Post-professional compendium

Between June and October 2023 I wrote eight ‘Stackposts on the theme of post-professionalism. This followed on from the first series on posthumanism that you can find here. As with that edition, I’ve collated all eight articles here into one compendium for ease of reading.

I’ve removed all of the decorative images and assimilated the references into one long list at the foot of the article.

Introduction

Most people alive today would find it hard to imagine a healthcare system that wasn’t underpinned by a small group of elite and established professions.

To even imagine that a person might engage in healthcare without the mediating influence of doctors, nurses, midwives, occupational therapists, physiotherapists, psychologists, and others, would seem incomprehensible.

But this is exactly what post-professionalism tries to imagine.

Over the course of the next few weeks. I want to try to set down some of the key principles of post-professionalism, and examine:

1. What it is;

2. What its main theories and ideas are;

3. How it is shaping and disrupting healthcare;

4. And why it’s been largely absent from the professional literature to date.

So, here’s a bit of a taster of what’s to come.

What is post-professionalism?

Post-professionalism is a relatively new term in healthcare.

The term was first used in the 1980s in the work of Ivan Illich, Terry Johnson, and Eliot Freidson, and has been applied to a wide range of other sectors but has only recently been applied to healthcare.

Post-professionalism does not refer to the complete disappearance of the professions, but rather their increasing decentralisation.

It argues that the established, traditional, orthodox, and legitimate professions will become increasingly marginal social actors, and people will make use of increasingly diverse resources to meet their healthcare needs.

Post-professionalism provides a set of conceptual tools to analyse today’s atomised, digitally disrupted, globalised, neoliberal, and postmodern zeitgeist.

Where once people said, “The doctor knows best”, in the post-professional era they are more likely to say, “The patient will see you now” (Topol, 2016).

What has made post-professionalism possible?

There are many reasons for the post-professional turn, here are two of the biggest:

1. The late, or advanced, capitalist shift from the pursuit of unlimited growth and surplus value through the ‘external’ colonisation of people and land, to the ‘inward’ atomisation of the body and health. Bodies and health are the new, almost limitless, frontier for commodification, innovation, and market expansion.

2. The critical unbundling of the orthodox professions’ claims to goodness and expertise (Burns, 2019), underpinned by the belief that the professionalisation project of many healthcare professions is coming to an end after 150 years of notable successes but also some significant failures.

Where can we see post-professionalisation at work?

The challenges now facing the professions are many and varied. Consider this list, for example:

• The increasing demands for holistic healthcare for ageing populations of increasingly complex, co-morbid, chronically ill people;

• Digital technologies and the rapid rise of AI and digital data;

• People’s appetite for personalised healthcare demanding more choice, greater flexibility, and more control over the services they receive;

• Demands for ever-increasing levels of professional expertise and specialisation, married to the publics’ progressive loss of faith in once-powerful — often professional — authorities;

• The pressure to remain up-to-date with the latest evidence-based findings;

• The loss of control of knowledge that was once ‘ours’ (with most of the information contained within a health curriculum now openly available online);

• Threats of encroachment from other professions looking for competitive advantage and greater social prestige;

• The rising cost of healthcare matched with the desire by governments to cut and contain healthcare expenditure; the rapid privatisation and atomisation of health and the growing social gradient between those who can afford professional care and those who cannot;

• The downstream costs of unhealthy lifestyles;

• The growing critique of the regulated professions for their intransigence, stubbornness, and resistance in the face of change.

We can add to this list some very ‘local’ anxieties that many of the healthcare professions are expressing individually, including that:

• The profession is spread too thin;

• Our professional status is in decline, and there doesn’t appear to be a clear plan for how to get it back;

• We lack the skills to be creative and innovative;

• Evidence-based research repeatedly undermines what we know to be good about our work;

• Our many healthcare professions are engineered for curative approaches towards acute, episodic illness and injury, in a world that needs sustained, long-term care where no ready fix is possible;

• Our remuneration is not keeping pace with rising student debt, making our professions less and less attractive to new graduates;

• Our care model was always individualistic, meaning we have no scaleable, population-level approach to healthcare.

To date, the professions have seen themselves as sovereign entities that must outlive these problems to survive. Post-professionalism inverts this belief, seeing the professions instead as contingent responses, effects, or achievements of biopolitical and governmental rationalities.

In post-professionalism, the professional era is seen as a recent historical invention (a largely Victorian middle-class prestige project) that served society well — mostly — during the 20th century, but is now coming to an end.

Post-professionalism is concerned with what follows.

Over the coming weeks I will try to unpack the arguments around post-professionalism in more depth and, as with the post-humanism pieces, try to provide resources and readings for further study.

