focus on enhancing their profession's status and indifference toward facilitating educational access and mobility played a significant role in the field's racial/ethnic homogeneity. To increase practitioner diversity in the future, especially following the 2023 US Supreme Court decision (600 U.S. 181) restricting race conscious affirmative action, health professions must do more to address barriers to student access. This will involve moving away from the Flexnerian model and pursuing approaches that have helped more diverse and inclusive health professions, like nursing, to achieve greater educational opportunity and mobility.

Making morbidity multiple: History, legacies, and possibilities for global health

Multimorbidity has been framed as a pressing global health challenge that exposes the limits of systems organised around single diseases. This article seeks to expand and strengthen current thinking around multimorbidity by analysing its construction within the field of global health. We suggest that the significance of multimorbidity lies not only in challenging divisions between disease categories but also in what it reveals about the culture and history of transnational biomedicine. Drawing on social research from sub-Saharan Africa to ground our arguments, we begin by describing the historical processes through which morbidity was made divisible in biomedicine and how the single disease became integral not only to disease control but to the extension of biopolitical power. Multimorbidity, we observe, is hoped to challenge single disease approaches but is assembled from the same problematic, historically-loaded categories that it exposes as breaking down. Next, we highlight the consequences of such classificatory legacies in everyday lives and suggest why frameworks and interventions to integrate care have tended to have limited traction in practice. Finally, we argue that efforts to align priorities and disciplines around a standardised biomedical definition of multimorbidity risks retracing the same steps. We call for transdisciplinary work across the field of global health around a more holistic, reflexive understanding of multimorbidity that foregrounds the culture and history of translocated biomedicine, the intractability of single disease thinking, and its often-adverse consequences in local worlds. We outline key domains within the architecture of global health where transformation is needed, including care delivery, medical training, the organisation of knowledge and expertise, global governance, and financing.

The shadows of waiting and care: on discourses of waiting in the history of the British National Health Service

Waiting is at the centre of experiences and practices of healthcare. However, we know very little about the relationship between the subjective experiences of patients who wait in and for care, health practitioners who 'prescribe' and manage waiting, and how this relates to broader cultural meanings of waiting. Waiting features heavily in the sociological, managerial, historical and health economics literatures that investigate UK healthcare, but the focus has been on service provision and quality, with waiting (including waiting lists and waiting times) drawn on as a key marker to test the efficiency and affordability of the NHS. In this article, we consider the historical contours of this framing of waiting, and ask what has been lost or occluded through its development. To do so, we review the available discourses in the existing literature on the NHS through a series of 'snapshots' or key moments in its history. Through its negative imprint, we argue that what shadows these discourses is the idea of waiting and care as phenomenological temporal experiences, and time as a practice of care. In response, we begin to trace the intellectual and historical resources available for alternative histories of waiting - materials that might enable scholars to reconstruct some of the complex temporalities of care marginalized in existing accounts of waiting, and which could help reframe both future historical accounts and contemporary debates about waiting in the NHS.

Refashioning the uneasy relationship between older people and geriatric medicine

A notable feature of most medical specialties is close joint working between patient advocacy groups and specialist societies in furthering improvements in policy and services. While growing old is not a disease, nor too is being a child, and the engagement of advocacy and international bodies such as UNICEF with paediatricians is well established and recognised. Yet almost eight decades after the founding of geriatric medicine, it is clear that this type of relationship does not hold for the advocacy bodies representing those we serve, as well as the wider constituency of older people. Geriatricians are an extraordinary resourceful and imaginative group, and a more effective promotion of our role as guardians of the longevity dividend is vital to a more positive and mutually beneficial relationship with older people and society. This will require a redirection of our focus to a more critical stance on our origins as a discipline, our relationship with ageing across the lifespan and with older people and a fuller engagement with the broader concepts of gerontology in training and research to develop a refreshed articulacy for, the opportunities arising from gerontologically attuned healthcare.

