Perspective

The Meanings of Autonomy for Physical Therapy

Robert W Sandstrom
RW Sandstrom, PT, PhD, is Associate Professor and Chair, Department of Physical Therapy, Creighton University, 2500 California Plaza, Omaha, NE 68178 (USA). Address all correspondence to Dr Sandstrom at: RobertSandstrom@ creighton.edu. [Sandstrom RW. The meanings of autonomy for physical therapy. Phys Ther. 2007;87:98 110.] 2007 American Physical Therapy Association

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 signicant social need and to preserve individual autonomy. Professional autonomy includes control over the decisions and procedures related to ones work (technical autonomy) and control over the economic resources necessary to complete ones work (socioeconomic autonomy). Professional autonomy is limited and weakened by the relationship of one profession to another (dominance), by the inuence 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.

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Meanings of Autonomy for Physical Therapy he 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 nd 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 insuJanuary 2007

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.
larity 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 reection 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.

community based on the elds 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 professions 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 inuences 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 ramications not only on personal health but on social role, responsibilities of the community, and distribution of economic resources. For example, professional examinations and evaluations dene 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 benets 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.

What Is Autonomy?
Professional autonomy, or the ability to control the conditions of ones work, is an outcome of a trust relationship established between a profession and the society.3 6 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 inuence over the everyday terms of his or her work than comparable freedoms available to other workers.4(p232) It reects deference to the profession by others in the

Types of Professional Autonomy

Freidson, a preeminent sociologist of the professions, dened 2 types of professional autonomy: technical autonomy and socioeconomic autonomy. Technical autonomy is the right to use discretion and judgment
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Meanings of Autonomy for Physical Therapy in the performance of work.7(p154) In general, society gives the professions wide, but not total, independence in terms of technical autonomy.4(pp3842),7(pp4445) 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 difculty of others in fairly evaluating professional work. Technical autonomy is regulated by standards of practice, accreditation, and licensure. These social policies act to dene 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 condence in government and capitalistic enterprises as mechanisms to address social problems. Changes in reimbursement policy (managed care is the best example) illustrates the inuence 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 re100 f Physical Therapy Volume 87

garding 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 denes 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.

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(pp161162),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 difculty 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)

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 dening 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 briey. Professional Dominance For the past 40 years, sociologists have studied the quest for power by the professionssometimes in the

During the period of greatest political power (19451960), 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 occupationsthe hospital.8(p39) Health care occupations that did not accept the dominance of medicine were labeled quack elds and were subjected to enormous pressure by organized medicine to cease their patient
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Meanings of Autonomy for Physical Therapy care activities.9(p49) Other occupations, including physical therapy, exchanged their autonomy for the necessary recognition of their eld by medicine.1315 In doing so, these elds 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 dened rationalization as the pervasive use of reason, sustained where possible by measurement, to gain the end of functional efciency.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.
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At rst 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 efciencies 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 inuence 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 patientcentered 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 conict between the professional and bureaucratic models of health care delivery.4(pp190 192) The root of this conict 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 dened 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 dene 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 peoples 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
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Meanings of Autonomy for Physical Therapy the inward focus of a profession that blinds itself to broad and signicant 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 eld as a profession and of its accompanying autonomy is dependent upon the ofcial 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 signicant reduction in its dominance.7(p370),9 As Krause remarked, no profession in our sample has own 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 scientic changes that brought improvements in health, sometimes spectacularly, these gains brought signicant 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

Figure 1.
Traditional medical model of physical therapist practice.

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 reafrmed 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 reected 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. In 1991, Guccione postulated a scope of physical therapist practice that focuses on addressing the impairments and functional limitations of disablement (in current International Classication 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.

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
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Meanings of Autonomy for Physical Therapy Disablement, however, is not completely understood as a medical problem. In fact, the medicalization of disablement has been criticized for its identication 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.33 Physician-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 eld, not because the physician has a monetary interest.34 Patient care is of bottom-line concern, with the business end, of necessity, needing to break even. It has been a pleasure to work with wellqualied orthopedic surgeons, osteopaths, and a practice administrator who understands ethical medical and business practice, quality care, and mutual respect [POPTS practitioner].35 It 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 physicianrendered physical therapy treatments, will lead to further degradation of the publics view of our profession while increasing cash ow to the entities involved.36

tonomy 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 dened 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 ve 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

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. Physicianowned physical therapy services are a threat to the socioeconomic au-

This denition emphasizes a reduction in medical dominance of the eld, professional responsibility of the physical therapist, the publics right to choose a provider, and quality of patient care. This denition is consistent with the denition of
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Meanings of Autonomy for Physical Therapy functional autonomy rst 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(pp795796) 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.
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Figure 2.
Interdependent, autonomous physical therapist practice. 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.