Atomisation and the arrival of late capitalism

There are no end of challenges now facing the health professions, but can we define some of the principal drivers of the post-professional movement specifically?

Most of the literature points to three main discursive forces behind the idea that the professions will be removed from the centre of healthcare thinking and planning over the next decade or so:

1. Atomisation under late capitalism

2. The unbundling of goodness and expertise

3. Digital disruption

Let’s begin with the first of these.

The emergence of late capitalism

Late, or advanced, capitalism is so called because of the distinctive way it reimagines the capitalist project of unlimited growth and progress.

Where early capitalism generally referred to the period from the 17th to the 20th centuries, and is synonymous with the industrial revolution and the development of high-income economies in the West, late capitalism has really only emerged since the 1970s.

Early capitalism functioned by feeding domestic growth with the expansion (read, forced colonisation and enslavement) of other territories and peoples. As resources for growth became depleted at ‘home’, colonial enterprises reached across the globe to feed continuing growth. 

In many ways, the birth of the orthodox health professions – along with many others within the professional classes (administrators, public servants, teachers, and so on), – derives from the need to have an ‘enabling class’ of trusted, regulated, and socialised workers who could perform the necessary ‘soft’ colonisation as a marker of the ‘civilisation’ and ‘ruthless benevolence’ (Fitzpatrick and Protschky 2009) of the colonial power.

By the middle of the 20th century, however, attitudes towards aggressive colonisation, land disposition, wars and treaties of convenience, the imposition of Western cultural systems, religious missionary work, and other forms of asynchronous power came under increasing critical scrutiny. 

What precipitated the move away from early capitalist ideologies, however, was not growing public consciousness, but rather the twin forces of declining domestic prosperity and increasing unavailability of new lands and peoples to exploit.

Fortunately – and here it hardly bears mentioning that I am being ironic – a solution was found to invert the logic of early capitalism and exploit a new, inconceivably vast, previously untapped market: a market that would have profound implications for healthcare.

New forms of capitalism began to emerge in the mid-1970s with a raft of neoliberal economic reforms, new forms of global economic market speculation, and the automation and restructuring of commodity supply chains. 

At a superficial level, these seem quite dry, economic and political changes. But what day did was to turn the idea of unlimited growth and expansion inwards. Instead of looking overseas for new lands and people to exploit, late capitalism has turned inwards; towards individual people: towards people’s bodies, people’s lifestyles and habits, people’s relationships, and people’s work.

In fact, every possible facet of human existence was turned into its own specialised field, replete with commodities and consumer goods, as well as a raft of dedicated advisors, analysts, coaches, counsellors, experts, influencers, practitioners and therapists. 

In effect, every single aspect of human life has been atomised: turned into its own market. And the possibilities for unlimited growth — and the future for a new form of capitalist exploitation — appears restored. 

This has obvious implications for all of the established health professionals because, on the one hand, we have seen a vast new field emerge in which the knowledge and skills we once commanded have taken on new relevance. But, on the other hand, this newly ‘atomised’ human being has been opened up as a market for any and all who can find an as yet un-tapped economic opportunity. 

Late capitalism is forcing the complete reorganisation of the orthodox health professions, but it is only one of the main drivers of change we need to consider. Next week I will look at the second of these drivers – the unbundling of goodness and expertise.

Unbundling of goodness and expertise

Alongside late capitalism, perhaps the next most important discourse shaping the post-professional era is what Edgar Burns has called the unbundling of goodness and expertise.

Let’s get into that now.

Health professionals are not as altruistic and public-spirited as they would have us believe

‘[w]e are on the brink of a period of fundamental and irreversible change in the ways that the expertise of the specialists is made available in society’ (Susskind and Susskind, 2015).

At the heart of the unbundling claim is the argument that professionals have long believed themselves to be altruistic and public-spirited; that they are disinterested in personal or professional status; that they are models of ethical comportment; bearers of specialised knowledge and affectively neutral.

Since the 1980s, however, authors like Ivan Illich, Eliot Freidson, Terry Johnson, and Magali Larson have challenged that belief.

By contrast, these authors portray the professions as inherently conservative, protectionist, deeply self-interested, disproportionately advantaged, and promoting attitudinal mythologies inherent to maintain them as apex social actors.

They highlight the ‘inverse care failures’ of aged care facilities, mental health institutions, professional training institutes, and workplaces.

They draw attention to the professogenic effects that are ‘systematically produced as part of the social organisation’ of things like healthcare (Wrigley & Dreby, 2005).

