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                                            Black Workers

                                                  Chapter 10

          Professional Work.

“All professions are conspiracies against the laity”.

George Bernard Shaw from  The Doctor’s  Dilemma.

          The workers who are seen as having the most freedom and least constraint are the professions. There is typically a long period of training, which is partly technical, and partly into the values and traditions of the profession. So one’s working life is spent applying the knowledge gained as a student. Constraint does occur when the professional is employed by a large organisation. Here one is salaried, as opposed to receiving fees from individual clients. There may well be a hierarchy, where one’s superior may be another professional, or increasingly may not. Doctors in hospitals, and architects in large building firms, are good examples of both possibilities. However, as the knowledge of the professional becomes more specialised and technical, it becomes more difficult for non-professional to control their work. This may mean that mechanisms of control have to be bureaucratic. These mechanisms will include  the length of time allocated to the professional’s work, the spaces in which it occurs, and the filling in of much paperwork to describe details of the work.

          The value of service to the client is seen as basic for professionals, and the celebration of this value in one recent study was used to claim that professionals would always have a degree of freedom. Even when there is some bureaucratic control over a doctor's diagnosis, the professional body set the standards, and even the forms to be filled in. How  much control is exercised over the professional is then not clear. It is however, probably more than was exercised in the recent past.

          Nonetheless the attraction of the professions, as a form of work, remains high. There has been a large increase of female students on university degrees leading to a professional job. Female students now account for more than half of all students of medicine and a number of other professions (Crompton, 117: 1997). The professional can give some of the most persuasive answers to the question why work.  In traditional terms there are the attractions of serving only one client at a time; as opposed to a large number of customers. Service to the client has a humanistic air of care and concern for the well-being of the client. There is the attraction of having specific knowledge defined by the professional body, yet based on hard sciences and the arts. The architect is the classic example here. There is the membership of one's professional body, which has a code of ethics, and sets professional fees. The code of ethics allows for the discipline of unprofessional conduct, and removal from the profession. The set fees creates a confidence in the client that they are not being overcharged for the professional services. There are also the more trivial aspects to the professional role, the brass plate outside the office door; the letters after one's name. Perhaps the most attractive aspect of this work is the ability to control one's own work; where  there is no non-professional superior above one.

          All of the above can be seen as part of the glamour, even mystique of the professions, and may go some way to explaining the increasing attractiveness of the profession to new entrants. The reality of professional work is more complex. Looking firstly at the claim that professionals control their own work, there are now many studies that show that professionals increasingly work in large organisations where there are senior managers controlling these professionals. Indeed the history of engineers in America is one where , from the 19th century these professionals never knew anything but working for managers in large firms (Larson, 30: 1977). Further, these engineers were salaried workers, as opposed to charging professionally fees to an individual client, which had been set by the professional body. Looking at the caring professions in Britain Richard Titmuss observed that professionals were pre-eminently people with status problems. This was because the work that they did, caring for people, was low status. For example caring for the very old or the very young was work anyone could do; but not everyone wanted to! Worse, it could be done by unpaid volunteers, some of whom might even be untrained. The British welfare state created a huge demand for professionals, even new professions like social workers, and educational welfare officers. Here there was little involvement by the client, who was provided by the state, as opposed to individually requesting the service of the professional. In this scenario the professional was seen as having power over the client. One study found that these professionals were unaware that they were exercising power, and even rejected the idea that they were powerful agents (Hugman, 33: 1991). However, the majority of their clients were from the working class, and much of the professional  work involved ensuring their clients obeyed a variety of laws.

          The social work professionals working in a large bureaucracy  are themselves constrained by the law, even though their work was to constrain others. Also, the existence of a large bureaucracy itself constrained these professionals. This was a problem as the professional had to present themselves as competent to their client in a typically face to face situation. However, many important decisions could only be made in consultation with colleagues. This meant that face saving excuses would have to be made to clients to explain the delays. This could produce scepticism in the client about the professional, and undermine the whole professional client relationship.

          These clients had often not entered the role of client willingly, partly because it was a legal requirement, or because they had become ill. In these cases the client cannot exit the role of client without professional intervention. Further, in the case of illness they will typically wish to exit the role as quickly as possible!  This creates obvious difficulties for the professional client relationship. In cases of extreme illness, where long term care is needed, the role is difficult, even impossible, to exit. Here the client is in permanent need of professional care, and is in the weakest position of all clients. This may well strengthen the power of the professional, but we have now moved some way from the more idealistic, and humanistic, vision of the relationship. Further, in these extreme cases, the professional may be seen less frequently, and a variety of  auxiliaries and assistants will be the daily contact for the client. So nurses, solicitor's clerks, technical draughtsmen, radiographers, victim support volunteers, and receptionists may be seen much more frequently. 

