Competition in the Health Care Professions: A Distant Mirror?

I’ve written at length about sociologist Andrew Abbott’s 1988 book, The System of Professions (Chicago, 1998), and his very astute analysis about how the information professions—all of them, ranging from librarians to MBA consultants—compete with each other, obstruct competing groups when they reach for more power, and so on. He describes what professionals do as offering a “treatment,” which requires special training and knowledge, and the exercise of independent judgment. When a particular group wants to gain the upper hand, moving into an emerging market, for example, they practice “treatment substitution.” Essentially they are saying “I know a lot too, and my strategy is a better one.”

Since we all work together in the information professions, the actual dynamics of treatment substitution can be obscured by good vibrations, collaborative spirit and so on—or at least, we can hope so. However, oftentimes the easiest way to perceive the current of competition in our own field of expertise is to look to other fields and see what is happening there.  With respect to treatment substitution, there is no better example than the medical professions, and Andrew Abbott devoted many pages of his book to the medical fields along with the information professions.

Well, unsurprisingly, the Affordable Care Act (ACA) is stirring up controversy and also creating opportunity. When opportunities abound, professional competition can heat up fast. And next comes treatment substitution!

Nurse Practitioners: Exercising New Muscle

On March 24, 2013, the San Francisco Chronicle reported on the current struggle of nurse practitioners to exercise more independent judgment in health care delivery. NPs already can diagnose acute and chronic illness, are trained in pharmacology and health care ethics, and they have become essential partners in care. They are regulated at the state level, and so what they can actually do varies by region. Chronicle Reporter Shannon Pettypiece describes the overall status of their struggle, which increasingly is playing out in the courts.

Physicians have always seen themselves as the “captain of the ship,” and they and their associations vigorously guard their primacy in the practice of medicine. Yet at the same time, there is a shortage of 13,000 doctors right now, and this shortage is forecast to grow to 130,000 in the coming years. Nurse practitioners argue that they could fill a crucial gap, if they are afforded the privileges needed to diagnose and treat patients. This is particularly true in rural regions.

Closer to Home: Opportunity from Atomization

In the information professions, there has been splintering of major concepts and established roles–you could even say atomization of “skill sets,” as the digital era unfolds. MIS managers, consultants, CIOs, information specialists and librarians all compete to offer the best information “treatments,” but new technology and ideas about social interaction are rewriting the rules. Treatments on offer include digital curation, digital publishing, preservation, digital conversations, reference consultations, and more. As digital convergence pushes us all closer together, we face more moments when we must choose to collaborate or compete.

In the journals marketplace, the emergence of SPARC and new strategies to promote open access scholarship are swiftly changing our expectations and assumptions about the future of information management and delivery. At the same time, technical skills can be learned readily by just about any enterprising person with a dream. These enterprising people can create apps and other tools that become “must-have” functionalities on our smartphones.

In other words:  competition, and treatment substitution, are alive and well in the information professions. We even have litigation over publishing markets and journal pricing, although our version seems a lot less personal than physicians’ assertion that they simply “know more” than nurses.

“A Finch Sang in Berkeley Square….”

I don’t think we have a single issue that defines current competition among the various information handling professions; rather we have a great many, and they are diverse. But for the moment, with the release of the “Finch Report” in the United Kingdom and its mandate to build “Gold Open Access” models to make research available to all, I’d say open access is a illuminating issue that defines what competition looks like. At what point does a publisher need the library, or for that matter, at what point does the library actually “become” the publisher? Or further: at what point do authors become the “agents of change” in an all-new style of writers’ guild, given that technology makes this possible, right now?

These and many other questions will not be answered soon, although the nature of competition may reveal some of the strategies that many of us will surely test. Meanwhile, while we continue to work together, we continue to hone our skill at monitoring the digital environment we work in, and the new opportunities that arise to extend our reach.

The Never Ending Quest for Relevance

I enjoyed viewing Brian Kelly’s slides for his recent presentation titled “What Next for Libraries? Making Sense of the Future!”  The presentation was given at the Emerging Technologies in Academic Libraries conference, which was held in Trondheim October 1-3, 2012. Brian synthesizes our perceptions and beliefs about what is to come and how things don’t always work out quite as we think they will. He uses the monorail—a “bleeding edge” technology some 50 years ago—as an example of a promising technology that reached a dead end.

