COMMUNITY HEALTH STUDIES VOLUME rx, NUMBER I , 1985

KNOWLEDGE, SKILL AND OCCUPATIONAL STRATEGY: THE PROFESSIONALISATION OF PARAMEDICAL GROUPS

Bryan S. Turner

Professor of Sociology, The Flinders University of South Australia

Two Perspectives on the Profesdon Sociology as a discipline appears to develop

by lurching from one exaggeration to another; the recent historyof the sociology of professions is no exception to this unfortunate rule. One of the first coherent accounts of the nature of professions was presented by. Talcott Parsons, who argued that professional practice was largely the opposite of business activity in that the professional code emphasised disinterested service of the client on the basis of a predetermined fee rather than an exchange between customers in pursuit of profit.' This approach to the professions drew attention to the importance of knowledge, skilland ethics in the definition of professionalism. In this sociological perspective on the professions, it is possible to provide a basic list of elements or traits which define the professions as a distinctive and separate set of occupations. The list of characteristics includes the use of skills based on theoretical knowledge, an extensive period of education to acquire these skills, the regulation of uniform standards by examinations, the development of a code of practice to guarantee professional integrity, the performance of services which are seen to be in the interests of the general public and finally the organisation of a professional association to regulate the activities of members.* The process of professionalisation was seen to involve an evolutionary acquisition of these characteristics by an aspiring occupation. In general the professions were seen to have a stabilising effect on industrial societies, which are competitive, commercial and individualistic.

This idealistic view of the professions was eventually challenged by sociologists who saw professionals as privileged workers who maintained their elite control over occupational prestige by a variety of strategies, which were designed to limit competition in the market. .The new approach to the nature of the professions was first associated with the work of Everett C. Hughes) and was illustrated in the contrast between two classic studies of medical education, namely The Student-Physician4 and Boys in

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White.' In this perspective, the concept of "profession" does not refer to an essential list of features which can be acquired through training and organisation; it refers instead to a strategy by which an occupation can gain professional autonomy with respect t o i ts clients. Professionalisation is thus the successful adoption of such exclusionary practices by which an occupation gains status and autonomy. A profession is not so much a prestigious occupation as a method of controlling an occupation in the interests of preserving prestige and power.6 This interpretation of professions is now widespread and dominant in the sociology of medical professionalism, partly as a consequence of the influence of Eliot Freidson.' Whereas Parsons stressed the importance of abstract knowledge and ethics in the definition of professions, recent writers in the tradition of Freidson tend to regard knowledge and ethics as largely irrelevant. For Freidson, a profession is defined ultimately by its autonomy from external control and this autonomy is determined by power conflicts and not by the elaboration of knowledge. The process of professionalisation is:

essentially political and social rather than technical in character - a process in which power and persuasive rhetoric are of greater importance than the objective character of knowledge, training and work.8

In contemporary medical sociology in Australia, one particularly powerful exposition of the political character of occupational strategies has been offered in Evan Willis's Medical Dominance.9

Medical dominance involves control over the work situation, professional autonomy within the medical division of labour and occupational sovereignty over related and neighbouring occupations. It also requires a privileged location within the class structure of a given society. There are three modes of medical domination in relation to allied or neighbouring occupations, namely subordination, limitation and exclusion. In the

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case of subordination, the nature and tasks of a n occupation are delegated by doctors and as a consequence there is no genuine scope for autonomy and independent decision making. One illustration of occupational subordination to medical dominance would be midwifery. By contrast, the nature of occupational limitation can be exemplified by dentistry, optometry and pharmacy. The restrictions or limitations on these occupations involve containment to a specific part of the body (as in dentistry) or t o a definite therapeutic technique (as in pharmacy). More importantly, medical dominance is exercised by the fact that physicians play an important part on registration boards of these occupations. Registration Acts specify the competence of these groups within a determined occupational territory and simultaneously confirm the ultimate control of the medical profession over this terrain. Finally there is the case of exclusion whereby alternative forms of medical practice are denied registration as bona fide forms of legitimate service. In most modern societies, the exorcism of demons is not accorded the status of a legitimate therapeutic practice.1° The conflict between the medical profession and chiropractic would be a further illustration of the use of exclusionary strategies by the medical profession to defend its monopolistic control over the provision of health care.”

