TRIBALISM

The medical tribe

Occupations do not exist in isolation, but form part of a greater whole, an interdependent system in which they compete for influence. This was understood by Andrew Abbott who explored the interplay between occupations in his essay on the division of expert labour, published in 1988. Abbott recognized that fields of knowledge are in continuous dispute, subject to greater or lesser control by different occupational groups. As a result of social interactions, some occupations rise to positions of dominance, while others are subordinated, limited or excluded (Turner, 1995, pp. 138-139). In the English speaking world, those career producing occupations most successful in achieving market control and status in the social order are often referred to as ‘professions’ (Macdonald, 1995, p. 188). It is important to recognize that this way of seeing professions does not characterize them as being entirely benign. Rather than “honoured servants of public need” (Freidson, 1983, p. 19), they are instead depicted as accomplished competitors in a struggle for power, their authority coming at the expense of others.

The profession of medicine is archetypal, the dominant player in the field of health care, its area of expertise being extensive and subject to specialization. The medical profession plays a vital and respected role in the delivery of health care, but through its power and influence the development of other health care occupations has been shaped. In Britain it is generally the case that nurses are subordinate to medical doctors, dentists limit their scope of practice to diseases of the teeth and gums, and practitioners of alternative medicine, whose work is seen to be incongruent with medical orthodoxy, are excluded from mainstream funding and support. Within health care the history of inter-occupational dynamics has been driven by tribalism, the medical profession being the foremost tribe.

In the workplace, tribalism can be a force for survival and it can be a force for good. Shared values, organization and unity can be advantageous in the face of external threats. Loyalty to the group can lead to the establishment of principled behaviours within it. Even so, a strong culture of self-protection, elitism and misplaced collegiality can be unhelpful (Irvine, 2003, pp. 24-25). As well as resulting in reluctance to acknowledge error, such a culture can lead to prejudice against those external to the tribe.

Joint manipulation: a marginal practice

The practice of joint manipulation has been a contested domain. No single occupational group has dominated it. Instead a number of different groups have made use of it. Why, we might ask, given its strength, did the medical profession not dominate its use? Why didn’t the medical profession make manipulation its own? The fundamental truth is that through the course of history there were not a sufficient number of medical doctors interested in, or practising manipulation, for it to become an essential component of medical orthodoxy. Aside from the reduction of frank dislocations, the practice of joint manipulation was not judged to be sufficiently important. Therefore it remained marginal and others were allowed to colonize the field.

For an occupation to flourish professionally there are those who have reasoned that a number of attributes are required (Greenwood, 1957; Wilensky, 1964). These include a field of specialized knowledge and expertise; a commitment to work in that field by a sufficient number of practitioners; the establishment of schools to train practitioners, ideally with links to the university sector; the development of active associations of practitioners; authority recognized by the clientele; and community sanction, typically with statutory regulation. If any of these are absent then the occupation is not likely to prosper and become a profession. Arguably, British bone-setters are a case in point. They lacked formal education, organization and legal protection. They did not adequately proliferate, nor professionalize, and they did not survive. Physiotherapists, osteopaths and chiropractors, on the other hand, became organized, establishing schools, associations and alliances. Through processes of political agitation they came to achieve statutory regulation, recognized by neo-Weberian sociologists as a key attainment in the professional journey (Saks, 2010).

Today the titles ‘chiropractor’, ‘osteopath’, ‘physiotherapist’ and ‘physical therapist’ are protected under law in Britain, but scope of practice is not. While it is illegal to call oneself an osteopath without being registered with the General Osteopathic Council, and it is illegal to call oneself a physiotherapist without being registered with the Health and Care Professions Council, anyone can practise joint manipulation. With respect to joint manipulative practice, there is incomplete protection of job territory.

In spite of their achievements, and accepting that the situation is not the same in the United States, in Britain the number of practising chiropractors and osteopaths has remained small and to date they have failed to become mainstream. This is evidenced by the fact that their services are, for the most part, excluded from the National Health Service. Working in the private sector, they have considerable autonomy, but this is at the expense of orthodoxy. By contrast, physiotherapists, who are more numerous, are a part of the National Health Service. They are mainstream, but this was achieved through the sacrifice of autonomy, something that they still strive to resolve.

The patients’ interest

“I will use treatments for the benefit of the ill in accordance with my ability and my judgement, but from what is to their harm or injustice I will keep them.” (Extract from the Hippocratic Oath, Miles, 2004, p. 55)

A lens that sees professions as self-interested and power seeking calls for legal controls to be put in place to limit the most successful from monopoly, hence bureaucracy and accountability have become a part of the landscape of regulated professions, governments putting constraints on their ability to wield power. But power and action-based views of professions belie the fact that many aspiring medical doctors choose to study medicine because they see it as a caring profession. In other words, because of its humanitarian impact (Gillies et al., 2009). They become doctors not only because the medical career is respected, not only because the medical profession is a successful profession, but also because it is a profession that benefits society through caring for the sick. Key to the career choice of many would-be doctors is the idea of service, particularly service to the patient. This notion has been a part of the culture of medicine since Hippocratic times.

Seen in this light the medical profession’s historical criticism of other disciplines, notably of bone-setters and chiropractors, takes on a new significance. Rather than being a demonstration of occupational imperialism, instead it can be viewed as an act of benevolence, undertaken to protect patients from unqualified practice. Bone-setters were seen to be a danger to the public because they lacked anatomical knowledge and formal training; and the claims of chiropractors to treat serious organic conditions, such as heart disease, by adjusting the spine, were not only patently ridiculous, they had the potential to keep patients from more appropriate care, thereby risking lives. The application of effective health care required specialized knowledge and skills. In view of its authority, the medical profession had a duty to help protect the public from the unqualified. It had a moral obligation to protect them from harm.

References

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

Freidson E. (1983). The theory of professions: state of the art. In: The Sociology of Professions: Lawyers, Doctors and Others (Edited by R. Dingwall and P. Lewis), pp. 19-37. The Macmillan Press Ltd., London.

Gillies R.A., Warren P.R., Messias E., Salazar W.H., Wagner P.J. and Huff T.A. (2009). Why a medical career and what makes a good doctor? Beliefs of incoming United States medical students. Education for Health 22 (3), 331 (Electronic publication).

Greenwood E. (1957). Attributes of a profession. Social Work 2 (3), 44-55.

Hood W. (1871). On Bone-setting (So Called), and its Relation to the Treatment of Joints Crippled by Injury, Rheumatism, &c &c. Macmillan and Co., London.

Irvine D. (2003). The Doctors’ Tale. Professionalism and Public Trust. Radcliffe Medical Press, Abingdon.

Macdonald K.M. (1995). The Sociology of the Professions. Sage Publications, London.

Miles S.H. (2004). The Hippocratic Oath and the Ethics of Medicine. Oxford University Press, Oxford.

Saks M. (2010). Analyzing the professions: the case for the Neo-Weberian approach. Comparative Sociology 9 (6), 887-915.

Turner B.S. (1995). Medical Power and Social Knowledge (Second Edition). Sage Publications, London.

Wilensky H.L. (1964). The professionalization of everyone? American Journal of Sociology 70 (2), 137-158.

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