And they accuse the professions of being agents of the capitalist state, patriarchal, racist, discriminatory, ableist, ageist, homophobic, and heteronormative (Abbott & Meerabeau, 1998).

What unbundling is doing

What Burns and others show is that;

'there is nothing inherent in goodness or expertise that demands the person be a professional, and there is nothing innate in professionalism that makes the person a good person or knowledgeable practitioner’ (Nicholls, 2022).

In other words, professionals hold no monopoly on goodness and expertise and while these claims might have been the basis for the professions’ claims to prestige and privilege in the past, they are no more.

So those resources, knowledges, roles and responsibilities once held within protective enclosures by the professions are now becoming increasingly democratised.

The social capital that they once controlled is being more widely distributed across a more diffuse network of social actors, such that the historical professions are just one mechanism among many through which people experience health and healthcare.

Inevitably, the professions are seeing their hard-won power and prestige diminish, and many are struggling to come to terms with this. But another factor in post-professionalism is the declining ability of the professions themselves to control events. Leading some to suggest that;

‘trusting the health professionals to bring about reform themselves is akin to the ‘rabbits guarding the lettuce’ (Susskind and Susskind, 2015), particularly given how adept the health professions have been in the past at ensuring their territorial security’ (Nicholls, 2022).

As Edgar Burns suggests;

‘While post-professionalism does not deny that society needs the service of articulate, clever, society-oriented actors and professionals, who can be a human beacon in a world of juridified, formalised, corporatised correctness, it does assume that professionals will be less important than they used to be’ (Burns, 2019).

A new opening

In the 17th and 18th centuries in Britain, common land was increasingly consolidated and privatised. People that used to farm, graze and glean in common with others were increasingly denied access as the land was turned to profit for landowners.

Unbundling makes the same claim about the professions: that they took lucrative aspects of healthcare and colonised them for their own benefit.

Part of the power professionals took for themselves was the ability to control the labour supply, and thereby ensuring demand.

In disability studies, professionals have been called parasites for their willingness to endlessly invent new forms of disability that they are conveniently best placed to address (Swain, French and Cameron, 2003).

But this self-interested privilege has now become a critical weakness for the professions because, ‘If professionals are only able to share their experience and knowledge by advising on a face-to-face basis, then there can be few beneficiaries of the genuinely outstanding’ (Susskind and Susskind, 2015).

Susskind and Susskind continue;

‘Professionals play such a central role in our lives that we can barely imagine different ways of tackling the problems that they sort out for us. But the professions are not immutable… To pick out a few of their shortcomings — we cannot afford them, they are often antiquated, the expertise of the best is enjoyed only by a few, and their workings are not transparent. For these and other reasons, we believe today’s professions should and will be displaced by feasible alternatives’ (Susskind and Susskind, 2015, emphasis added).

Perhaps unsurprisingly, many advocates for post-professionalism would see the capacities, knowledges, and resources that the professions once claimed as their own returned to the people.

And, in truth, this is now happening at a remarkable rate sometimes because, but often despite the professions themselves. I’ll cover some of this in the next instalment when we tackle the third main driver of post-professionalism: digital disruption.

Digital disruption

Over the last 20 years, we have seen the gap between what is analogue and what is digital, what is human and what is machine, collapse.

Consider this on the hyper-personalisation of AI in a recent ‘Stackpost from Scott Belsky. Keep in mind the earlier piece in this series on atomisation and late capitalism, and also how things like this are going to affect future healthcare practice;

’Two weeks traveling Japan proved to be the perfect setting to contemplate some of the sweeping changes facing our society over the coming years and decades. The smart people I know generally agree that 80% of the work of 80%+ of jobs will be refactored significantly by AI… And it’s still early days! So, the question that keeps me up at night is, what are us humans gonna do with all of our newfound time? Which brings me back to Japan, and this quaint Kyoto restaurant I found myself sitting in one evening. There were 10 seats, one chef/owner and one apprentice, and the most incredibly crafted experience. It wasn’t expensive, but everything was intentional. I found myself admiring this sensational and remarkably unscalable experience. The chef seems to make a good living, loves meeting interesting people, and gets to be wildly creative (the selection of glassware, the decor, the care and craft applied to every dish). Japan is full of these experiences, where art, curiosity, and craftsmanship yield tiny scattered wonders like “owl cafes,” micro arcades, plastic food shops, cotton candy shops, and the list goes one. I found myself wondering, why aren’t there 1000x more of these experiences in all societies? Why must the purpose of business be to scale, grow bigger, become franchises, squeeze in more seats, and compromise quality for automation and reach? Could a fundamental change in society, like mass automation and AI, spur both the growth and demand of human-intensive highly crafted unscalable experiences?’ Link.