It is important to note one further feature of the new sociology of the professions as a n account of occupational strategies of market control. While occupations can enhance their social standing and their occupational autonomy by the exercise of dominance, it is also possible for occupations to become de-skilled and de-professionalised. De- skilling may occur when the traditional skills of a n occupation are replaced by new technology, especially by the application of computers.’* It has been suggested, for example, that pharmacy has experienced de-skilling as a consequence of the intervention of the large drug company which has usurped the traditional role of the pharmacist as a compounder of drugs. The community pharmacist has to some extent lost control over the application and utilisation of his skills.13 Of course, the ability to resist de-skilling will be largely a consequence of professional status and of the cohesion of the profession. It is possible to resist the de-skilling consequences of the intervention of the drug companies by emphasizing the notion that only trained pharmacists are competent to interpret and understand the diverse consequences of the same drug for different patients. However, one should not think of de-skilling as a process which effects

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all levels of a profession with equal force at the same point in time.

The lower levels of a n occupational group may be de-skilled by technological change while leaving the higher eschelons untouched by such transformations of work skills. For example, the work of accountants has been routinised by the introduction of computers which has removed the skill from simple processes of auditing. However, the higher levels of the accountancy profession have continued to maintain their status as financial advisors t o business.t4 It could also be suggested that, in the medical profession, there has been a certain de-skilling and loss of professional status by the general practitioner in relation to the hospital consultant. The community doctor is reduced to a referee who simply negotiates between the patient and the specialist. The traditional autonomy of the doctor is also threatened by the growing sophistication of clients, the formation of c o n s u m e r pro tec t ion societ ies a n d t h e development of malpractice legislation. I5

There has been, in summary, a significant change in the sociology of the professions from a n argument that professions are defined primarily by reference to knowledge and ethics to an argument that professionalisation involves a successful occupational strategy of dominance and closure. In the first position, knowledge is the dominant criterion and occupational power is irrelevant. In the second position, occupational dominance is central and a systematic body of knoweldge is irrelevant. In this paper, the aim is to develop a theory of professions which combines an emphasis on both knowledge and power as necessarily combined in any explanation of professional status. The theory attempts to combine aspects of ‘both existing perspectives and to demonstrate the i m p o r t a n c e o f t h i s c o m b i n a t i o n o f knowledge/power by special reference t o pharmacy. Before developing this alternative approach, it is instructive to consider recent interpretations of the professionalisation of paramedical groups.

Knowledge and Professionalisation As a general rule, sociologists are reluctant to

engage in debates about the truth or falsity of the beliefs of the groups they wish to study. It is very common for sociologists to assert that the truth or falsity of beliefs is an irrelevant issue from a sociological perspective. The classic illustration is Durkheim’s argument that the truth status of religious beliefs was of no consequence for the sociology of religion which is concerned with the

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social functions of religion and not with the validity of religious statements.16 Adherence to such overt neutrality has often been criticised by philosophers of social science who claim, for example, that the truth or falsity of beliefs is an important part of the explanation of rational a~ t i0ns . l~ It is normally the case that we seek explanations for behaviour in situations where we are puzzled by what looks like irrational, untoward or peculiar behaviour. There is a commonsense plausibility to the notion that people do things because they believe there are good reasons for so doing. In short, the truth of beliefs may be causally important in actions and thus the problem of valid knowledge is important to any debate about the rationality of actions. There are consequently philosophical arguments t o suggest that sociological explanations of human actions and social relations cannot sweep the issue of truth and falsity under the carpet. This paper argues furthermore that it is sociologically inappropriate to suppress the nature of professional beliefs in any attempt to explain processes of professionalisation and de-skilling. Prior to spelling out this counter position in more detail, it is instructive to consider an influential sociological interpretation of dentistry.

