Invited commentary.

Autonomy. What a charged word that is for our profession! Is professional autonomy a great good for the profession, one of the most important developments over the last 50 years and the soon-to-be-realized end point of nearly a century of growth and development? Or it a fading ideal, lost in a sea of profound changes in the health care system of the United States that serve to restrict the autonomy of even the once-venerated physician? Or is it an unfortunate misnomer, implying arrogant isolationism when interdependent, but unfettered, practice is what we are really trying to achieve? Your view may depend on whether you are influenced by the recently published reflections of the Catherine Worthingham Fellows of the American Physical Therapy Association (APTA) (1) and APTA's Vision 2020, (2) by the writings of medical sociologists, (3,4) or by the always thought-provoking commentary of the late Jules Rothstein. (5)

Given the charged nature of "autonomy" to physical therapists, Sandstrom does a great service to the profession in writing this article, which articulates what autonomy means in a wider space than the profession of physical therapy. As I read his article, I identified 5 areas that seemed most ripe for comment: the relationship between professionalism and autonomy, the separation of autonomy into technical and socioeconomic elements, the concept of "functional autonomy," the changing role of autonomy in the health care system today, and the linking of professional autonomy with the autonomy of the individuals we serve.

Relationship Between Professionalism and

Autonomy

Professional autonomy, the interesting focus of this article, is but one element of professionalism. An understanding of both concepts is needed, I believe, to hilly understand the concept of autonomy. Indeed, both concepts--autonomous practice and professionalism--appear in the focused list of 6 elements of APTA's Vision 2020, with the other 4 elements being direct access, Doctor of Physical Therapy, evidence-based practice, and practitioner of choice. (2) Professionalism, I'm afraid, is sometimes reduced to considerations of a set of appearances and behaviors of individual therapists--Does this therapist dress professionally? Does this one have a warm, yet professional manner with patients? Does another interact professionally with physician colleagues? In reducing our thinking on professionalism to these individual behaviors, we ignore the considerable scholarship about the professions and the role of professionals in society.

The characteristics of professions and of individual professionals have been addressed by many scholars. One concise definition of a profession is offered by Starr in his seminal work on the transformation of American medicine: "A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation, enshrined in its code of ethics." (4(p15)) The importance of autonomy to the concept of a profession is seen in the very structure of the definition, with "regulates itself" appearing first in Starr's short list of characteristics of a profession. Part of this self-regulation is through "systematic, required training" (controlled in physical therapy by the Commission on Accreditation in Physical Therapy Education) and "collegial discipline" (controlled in physical therapy by the disciplinary procedures established in state physical therapist practice acts). But autonomy is not the only element of a profession--a profession has a base of "specialized knowledge" (physical therapy's base of knowledge is now codified in the Guide to Physical Therapist Practice (6) and added to and modified regularly through the peer-reviewed literature of the profession) and a "service orientation enshrined in its code of ethics" (articulated in many physical therapist practice acts as "standards of practice" and by APTA in its Code of Ethics (7)). Autonomous practice must exist within this larger framework of professionalism.

Technical and Socioeconomic Autonomy

The articulation of both technical and socioeconomic aspects of autonomy is an exceedingly useful element of this article. Technical autonomy, as presented by Sandstrom, relates to discretion and judgment in exercising one's profession and is regulated by standards of practice, accreditation, and licensure. Socioeconomic autonomy relates to access to the economic resources needed for accomplishing one's work. Conceiving of autonomy in these 2 different ways was particularly useful for Sandstrom's presentation of different points of view on physician ownership of physical therapist practices as relating to either technical autonomy (I make my own patient care decisions) or socioeconomic autonomy (the physicians profit from physical therapist services).

As I sat down to prepare this commentary, it occurred to me that the recently published reflections of the Catherine Worthingham Fellows of APTA on the most significant advances in physical therapy during the previous 50 years (1) might provide some useful perspective. With just a superficial reading of their comments, it was obvious that many Fellows used the term "autonomy" in their responses, with most of the responses referring to autonomy in clinical decision making.