Of course, people like the economist John Maynard Keynes and the philosopher Bertrand Russell have been arguing that future humans will benefit greatly from automation since the 1930s, but the effects of digital disruption go far beyond questions of whether robots will do most of the surgery, triaging, prescribing, diagnosing, therapy, and empathy work of healthcare in the future. (They will).

Perhaps the most telling digital disruptions have arrived with some of the most mundane technologies. People’s ubiquitous use of digital Google Maps, for instance, has meant that people are rarely ever lost anymore. Being lost and using one’s own wits to find safe haven has always been a crucial human skill. Perhaps people in the future will be less resourceful when they encounter serious illness having never had to find their way out of the woods at night.

Spotify and Apple Music have given us the ability to play only the songs we love. But has this engendered a belief that other things like educational pathways and healthcare choices should work the same way? 

Facebook, Instagram, Twitter, TikTok, and other social networking apps have replaced validation by proof with popularity. And YouTube and Wikipedia have shown us that professionals were never the only repositories of expertise and that so much knowledge could be shared for free. 

We may be experiencing the most disruptive period ever in the history of healthcare with changes happening at lightning speed. Tomorrow’s healthcare professional is a 10-year-old on Discord today. How they see the world will shape the future of healthcare.

Daniel and Richard Susskind in their book The Future of the Professions make the point that ‘If professionals are only able to share their experience and knowledge by advising on a face-to-face basis, then there can be few beneficiaries of the genuinely outstanding’ (Susskind and Susskind, 2015). 

This is a very common feature of many forms of healthcare practice and part of the reason they believe digitisation will have such a profound impact on our work. Digitisation succeeds because it offers the promise of mass customisation and personalised care; ‘systems and processes that do indeed meet the specific needs of individual recipients of service, and yet are implemented with a level of efficiency that is analogous with mass production’ (ibid). 

Put another way, digitisation is how the health professions’ monopoly on goodness and expertise is finally broken by late capitalist atomisation.

Scott Belsky seems to suggest that such large-scale, digitally-mediated personalisation may be the direction centralised healthcare tracks in the future. But he also suggests that such moves will create spaces in which other forms of work become possible: work that goes in the opposite direction and makes a virtue out of bespoke care;

‘As human workflows are refactored by a step-function and our capacity is liberated, I see a compelling future where the demand for and economic viability of crafted non-scalable experiences transforms society. The “experience economy,” is already underway with the emergence of experts for everything - from lactation consultants and pet therapists to for-hire violinists and chefs and…who knows what’s next. I enjoyed this post by Dror Poleg where he forecasts a world where “most people no longer need to work. Our survival depends on convincing them it's ok to do something else.” “There are many more professions to invent,” he declares, “and they will only be invented if more people experiment.”’ Link.

Then again, perhaps AI will do this for us.

The politics

We can read the history of the professions in a number of ways. They have been a:

• reflection of a desire to bring order to society;

• mirror of a feudal, patriarchal, Western social order;

• tool for emancipation pursued by previously marginalised people — women, working classes, racialised minorities, etc.;

• vital cog in the machinery of soft colonisation;

• way to humanise the alienation of wage slavery;

• vehicle to provide healthcare, education, and public administration in the most efficient and trustworthy way.

But however one looks at the professions, what is clear is how closely they have been tied to the idea of modern forms of governmentality.

Securing people’s health and vitality was both a means to maximise the population’s productivity and efficiency, but also a way to manage the inherent contradictions of modern life. (We want cheap coal but hate the idea that mining is dangerous, so we offer healthcare as a way to ameliorate our ethical conflict.)

So the link between the health professions and ‘the state’ has always been strong. In fact, I’ve suggested in recent years that without the state, some professions like physiotherapy would likely not even exist (Nicholls & Harwood 2016a; 2016b; 2017; Nicholls 2022; 2023).

By contrast, one of the driving forces behind post-professionalism today is the belief that there is a growing distance between ‘the state’ and the professions.

As Deleuze pointed out, the disciplinary society has largely been replaced by a society of control. 

In the disciplinary society, a person’s life was marked by their passage through a series of regulated institutions — the family, school, the barracks, the university, the factory, the office, the professions, etc. But with the advent of digital technology and many new forms of remote surveillance, it’s no longer necessary for a person to be held within these institutions in order to be governed. 

Now, it’s even desirable that the person explores far and wide beyond the boundaries of institutions if only to test the system’s ability to keep track of them and monitor their consumption and feed their desires.

In a society of control, professions no longer work as a central plank of government but act only as one of its many arms: an arm that looks increasingly inflexible and too muscular to be of use in the slippery plastic world of person-centred healthcare.