The development of the new assistant practitioner role in the English National Health Service: a critical realist perspective

Adopting a critical realist perspective, this article examines the emergence of a relatively new non-professional healthcare role, the assistant practitioner (AP). The role is presented as a malleable construct cascading through and sensitive to structure-agency interaction at different levels of NHS England: the sector, organisation and department. At the core of the analysis is the permissiveness of structures established at the respective levels of the NHS, facilitating or restricting agency as the role progresses through the healthcare system. A permissive regulatory framework at the sector level is reflected in the different choices made by two case study NHS acute hospital trusts, in their engagement with the AP role. These different choices have consequences for how the AP impacts at the departmental level.

Understanding Professional Jurisdiction Changes in the Field of Anesthesiology

We further our understanding of jurisdictional disputes between established professional groups through a 10-year longitudinal analysis of the differential adoption by U.S. states of policies expanding Certified Registered Nurse Anesthetists’ (CRNAs) autonomy. In the United States, CRNAs are trained to deliver anesthetics to patients in the same way as physician anesthesiologists but have more restrictions in practice. Following a 2001 federal decision regarding Medicare reimbursement, states were permitted but not required to allow CRNAs to practice without physician supervision, potentially reducing health care costs. We show that higher levels of incumbent physician power makes it less likely that a state will change jurisdictional boundaries, while increasing relative power among challenging CRNAs and the past successes of other challenging health professionals increase the likelihood. State labor deficiency and proximity to other adopting states also positively influenced the expansion of CRNAs’ autonomy. Implications for the professions and health services literature are discussed.

Comparing medicine and management: methodological issues

Background

In the study of medicine and management, there is a strong interest in cross-country comparison. Across healthcare systems in industrialised countries, New Public Management has provided a similar reform template, but new governing arrangements exhibit significant national variations. The comparative perspective also offers a leverage to overcome the resistance focus of earlier studies. Comparison raises two overall questions: in what similar and different ways are relations between medicine and management changing across industrialised countries? Why is change occurring in different ways? The questions reflect exploration and explanation as the two basic rationales for comparison.

Methods

The aim was to provide a critical discussion of different approaches to comparing medicine and management across countries. The analysis was based on a narrative review of relevant studies from several bodies of literature.

Results and discussion

The majority of studies exploring medicine and management adopt macro level approaches to comparison. Studies draw on a range of notions, including area specific ideal types of professionalism, professionalism as countervailing powers and governmentality. There are much fewer studies exploring relations between medicine and management at the meso level. Analyses treat comparison as a two-dimensional exercise looking across both countries and levels. The majority of studies draws on institutional explanations. These are variations of the path dependency argument and studies include both sector specific and broader political and administrative institutions. There is an emerging body of process-based explanations which connect macro level institutions to organisations and which promote more non-linear comparisons.

Conclusion

The lack of meso level comparisons drawing on process explanations is problematic. Empirically, we need to know more about how relations between medicine and management are different across countries. Theoretically, we need to better understand how we can transpose analytical insights from institutional explanations at macro level to studies that are multi-level and also include the meso level of organisations. Methodologically, we need to address the challenges arising from more non-linear approaches to comparison, especially how to organise close international research collaboration over an extended period of time.

Revisionist or simply wrong? A response to Armstrong's article on chronic illness

This article is a response to David Armstrong's recent, revisionist account of the epidemiological transition which he claims replaced earlier discourses of ageing with new discourses of chronic disease. We argue (i) that he misrepresents a key element in Omran's account of the epidemiological transition, namely the decline in infant, child and maternal mortality; (ii) that he fails to acknowledge debates going back centuries in Western medicine over the distinctions between natural and accidental death and between endogenous and extrinsic causes of ageing and (iii) that he misrepresents the growth of medical interest in the everyday illnesses of old age over the course of the 20th century as a discourse of suppression rather than a process of inclusion. While we would acknowledge that the chronic illnesses of today are different from those of the past, this amounts to something more than the changing semantics of senility.

The development of the specialism of emergency medicine: media and cultural influences

In this article we analyse, via a critical review of the literature, the development of a relatively new medical specialism in the United Kingdom, that of emergency medicine. Despite the high media profile of emergency care, it is a low-status specialism within UK medicine. The creation of a specialist College in 2008 means that, symbolically, recognition as a full specialism has now been achieved. In this article, we will show, using a sociology of professions approach, how emergency medicine defined itself as a specialism, and sought to carve out a distinctive jurisdiction. While, in the context of the UK National Health Service, the state was clearly an important factor in the development of this profession, we wish to develop the analysis further than is usual in the sociology of professions. We will analyse the wider cultural context for the development of this specialism, which has benefited from its high profile in the media, through both fictional and documentary sources.