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 rst 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 professionstheir ideology of service. . . . The professional ideology of service goes beyond serving others choices. Rather it claims devotion to a transcendent value which inuences 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 [authors italics] when the practical demands of patrons and clients stie it.40(pp122123)

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

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Meanings of Autonomy for Physical Therapy 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).
This article was received August 9, 2005, and was accepted August 23, 2006. DOI: 10.2522/ptj.20050245 9 Callinicos A. Social Theory: A Historical Introduction. Washington Square, NY: New York University Press; 1999. 10 Ritzer G, Walczak D. Rationalization and the deprofessionalization of physicians. Social Forces. 1988;67:121. 11 Horner JS. Autonomy in the medical profession in the United Kingdom: an historical perspective. Theor Med Bioeth. 2000; 21:409 423. 12 Magistro CM. No descriptor required [letter to the editor]. Phys Ther. 2002;83: 10431044. 13 Kenny D, Adamson B. Medicine and the health professions: issues of dominance, autonomy and authority. Aust Health Rev. 1992;15:319 334. 14 Gritzer G, Arluke A. The Making of Rehabilitation: A Political Economy of Medical Specialization, 1890 1980. Berkeley, Calif: University of California Press; 1985: 711, 54. 15 Parry A. Ginger Rodgers did everything Fred Astaire did backwards and in high heels. Physiotherapy. 1995;85:310 319. 16 Wagner D. The proletarianization of nursing in the United States, 19321948. Int J Health Serv. 1980;10:271290. 17 Ovretveit J. Medical dominance and the development of professional autonomy in physical therapy. Soc Health Illness. 1985; 7:76 93. 18 Roemer M, McKinlay HB, Arches J. Proletarianization of physicians, organization of health services? Int J Health Serv. 1986; 16:469 471. 19 Morris J. Current issues of accountability in physiotherapy and higher education: implications for the physical therapy educator. Physiotherapy. 2002;88:354 363. 20 Ferlie E. Large scale organizational and managerial change in health care: a review of the literature. J Health Serv Res Policy. 1997;2:180 189. 21 Dougherty CJ. The excesses of individuality: for meaningful healthcare reform, the US needs a renewed sense of community. Health Prog. 1992;73:2225. 22 Bruckner J. Physical therapists as double agents: ethical dilemmas of divided loyalties. Phys Ther. 1987;67:383387. 23 Haug MR. A re-examination of the hypothesis of physician deprofessionalization. Milbank Q. 1988;66(suppl 2):48 56. 24 Mechanic D. Sources of countervailing power in medicine. J Health Politics Policy Law. 1991;16:485 498. 25 Schlesinger M. A loss of faith: the sources of reduced political legitimacy for the American medical profession. Milbank Q. 2002;80:185235. 26 Kassirer JP. Pseudoaccountability. Ann Intern Med. 2001;134:587590. 27 Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941952. 28 Light D, Levine S. The changing character of the medical profession: a theoretical overview. Milbank Q. 1988;6(suppl 2):10 30. 29 Medicare Payment Advisory Commission. Report to Congress: Eliminating Physician Referrals to Physical Therapy (December 2004). Available at: http://www.medpac. gov/publications/congressional_reports/ Dec04_PTaccess.pdf. Accessed June 28, 2006. 30 Guccione A. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991;71:499 503. 31 Boissonnault W, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthop Sports Phys Ther. 2006;36:351353. 32 Kennedy J, Minkler M. Disability theory and public policy: implications for critical gerontology. Int J Health Law. 1998;28: 757776. 33 Fife S. POPTS: another view [letter]. PT Magazine. 2003;11(12):8. 34 Scarpelli E. POPTS inhibit competition [letter]. PT Magazine. 2004;12(4):8. 35 Osterhues DJ. POPTS: an appropriate relationship [letter]. PT Magazine. 2004; 12(4):8 9. 36 Schaefer K. POPTS deprive patients of choice [letter]. PT Magazine. 2004;12(4):8. 37 American Physical Therapy Association. Board of Directors minutes (Program 32, Competencies of the Autonomous Physical Therapist Practitioner, B of D 11/01). Available at: www.apta.org/governance/ governance_5/BODminutes. Accessed May 25, 2004. 38 Swisher LL, Beckstead JW, Bebeau M. Factor analysis as a tool for survey analysis using a professional role inventory as an example. Phys Ther. 2004;84:784 799. 39 Johnson MP, Abrams SL. Historical perspectives of autonomy within the medical profession: considerations for 21st century physical therapist practice. J Orthop Sports Phys Ther. 2005;35:628 636. 40 Freidson E. Professionalism: The Third Logic. Chicago, Ill: University of Chicago Press; 2001.