In the British context, the Dentists Act of 1878 was inadequate as a basis for professionalisation because it did not give the qualified practitioner a monopolistic and exclusive control over the provision of services. Unregistered and unqualified dentistry was a regular feature of the occupation into the twentieth century; many chemists, for example, practised dentistry as a secondary activity. Pressure to improve the dental health of the population came about as a consequence of the discovery of poor standards of general health amongst British troops during the Boer and First World War and as a consequence of attempts to improve the health of children following the 1907 Education Act.18 The outcome of public and occupational pressure was that dentistry became a closed profession in 1921 with entry to the profession regulated by schools under the control of the General Medical Council.19 The professionalisation of dentistry was thus associated with an increase in public demand for an improved service and this demand was backed by legislation and state intervention. At the same time, dentists were making important claims about the benefit of dental healfh for the general well- being of the population. These claims were supported by reference to the theory of focal sepsis, and specifically to the notion of oral sepsis. Under

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the slogan that "good teeth mean good health", the profession asserted that it had a crucial role to play in promoting and maintaining the health of the nation. Subsequent scientific investigation of the theory of focal sepsis showed that the theory was false and that the claims made for interventionist dentistry were largely unjustified, but this rejection of the theory took place after the dentists had achieved their goal of enhanced professional standing.

The conventional sociological interpretation of this episode is that the scientific status of the theory was relatively unimportant in the occupational sthggle for professional closure and social recognition. Whereas some writers on professions have suggested that a coherent and valid scientific basis is a prerequisite for professionalisation, the example of dentistry might suggest an alternative theory." Against this perspective, Dussault and Sheiham argued that, in advancing professional claims:

it is of little relevance whether this "scientific" base is sound or not, so long as it seems credible and acceptable to the professional community. ... the existence of a structured cognitive base - more than its validity - is a favourable factor in the process of achieving professional status.*'

This argument is a characteristic position of sociological explanation in general. It is not the truth or falsity of a belief system which is important, but whether it can function to legitimate a certain set of activities. Oral sepsis turned out to be false, but, at the time, it functioned adequately to legitimate professionalisation, because oral sepsis was regarded by dentists as plausible. More importantly, the theory was compatible with the interests of the dentists. Sociology is thus characteristically more interested in the social role of professional ideologies and relatively uninterested in the validity of the claims as such. Although these perspetives in sociology on professional ideologies are perfectly appropriate as a general perspective and provide an important critique of idealistic interpretations of professional knowledge and ethics, this functionalist account of professional ideology is not wholly adequate and more importantly is relatively underdeveloped as a theoretical perspective.

The conflict between the opthalmic optician and the medical' profession in many respects parallels the history of dentistry. In Britain, opticians gained some autonomy and occupational control with the Royal Charter of 1629 which was

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granted to the Worshipful Company of Spectacle Makers. Certain scientific developments in the nineteenth century (the invention of the opthalmoscope and opthalmeter) provided a technical knowledge base for opthalmology. In the early decades of the twentieth century, opthalmic opticians developed as a special group within the paramedical division of labour because there was a mass market for spectacles and a shortage of qualified opthalmologists. In the period leading up to the foundation of the National Health Scheme, a lucrative market was opened up and eventually the British Medical Association sought t o exert greater medical control over the activities of the opthalmic opticians. This struggle was couched in terms of professional ethics, the scientific status of the service and the profit motivation which dominated the supply of spectacles. Medical control in the Opticians Act (1958) took the form of restricting the optician to sight testing and ensuring that opticians always referred a suspected eye disease to a doctor. State recognition of grades of work and confirmation of the medical division of labour had the effect of recognising a n occupational ceiling and establishing medical surveillance of opticians.22 Although the rivalry between opticians and doctors was essentially economic in character, the claims of opticians to have a valid skill was based on important devetopments in the physical sciences in optics. Their market position depended on a knowledge base as well as on a capacity to organise and to deliver a service.

