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The Meanings of Autonomy for Physical Therapy

Robert W Sandstrom

Abstract

The purpose of this article is to explore the social context and meanings of autonomy to physical therapy. Professional autonomy is a social contract based on public trust in an occupation to meet a significant social need and to preserve individual autonomy. Professional autonomy includes control over the decisions and procedures related to one’s work (technical autonomy) and control over the economic resources necessary to complete one’s work (socioeconomic autonomy). Professional autonomy is limited and weakened by the relationship of one profession to another (dominance), by the influence of other social institutions (rationalization and deprofessionalization), and by the internal disposition of the profession itself (insularity). Professional autonomy for physical therapists is increasing as medical dominance has declined but is limited by the trends of rationalization and deprofessionalization in health care. Physical therapists must recognize that professional autonomy represents a social contract based on public trust and service to meet the health needs of people who are experiencing disablement in order to maintain their individual autonomy.

Correction

In Figure 2 of the print version of this article, “Physical” was incorrectly typeset as “Physician.” This error has been corrected in both the PDF and full-text versions of the article.

The attainment of increased autonomy for physical therapists is a high priority for the profession. Autonomous physical therapist practice is the centerpiece of the Vision 2020 statement for physical therapy. The issue has engendered great debate about its meaning within the profession.1,2 It has also engendered interest and controversy outside the profession. The challenge for physical therapy is to achieve greater autonomy over the terms of its work during a period of increasing control by outside social forces interested in reorganizing and controlling the health care system where physical therapists find work.

The purpose of this article is to explore the meanings of autonomy for physical therapy. In this article, I will explore these concepts:

  1. Autonomy is a negotiated, social contract between a profession and policy elites based on the public trust in a profession to act in the best interests of the society. A core purpose of professional autonomy is to preserve the individual autonomy of people.

  2. Autonomy can be described in both technical and socioeconomic terms. In general, society grants professions greater autonomy over technical matters. Given the size of resources dedicated to health care, the socioeconomic autonomy of professional work will be shared with other interested parties, especially business and government. Technical and socioeconomic autonomy are interrelated.

  3. Professional autonomy is threatened by the rise of rationalization and bureaucracies, which supplants individual decision making in health care. Professional autonomy can breed insularity and a dominant attitude in a profession, which increases the strength of rationalized organizations when societal priorities change.

First, I will explore what is meant by professional autonomy. Second, I will explore the external and internal countervailing forces to professional autonomy (ie, dominance, rationalization, deprofessionalization, and insularity). Finally, I will conclude with a reflection on the future of autonomy for physical therapy. A glossary of terms is presented in the Appendix. It is the intent of this article to broaden the understanding of physical therapists regarding the social foundations of professional autonomy as the profession moves toward this expanded social role.

What Is Autonomy?

Professional autonomy, or the ability to control the conditions of one’s work, is an outcome of a trust relationship established between a profession and the society.36 It is more than a set of traits that set apart an occupation from other types of work. Autonomy is a privilege and allows the professional to have greater influence over the everyday terms of his or her work than comparable freedoms available to other workers.4(p232) It reflects deference to the profession by others in the community based on the field’s demonstration of specialized knowledge, integrity, and altruistic orientation.7(p82) In return, the society receives necessary and specialized services that are uniquely based on the profession’s skills and abilities. These services address fundamental life issues (eg, health), and the professional with social power and prestige is expected to be an advocate for the patient or client, who is often in a position of powerlessness and vulnerability. In this way, professional autonomy can protect and reinforce autonomy of the individual in society.3,4(p58)

As advocate for individual autonomy, professional autonomy also influences the broader society.5(pp166–168) What is illness? What are the services to which a person with disability is entitled? How many days in a hospital or visits in an outpatient therapy clinic should a person receive? Each of these questions has ramifications not only on personal health but on social role, responsibilities of the community, and distribution of economic resources. For example, professional examinations and evaluations define illness and disability and who will receive services. They allow people to be relieved of their social responsibilities (eg, to work). They use science and “objective” measures to make socioeconomic decisions that transfer benefits from one group to another. For these reasons, we must recognize that professional autonomy extends well beyond the professional-patient relationship and originates in social and political relationships within the society.