References
1 Rothstein JM. Editors note: Autonomy or dependency. Phys Ther. 2002;82:750 751. 2 Rothstein JM. Editors note: Autonomy or professionalism? Phys Ther. 2003;83: 206 207. 3 Hoogland J, Jochemson H. Professional autonomy and the normative structure of medical practice. Theor Med Bioeth. 2000;21:457 475. 4 Larson MS. The Rise of Professionalism: A Sociological Analysis. Berkeley, Calif: University of California Press; 1977. 5 Freidson E. Professional Powers: A Study of the Institutionalization of Formal Knowledge. Chicago, Ill: University of Chicago Press; 1986. 6 Mechanic D. The functions and limitations of trust in the provision of medical care. J Health Politics Policy Law. 1998;23: 661 686. 7 Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York, NY: Harper & Row; 1970. 8 Krause EA. Death of the Guilds: Profession, State and the Advance of Capitalism; 1930 to Present. New Haven, Conn: Yale University Press; 1996.

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Appendix.
Glossary of Terms

AutonomyThe ability to control the terms of ones work. Countervailing ForceA social force that is limiting or preventing a social change (eg, a policy revision) from occurring. DeprofessionalizationThe social process by which the professions are losing the characteristics of a profession, including autonomy.

DominanceThe ability of a profession to control the terms of another professions work. InsularityAn internal process by which a profession focuses on its own needs to the detriment of larger social needs and responsibilities. MedicalizationA process by which disablement is viewed as a problem centered in the person (pathology) and the solution to be controlled by a medical provider.

RationalizationThe social process by which human work behavior is organized into bureaucracies through the development of rules and protocols. Socioeconomic AutonomyThe ability of a profession to ascertain and allocate the economic resources necessary to complete their work. Technical AutonomyThe ability of a profession to control the decisions and procedures related to their work.

Invited Commentary
Autonomy. What a charged word that is for our profession! Is professional autonomy a great good for the profession, one of the most important developments over the last 50 years and the soon-to-be-realized end point of nearly a century of growth and development? Or it a fading ideal, lost in a sea of profound changes in the health care system of the United States that serve to restrict the autonomy of even the once-venerated physician? Or is it an unfortunate misnomer, implying arrogant isolationism when interdependent, but unfettered, practice is what we are really trying to achieve? Your view may depend on whether you are inuenced by the recently published reections of the Catherine Worthingham Fellows of the American Physical Therapy Association (APTA)1 and APTAs Vision 2020,2 by the writings of medical sociologists,3,4 or by the always thought-provoking commentary of the late Jules Rothstein.5 Given the charged nature of autonomy to physical therapists, Sandstrom does a great service to the profession in writing this article, which articulates what autonomy means in a wider space than the profession of physical therapy. As I read
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his article, I identied 5 areas that seemed most ripe for comment: the relationship between professionalism and autonomy, the separation of autonomy into technical and socioeconomic elements, the concept of functional autonomy, the changing role of autonomy in the health care system today, and the linking of professional autonomy with the autonomy of the individuals we serve.

