The Continuum of Health Professions

Abstract

The large number of health care professions with overlapping scopes of practice is intimidating to students, confusing to patients, and frustrating to policymakers. As abundant and diverse as the hundreds of health care professions are, they possess sufficient numbers of common characteristics to warrant their placement on a common continuum of health professions that permits methodical comparisons. From 2009–2012, the author developed and delivered experimental courses at 2 community colleges for the purposes of creating and validating a novel method for comparing health care professions. This paper describes the bidirectional health professions continuum that emerged from these courses and its potential value in helping students select a health care career, motivating health care providers to seek interprofessional collaboration, assisting patients with the selection of health care providers, and helping policymakers to better understand the health care professions they regulate.

More than 250 health care professions exist. Each possesses distinctive scopes of practice that often overlap with those of other similar professions. This results in a combination of abundance and ambiguity that is intimidating to students attempting to select a career, confusing to patients attempting to select a provider, and frustrating to policymakers attempting to regulate the professions. The current article describes a method for objectively placing health care professions on a 2-dimensional health care continuum that can help students, consumers, and policymakers methodically compare and contrast health care professions.

Evolution of Professions

Professions, including those responsible for the delivery of health care services, evolve through a series of sequential events.1 Those events constitute the professionalization process, and 12 of them are listed in their approximate order of occurrence in Table 1. Emerging professions are those that are experiencing the early events in that process. More mature professions are those that are experiencing the latter events in the process and that may have been responsible for spawning additional and related professions.

Table 1.

Professionalization Process

Event	Activity
Informal Collaboration	Assembly of a group of people with common skills or knowledge
Formalized Collaboration	Formation of professional association (often national)
Authorized Practice	Passage of governmentally sponsored licensure or registration
Standardized Qualifications	Administration of professional examinations
Educational Identity	Establishment of distinctive programs for professional education
Educational Uniformity	Standardization of process for professional education
Consolidated Beliefs	Establishment of professional code of ethics, values, and philosophies
Enhanced Communication	Publication of a professional journal
Regulated Education	Accreditation of educational process
Enlarged Influence	Expansion of practice scope
Intensified Training	Expansion of education to accommodate growth of practice scope
Specialization	Division into multiple and more restricted professions

Inventory of Professions

Using the events of the professionalization process as criteria, it is possible to identify, inventory, and classify health care professions. Perhaps the most comprehensive inventory of health care professions is contained in the Healthcare Provider Taxonomy prepared by the US Centers for Medicare and Medicaid Services. Developed for the purpose of reimbursing health care providers, the taxonomy assigns a 10-digit code to each identified profession and job. As of August 2014, approximately 640 codes appeared in the code set.2

Many of the 640 codes represent jobs that have not yet experienced the events in the professionalization process that are consistent with the establishment of a health care profession, but the author conservatively estimates that more than 250 have reached that threshold. A superficial inventory of health care professions that have achieved the critical events in the professionalization process is provided in Table 2. An awareness of the diversity and distribution of health care professions is helpful to students seeking a career, patients seeking a provider, and policymakers seeking to regulate them appropriately.

Table 2.

Categorization and Partial Inventory of Health Care Professions

Service Provider Categoriesa	No. of Professions	Names of Professionsb
Allopathic and Osteopathic	100	Specialties meet criteria for profession
Behavioral and Social	20	Psychologists, counselors, marriage and family therapists, social workers
CAMc	20	Chiropractors, dieticians, acupuncturists, nutritionists, naturopaths, homeopaths, midwives, and mechanotherapists
Dental	15	Dentists, hygienists, assistants, denturists, therapists
Optical	10	Optometrists, opticians, ocularists, assistants
Emergency Medical	3	Emergency medical technicians and paramedics
Nursing and Nursing Service-related	70	Registered nurses, practical nurses, vocational nurses, nurse’s aides, home health aides
Pharmaceutical	10	Pharmacists, pharmacy technicians.
Advanced Practice Nursing	30	Nurse practitioners, clinical nurse specialists, advanced practice midwife, nurse anesthetists, physician assistants
Podiatric	5	Podiatrists, assistants
Rehabilitative and Restorative	15	Physical therapists, occupational therapists, respiratory therapists, recreational therapists, exercise physiologists, orthotists, athletic trainers, massage therapists
Speech and Hearing Pathological	4	Audiologists, speech-language pathologists, hearing technicians and instrument specialists
Technological and Technical	20	Laboratory technologists, radiology technologists, perfusionists, surgical assistants, radiology technologists

Abbreviations: CAM, complementary and alternative medicine; CMS, US Centers for Medicare and Medicaid Services.