Brian’s UKWebFocus post about his presentation at EMTAC also “reblogged” Lukas Koster’s post title about the event: “Change or Be Irrelevant.”  This is a topic I always warm to, having been engaged in this debate, mission, or aspiration about library futures as long as I’ve been in the profession.

Librarians are rightly concerned about their future, as new technologies influence how people use information. But our recent history is one of continuous change, with many smart moves paying off in big ways. One example is our early move into Web-based database aggregation, and becoming content creators is my current favorite. But for now, I want to respond to the risk of irrelevance that seems to stalk us, and add one thought based on some reading I have done over the years.

We’re not alone.

Virtually every profession that styles itself the guarantor of quality service, advice or judgment is facing the same uncertainty that librarians do. The shrillness of the alarm that other professionals articulate can make librarians seem like calm, unruffled masters of the universe.

Some of the most august professions are confronting bigger challenges than librarians, with varied degrees of success. For example, law is currently the site of high anxiety about partner profits, new models for providing legal services more cheaply, what young lawyers ought to be doing once they leave law school, and even the demise of the practice of law as we know it. The prime culprit is once again technology, with a boost from the economic downturn.

Further afield, health care professionals of many stripes struggle to increase their status, sometimes engaging in fierce debate their fellow care givers. Nurses have seen their status grow, while doctors openly complain about the growing burdens they face in the administrative and bureaucratic arenas. Psychologists clamor for the right to prescribe medicines for mental health issues, while psychiatrists man the battlements and will not give an inch. My sense is that the entire system of professions is being upended by new technologies, new ideas, new players taking on the establishment and so on.

This is a good thing.

But technology along is not the sole driver of professional distress—which is being voiced in the trade journals of every field in one form or another. Competition between professions is another new and revitalized factor in the batter for relevance. Technology speeds up the impact of competition between people, and it challenges professions to respond. In a way, the “marketplace of ideas” that is at the heart of intellectual inquiry is joined by a marketplace of “skill,” which is marked by fierce competition and innovation. This process affects all professions.

The Battling Professions, and their “Treatments”

It is also not a new process. Any serious student of the future and of the information professions in particular has some required reading to do in the discipline of sociology. Andrew Abbott, a sociologist at the University of Chicago, penned a book in 1988 titled The System of Professions (University of Chicago Press, 1988). In this book he outlines the dynamic process by which all professions compete to gain special status, and then organize to hold onto it. One group can gain leverage over another by offering a better solution—for example, paralegals could offer in-depth services that step onto the turf of attorneys. This process is known as “treatment substitution.” Essentially new groups rise and offer a better “treatment” than the traditional players, and gain ground as a result. Abbott devotes an entire chapter to the information professions—of which librarianship, even in 1988, was just one among many.

Abbott returned to his study of librarians and the challenges they face in 1998, in his article titled “Professionalism and the Future of Librarianship”  (Library Trends, Vol. 46 (no. 3), Winter 1998, 430-443). This article gained some attention in its day, and both his book and the article have passed the test of time quite well.

A Basis for a Relevancy Strategy

The core of Abbott’s thinking is compelling, and holds many lessons for the library professions. If we can understand challenges to our status as professionals and in particular our ability to master new technologies as based in “treatment substitution”—that is, others moving into our turf—we are more likely to develop survival strategies that advance our own “unique skill.”  Essentially, we would be telling the professional world, “Our solution is the best solution. Here’s why.” –and take it from there.

Consider the idea of an organization’s mission statement. It should outline the core beliefs of the organization in ways that keep it on course and enable it to thrive. Likewise, a strategy that is based on the belief that all professions are certain to compete—especially in this present era of disruptive technology—is more likely to facilitate action-oriented thinking that looks to the future, rather than the past, for inspiration.

And so in the quest for relevance, I look not only to examples of dead-end technologies or the emergence of mobile and app-based computing; I look also to see what strategies new players in the information sphere are trying out to create a niche themselves.  We have solid data that tells us that people are not effective searchers when it comes to finding articles via Google or the Library Web site. Maybe that’s one issue that could inform a fresh strategy to make ourselves not only relevant, but indispensable….