Types of Professional Autonomy

Freidson, a preeminent sociologist of the professions, defined 2 types of professional autonomy: technical autonomy and socioeconomic autonomy. Technical autonomy is the “right to use discretion and judgment in the performance of work.”7(p154) In general, society gives the professions wide, but not total, independence in terms of technical autonomy.4(pp38–42),7(pp44–45) For example, professional boards promulgate rules and make decisions regarding the practice of their profession. This authority stems from recognition of the distinct and complex knowledge possessed by a profession, the specialized training and ability of the professional, and the difficulty of others in fairly evaluating professional work. Technical autonomy is regulated by standards of practice, accreditation, and licensure. These social policies act to define the technical autonomy of a profession.

Socioeconomic autonomy is the ability of the worker to ascertain and allocate the economic resources needed to complete his or her work.7(pp24–25) The socioeconomic autonomy of professionals has increasingly been limited by bureaucracies in recent years.8(pp47–48) This change is related to the increasing costs of health care, public perceptions of insularity of the professions, and increased public confidence in government and capitalistic enterprises as mechanisms to address social problems. Changes in reimbursement policy (managed care is the best example) illustrates the influence of these social organizations on the professions.

The goal of complete technical and socioeconomic autonomy is unrealistic. Freidson postulated that complete autonomy for the professional is an inherently unstable position.5(p124) An isolated, independent provider will ultimately lose socioeconomic autonomy. A provider in this situation is dependent upon the wishes and demands of a lay clientele for economic survival, not on his or her own professional judgment. To prevent this potentially dangerous situation, providers form associations to develop policies and procedures regarding the education and practice of their profession. These standards communicate to the society the appropriate standards of practice and expectations for professional performance. For example, “skilled” physical therapy defines who can perform physical therapy and what procedures are acceptable. Because professional autonomy originates in the relationship between a profession and society, much of the power associated with professional autonomy lies in the association of professionals.

Countervailing Forces to Autonomy

There are 2 major sources of social force acting to restrain and redirect professional autonomy: threats from outside the profession and weaknesses within the profession itself. The external threats to autonomy are domination, rationalization, and deprofessionalization. Professional domination is the control by a profession of all aspects of its work, that of other occupations, and in certain situations that of its clientele and the society. Rationalization, a sociological theory developed by Weber in the 19th century, describes the historical movement of people to organize society by developing formal rules, responsibilities, and hierarchies defining acceptable behaviors and relationships, culminating in a bureaucracy.9(pp159–160) With deprofessionalization, the trust relationship between professional and individual is being replaced by trust in organizations that objectify their relationship by rules, regulations, and protocols.10 Insularity, an internal disposition that ignores the social views and forces outside the profession, is the internal threat to professional autonomy. I will explore each social force briefly.

Professional Dominance

For the past 40 years, sociologists have studied the quest for power by the professions—sometimes in the public interest but also at times in their self-interest. Often, this goal has been described as the establishment of a protected monopoly, sometimes with sweeping power over large portions of the society. The pinnacle of this striving for power is “professional dominance” explicated by Freidson in his 1970 study of medicine.7

From the end of World War II until the early 1980s, organized medicine dominated the organization and delivery of health care. The foundation for this dominance was political. Medicine was able to use the power of the state (harnessed by effective control by the professional association of the mechanics of the state) to create a preeminent position in a developing health care industry.4(pp161–162),8(p38),11 Consider this recent quotation about the relationship of physical therapists to physicians in the 1950s: I am certain that some of our younger members will have difficulty comprehending the role of physical therapists in delivering their services several decades ago. It was one of almost total subservience to medicine in general, and to one specialty group in particular. … Our arduous struggle to extricate ourselves from this bondage over the course of many years and to become more independent in all aspects of our education and practice is a tribute to the tenacity and foresight of our predecessors.12(p1044)

During the period of greatest political power (1945–1960), medicine controlled the education system of other health care providers, determined the scope of practice for these occupations, and controlled the workplace for many health care occupations—the hospital.8(p39) Health care occupations that did not accept the dominance of medicine were labeled “quack” fields and were subjected to enormous pressure by organized medicine to cease their patient care activities.9(p49) Other occupations, including physical therapy, exchanged their autonomy for the necessary recognition of their field by medicine.1315 In doing so, these fields had to accept restrictions on private practice and medical dominance of their affairs.13,16,17

Rationalization and Deprofessionalization

In contrast to autonomy is control of the human experience by outside forces (eg, social norms, rules, regulations, and bureaucracies). Freidson defined rationalization as the “pervasive use of reason, sustained where possible by measurement, to gain the end of functional efficiency.”5(p3) The process of rationalization is inherent to the structure and function of the government and of large capitalistic organizations. As Callinicos quotes Weber, “modern capitalism is the rationalistic organization of free labor.”9(p160) These controls are necessary and socially valuable to organize the behavior of individuals in order to achieve desired societal outcomes (eg, in a business). These controls, however, become more complicated when applied to social interactions that affect individual autonomy. Authorizations, protocols, and contracts are all examples of rules and regulations devised by bureaucracies to affect the patient-provider relationship in health care. Individual patient-provider decisions are made in the context of the broader contracts and structures that exist in the society. This organization of work limits and directs worker behavior to meet the goals of the bureaucracy.