Frail bodies: geriatric medicine and the constitution of the fourth age

Clinical discourses of frailty are central both to the construction of the social category of the fourth age and to the role and identity of hospital geriatric medicine. However, the influence of such clinical discourses is not just from science to the social sphere and nor do these discourses have their source in a putative truth of the old body but emerge from an interplay between physiological facts, discourses of governmentality, productive processes associated with late modern capitalism and the professional ambitions of geriatric medicine. The article explores this interplay in the two key discourses of frailty that have emerged in the clinical literature during the past 15 years, that of the phenotype and the accumulation of deficits, respectively. Outlining the development of the discourse of senescence from its origins to the more recent emergence of a nosological category of frailty the article explores how these key discourses capture the older body according to particular sets of norms. These norms link physiological understanding with broader discourses of governmentality, including the professional project of geriatric medicine. In particular, metaphorical representations in the discourses of frailty convey key cultural and clinical assumptions concerning both older bodies and old age more generally.

Charismatic authority in modern healthcare: the case of the 'diabetes specialist podiatrist'

Professional specialisation is broadly considered to result from increased complexity in professional knowledge and to be linked to specialist education, formalised credentials and registration. However, the degree of formal organisation may vary across professions. In healthcare, although medical specialisation is linked to rigorous selection criteria, formal training programmes and specialist registration, some forms of specialisation in the allied health professions are much less formal. Drawing on Weber's concept of charismatic authority, the establishment of a specialist role in podiatry, the 'diabetes specialist podiatrist', in the absence of codified or credentialed authority, is explored. 'Charismatic' leaders in podiatry, having attracted a following of practitioners, were able to constitute a speciality area of practice in the absence of established career pathways and acquire a degree of legitimacy in the medical field of diabetology.

Biology as destiny? Rethinking embodiment in ‘deep’ old age

Despite sociological understanding that bodies are social and morphological, material and discursive, there is a persistent, prevailing tendency within sociology to approach the old body – particularly in ‘deep old age’ – as non-social. No longer amenable either to reflexive (consumerist) choice, or expressive of the self, it is viewed rather through a biomedical explanatory framework in which it is held to succumb to ‘natural’ physiological processes of decline that lie outside culture. This paper critically questions such assumptions which it links to sociology's acquiescing in modernity's age ideology rather than taking it as a starting point for critique. This means that sociology's sensitivity towards ageing is displayed not in challenging models of the older body but in diverting attention away from the body altogether and focusing on structural and cultural determinants which are not considered to encompass physiology. Arguing, however, that biology and society do not exist on separate plains, and that the body in deep old age is, like other bodies, first and foremost a social body, the paper draws upon feminist methodology and epistemology for the purpose of dismantling such essentialism. It suggests that the sociological imagination will benefit from the eradication of age ideology through a clearer understanding not just of ageing but of embodiment at all stages of the lifecourse.

A new political anatomy of the older body? An examination of approaches to illness in old age in primary care

This paper examines the new approaches to older bodies found within primary care, with the purpose of determining whether they represent a significant disjunction from established approaches in geriatric medicine. A genealogical review of clinical approaches to certain conditions commonly found in old age is undertaken utilising (a) key texts of pioneering British geriatricians and (b) three editions of a key textbook of general practice, published between 1989 and 2009. The discourses and practices established by the Quality and Outcome Frameworks in England are then examined, focusing on evidence-based guidance for these same conditions. Following this excavation of written texts, empirical data are analysed, namely the accounts of general practitioners and practice nurses regarding application of the technologies associated with chronic disease management to older patients. Continuities and changes identified by these practitioners are explored in terms of three specific consequences, namely conceptualising and treatment of older bodies and interaction with patients. The paper's conclusion considers whether these changes are significant enough to warrant describing them as representative of an epistemic rupture or break in the way older bodies are perceived, both in medicine and also in society more generally, and thus of constituting a new political anatomy of the older body.