          Some writers have responded to these changes from the 19th century image of the self employed free professional, to the employees of some large organisation, by claiming that the professional has now become proletarianised; that is that they no longer have the prestige of the past, and have been pushed down into the working class (Johnson, 1977). The evidence for this thesis is that the large organisation has a variety of managers, and accountants (also professionals of course), who control much of what the professional does. The professional is paid a wage by the organisation, and not by the client. There is often a hierarchy of ranks, through which the professional may be promoted. Many professionals belong to a trade union as well as to their professional body. Professionals, such as architects in large organisations producing large scale housing projects for poor clients, rarely meet their clients. Rather the real client is a government department. Finally, the authority of the professional based on their command of a body of knowledge, may be reduced by a increasing  knowledge on the part of the client. This can come partly from more  state education; but also the growth in consumer awareness, and a range of do-it-yourself publications. This makes it possible for the client to question the professional's opinion. A related problem is that the knowledge base is constantly changing. This may be due to changes in the basic science, changes in government regulations, changes in technology, and changes in professional practices. For those, perhaps older, members of  the profession who have not kept up to date with these changes their practice may become out of date, redundant, even dangerous.

          The proletarianisation thesis can be seen as having two forms; a weak form and a strong one (Murphy, 1990). The weak form argues that all the professionals have lost to various managers is the control over policy decisions about how their work is to be organised, and perhaps control over who is the client. They have retained effective control over the technical detail of their work practices. Whereas manual workers have lost this technical control over their work practices. So there is a major difference between manual workers and professionals. This brings into question even the weak claim to proletarianisation. The strong thesis argues that professionals have lost control over organisation, that is over how their services are to be sold on which markets; but also over the technical aspect of how their work is to be done. At this point the debate turns on exactly how much of the daily work of  how many professionals is controlled by others in a management hierarchy. For one influential writer on the professions this ability to control one's own work is what defines a profession, as no other occupation can do this (Larson, xii: 1977)! 

          Freidson uses this argument, not only to reject proletarianisation in it's strong form, but to present a robust defence of the continuing relevance of the professional.  He argues that

          "Ideal typically, professional autonomy is the antithesis of proletarianisation the workers themselves determine what work they do, and how they do it."

          (Freidson, 164: 1994).

          Further, professionals have discretion, judgement, and responsibility for their work.  The very complexity and uncertainty of the work requires discretion etc.. The mechanism for achieving and practising these values is the peer review, by other professionals. He does admit that computerised records of  the past practices of professionals may be easily stored in computer files. But argues that it is the professionals themselves who determine what is stored and how; and even interpret the results when published. Also,

          “the first line of hierarchical supervision  is always filled by a professional”.

          (Freidson, 139: 1994).

This is often required by law. However, this leaves open the real possibility that higher levels of supervision may well not be by professionals, as argued earlier. Even where higher levels are filled by professionals, there are two possible outcomes. One is that there increasing contact with senior managers may influence their view of current events and problems, which may weaken their professional values. The second possibility is that the professional at the top of an organisation may cease to be a professional in terms of their practice. They may not see patients , or clients, at all any more. Their full time work can be largely, or entirely, managerial.

          Freidson gives the example of the management of health care in America. Here hospital managers produce quantitative data for patient type, length of stay in hospital, doctor's diagnosis and much more. This data can be manipulated to provide analysis of historical practices, and compare this past to an ideal set of norms for doctor's practices. This creates the possibility for the managers to set norms for doctors which affect clinical judgement and diagnosis. Some diagnoses cost more than others. There may be a longer stay in hospital with some diagnoses, this stay  provides more income for the hospital. This can create a sort of "creep" (Freidson, 186: 1994) towards longer stays. So the person who enters these records of decisions and manipulates them may well affect the clinical judgement of the doctor.  Freidson insists that this person is the doctor, and not the hospital manager. Further, that the contents, format, and standards used are created, reviewed, and validated by professionals, and not managers. However, this insistence is not accompanied by any evidence.

          Another basic mechanism by which the profession can keep control of their work is through credentialism. This means that one can only become a professional through passing certain exams, and thus becoming credentialised. This is a way of excluding others, such as managers, civil servants or politicians, from professional knowledge. This makes it difficult for non-professionals, including clients, to question professional judgements. For Freidson the other side of this exclusion is the inclusion of  professionals, and students of the profession in a "shelter" (Friedson, 161: 1994), which assures both of a life long career in return for a long period of training. Also there is the issue of earnings foregone during training. There has to be some recompense for this in the form of professionally set fees. This makes the professional life attractive to the young. Further, the profession's control over the knowledge base during training implies that only other professionals will control this work. This shelter should make the practice of the professional into a central life interest, producing considerable commitment to the work. All this, for Freidson, adds up to the very antithesis of alienation and proletarianisation.