The 20th century saw the growth and development of large bureaucracies that regulate, fund, and deliver health care services.4(pp179–190) A large private insurance industry and government bureaucracies were created to implement rules and procedures to pay for health care services. At first intended to increase access to health care, the goals of these organizations have shifted to cost containment as the cost of health care has grown rapidly.3 With this paradigm shift, the efficiencies of rationalized organizations, not professional autonomy, have become increasingly attractive to policy makers as a way to organize the health care system.18,19 Health care is viewed increasingly as a commodity that can and should be bought in a marketplace.20,21

Employment in bureaucracies creates a socioeconomic arrangement that limits professional autonomy and places power in the bureaucracy.5(p119) The power of bureaucracies is often distributed and controlled by “technobureaucratic” professionals (eg, administrators, accountants) who influence primarily the resource allocation (affecting socieoeconomic autonomy) that supports professional work. Physical therapists were primarily employed by hospitals with limited private practice for decades. Nurses, who originally were relatively autonomous, private providers of care in homes, were later rationalized and incorporated into institutional environments (eg, hospitals).16 Unlike the patient-centered professions, the livelihood of the technobureaucratic professions in health care do not directly depend upon the provision of a service to a patient but rather to the organization itself.4(p189) This situation, not uncommonly, creates a conflict between the professional and bureaucratic models of health care delivery.4(pp190–192) The root of this conflict is the competing loyalties to the autonomy of the profession and to the employer.22 For physical therapists, physician-owned practice creates a new complexity to this situation.

In the 1980s, Haug, a sociologist, proposed that professional monopolization of knowledge, autonomy over work, and authority over clients was declining.23 Economic changes in health care, health system reorganization, and, more recently, the rise of the Internet and other sources of publicly available health information were leading to a “deprofessionalization” of the health care professions. To some, the changes wrought by managed care have caused a “proletarianization” of health care professionals by large capitalistic organizations.11,16,18,19

Ritzer and Walczak defined deprofessionalization as the “decline in the possession, or perception that the professions possess altruism, autonomy, authority over clients, general systematic knowledge, distinctive occupational culture, and community and legal recognition.”10(p6) Mechanic summarized the state of deprofessionalization in medicine by the mid-1990s: The model of the individual physician as an entrepreneurial professional, free to define the characteristics of his or her work and how to perform it has diminishing relevance, given an increasingly sophisticated technological superstructure and at a time when biomedical knowledge is rapidly advancing and professional decisions translate into enormous expenditures of other people’s money, whether government or private.24(pp486–487)

In summary, rationalization affects professional autonomy by organizing professional work into systems that can be controlled by policies and managers. This reorganization has been used most often to limit socioeconomic autonomy. Trust, instead of existing in the patient-provider relationship, is placed in the organization and in its rules and procedures in order to ensure high-quality, cost-effective care.

Insularity

The internal threat to autonomy is professional insularity. Insularity is the inward focus of a profession that blinds itself to broad and significant social concerns in favor of its own narrow and parochial agendas. As a result, the professions are cast by policy elites as self-centered and myopic. Recognition of a field as a profession and of its accompanying autonomy is dependent upon the official recognition of its social position by the state.

The attitude of societal elites toward the professions is important to the institution and to the support of professional autonomy.14 The dangers of ignoring the social forces that produce autonomy, especially in a democracy, are illustrated by medicine. The position of near absolute control and authority over the health care system by organized medicine bred over time an insularity that ultimately led to a significant reduction in its dominance.7(p370),9 As Krause remarked, “no profession in our sample has flown quite as high in guild power and control as American medicine and few have fallen as fast.”8(p36) The position of unfettered authority results in professional insularity, evidenced by a mission to protect itself, not the public7(pp369–370),17,20 and ultimately to lose support from policy elites.25 Although medicine developed and implemented scientific changes that brought improvements in health, sometimes spectacularly, these gains brought significant other social costs.26,27 While medicine maintains an important position of authority in the health care system, the response to this circumstance has been increasing involvement in health care by bureaucracies and weakened professional autonomy.28

The Future of Autonomy for Physical Therapy

In this article, I have considered the technical and socioeconomic bases of professional autonomy as well as the complex interplay of the professions, bureaucracies, and the society that supports and controls the extent to which the professions can control the terms of their work. In this section, I will discuss what physical therapy must do to address contemporary countervailing forces to the development of its technical and socioeconomic autonomy. I will conclude with some thoughts about the importance of articulating the value of physical therapy autonomy as a solution to the societal challenge of improving the health of people who are experiencing disablement.