Several other responses, however, referred to other important aspects that I now think of as additional expressions of our technical autonomy as a profession--the publishing of the Guide to Physical Therapist Practice, (6) not technically a "standard of practice," but certainly a statement in which physical therapists articulate their own vision of the scope of practice; the establishment in 1977 of an educational accreditation body separate from medicine, the predecessor to today's Commission on Accreditation of Physical Therapy Accreditation, (8) an important element in translating the profession's practice expectations into educational practice; greater regulatory autonomy through the establishment of independent physical therapist practice boards in some states rather than regulation through a medical board as was common earlier in the profession's history; and greater regulatory consistency through the establishment of the Federation of State Boards of Physical Therapy, with its Model Practice Act (9) and nationwide licensure testing.

"Functional Autonomy"

In his concluding thoughts, Sandstrom indicates that APTA's definition of autonomy is consistent with another type of autonomy--"functional autonomy," which he defines through Friedson's words as "the degree to which work can be carried out independently of organizational or medical supervision and can attract its own clientele independently." (10(p53)) Furthermore, this term is linked to a "paraprofession," suggesting that it is not a characteristic of the "real" professions. Sandstrom's characterization of APTA's vision as consistent with Friedson's "paraprofessional functional autonomy" is troubling to me without further explanation.

Using different language, but perhaps a similar concept, Starr, in discussing the autonomy of physicians in the United States health system in the early 20th century, noted:

   [Physicians] wanted to be able to use
   hospitals and laboratories without
   being their employees, and consequently,
   they needed technical assistants
   who would be sufficiently competent
   to carry on in their absence
   and yet not threaten their authority.
   The solution to this problem--how
   to maintain autonomy, yet not lose
   control--had three elements: first,
   the use of doctors in training (interns
   and residents) in the operation of hospitals;
   second, the encouragement of
   a kind of responsible professionalism
   among the higher ranks of subordinate
   health workers; and third, the
   employment in these auxiliary roles
   of women who, though professionally
   trained, would not challenge the
   authority or economic position of the
   doctor." (4(p221))

This "responsible professionalism" that Starr refers to is surely not the type of autonomy that contemporary physical therapists have in mind--and I assume it is not what Sandstrom had in mind. But Friedson's "functional autonomy," in being linked to the paraprofessions, seems to have something in common with Starr's "responsible professionalism" in the "higher ranks of subordinate health workers." I'd be interested to hear more from Sandstrom about what he means when he uses the term "functional autonomy."

Autonomy in the Health Care System Today

Sandstrom reminds us of the changing role of autonomy in the health care system today; reminds us that the increased autonomy enjoyed by physical therapists is occurring at a "historical low point for the autonomy of the professions." Physicians, long used to being self-employed professionals who served as gatekeepers to all health care services and practiced as their judgment dictated, are now often employed by health systems, must work collaboratively with an increasing number of nonphysician first-contact providers, must precertify with insurers before performing surgeries or other expensive procedures, and must limit drug prescriptions to a narrowing set of products approved by a particular insurer. No wonder that associations for medical professionals move into high gear when other professions--physical therapy included--advocate for more autonomy.

This turf protection--and turf erosion--is not new. Numbers, writing about medicine in the 1930s, noted:

   Medical doctors encountered equal
   difficulty keeping assorted other
   health-care professions from intruding
   on what they regarded as their
   rightful domain. Although they actually
   assisted podiatrists in achieving
   their independent status--on the
   grounds that corn-cutting like tooth-pulling
   was too trivial to control--they
   fought continually to limit the
   activities of such interlopers as optometrists,
   psychologists, and midwives,
   who competed directly with physicians
   specializing in ophthalmology,
   psychiatry, and obstetrics." (3(p233))

Although not a new phenomenon, today there are both new interlopers (eg, physical therapists, pharmacists, nurse practitioners) and new forms of interloping (controls instituted by insurers and employers). Sandstrom's work reminds us that physical therapists who are working to enact greater autonomy for physical therapists need to operate deftly within the changing political, economic, and social milieu of the contemporary health care system.