one have a warm, yet professional manner with patients? Does another interact professionally with physician colleagues? In reducing our thinking on professionalism to these individual behaviors, we ignore the considerable scholarship about the professions and the role of professionals in society. The characteristics of professions and of individual professionals have been addressed by many scholars. One concise denition of a profession is offered by Starr in his seminal work on the transformation of American medicine: A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than prot orientation, enshrined in its code of ethics.4(p15) The importance of autonomy to the concept of a profession is seen in the very structure of the denition, with regulates itself appearing rst in Starrs short list of characteristics of a profession. Part of this self-regulation is through systematic, required training (controlled in physical therapy by the Commission on Accreditation in Physical Therapy Education) and collegial discipline (controlled in physical therapy by the
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Relationship Between Professionalism and Autonomy

Professional autonomy, the interesting focus of this article, is but one element of professionalism. An understanding of both concepts is needed, I believe, to fully understand the concept of autonomy. Indeed, both conceptsautonomous practice and professionalismappear in the focused list of 6 elements of APTAs Vision 2020, with the other 4 elements being direct access, Doctor of Physical Therapy, evidence-based practice, and practitioner of choice.2 Professionalism, Im afraid, is sometimes reduced to considerations of a set of appearances and behaviors of individual therapistsDoes this therapist dress professionally? Does this

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Meanings of Autonomy for Physical Therapy disciplinary procedures established in state physical therapist practice acts). But autonomy is not the only element of a professiona profession has a base of specialized knowledge (physical therapys base of knowledge is now codied in the Guide to Physical Therapist Practice6 and added to and modied regularly through the peerreviewed literature of the profession) and a service orientation enshrined in its code of ethics (articulated in many physical therapist practice acts as standards of practice and by APTA in its Code of Ethics7). Autonomous practice must exist within this larger framework of professionalism. lows used the term autonomy in their responses, with most of the responses referring to autonomy in clinical decision making. Several other responses, however, referred to other important aspects that I now think of as additional expressions of our technical autonomy as a professionthe publishing of the Guide to Physical Therapist Practice,6 not technically a standard of practice, but certainly a statement in which physical therapists articulate their own vision of the scope of practice; the establishment in 1977 of an educational accreditation body separate from medicine, the predecessor to todays Commission on Accreditation of Physical Therapy Accreditation,8 an important element in translating the professions practice expectations into educational practice; greater regulatory autonomy through the establishment of independent physical therapist practice boards in some states rather than regulation through a medical board as was common earlier in the professions history; and greater regulatory consistency through the establishment of the Federation of State Boards of Physical Therapy, with its Model Practice Act9 and nationwide licensure testing. troubling to me without further explanation. Using different language, but perhaps a similar concept, Starr, in discussing the autonomy of physicians in the United States health system in the early 20th century, noted:
[Physicians] wanted to be able to use hospitals and laboratories without being their employees, and consequently, they needed technical assistants who would be sufciently competent to carry on in their absence and yet not threaten their authority. The solution to this problem how to maintain autonomy, yet not lose control had three elements: rst, the use of doctors in training (interns and residents) in the operation of hospitals; second, the encouragement of a kind of responsible professionalism among the higher ranks of subordinate health workers; and third, the employment in these auxiliary roles of women who, though professionally trained, would not challenge the authority or economic position of the doctor.4(p221)

Technical and Socioeconomic Autonomy

The articulation of both technical and socioeconomic aspects of autonomy is an exceedingly useful element of this article. Technical autonomy, as presented by Sandstrom, relates to discretion and judgment in exercising ones profession and is regulated by standards of practice, accreditation, and licensure. Socioeconomic autonomy relates to access to the economic resources needed for accomplishing ones work. Conceiving of autonomy in these 2 different ways was particularly useful for Sandstroms presentation of different points of view on physician ownership of physical therapist practices as relating to either technical autonomy (I make my own patient care decisions) or socioeconomic autonomy (the physicians prot from physical therapist services). As I sat down to prepare this commentary, it occurred to me that the recently published reections of the Catherine Worthingham Fellows of APTA on the most signicant advances in physical therapy during the previous 50 years1 might provide some useful perspective. With just a supercial reading of their comments, it was obvious that many FelJanuary 2007

Functional Autonomy
In his concluding thoughts, Sandstrom indicates that APTAs denition of autonomy is consistent with another type of autonomyfunctional autonomy, which he denes through Friedsons words as the degree to which work can be carried out independently of organizational or medical supervision and can attract its own clientele independently.10(p53) Furthermore, this term is linked to a paraprofession, suggesting that it is not a characteristic of the real professions. Sandstroms characterization of APTAs vision as consistent with Friedsons paraprofessional functional autonomy is

This responsible professionalism that Starr refers to is surely not the type of autonomy that contemporary physical therapists have in mind and I assume it is not what Sandstrom had in mind. But Friedsons functional autonomy, in being linked to the paraprofessions, seems to have something in common with Starrs responsible professionalism in the higher ranks of subordinate health workers. Id be interested to hear more from Sandstrom about what he means when he uses the term functional autonomy.