Challenges to Technical Autonomy

In December 2004, the Medicare Payment Advisory Commission (MEDPAC) released a report to Congress advising against changes in Medicare policy that would allow payment for physical therapy services without physician referral.29 The MEDPAC report reaffirmed the traditional dominance of physicians to control and direct patient access and the resources available for physical therapy within Medicare (Fig. 1). This report was made in contrast to the decision of most state governments to explicitly or implicitly permit some form of direct public access to physical therapy services for people who are experiencing temporary or permanent disablement. The MEDPAC decision reflected a setback to efforts by organized physical therapy to achieve a higher level of autonomy within the health care system. It reinforced the traditional view of physical therapy as an extension of medical practice and therefore to be controlled by physicians.

Figure 1.

Traditional medical model of physical therapist practice.

In 1991, Guccione postulated a scope of physical therapist practice that focuses on addressing the impairments and functional limitations of disablement (in current International Classification of Functioning, Disability and Health [ICF] terms, activity and participation limitations).30 The contribution of physical therapy to addressing disablement is not to diagnose pathology as it is understood in the disablement conceptualization.31 Physical therapist examination, evaluation, diagnosis, and intervention planning for impairments and functional limitations is core to the physical therapist contribution to the disablement challenge. Current policy elite (MEDPAC) thinking about the technical autonomy of physical therapists has reinforced the role of the physician (expert on pathology) as gatekeeper to therapy services that address impairments and functional limitations.

Disablement, however, is not completely understood as a medical problem. In fact, the “medicalization” of disablement has been criticized for its identification of the person with disability as the source of the problem, overemphasis on diagnosis of pathology as the cause of disablement, focus on the primacy of the provider (especially the physician) instead of the “patient” as the source of the solution, and the need of the person with a disability to assume the sick role in order to receive services.32 It will be important for physical therapists to continue to communicate the importance to policy makers of the ability of physical therapists to address, in a cost-effective manner, the impairments and functional limitations of people who are experiencing disablement and to assess and refer possible pathology to appropriate providers at appropriate times when doing so.

Challenges to Socioeconomic Autonomy

The growth of private-practice physical therapist services has been concentrated in the outpatient, musculoskeletal practice area. This type of practice organization increases socioeconomic autonomy and allows the physical therapist to develop and organize a service to meet the needs of people who are experiencing disablement and of local, referring providers. However, changes in the organization of the health care system are creating new challenges and complexities for this form of practice. Consider the effect of physician-owned physical therapy services (POPTS) on autonomous physical therapist practice.

The POPTS issue illustrates both a new form of socioeconomic control as well as the improvements in technical autonomy that have been achieved by physical therapists in relation to medicine since the 1950s. Consider the following statements by physical therapists: For example, at the POPTS at which I am employed, the physical therapists have an excellent relationship with the physicians and our equipment is state-of-the-art—both of which enhance our patient care. They do not dictate in any way how we should practice.33Physician-owned physical therapy services stop competition for the private practitioner, and POPTS stop consumer choice. I want to be referred patients based on my expertise in the field, not because the physician has a monetary interest.34Patient care is of bottom-line concern, with the business end, of necessity, needing to break even. It has been a pleasure to work with well-qualified orthopedic surgeons, osteopaths, and a practice administrator who understands ethical medical and business practice, quality care, and mutual respect [POPTS practitioner].35It has long been the goal of our profession to be acknowledged for our expertise and our unique body of knowledge. To this end, it is my belief that POPTS, as well as physician-rendered “physical therapy treatments,” will lead to further degradation of the public’s view of our profession while increasing cash flow to the entities involved.36

The POPTS issue illustrates the social complexities of relationships in health care that affect autonomy. Some writers emphasize the importance of technical autonomy, while others emphasize the importance of socioeconomic autonomy to their professional life. Physician-owned physical therapy services are a new form of employment (rationalization) of physical therapists. It is less clear from these anecdotes, however, that POPTS are, in all circumstances, a reassertion of medical dominance over the technical autonomy of physical therapists. Physician-owned physical therapy services are a threat to the socioeconomic autonomy of private-practice physical therapists. This is compounded by reimbursement limits on the socioeconomic autonomy of physical therapists who choose to organize and invest in a private business to meet community needs (ie, the $1,500 Medicare cap).