^aFrom CMS code set, August 2014.2

^bMany specialties qualify as separate professions.

^cCAM is not mentioned in the CMS code set but has been added by the author.

Continuum of Professions

As abundant and diverse as the hundreds of health care professions are, they possess sufficient numbers of common characteristics to warrant their placement on a common continuum of health professions. Doing so enables comparisons among health care professions that benefit students who are attempting to select a health care career, patients attempting to select a health care professional, and policymakers attempting to regulate the health care professions.

From 2009 to 2012, the author developed and delivered experimental courses in the Health Professions Continuum at Clackamas Community College and Mt Hood Community College, both located in Oregon, for the purposes of creating and validating a novel method for comparing health care professions.3–6 The courses were regarded as experimental because students were selected from a broad range of experiential backgrounds and were guided through the collaborative development of instruments that could help them compare and contrast health care professions for their unique personal and professional needs.

Among the earliest discoveries in the courses was the need for a 2-dimensional continuum using an ordinal scaling process on which the health care professions could be objectively placed on the basis of scope of practice and professional values. An ordinal scale is one on which content is arranged in order of magnitude without regard for the distance between the items on the scale.7 First published in 1932, the Likert scale continues to serve as a commonly used ordinal scale.8

The students consistently selected some modification of the Likert scale to make relative comparisons among health care professions. Because the resulting bidirectional continuum was reminiscent of the rainbow that was familiar to all students, the students often used it as a metaphor that enabled them to visualize the relationships among diverse health care professions. The author applies that metaphor in the text that follows.

With its vertical spectrum of colors and its horizontal gradient of intensity, a rainbow forms a bidirectional continuum such as the one that the health care professions also form (Figure 1). The vertical continuum of the health professions rainbow contains a spectrum-of-practice scope, commencing with the entry-level practices that assist other providers and extending through the progressively technical tiers of prevention, therapeutics, and diagnostics.

Figure 1.

Like a rainbow, the Health Professions Continuum is bidirectional. The vertical continuum represents scope of practice, and the horizontal continuum represents philosophies of care.

The horizontal continuum of the health care rainbow contains the range of health care philosophies or values that constitute one of the steps of the professionalization process and that often distinguish health care professions from one another, including professions involving conventional and complementary health care. The following continua are the common philosophical ranges that students in the experimental courses found useful in distinguishing among health care professions: (1) invasive care to noninvasive care, (2) disease-based care to wellness-based care, (3) standardized patient care to individualized patient care, (4) palliative care to curative care, (5) high-tech care to low-tech care, (6) inpatient care to outpatient care, (7) synthetic therapies to natural therapies, and (8) evidence-based care to empirically based care.

The several dozen community college students participating in the courses on the Health Professions Continuum included (1) high school and community college students who were contemplating choices of health professions for their careers, (2) community college students who had selected and were currently enrolled in various programs related to health professions, (3) health care consumers desiring to learn how to select a health care professional, and (4) practicing health care professionals who were interested in learning how to collaborate with providers from other health care professions. When the students were challenged to develop instruments collaboratively that enabled the placement of health care professions on a health professions rainbow, they consistently created tools similar to the example presented in Table 3.

Table 3.

Health Professions Continuum Worksheet^a

Introduction	Health care professions can be arranged on a vertical continuum based on their scopes of practice and related criteria and on a horizontal continuum based on their philosophies and values. This worksheet enables the professions listed below to be placed on such a Health Professions Continuum.
Health Care Professions	1	2	3

Scope of Practice
Instructions: (1) Enter the profession’s number into the Likert scale cells that are most consistent with the scope-of-practice statement; (2) enter in each profession’s composite column the number of times the profession has been entered, multiplied by the points for the column; and (3) enter the total points for each profession in the Scope of Practice Totals column.
Professional Scope of Practice Statements	Strongly Disagree (1 point)	Disagree (2 points)	Indifferent (3 points)	Agree (4 points)	Strongly Agree (5 points)	Scope of Practice Totals
Professionals are authorized to practice independently.
Professionals are authorized to prevent disease.
Professionals are authorized to treat disease.
Professionals are authorized to diagnose disease.
Other professions refer patients to this profession.
Professionals are very well compensated.
Professionals are highly educated.
Profession 1: Scope of Practice Composite
Profession 2: Scope of Practice Composite
Profession 3: Scope of Practice Composite