Autonomy in the Health Care System Today

Sandstrom reminds us of the changing role of autonomy in the health care system today; reminds us that the increased autonomy enjoyed by physical therapists is occurring at a historical low point for the autonomy of the professions. Physicians,
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Meanings of Autonomy for Physical Therapy long used to being self-employed professionals who served as gatekeepers to all health care services and practiced as their judgment dictated, are now often employed by health systems, must work collaboratively with an increasing number of nonphysician rst-contact providers, must precertify with insurers before performing surgeries or other expensive procedures, and must limit drug prescriptions to a narrowing set of products approved by a particular insurer. No wonder that associations for medical professionals move into high gear when other professionsphysical therapy includedadvocate for more autonomy. This turf protectionand turf erosionis not new. Numbers, writing about medicine in the 1930s, noted:
Medical doctors encountered equal difculty keeping assorted other health-care professions from intruding on what they regarded as their rightful domain. Although they actually assisted podiatrists in achieving their independent status on the grounds that corn-cutting like toothpulling was too trivial to control they fought continually to limit the activities of such interlopers as optometrists, psychologists, and midwives, who competed directly with physicians specializing in ophthalmology, psychiatry, and obstetrics.3(p233)

between professional autonomy for physical therapists and the autonomy of the individuals they serve. In part, this is clever wordplaynot just speaking to serving our patients and clients, but characterizing this service as autonomy for our patients, parallel to our increasing autonomy as a profession. But more than just clever wordplay, this idea is clearly consistent with Starrs denition of a professional, which speaks to service rather than a prot motive.4 However, physical therapists should take care not to be too disingenuous about this aspect of autonomy. The following quote, about medicine, should give us pause:
Medical apologists have long argued that professional advancement brought corresponding gains to the public. . . . In recent years, however, critics of the medical profession have increasingly questioned such assumptions, arguing instead that the reforms we have described centralized, bureaucratized, modernized and expanded medicine and medical education in the interests of physicians own professional needs and with little regard for the needs of the public. The truth, I believe, lies somewhere between these two extremes. On the one hand, there can be little doubt that physicians beneted handsomely from their efforts to regulate and monopolize the practice of medicine. It is equally apparent that the elevation of the profession, in conjunction with other factors, drove up the cost of medical care, created a shortage of American-trained doctors, and damaged the chances for the poor and minorities to pursue careers in medicine. On the other hand, only the most prejudiced observer would argue that the public did not gain as well. Curative medicine may have contributed little to the dramatic reduction in mortality during the past century, but physicians using preventive and ameliorative measures did signicantly improve the quality and length of life in America. And although the profession continues to harbor its share of scoundrels, patients today enter doctors ofces with much

less cause of fearand much more hope of being helpedthan did their grandparents and great-grandparents. The interests of the profession and the public may not be identical, but neither are they antithetical.3(p234)

Although not a new phenomenon, today there are both new interlopers (eg, physical therapists, pharmacists, nurse practitioners) and new forms of interloping (controls instituted by insurers and employers). Sandstroms work reminds us that physical therapists who are working to enact greater autonomy for physical therapists need to operate deftly within the changing political, economic, and social milieu of the contemporary health care system.