Crucially, this shift happened regardless of political ideology and the forces of reform have come from both left and right.

On the right, the established professions have been criticised for their monopoly power, for being expensive, statist, controlling, unionised, for promoting passivity and dependence in people, and for being ineffective in boosting economic productivity.

On the left, the professions have been criticised for being in service of capitalism, ableist, misogynistic, racist, elitist, colonial, conformist, and Victorian. 

Neither left nor right, it seems, want to hold on to the virtues of an enabling middle class whose place in the social order was once taken for granted.

Who, then, speaks up for the professions?

Without the same political support that the professions enjoyed during the greater part of the 20th century, only the professions themselves are now advocating for the continuation. They have done this since the 1980s in a number of ways: 

• by promoting evidence based practice and hierarchies of evidence;

• in claims to now being person-centred (with the implication being that they believe they were not before);

• through new territorial claims to holism and biopsychosocial;

• through inter-, multi-, and trans-professional collaboration; 

• greater openness to complimentary and alternative approaches, and so on.

The salient point here though, is that these responses are a stark reminder that the professions are an effect or achievement of shifting social discourses. They are not, themselves, the agents of their own destiny. 

They are an answer to a series of problems that have been posed in largely high-income economies over the last 150 years.

But as Foucault reminds us, they are neither the only nor necessarily the best solution to the problems that society faces. They are merely one contingent response amongst many.

The likelihood is that we are in the late stages of the professional era and that many new solutions will emerge in the coming decades for concerns like the accelerating planetary health crisis, growing inequality, and the mind-boggling complexity of health.

The professions may form part of a panoply of solutions, but without their political patrons – of any stripe – it is likely their role will be significantly curtailed as years go by.

The question that the professions themselves should be asking, then, is how can they best democratise and share the privileges and benefits they have acquired over the last century or more?

In the next piece, I’ll look at some of the ways the professions are actually responding and show that, sadly, their instinct to preserve their status appears to be currently overriding their desire to nurture the greatest access for the greatest number of people. Ironically, of course, this kind of reaction is one of the main drivers of post-professionalism in the first place. Something we will return to next time.

Diagnosis

How do we know that post-professionalism is taking hold in healthcare? Where would we look to find signs of the atomisation of the body, late capitalist expansion, the unbundling of goodness and expertise, and digital innovation? And, if we found them, would they represent a genuine break with the everyday incremental kinds of change that people in healthcare seem to have experienced all of their lives?

Given how complex health care is, it’s hard to be absolutely definitive about the degree to which post-professionalism is becoming the dominant discourse. However, although one could point to innovations and healthcare reforms as evidence of post-professionalism, perhaps the paradigmatic sign of a new philosophy of healthcare can be found in the professions and disciplines themselves, and the way they are reacting to this new epoch.

In Physiotherapy Otherwise, I set out four broad archetypes to explain the ways that the physiotherapy profession internationally appears to be responding to post-professionalism. Although these archetypes relate directly to physiotherapy, I think there are many commonalities across the entire healthcare spectrum.

Here are the four archetypes:

1| Watching and waiting

Perhaps the hardest to locate, this approach is the most conservative response with the profession trusting in its stability, and arguing that reactive change might endanger the profession's future prospects. Innovations are sometimes described as trends or fads, or threats that the profession has faced down before. And the profession is reassured that people have nothing to worry about and that the future won’t be that dissimilar to today.

Pros: the profession promotes a sense of confidence amongst its members and reassures people that the profession is here for the long haul.

Cons: the profession gets left behind and becomes obsolete, replaced by more agile competition, or what Susskind and Susskind call ‘viable alternatives’.

2| Modern heritage

This approach sees the profession return to its founding values; its most grounding ontological presuppositions. As a way of actively resisting the threat of radical reform, people within the profession call for a return to core values. New ways of thinking and innovation become the target of critique, and the profession’s history is mobilised to remind members how the profession got here in the first place.

Pros: this is a very straightforward professional identity to ‘sell’ to members, the public, funders and regulators. It is often very familiar, particularly to elite members of the profession who have prospered because of their mastery of the same core values. And it is often easy to consolidate in a curriculum or revisionary scopes of practice.

Cons: the biggest danger here is that the profession is actively marginalised because it fails to address changing social priorities. It might be seen to serve the interests of the profession’s elite, or the kind of population that the profession was suited to in the past. In both cases, the profession may be seen as arcane and increasingly irrelevant.

3| Renaissance

This approach involves throwing the baby out with the bathwater, radical professional reform, the subversion or inversion of traditional values, and a desire to profoundly redesign the profession's identity and purpose.