Knowledge, Interpretation and Systematisation Within a comparative analysis of professions,

it is important to give attention to the claim to validity of professional knowledge. In the process of professionalisation, there has to be some social consensus that the knowledge base of a n occupation is relatively coherent, valid and relevant in order to win the loyalty of a clientele and the legal backing ofthe state. As a general rule, the social status of an occupation is closely tied t o the social standing of its clients or audience. The low status of prison officers, asylum attendants and nurses in the nineteenth century appears to have been related t o the stigmatised populations of "total institution^".^^ With the increase in literacy, education and expectations in the general public in industrial, urban societies, the knowledge base of professions is subject to more scrutiny and criticism than in previous periods. One aspect of the argument in this paper is that the question of validity tends to become more important with the

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improvement in genera l e d u c a t i o n , t h e organisation of professional clients into consumer organisations and with the development intra- professional and inter-professional rivalries. Two illustrations are relevant to this argument. In the nineteenth century, the principal therapeutic practice of the general practitioner was bed-rest, This treatment was based primarily on common- sense understanding of illness rather than on an articulate and systematic theory of therapeutics. It was a craft skill handed down in the profession rather than an element of a "structured cognitive base", but the important point is that bed-rest did not harm the patient and in most cases the treatment probably contributed to recovery. Historical evidence suggests that, provided doctors did not encourage their patients to enter hospital, medical practice did not seriously undermine health. Medical practice was plausible, being grounded in traditional empiricism and the test of medical intervention has probably always been highly pragmatic - if the patient survives, then the intervention is successful. Modern medicine is practised in a very different public climate in that there is a far more extensive debateabout thevalue and quality of modern medicine and about the nature of alternative systems. In addition, there are greater intra-professional rivalries and inter- professional conflicts over alternative treatment systems; these conflicts and rivalries are fought out in terms of conflicting scientific and treatment principles. In the area of mental illness and its treatment, there is considerable conflict between rival systems and competing occupations.

The growth of a more sophisticated public means that the question of the validity of professional knowledge becomes more rather than less relevant to debates about professional status. Conflicts between and within occupational groups mean that these struggles over the validity of knowledge are more likely to take place in the open and that state support will be, a t least in part, based on successful claims as to validity and effectivity. One illustration of this problem is the social status of the ministry as a profession. The minister of religion enjoyed high social status on the basis of training, communitjr service, professional closure, absence of a prof i t motive a n d el i te r e ~ r u i t m e n t . ~ ~ I n the twentieth century, the ministry has experienced a decline in social status and professional autonomy, in combination with a decline in the quality of intake. One feature of this decline is that theological knowledge is no longer seen to be relevant t o the problems of a modern society and, as a consequence, the ministry has

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been forced out of the personal-service market by social workers, teachers, psychiatrists, health workers and community workers. Theological knowledge can no longer provide the basis for successful claims to professional autonomy and social influence. The area of professional competence is thus confined to liturgical activity and to rituals associated with the life-cycle, namely birth, marriage and death.25

There are philosophical reasons for arguing that sociology cannot simply ignore the problem of the validity of knowledge in formulating explanations of human action. Furthermore, there are empirical grounds for suggesting that the availability of a body of valid knowledge may play a role in the successful professionalisation of occupations. There are also historical examples which suggest that the plausibility of knowledge may be causally important in the rise and fall of occupational status. It is unlikely that credentialism will be successful on the basis of occupational knowledge and skill which have little or no grounding in valid principles.26 Finally, plausibility as a criterion of professional knowledge is increasingly important with the educational “up grading” of the population in industrial societies.