Both the 2004 MEDPAC decision and the POPTS issue illustrate the continuing need of the profession to advocate with policy elites for recognition of physical therapy as a distinct technology performed by physical therapists capable of interdependently addressing components of the disablement problem and not as a set of procedures to be controlled as an extension of medical practice.

Concluding Thoughts

The Board of Directors of the American Physical Therapy Association has defined autonomous physical therapist practice as: “independent, self-determined professional judgment and action. Physical therapists have the capability, ability, and responsibility to exercise professional judgment within their scope of practice, and to professionally act on that judgment. The goal will be explicated through the achievement of five major objectives:

  • demonstrating professionalism

  • achieving direct patient access to physical therapist services

  • use of evidence-based practice

  • attaining entry-level education at the Doctor of Physical Therapy degree

  • becoming the practitioner of choice.”37

This definition emphasizes a reduction in medical dominance of the field, professional responsibility of the physical therapist, the public’s right to choose a provider, and quality of patient care. This definition is consistent with the definition of “functional autonomy” first described by Freidson more than 30 years ago. Functional autonomy of a “paraprofession” is “the degree to which work can be carried out independently of organizational or medical supervision and can attract its own clientele independently.”7(p53)

Physical therapists need to recognize current societal pressures on professional autonomy; the need for continued cooperation with government, business, and other health care professions; and the emergence of new opportunities in the health care system. As Swisher et al recently summarized: “Although many physical therapists continue to rely on models of professionalism that emphasize autonomy, this approach is regarded by some sociologists as outdated. If a person accepts this premise that professional autonomy is a ‘litmus test’ for professionals, then physicians and other health care providers may be forced to accept the fact that they have been ‘deprofessionalized.’”38(pp795–796) They further stated, however, that “changes in the health care environment present opportunities for professionals to renegotiate their contract with society.”38(p796)

Johnson and Abrams emphasized that “physical therapists appear poised and ready for the emergence of a multidisciplinary, interdependent health care model in an era of chronic illness and growing emphasis on health and wellness. We believe that a construct for autonomous practice that includes self-directing freedom within the framework of moral independence and interdependent [italics added] practice will facilitate the creation of a more autonomous profession.”39(p635) The profession needs to continue to reach out, invite, and engage in meaningful negotiations with all interested parties about how physical therapy can contribute in new ways to meet the social challenge of disablement. More, not less, communication (especially with opponents of greater autonomy) will lead to and sustain an expanded social role for physical therapists.

The goal of professional autonomy should not distract the profession from its first responsibility: to meet the needs of the public who require physical therapy services while preserving their individual autonomy in relation to their health. In a recent analysis of the position of professions in modern society, Freidson wrote: Ideal-typical professionalism is always dependent on the direct support of the state and some degree of tolerance of its position by both consumers and managers. Such support cannot be gained by relying solely on what many writers have emphasized about professions—their ideology of service. … The professional ideology of service goes beyond serving others’ choices. Rather it claims devotion to a transcendent value which influences its specialization with a larger and putatively higher goal which may reach beyond that of those they are supposed to serve [italics added].… Lying behind that, however, separate from individual conscience, is the ideological claim of collective devotion to that transcendent value and more importantly, the right to serve it independently [author’s italics] when the practical demands of patrons and clients stifle it.40(pp122–123)

The foundation of a claim of autonomy for physical therapists rests in the societal problem of disablement and its effects on the autonomy of people to function in society. Movement disorders related to disabling conditions adversely affect personal health, burden society, and limit productivity. Immobility is associated with increasing rates of institutionalization and decreased quality of life.

Physical therapists historically have been committed to addressing the personal and societal problems of temporary and permanent disablement across the life span with the goal of improving independence, productivity, and quality of life. This commitment to patient-centered, public service is a hallmark of the profession and must be central to all activities of autonomous physical therapists.

Increased autonomy for physical therapists is occurring at a recent historical low point for the autonomy of the professions. A crucial direction, then, for the profession will be to explain to society in new and more powerful ways how health for people with disabilities is a transcendent value and why interdependent, autonomous physical therapist practice in a patient-centered system is necessary to improve health for all citizens so they may fully participate (autonomously) in society (Fig. 2).

Figure 2.

Interdependent, autonomous physical therapist practice.

  • Received August 9, 2005.
  • Accepted August 23, 2006.

References

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