Pros: this is perhaps seen as the most responsive of the four archetypes because it shows that the profession is attuned to shifting social dynamics, as well as being agile enough and willing to adapt when the need arises.

Cons: the biggest danger of this approach is that it can be extremely unappealing to those people within the profession who have built their professional identity on an earlier image that has now been rejected. This can make it very difficult to change curricula or scopes of practice because the very people who have to instigate the change are the ones that don’t want it to happen.

4| Hybrid

The fourth and final archetype is, perhaps, the one that has the broadest appeal and the one that has so far had the widest impact in healthcare. The hybrid approach attempts to take the best of the profession's past and incorporate the best of the new. In many cases, this opens up the possibility of a new ‘holistic’ professional identity in which traditional professional boundaries become much more porous.

Pros: for many within the profession, the hybrid approach creates the possibility for a much more diverse and inclusive understanding of the profession. It can liberate many people to finally acknowledge aspects of the profession that were previously latent or sublimated. It may open up the possibility for territorial expansion and justify the expansion of the profession into new markets and new territories.

Cons: the biggest danger with a hybrid approach is that it embraces such a wide set of beliefs about the nature of the reality of healthcare (that it is biologically based, experientially based, culturally based, environmentally based, spiritually based, socially based, or all of the above) that people can no longer see clearly what the profession believes or stands for. In trying to be all things to all people, the professional loses the distinctiveness and has to operate at a much more superficial level that, in the end, doesn’t require the kinds of depths of training that conventional approaches demand. Similarly, the curriculum now takes 17 years to complete and teaches the student one thing in the morning, and it’s direct obverse in the afternoon. All is confusion.

We are seeing some or all of these archetypes being played out in the different healthcare disciplines today. But as can be seen, there isn’t any one approach that does not come with some significant flaws.

As diagnostic tools, though, they do show the degree to which all of the professions are now asking fundamental questions about their ongoing viability.

And whereas in the ‘golden age’ of the health professions the question was really only how the orthodox and legitimate state-sanctioned professions could work most efficiently in an otherwise stable and unchanging field, the professions are all now asking whether the field even exists in the same way does it used to.

One of the features of this new field is a change in the ability of the professions themselves to influence the future.

In the previous post in this series (Link), I argued that one of the two main features of post-professionalism is the degree to which the professions are having their own agency de-centred, suggesting that even if the professions do adopt a modern heritage, renaissance or hybrid approach, it will have little impact on the relentless turn away from the professions as a governing principle in western healthcare today.

So, what might be a more viable way forward for people within the professions, if their future is going to be increasingly marginal?

This will be the subject of the last substantive post in the series looking at the future for the professions in a post-professional world.

Do the professions have a future?

To even begin to answer this question, we need to establish a few principles: key things to remember when we debate whether the professions even have a future.

Firstly, what we are talking about here when we talk about ‘the professions’ is the future for a particular social class: an ‘enabling’ class of people, and a relatively recent historical invention. They are neither the only nor necessarily the best solution for social problems like illness and disability. They are simply one — albeit unprecedented — contingent response among many.

Secondly, the vast majority of the literature now makes it clear that the only people now really advocating for the professions are the professions themselves. What this means, though, is that as long as professions like medicine and nursing continue to hold enormous power and prestige, it will appear that the professions have an important part to play in the future of social organisation. But what we now know from late capitalism, the unbundling of goodness and expertise, and the automation and rapid digital transformation of human affairs, is that the Doomsday clock for healthcare and education is already sitting at 11:55 pm and ticking, ticking, ticking.

And so, even though it seems hard to conceive of a time when we won’t have professionals like physiotherapists, podiatrists, audiologists, and even doctors and nurses running our healthcare system, there is an increasing argument to be made that if those of us within the profession genuinely care about the future of health, it is our ethical duty to think about a future in which healthcare is a) not delivered by the current cadre of elite professionals, and b) does not return to a pre-modern world in which healthcare is a luxury for those who can afford it or mere charity for those who cannot.

Thinking about a post-professional future in this way will not be easy though, and it’s likely that the greatest resistance to change will come from the professions themselves. So, is there a process that can be generative for the public and the professions? I think there is. 

To begin with, the established professions will need to put in place ‘transition arrangements’ that transfer power and knowledge to communities of need. These arrangements uncouple each profession from its established allies — including The State — and actively work to redesign legislation; nurture trust and capability; share a century or more of wisdom, knowledge and resources; and relentlessly build capacity. 