Serving the Public

Another very useful element of Sandstrom's article is the link it draws between professional autonomy for physical therapists and the autonomy of the individuals they serve. In part, this is clever wordplay--not just speaking to "serving" our patients and clients, but characterizing this service as autonomy for our patients, parallel to our increasing autonomy as a profession. But more than just clever wordplay, this idea is clearly consistent with Starr's definition of a professional, which speaks to "service rather than a profit motive. (4)

However, physical therapists should take care not to be too disingenuous about this aspect of autonomy. The following quote, about medicine, should give us pause:

   Medical apologists have long argued
   that professional advancement brought
   corresponding gains to the public....
   In recent years, however, critics of the
   medical profession have increasingly
   questioned such assumptions, arguing
   instead that the reforms we have described
   "centralized, bureaucratized,
   modernized and expanded medicine
   and medical education in the interests
   of physicians' own professional needs
   and with little regard for the needs of
   the public." The truth, I believe, lies
   somewhere between these two extremes.
   On the one hand, there can be
   little doubt that physicians benefited
   handsomely from their efforts to regulate
   and monopolize the practice of
   medicine. It is equally apparent that the
   elevation of the profession, in conjunction
   with other factors, drove up the
   cost of medical care, created a shortage
   of American-trained doctors, and damaged
   the chances for the poor and
   minorities to pursue careers in medicine.
   On the other hand, only the most
   prejudiced observer would argue that
   the public did not gain as well. Curative
   medicine may have contributed little to
   the dramatic reduction in mortality during
   the past century, but physicians
   using preventive and ameliorative measures
   did significantly improve the quality
   and length of life in America. And
   although the profession continues to
   harbor its share of scoundrels, patients
   today enter doctors' offices with much
   less cause of fear--and much more
   hope of being helped--than did their
   grandparents and great-grandparents.
   The interests of the profession and the
   public may not be identical, but neither
   are they antithetical. (3(p234))

I believe the same is true for physical therapy--that our recent advances as a profession have benefited not only physical therapists but also our publics. Physical therapists command higher salaries, work in more varied settings, see patients without referral, work with "evaluate and treat" models when referral is required, and own more private practices than previously. Patients have more choices of where to receive physical therapy, have more physical therapists to choose from, have more ways to gain access to physical therapy, and are served by therapists with more diagnostic acumen and a deeper therapeutic toolbox than previously. It is a great time to be a physical therapist, to exercise a great deal of professional autonomy in the service of individuals with disabling conditions that limit their own autonomy. Sandstrom's article has helped me think of autonomy in a more sophisticated ways--I trust it will do the same for individual practitioners as well as change agents within the profession, both of whom continue to work toward a higher, more consistent level of autonomy for physical therapists.

References

(1) The Worthingham Fellows opine: the most significant advance in physical therapy in the past 50 years. PT Magazine. 2006;14(6):60-62, 64, 66, 68, 70.

(2) American Physical Therapy Association Vision 2020. Available at: http://www.apta. org/AM/Template.cfm?Section=Vision_20201&Template=/TaggedPage/ TaggedPageDisplay.cfm&TPLID= 285&ContentID= 32061. Accessed October 22, 2006.

(3) Numbers RL. The fall and rise of the American medical profession. In: Leavitt JW, Numbers RL, eds. Sickness and Health in America: Readings in the History of Medicine and Public Health. 3rd rev ed. Madison, Wis: University of Wisconsin Press; 1997. Originally in Hatch NO. The Professions in American History. Notre Dame, Ind: University of Notre Dame Press; 1988.

(4) Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books, The Perseus Books Group; 1982.

(5) Rothstein JM. Editor's note: Autonomy or dependency. Phys Ther. 2002;82:750-751.

(6) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001:9-746.

(7) American Physical Therapy Association Code of Ethics. Available at: http://www. apta.org/AM/Template.cfln?Section=Home &TEMPLATE=/CM/ContentDisplay.cfm& CONTENTID=21760. Accessed October 22, 2006.

(8) Commission on Accreditation in Physical Therapy Education Handbook. Preface and Introduction. Available at: http://www. apta.org/AM/Template.com?Section=Home &Template=/CM/ContentDisplay.cfm& ContentID=19985. Accessed October 22, 2006.

(9) Federation of State Boards of Physical Therapy. The Model Practice Act for Physical Therapy. 4th ed. Available at: http:// www.fsbpt.org/download/MPA2006.pdf. Accessed October 22, 2006.

(10) Friedson E. Profession of Medicine." A Study of the Sociology of Applied Knowledge. New York, NY: Harper & Row; 1970.

E Domholdt, PT, EdD, FAPTA, is Vice President for Academic Affairs and Professor of Physical Therapy, The College of St Scholastica, 1400 Kenwood Ave, Duluth, MN 55811 (USA), [e-mail].

DOI: 10.2522/ptj.20050245.ic