4 A brief primer on the sociology of the professions

There are many subdivisions within the broad field of sociology. There are sociologists interested in criminal justice, the environment, religion, and economics; there are sociologists of education, travel, food, and politics; as well as branches of sociology devoted to urban design, film, literature and the family. But perhaps one of the strongest and most fertile areas of sociology over the last century has been the branch of sociology devoted to health and, most especially, the health professions. But there are even subdivisions and specialties within this field, with scholars specialising in disability, work, health policy, aboriginal and Indigenous peoples’ health, commodification, alienation, bodies and boundaries, bureaucracy, disease, ideas of progress, solidarity, lay/professional interactions, myths, authority, domination, power and oppression, social rituals, marginalisation, the division of labour, class conflict, status, intersubjectivity, labelling and stigma, social values, deviance, profanity and transgression, religious beliefs, economics, morality, the body, social order, globalisation, emancipation, health policy, surveillance, emotions, legitimacy, equality, social theories like feminism, Marxism and postmodernism, science and progress, the self, technological knowledge, racism, societal norms, industrialisation, and language. Clearly, then, it is a vast field.

Notwithstanding its diversity, though, it would be no exaggeration to say that sociologists have been quite obsessed with healthcare. There are perhaps a number of important reasons for this. Health occupies many people’s lives, it is very important in shaping our lived experiences and, therefore, our attitudes and beliefs about the world. Plus it is dominated, in the West at least, by a very particular and powerful approach to the body and health, so perhaps naturally, sociologists are interested in how this shapes society, the way people think, and behave. Health also consumes an enormous amount of a country’s resources, not only in terms of its government budgets, but also time spent in organising, reorganising, and discussing how health could be better.

Perhaps it is not surprising, then, that sociologists have had an enduring interest in the nature and functions of the health professions. Jonathan Gabe has suggested that this work has focused on two complex and inter-related issues:

‘First, what (if anything) distinguishes those occupations that are generally accepted as being professions from those that are not, given that many occupations would apparently like to be regarded as professions? Second, can we trust these professionals’ claims to trustworthiness and their connected demands for autonomy (freedom from external monitoring), and what are the consequences of accepting (or, indeed, of refusing to accept) professionals’ claims?’ ^[1].

Different authors have approached these questions in different ways. David Landy suggested that healthcare could be divided into its social and cultural aspects ^[2]. The social being the domain of organisations, professional roles, and rules governing relationships, and the cultural being the domain of perceptions, beliefs, practices, and theories. Arthur Kleinman ^[3] suggested three different healthcare ‘sectors’: the popular sector of the non-professional, or the kinds of informal, non-expert, fee-free care and support that is usually the first place illness manifests; the folk sector of non-orthodox, Indigenous, sacred and secular healers, offering more holistic healing options; and the third professional sector, an organised, legally sanctioned space.

What these approaches point to is that the sociological study of the professions has largely remained ‘a rather narrow field of research despite its vast literature’ ^[4]. This has meant that ’few other fields in sociology present such a linear development of the theoretical discussion’, with each decade ‘characterized by a dominant theoretical perspective that has first been gradually challenged and then superseded by alternative interpretations’ (ibid). This relatively contained body of work is good for us because it makes it easier to explain the different perspectives. But there is also real depth lying behind these ideas, and to date very little of this has been applied directly to physiotherapy.

To begin with, sociologists only really began to be interested in the professions in the 1930s. But then the professions, as we know them today, only began to establish themselves towards the end of the 19th century. So, although the ‘true’ professions — medicine, law, and theology — had existed in some form for centuries, professions as a whole were neither organised, nationalised, nor theoretically and practically coherent before 1900. The reason the professions came to the attention of sociologists in the inter-war years was probably because sociology itself was becoming an established discipline. But professions like medicine were also acquiring significant social status, and so naturally prompted sociologists to ask how and why.

The first people to critique the rise of a new professional class came to be known as the functionalists. These sociologists theorised that the elite professions had achieved special prestige because they possessed certain traits and characteristics that brought balance to society. Because all societies included people who were ill, criminal, immoral, and idle, functionalists theorised that certain elite professions had risen to prominence because they represented the best response to social disorder. Functionalists studied medicine extensively, and concluded that it was doctors’ altruism and public service ethic, their specific expertise, shared moral code, and lengthy training, that set them apart, and justified their social privileges. This view dominated people’s understanding of professions through to the 1960s, and still has echoes today. As you will see later in the book, one of the key arguments I make is that physiotherapists still think very much in functionalist terms, despite the fact that it is now largely discredited. But functionalism is where we have to begin if we want to understand the professions sociologically, and so it is the subject of Chapter 2.