The crucial issue in the process of professionalisation on the basis of valid knowledge is not so much one of plausibility, but an issue of the scope of interpretation of knowledge. Professional knowledge has to be valid (or at least highly plausible in the context of existing knowledge), but there has to be a gap between the knowledge and its application to specific cases and it is in this gap that professional skills of interpretation and application are significant, especially for the untutored client. Where this gap does not exist, knowledge can be routinely applied without the intervention of professional judgement and this type of systematised knowledge can thus be reduced to formulae. The more systematic the knowledge, the smaller the scope for professional competence and the greater the possibility for the development of computerised application. The paradox may be that if the knowledge base of an occupation is too systematically developed, then there is a greater threat of de-skilling. It is for these reasons that law and medicine stand at the pinnacle of the occupational hierarchy, not because they are “scientific”, but because they maximise the scope of application and interpretation of knowledge in particular cases. The knowledge base of law is typically hybrid in societies where the English legal system has been adopted; English case-law tends to

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result in legal systems which are traditional rather than rational in character.27 The point is, however, that even in situations where the law is highly stable and systematic, there is endless scope for interpretation and application of the law to specific situations. Interpretative activity is maximised because law-finding normally takes place in a court where there is a conflict of interests between the contending parties. The greater the uncertainty in matters of application and the wider the scope. for interpretation and dispute, the greater the dependence of the client on the professional. It would be difficult to imagine a situation in which legal decision-making could be wholly computerised, because the interpretation of. conflicting forms of precedent always involves a legal judgement. Another aspect of this situation is that the lawyer draws upon skills and knowledge which are not part of his or her legal training and which cannot be written down in legal text books. This extra-professional body of knowledge and skill includes interpersonal skills of social interaction, skills in public performances and especially skills in making addresses and speeches, pleading the cause of the client.28

It is clear that this argument about the importance of interpretation and professional judgement is dependent on an earlier distinction between technicality and indetermination which was developed by H. Jamous and B. Peloille in their study of the French university-hospital.29 By technicality, Jamous and Peloille mean the body of systematic professional knowledge which can be communicated as a set of rules, solutions and procedures. This body of knowledge can be codified and routinised, and thus provides one basis whereby an occupation can be de-skilled. By contrast, indetermination refers to the taken-for- granted values of an occupation -its mythology, mystique, ideology and symbols of legitimation. Since all occupations have this duality of rationality and mystique, occupations may be simultaneously subject to processes of professionalisation and de-skilling. The rate of these processes will depend in part on the nature of the technicalityIindetermination ratio which characterises an occupation. One aspect of the political struggle over the autonomy of a profession will thus involve resistance to the standafdisation of knowledge and the promotion of professional myth~logy.~o

The point of this approach to the professions is not to deny the importance of power, social closure and professional autonomy as features of occupational control and market strategy. These

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features of the professionalisation process are simply taken for granted in this discussion. It is simply the case that a sociology of the professions should also take into account the role of knowledge as a resource in an occupational strategy. From the above outline, three features of the professional situation emerge as important. The first is the possession of a valid body of knowledge which is seen to be socially relevant and effective in relation to the needs of clients. Second, there should be a wide scope for the interpretation of this knowledge in meeting the needs of clients, because without this scope by reference to particular situations, professional knowledge and skill can be easily routinised into a set of unambiguous rules of procedure. This argument suggests that there should be a high degree of indeterminacy in the applications of knowledge. Third, professional status and the scope of interpretation appears to depend in some measure on whether an occupation has direct access to people and whether this involves the interests of the person "as a whole". Thus, the traditional professions of law, medicine and religion involved a service to the whole person, direct access to the client rather than a mediated relationship, and the mobilisation of powers of interpretation of bodies of knowledge. Although theology is a systematic body of knowledge, it lacks (at least in the modern world) plausibility and relevance. One solution for the ministry has been the attempt to develop a social theology which addresses itself to the this- worldly needs of a lay audience. The development of "clinical theology" would be one illustration of this occupational strategy for relevance, but these forms of training for the modern ministry obviously compete with other professions (or quasi-professions) which claim competence in the field of counselling and personal service. Although legal theory is not developed systematically to the same level of the modern biological sciences which lie behind the scientific claims of medicine, law has the advantage of open-ended interpretahon in the concrete interests of the client. Occupations which d o not exist to deal with needs in a comprehensive fashion and whose knowledge is over systematised may seek to define their activities as a response to general human needs. For example, architects have regarded themselves not simply as designers of buildings employing "exact sciences", but rather as professionals whose vocation is to shape the space of human existence.-"