In many ways, this is a post-colonial project, because the establishment of the professions bears many similarities to other historic acts of enclosure. So, the transition arrangements mentioned above are effectively designed to “give the land back to the people.” But those people who have been through the traumas of post-colonial succession will know all too well that the actions of the colonial powers in leaving their occupied territories can make all the difference to the way resources are returned to their rightful owners. And the transfer of health back to the community will depend very much on how begrudgingly, or otherwise, the orthodox professions give up their power.

Is this not, then, an entirely counter-intuitive step for the professions to take? After all, why would turkeys vote for Christmas?

The answer to this may lie in a parallel process that needs to be followed within the professions themselves. 

Alongside these ‘outward facing’ transition arrangements, there will need to be internal arrangements made which might make all the difference to the success of the project. These internal arrangements have to do with the way that professionals are coached to entirely rethink their professional purpose. Instead of valorising the preservation of their distinctive professional identity, autonomy and sovereign authority, health professionals will need to understand that their knowledge and skills will continue to play an important role in future health care despite the demise of their professional class. People’s predisposition to care, to want to heal, and to act therapeutically, is as ancient as their urge to domination, conflict, and destruction. And so, just as the negative traits of humankind are unlikely to dissipate in post-modern life, so is its caring. What this means is that those things that endure and remain after the instrumental and reductive aspects of healthcare practice our hollowed out, will play a key role in future healthcare.

There are ‘intensities’ at the heart of healthcare that have been captured and exploited by the orthodox health professions over the last century. But these have been somewhat obscured by layers of standardisation, technique, reason, formalisation, and instrumental objectivity. And so the ‘essences’ of these various practices are now very hard to see. But they are there nonetheless.

This is why there is now a close tie in between post-professionalism and some of the recent work on posthumanism, because a lot of this work has been directed to the study of the essential vitality of ‘things’ – be they non-human objects, metaphysical processes, social constructs, or human feelings. If there is something lying ‘beneath’ professionalised healthcare that can be mobilised in a future in which the controlling, elite professions no longer carry the same weight — whilst, at the same time, resisting the nihilistic logic of neoliberalism and the totalising spirit of the Welfare State — then, perhaps it’s possible to see why posthumanism is becoming increasingly interesting to those people working in healthcare, and why a post-professional future might be the best thing to happen to healthcare since the first Being went back to the primordial swamp for a hot bath.

Key readings

Here I want to highlight some of the key texts in the post-professional literature.

Five key texts

1. Edgar Burns’s Theorising professions: A sociological introduction Link does as much as any text to lay out the argument for why we have now entered a post-professional era. If you read only one book on post-professionalism, this would be the one I would recommend.

2. If you wanted a general introduction to the contemporary conditions now producing post-professionalism, you might look at Richard and Daniel Susskind’s excellent The future of the professions Link.

3. The origins of our understanding of post-professionalism lies in post-Marxian and neo-Weberian sociology of the 1970s, which radically critiqued professionals’ claims to goodness and expertise. A lot of that work (see, for instance, Johnson, Larson, Witz, Abbott, et al below) started with Eliot Freidson’s iconoclastic The profession of medicine: A study of the sociology of applied knowledge Link.

4. But perhaps the most scathing attack on the professions came from three 1970s masterpieces by Ivan Illich: Medical nemesis Link and Disabling professions Link, all predated by Deschooling society Link (with its nod to Jacques Rancière’s The ignorant schoolmaster referenced below).

5. And we cannot talk of post-professionalism without mentioning Silvia Federici’s groundbreaking 1975 feminist study Wages against housework Link.

Some notable additions:

Abbott A. (1998). The System of Professions: An Essay on the Division of Expert Labor. Chicago, IL: University of Chicago Press.

Fournier V. (2000). Boundary work and the (un)making of the professions. In: Malin N, editor. Professionalism, boundaries and the workplace. Abongdon, Oxon: Routledge. p. 67-86.

Johnson T. (1972). Professions and power. London: Macmillan.

Larson MS. (1977). The rise of professionalism: A sociological analysis. Berkeley: University of California Press.

Rancière J. (1991). The ignorant schoolmaster: Five lessons in intellectual emancipation. Stanford: Stanford University Press.

Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.

Witz A. (1992). Professions and patriarchy. Abingdon, Oxon: Routledge.

Some current thinking

In recent years most of the sociological work has focused on the margins of traditional professional territory, either in the form of new professional work or new professional identities (Kronblad & Jensen, 2023; Hayes, Kulkarni & Lee, 2023). Much of this has focused on forms of ‘hybrid’ professionalism — an almost ubiquitous term in the literature today.