Philosophies/Values
Instructions: (1) Enter the profession’s number into the Likert scale cells that are most consistent with the philosophies/values statement; (2) enter in each profession’s composite column the number of times the profession has been entered, multiplied by the points for the column; and (3) enter the total points for each profession in the Philosophy/Values Totals column.
Professional Philosophy Statements	Strongly Disagree (1 point)	Disagree (2 points)	Indifferent (3 points)	Agree (4 points)	Strongly Agree (5 points)	Philosophy/Values Totals
Professionals apply a uniform standard of care.
Professionals see large daily patient volumes.
Professionals are experts on patients’ healthcare needs.
Professionals value invasive procedures.
Professionals value symptomatic relief.
Professionals delegate patient interaction to subordinates.
Procedures confined to evidence-based.
Procedures rely on man-made remedies.
Professionals focus on correcting pathology.
Professionals consider medicine as cure.
Profession 1: Philosophies/Values Composite
Profession 2: Philosophies/Values Composite
Profession 3: Philosophies/Values Composite

^aDraft version (April 10, 2010).

Four characteristics in Table 3 were common among virtually all of the student-developed scaling instruments: (1) Three to 5 health care professions that had experienced the critical events in the professionalization process were selected for comparison; (2) a modified Likert Scale was used to place each selected profession, relative to the others, on a vertical scope-of-practice continuum; (3) a modified Likert scale was used to place each selected profession, relative to the others, on a horizontal professional values continuum using some of the philosophical ranges that had been previously identified and accepted; and (4) the scaling was polarized so that the entry-level professions were always at the base of the scope-of-practice continuum and the conservative professions were always on the right end of the philosophical continuum. The results showed a remarkable consistency in the relative placement of health care professions on the Health Professions Continuum.

Using Table 3 and similar ordinal scaling instruments that they designed, the students demonstrated that it is practical to arrange health care professions systematically, relative to each other, on a bidirectional continuum in which the vertical continuum orders professions on the basis of their scope of practice and the horizontal continuum orders professions on the basis of their philosophies and values. An example of their work is illustrated in Figure 2.

Figure 2.

The health professions can be arranged on a bidirectional continuum in which the scopes of practice appear on the vertical continuum and the professional philosophies appear on the horizontal continuum.

Abbreviations: ND, naturopathic doctor; DC, doctor of chiropractic; LAc, licensed acupuncturist; MT, massage therapist; MD, doctor of medicine; DO, doctor of osteopathic medicine; PA, physician assistant; PT, physical therapist; NP, nurse practitioner; RN, registered nurse; OT, occupational therapist; LPN, licensed practical nurse; MA, medical assistant; CNA, certified nurse assistant.

Applying the Continuum

At the conclusion of each course on the Health Professions Continuum, students applied the instruments that they had developed to themselves to determine where their personal and professional health care aspirations placed them. The majority of students were surprised to discover previously unrecognized philosophical leanings toward the conservative end of the horizontal continuum. Many who had begun the course with entry-level career objectives realized that they preferred careers in the therapeutic and diagnostic tears of the vertical continuum.

Students who were contemplating choices among careers in the health professions reported that the visualization of the Health Professions Continuum clarified their choices, often adding that such a course should be required of all preprofessional health science students. Students who had previously selected and were currently enrolled in health profession programs reported a greater awareness of other health care professions and a desire to share interprofessional experiences in clinical training. Students who had enrolled as health care consumers reported an enhanced awareness of their own health care preferences and an improved understanding of how to select providers to meet those needs. Students who were practicing health care professionals reported improved understanding of and feelings of collegiality with colleagues in other professions.

Finally, the process of developing and visualizing the Health Professions Continuum revealed the gaps and other imperfections in it. The students elected to refer to such gaps as the Continuum Clefts, an awareness that subsequently led to additional discussions, presentations, courses, and discoveries pertaining to the health care continuum.

Conclusions

Health care professions can be placed on a bidirectional continuum on the basis of scope of practice and professional values/philosophies. Doing so enables visual comparisons among professions that help students select health care careers, help patients select health care professionals, motivate providers to engage in interprofessional collaboration, and assist policymakers in better understanding the professions they regulate.