This outline of a theory of the profession can be shown to have specific relevance to occupations like pharmacy which lack certain crucial features

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of full professional status. This absence of professional status is normally explained by reference to the work and market situation of pharmacists, but in this paper it is suggested that, in addition to these structural features, there may be a n element in the formulation of pharmacology as a science which does not lend itself to the intervention of professional judgement as interpretation. Before turning to this argument, one can suitably open this analysis with a review of the sociological literature on pharmacy.

Work and Market Situation of Pharmacy The relationship between physicians and

apothecaries was historically competitive and conflictual, since there was considerable overlap of skill and service. Physicians often had assistants to compound and dispense medical products; in a situation where doctors charged a fee which was prohibitive, the working class typically consulted the local apothecary.32 In Britain, the apothecaries had separated from the grocers in 1617 and by the end of the eighteenth century they had abandoned their traditional role as druggists. The work of the pharmacist came to be regulated by the Pharmaceutical Society which was formed in 1841. The pharmacists wanted to be recognised as a professional group which would have an official monopoly over the compounding and dispensing of drugs. The petty bourgeois image of retail pharmacy and the , apprenticeship system of training impeded the acceptance of pharmacists' claims to professional status and in the twentieth century their traditional role as compounders of medicines had been undermined by the pharmaceutical industry. As a result of these changes, the pharmacists have "been referred to as overtrained for what they d o and under-utilised in what they know".33 However, public anxiety about iatrogenic disordersx in relation to the drug explosion of the post-war period and recognition that the public requires drug counselling has opened out new roles for the pharmacist, especially in the area of hospital pharmacy. The occupational possibilities which are created by these advisory functions require new forms of education, university training and the development of new skills. This development in pharmacy within the hospitals suggests a n important shift in the technicality/indetermination ratio, because the clinical pharmacist is no longer simply supplying a drug, but offering professional advice about therapeutics.

Pharmacy has received relatively little systematic investigation from the social sciences.

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Despite this neglect, there is broad agreement that pharmacy is underdeveloped as a profession and that it is limited by the authority of thedoctor who delegates to the pharmacist within the medical division of labour. Pharmacy has been described in the literature as "incomplete", as "marginal" and as "limited".35 The underlying causes of this pattern of incomplete professionalisation appear to be relatively obvious. First, the occupation is bifurcated into two sectors, the world of private business and the world of medical service. Because pharmacy training may lead to a career in retail pharmacy, it has been argued that pharmacistsas a whole have not developed an ethical system of altruistic, disinterested, community service. On the contrary, for retail pharmacists the profit motive is an important feature of their work. Students undergoing training in pharmacy tend to have attitudes and social aspirations which are regarded as incompatible with a professional orientation of service to the client. North American research indicates that the majority of pharmacy students want to run their own business and that their social background is primarily from small business and white-collar classes.35 The presence of these business aspirations suggests that the majority of pharmacists would not have a strong sense of vocation to develop the profession as an autonomous practice within a system of health care. Second, there is a process of de-skilling in pharmacy, since the pharmaceutical industry produces drugs which were formerly compounded and prepared by the pharmacist. In addition, chemists sell a variety of commodities and do not specialise as retail outlets for drugs. Pharmacists have not organised themseIves collectively to resist this de-skilling through the large pharmaceutical industry's production of packaged drugs. Third, the pharmacy occupation is fragmented horizontally and vertically. There are different types of retail pharmacists, alongside hospital pharmacists, administrators and pharmacists in industrial production. One obvious consequence of this fragmentation is that it makes collective actions to protect and promote the profession extremely difficult to organise and sustain. Fragmentation also meaps that it is difficult to develop a professional ideology of service which will unite the membership and present a common front to the public. Finally, although the hospital pharmacist is not involved in business, within the hospital setting the pharmacist is ultimately controlled or at least limited by the medical dominance of the medical profession.