One of the main problems with functionalism is that it says almost nothing about power. It assumes that professions are disinterested in their own social status, and work only for the betterment of the public. It assumes that lists of value-neutral traits and professional characteristics explain why some professions hold elite social positions and others don’t. And it tells us nothing about how occupations managed to persuade society to grant them a privileged position in the first place. These limitations were starting to be unpacked in the early 1950s, but became a cacophony of criticism a decade later.

Functionalists belong to a group of sociological thinkers known as consensus theorists. Their belief is that social order ‘flows from consensus — from the existence of shared norms and values’ ^[5]. But through the 1950s and 60s, consensus theories were progressively undermined and replaced by the work of prominent conflict theorists, who then held sway in social theory circles for much of the next three decades. Conflict theories are based on the idea that society is not self-balancing, but is an ongoing struggle for power. Many of the most prominent conflict theorists used the tools of sociological research to show that the social conditions people were born into and had to live with — despite their abilities and choices — shaped the life they led. Today’s focus on the social determinants of health (poverty, access to services, discrimination, educational opportunity, employment, environmental degradation, etc.), is a direct legacy of this work ^{[6][7][8][9][10][11]}.

The impetus behind much of the conflict theory work was a desire to give voice to people increasingly marginalised by the now elite mainstream professions: women, people from racialised ethnicities, disabled people, gender non-binary people, people in the LGBTQ+ community, … In fact, the majority of people who were not the white, heterosexual, affluent, non-disabled, straight, ‘Northern’ men, who had come to dominate the elite professions over the previous 60 years. Conflict theorists argued in a string of eviscerating critiques through the 1960s, 70s, 80s and 90s, that professions like medicine seemed happy to ignore the rich cultural contribution that under-represented people and groups made in society, and through their ignorance, perpetuate stigma and disadvantage ^{[12][13][14][15][16]}. Beyond health itself, conflict theories were part of the broad sociological turn towards Marxist, feminist, post-colonial, and disability rights scholarship that dominated sociology in the second half of the twentieth century, and these are the subject of Chapters 4 and 5. But these ideas too began to be critiqued in the 1980s and 90s, just as functionalism had been decades before.

Conflict theories are powerful critiques of the professions, but sometimes they can imply that there are deep social forces shaping our lives that are hard to see and even harder to resist. There is little place for human agency in conflict theory. Some sociologists in the early 1980s, seeing society shifting subtly away from the radical activism of the 1960s and feeling the first blushes of neoliberalism, began to turn their focus away from conflict theories and concentrate, instead, on the sociology of inter-personal relationships and the ways societies gave collective meaning to things. These came to be known as symbolic interactionists because they were interested in how societies created meaning through inter-personal dialogue and exchange. This gave birth to an enormous body of work looking at lay-professional relationships, and, in healthcare, the way physicians and patients co-constructed what it meant to be healthy and sick. This field drew heavily on phenomenology and contributed a large part to the birth of the new field of qualitative research, that began to have an impact on healthcare in the 1990s. It also underpinned what we now call person-centred care.

At the same time, a second group of sociologists departed from conflict theories, but retained an interest in professional power. These sociologists drew heavily on the work of Max Weber — one of the founding fathers of sociology — and so came to be known as the neo-Weberians. These scholars concentrated on professional boundaries and the ways occupations practiced ‘social closure’ and encroachment as part of their professional ‘projects’. Inter-professional practice today is a beneficiary of this work, and much of the discussion about post-professional healthcare derives from them. Symbolic interactionism and neo-Weberianism are both unpacked in Chapter 6. But, as seems to happen in the sociology of the professions, both the symbolic interactionists and neo-Weberians accumulated more and more critique towards the end of the 20th century, and as we entered the new millennium, postmodernism came to prominence.

Postmodernists argued that there was no objective reality lying behind our experience of the world, and that it was the human hubris of the Enlightenment that had convinced us that science could discover some kind of universal truth. Postmodernists argued that all major beliefs, be they about science, religion, or even those pertaining to the professions themselves, were attempts to impose some ideas on to society at the expense of others. They argued that our task was not to pick a winner, but to expose the game being played and open doors to its alternatives. Postmodern approaches to the professions are explored in more depth in Chapter 7. Of course, postmodernism has not been immune from strong criticism in recent years either, and we are now beginning to see the emergence of even more diverse and interesting approaches to social institutions like expertise and the professions as a result of this critique.

Despite the seeming linearity of this very brief history of the sociology of the professions, the reality is that all the approaches mentioned above are alive and well, and operating very happily in a physiotherapy clinic, hospital ward, or online venue near you. Some of these approaches will resonate with readers more than others. That is fine. My goal with this book is not to try to sell you a particular perspective, but to try to use these tools to analyse physiotherapy and show how they can guide us to meet the challenges of 21st century healthcare. Whether you agree or not with my conclusions will depend, to some extent, on your own sociological orientation, and this will inform what you believe a profession is and can be. Before beginning this work in earnest, though, it would be useful to understand the role sociology has played in physiotherapy to date.