Perhaps the most heavily cited work in recent times comes from Mirko Noordegraaf and his team in Utrecht. Noordegraaf introduced the concept of ‘connective professionalism’ (Noordegraaf et al, 2014; 2015), arguing that new professional work will be much more about connection than boundary protection. Some have suggested this only replaces one bad hegemony with another form of ‘ideal type’ professional identity (Adams et al, 2020).

And in healthcare, a great deal of work is now going into professional work in aged care, new approaches caring and therapeutic work, and the clamour for regulation of a raft of new professions (see, Kamp & Dybbroe, 2023; Sedda & Hussan, 2023; Syrigou & Williams, 2023).

References

Adams, T. L., Clegg, S., Eyal, G., Reed, M., & Saks, M. (2020). Connective professionalism: Towards (yet another) ideal type. Journal of Professions and Organization, 7(2), 224-233. https://doi.org/10.1093/jpo/joaa013

Burns, E. A. (2019). Theorising professions: A sociological introduction. Palgrage Macmillan.

Fitzpatrick MP, Protschky S. (2009). Families, frontiers and the new imperial history. The History of the Family. pp. 323-326.

Hayes, C., Kulkarni, C., & Kee, K. F. (2023). The situational window for boundary-spanning infrastructure professions: Making sense of cyberinfrastructure emergence. Journal of Professions and Organization. https://doi.org/10.1093/jpo/joad007

Kamp, A., & Dybbroe, B. (2023). Training the ageing bodies: New knowledge paradigms and professional practices in elderly care. Sociol Health Illn. https://doi.org/10.1111/1467-9566.13675

Kronblad, C., & Jensen, S. H. (2023). ‘Being a professional is not the same as acting professionally’—How digital technologies have empowered the creation and enactment of a new professional identity in law. Journal of Professions and Organization. https://doi.org/10.1093/jpo/joad005

Nicholls, D.A. & Harwood, G. (2017) Physical therapies in 19th century Aotearoa/New Zealand: Part 3 – Rotorua Spa and discussion. New Zealand Journal of Physiotherapy 45(1): 9-16. doi: 10.15619/NZJP/45.1.02. 

Nicholls, D.A. & Harwood, G. (2016b). Physical therapies in 19th century Aotearoa/New Zealand: Part 2 – Settler physical therapies. New Zealand Journal of Physiotherapy, 44(3), 124-132. doi: 10.15619/NZJP/44.3.02

Nicholls, D.A., Harwood, G. & Bell, R. (2016a). Physical therapies in 19th century Aotearoa/New Zealand: Part 1 – Māori physical therapies. New Zealand Journal of Physiotherapy, 44(2), 75-83. doi: 10.15619/NZJP/44.2.02.

Nicholls, D. A. (2022). Physiotherapy Otherwise. Tuwhera Open Access. https://ojs.aut.ac.nz/tuwhera-open-monographs/catalog/book/8

Nicholls, D.A. (2023). Is physiotherapy a luxury? What can the perplexing absence of the physical therapies tell us about the profession’s future? Physiotherapy Theory & Practice. https://doi.org/10.1080/09593985.2023.2211675 

Noordegraaf, M., Van Der Steen, M., & Van Twist, M. (2014). Fragmented or connective professionalism? Strategies for professionalizing the work of strategists and other (organizational) professionals. Public Administration, 92(1), 21-38. https://doi.org/10.1111/padm.12018

Noordegraaf, M. (2015). Hybrid professionalism and beyond: (New) Forms of public professionalism in changing organizational and societal contexts. Journal of Professions and Organization, 2(2), 187-206. https://doi.org/10.1093/jpo/jov002

Sedda, P., & Hussan, O. (2023). Social media influencer: a new hybrid professionalism in the age of platform capitalism? In L. Maestripieri & A. Bellini (Eds.), Professionalism and Social Change: Processes of Differentiation Within, Between and Beyond Professions. Palgrave Macmillan. https://hal.science/hal-03700657

Susskind, R., & Susskind, D. (2015). The future of the professions. Oxford University Press.

Swain, J., French, S., & Cameron, C. (2003). Practice: are professionals parasites? In Controversial issues in a disabling society (pp. 131-140). Open University Press. 

Syrigou, A., & Williams, S. (2023). Professionalism and professionalization in human resources (HR): HR practitioners as professionals and the organizational professional project. Journal of Professions and Organization. https://doi.org/10.1093/jpo/joad008

Topol, E. (2016). The patient will see you now: The future of medicine is in your hands. Basic Books.

Wrigley, J., & Dreby, J. (2005). Fatalities and the organization of child care in the United States, 1985–2003. American Sociological Review, 70(5), 729-757.