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An additional explanation of the under- professionalisation of pharmacy would have to take into account two further features of pharmacy, especially the hospital pharmacist. One disadvantage for the pharmacist is that knowledge of the action and effects of drugs may be too precise and systematic to allow for a wide scope of interpretation. Unlike legal theory, pharmacology has been too susceptible to axiomatisation. Pharmaceutical knowledge is rooted in an exact science and has been developed by widely accepted procedures of experimental trials. Unlike psychiatry, pharmacy leaves little scope for the interpretation of the gap betwen principles and practice. The second problem for traditional pharmacy is the absence of a direct counselling role with the whole patient without the mediation of physicians, or to a lesser extent, the nurse. The paradox of the argument is that pharmacology is overdeveloped as a science of drugs and under- developed as an interpretative skill of patient welt- being. As a result the space around the patient has been dominated by physicians, psychiatrists, nurses and priests. As against 'most conventional sociologies of professionalism, the argument is that the development of a systematic body of knowledge may stand in the way of successful professionalisation. The main strategy has to involve the development of valid knowledge which allows for indefinitie elaboration through interpretation and secondly this interpretative work has to be achieved as a result of direct access to the client.

The implication of these arguments is that, in order to attain higher status as a profession, the hospital pharmacist would have to expand the role of interpretation in the exercise of pharmaceutical skills and also attain greater access to hospital patients. Both aspects of this strategy can be detected in some recent developments in pharmacy. Interpretative skills could be enlarged by arguing that, although the actions of the drug are scientifically known, the reactions of the patient to tested drugs are in practice always variable and idiosyncratic. This strategy would involve an emphasis on the phsychological and sociological dimensions of drug reactions and an argument that the management of a drug regime for the patient should be in the hands of the pharmacist. Some elements of this strategy are implicit in the "unit dose" concept, which allows the pharmacist to dispense the drug on the ward directly to the patient. This strategy permits the pharmacist to enter a consultancy role with the

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patient and to advise on the range of side-effects and their treatment for individual drugs. It is obvious that an increase in such interpretative activity involves a fundamental change in the relationship between physician, nurse and pharmacist. In particular, it requires a decisive break with the traditional relations of authority which have regulated the hospital ward under a system of medical dominance. It has been argued that the relationship between the doctor and the nurse traditionally resembled that between husband and wife, namely a patriarchal relationship in which doctors made decisions which nurses subsequently executed.)’ The nurses have progressively challenged this system by attempting to assume decision-making roles which require skill and interpretation. These usurpatory strategies might prove a valuable model for upgrading pharmaceutical tasks within the hospital setting. One example of in siru participation of the pharmacist with patients would be the inclusion of the pharmacist in ca rd iopu lmonary resusc i ta t ion teams.38 Participation in the ward directly with patients would be significant in changing the status of hospital pharmacy, but the test of professionalism is in the last analysis the presence of genuine professional autonomy, and autonomy means actual decision-making activities rather than mere execution of decisions taken by doctors. Professionalisation thus implies conflict between medical occupations in the search for autonomy in the work-place and social status in the market. In these conflicts, validity of knowledge and a plausible scientific background are important resources in the professionalisation strategy.

It has been suggested that the expanding role of the clinical pharmacist has been made possible by the gaps left by physicians in adequate drug counselling and drug information. This gap in service has provided an opportunity for the hospital pharmacist (and to some extent the retail pharmacist) to gain access directly to the patient. The relations between clinical pharmacists and physicians are likely to be unstable and uneven, because the acquisition of a counselling role involves some encroachment onto the medical terrain of the physician. It also implies a new relationship with clinical pharmacology. However, what looks like occupational encroachment may turn out to be an example of delegation and co- optation, in which the hospital pharmacist takes on new responsibilities with relatively little improvement in status and autonomy. For example, the new counselling role may also expand

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the area of legal liability of the pharmacist with respect to the efficacy of drug therapy. The expansion of activities may bring new responsibility in the delivery of a service to the patient in a situation where there is relatively little enhancement of professional prestige; this situation may explain the reluctance of members of the Pharmaceutical Society of Australia to launch themselves into an enlarged out-patient advisory role.