          Another aspect of credentialism is monopoly. As only those who are credentialised can practice, this creates a monopoly over professional work. This monopoly can be seen as benign, where those excluded in the past were poorly trained in the law, or even corrupt. The nineteenth century history of the Chicago Bar Association showed that  there was a concern for the public, and some beneficial changes in the law (Mac Donald, 32: 1995). But this monopoly was not entirely disinterested. It also created a sort of scarcity, which helped to raise the status of the profession. There was also more control over the knowledge base. The academics could make the knowledge base more abstract. The monopolised professionals could relate this abstract knowledge to the mundane everyday practice. The knowledge could not be too abstract, else it became too formal and distant from the client; nor should it become too concrete, as this was too close to the clients everyday knowledge. A middle position was both ideal, and probably difficult to maintain over time. This is because both the academic/scientific knowledge changes over time, as does the client's knowledge through do-it-yourself etc.. Managing this difficult balancing act is very much the job of the professional body. 

          Changing the focus of those who are excluded, from poorly paid lawyer to the client, another picture emerges. Firstly, there is the  inequality of reward as between professional and client, and even between one professional and another. Freidson even quotes the example of some American Lawyers who have been described as the "hired guns"(Freidson, 169: 1994) of the rich and powerful, and can become rich themselves. Secondly, there is inequality of knowledge as between professional and others. So some are excluded from professional knowledge.  This can give more control and power to the professional. Freidson's defence of the professional is that inequality, properly understood, is functional difference. What this means is that with a complex division of labour in an industrialised society, some occupations will be more complex than others, and may well be more valuable to society. So society should preserve  this value with higher rewards. Further, this valuable work  will be done in a form of co-operative control, which also encourages reflection on professional practice; and may even produce new knowledge through research within the profession, often in collaboration with universities. If professional work  is not restricted to the needs of managers or clients, then a milieu of intellectual innovation is possible. Here scholars and scientists become  a model for professionals, or are even seen as professionals themselves. This focus is away from the more mundane everyday practice of the professional, which may be more routinised, in the sense of the application of prior training to a variety of client needs. Including scientists and scholars also blurs the boundaries of who is, and is not, a professional. At an extreme it raises the possibility of the professionalisation of everyone; which would result in the category of profession ceasing  to have any meaning.

          It is, of course, utopian to pretend that with a complex division of labour a client can learn enough about a number of professions in one lifetime, in order to reduce the inequalities of knowledge. However, the spread of alternative medicines, the boom in do-it-yourself magazines, the increasing use of insurance by professionals to protect themselves from angry clients, all point to a growing willingness of clients to learn. Indeed the increasing participation in post-compulsory state education may give greater confidence to clients, and even more knowledge.

          Perhaps those affected most by the strategy of exclusion are those ancillary workers like nurses who work closely with doctors, but are not themselves professionals. These ancillary workers have been called "a class of ineligibles", (Witz, 46: 1992) who cannot gain professional status. They are frequently women. More complexly,  this been called demarcationary closure. This is where there are boundary controls within a large profession of, say, medicine: such that nurses are within the occupation, but their presence is bounded. This means that they cannot normally cross this boundary between nurse and doctor. There is a set of defined competencies for the nurse, beyond which s/he must not go! Recently, some detailed changes have been made to enlarge the role of nurses. Whether the boundary becomes more blurred in the future remains to be seen. 

          Some occupations have attempted to usurp these boundaries of competence. Arguments of equality of opportunity have been used. So when certain qualifications in radiography, or physiotherapy, have been acquired then those individuals may be seen as professionals. However, those individuals who do not acquire these qualifications remain where they were. This is an individualist strategy, which does little, apart from adding more rungs to the ladder, to change the structure of the occupations. Another strategy is to change the very structure itself, rather than to ask for inclusion within it. The example of alternative medicine can be seen as a radical challenge to the traditional structure of medicine. Indeed  homeopathy has recently been given some recognition in Britain.

          The efforts of radiographers and midwives for more recognition, and inclusion within the medical profession has traditionally been met with top down exclusionary strategies. This is a conflict with a long history. Within radiography the men argued that they should have control over the technical aspects; whilst the women should be more involved in patient care. So here is an example of a strategy with only limited success for the women involved. They were again within a set of defined competencies. The earliest attempts of women to gain an education in medicine in the University of Edinburgh were met by a series of petty restrictions. These included refusing to teach only one woman, eventually accepting five women, but charging three times the fees that men paid. One woman gained the top mark in chemistry, but the prize went to the man immediately below her on the class list. Women were prevented from entering an examination hall by drunken students; when inside the hall a sheep was pushed into the hall. When the exam was over the women had to be escorted from the hall by a body guard to protect them from rioters. This was exclusion that was gender specific. It was not just ineligibles to be excluded, but women.

          More recently women have entered the professions in larger numbers, and account for more than half of  students of many of the professions. Yet even here there are significant gender differences after graduation. Women accountants do personal taxation as this allows work from home. Men travel to firms to do the legally required annual audit of the books. Women pharmacists tend to work for high street chemists, sometimes part time. Male pharmacists tend to work for large hospitals, or in research. Even after becoming a fully qualified professional there seem to be boundaries of specific competencies, within which women are enclosed. This makes the more general point that professions are exclusionary bodies to managers, clients, ancillary workers, and even some members of their own profession.

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Conclusion.