These changes in both the hospital and retail sectors of pharmacy imply new relationships with medical professionals and paramedical groups. The expansion of the indetermination element in pharmaceutical knowledge and the creation of an interpretative role vis-a-vis the patient may lead to changes in the education of pharmacists. In turn, these developments will require occupational strategies, such as the lobbying of relevant political audiences. Such strategies will depend heavily on the degree of occupational solidarity within the Pharmaceutical Society. The relationship between professionalisation and occupational solidarity is probably circular. To achieve greater professional status, pharmacists would be forced to engage in industrial relations disputes to maximise their occupational autonomy. To be successful in such industrial struggles, pharmacists would have to be relatively united. However, pharmacists as a whole lack occupational solidarity as a consequence of their lack of professional status, since they are fragmented into a variety of occupations and sectors which are loosely assembled under the label of “pharmacy”. To break into this circle, it would be necessary for hospital pharmacists to sever any connection with retail pharmacy and this occupational Split could be achieved by developing special postgraduate training courses for hospital pharmacists with the aim of achieving a greater professional closure through credentialism.39 The achievement of extended training for specialists in clinical pharmacy would then lead to new occupational titles, job descriptions and enhanced standing within the hospital hierarchy. This type of strategy is in fact recommended by the Speciality Practice Committee of the Society of Hospital Pharmacists of Australia. The proposals for postgraduate education in clinical pharmacy do not include courses in etiology or on the socio- psychological dimensions of addiction and responses to pharmaceutical regimes. The inclusion of these “unscientific” disciplines might enhance the scope of pharmaceutical interpretative skills and thereby promote the status of the occupation. In this respect. sociology which is itself

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an interpretative rather than behavioural discipline and is often referred to as “interpretative sociology” (verstehende soziologie) may prove a useful addendum to pharmaceutical credentials.

Conclusion Over a period of some four decades of

research into the professions, sociology has produced two models of professionalisation which are mirror-image accounts. In the first model, a profession is defined in terms of a group of attributes which takes particular notice of the prominence of knowledge (which is exact and systematic) and ethics (which underline the importance of a service rather than a business orientation to the client). In the second model, professionalisation involves occupational control which, through credentialism and social closure, excludes competitors and allows the exercise of occupational dominance and autonomy. In the first model, knowledge is prominent and power absent; in the second model, power is dominant and ethics absent. In this paper, a third model has been presented which provides a bridge between existing approaches. There is a prima facie argument in sociology generally for taking both knowledge and power seriously, indeed it is

difficult to see how these dimensions could be theoretically separated. The paper has attempted to show the merit of such a perspective with special reference to paramedical groups. Against conventional approaches, the paper suggests that it is ironic that one impediment to successful professionalisation might be the presence of a knowledge base which is too systematic and coherent. The traditional professions and the scholarly professions achieved their social status on the basis of knowledge which required massive interpretation. The real issue then is not about the validity of professional knowledge, but about the range and necessity for professional judgement. This approach enables sociology to avoid the simplistic assumption that all professional knowledge is at worst merely an ideologkal justification for occupational interests or at best an irrelevant feature of professional status. It is suggested that professionalism requires knowledge which is plausible and hermeneutically extendable. Although pharmacy is an incomplete profession because it is constrained in work and market terms by structural problems (such as the dominance of retail pharmacy), it is also hampered by a knowledge base which is too precise, over systematic and lacking in hermeneutics.

References

1. Parsons T. The Professions and social structure. Social Forces 1939; 17457-467.

2. Millerson GL. T%e Qualifring Association. London, Routledge and Kegan Paul, 1964.

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4. Merton RK, Reader GG and Kendall PL. (eds.) The Student-Physician: intro- ductory studies in the sociology of medical education. Cambridge, Mass.: Harvard University Press, 1957.

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