I believe the same is true for physical therapythat our recent advances as a profession have beneted not only physical therapists but also our publics. Physical therapists command higher salaries, work in more varied settings, see patients without referral, work with evaluate and treat models when referral is required, and own more private practices than previously. Patients have more choices of where to receive physical therapy, have more physical therapists to choose from, have more ways to gain access to physical therapy, and are served by therapists with more diagnostic acumen and a deeper therapeutic toolbox than previously. It is a great time to be a physical therapist, to exercise a great deal of professional autonomy in the service of individuals with disabling conditions that limit their own autonomy. Sandstroms article has helped me think of autonomy in a more sophisticated waysI trust it will do the same for individual practitioners as well as change agents within the profession, both of whom continue to work toward a higher, more consistent level of autonomy for physical therapists.
E Domholdt, PT, EdD, FAPTA, is Vice President for Academic Affairs and Professor of Physical Therapy, The College of St Scholastica, 1400 Kenwood Ave, Duluth, MN 55811 (USA), bdomhold@css.edu. DOI: 10.2522/ptj.20050245.ic

References
1 The Worthingham Fellows opine: the most signicant advance in physical therapy in the past 50 years. PT Magazine. 2006;14(6):60 62, 64, 66, 68, 70.

Serving the Public

Another very useful element of Sandstroms article is the link it draws
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2 American Physical Therapy Association Vision 2020. Available at: http://www.apta. org/AM/Template.cfm?Section Vision_ 20201&Template /TaggedPage/ TaggedPageDisplay.cfm&TPLID 285&ContentID 32061. Accessed October 22, 2006. 3 Numbers RL. The fall and rise of the American medical profession. In: Leavitt JW, Numbers RL, eds. Sickness and Health in America: Readings in the History of Medicine and Public Health. 3rd rev ed. Madison, Wis: University of Wisconsin Press; 1997. Originally in Hatch NO. The Professions in American History. Notre Dame, Ind: University of Notre Dame Press; 1988. 4 Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books, The Perseus Books Group; 1982. 5 Rothstein JM. Editors note: Autonomy or dependency. Phys Ther. 2002;82:750 751. 6 Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001:9 746. 7 American Physical Therapy Association Code of Ethics. Available at: http://www. apta.org/AM/Template.cfm?Section Home & TEMPLATE / CM / ContentDisplay.cfm& CONTENTID 21760. Accessed October 22, 2006. 8 Commission on Accreditation in Physical Therapy Education Handbook. Preface and Introduction. Available at: http://www. apta.org/AM/Template.cfm?Section Home &Template / CM/ ContentDisplay.cfm& ContentID 19985. Accessed October 22, 2006. 9 Federation of State Boards of Physical Therapy. The Model Practice Act for Physical Therapy. 4th ed. Available at: http:// www.fsbpt.org/download/MPA2006.pdf. Accessed October 22, 2006. 10 Friedson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York, NY: Harper & Row; 1970.

Author Response
I thank Domholdt for her commentary and insights into this article. Her contributions in this area and to the profession are notable, and I am most grateful that she has taken the time to comment upon this perspective. A central thesis of this article is that increasing autonomy for physical therapists does not exist in a social vacuum and that changes in autonomy have anticipated, and some unanticipated, consequences for the profession, the health care system, and society. In fact, I would argue that the relationship of physical therapists to their communities and society dene the type and amount of autonomy that physical therapists enjoy and will enjoy in the future. It is also true, I believe, that there is a time for everything. While we may be impatient or frustrated by the changes that do or do not occur, we must be always cognizant of the needs of our communities so that policies are in place to meet the need for necessary physical therapy services for the public we serve. Fundamentally, our autonomy depends on the needs of people who need our services and on our ability,

Robert W Sandstrom

in an unfettered and efcient manner, to meet those needs. Physical therapists need to recognize that the communities with which we need to interact as our social role changes are diverse and that this diversity exists both between and within us and those communities. I believe many assumptions are made about the meaning of physical therapist autonomy. As Domholdt writes, physicians have their own motives to control physical therapy as an extension of medical practice. Policymakers may be concerned about the cost and efciency of allowing another provider to have unsupervised access to insurance dollars. They also may be dissatised with the status quo and be looking for new provider structures to promote efciencies and improve outcomes. Sociologists may write of us as a paraprofession1 or as demonstrating responsible professionalism in the higher ranks of subordinate health care workers.2 I believe that some physical therapists today believe that autonomy is primarily a technical matter, whereas many others believe it has signicant socioeconomic connotations. Domholdts

contribution to this dialogue is exceptional as she reinforces the need to consider autonomy within the realm of professionalism and articulates the improvements in physical therapist professional status and autonomy over the last several decades. I believe that Domholdt misreads the connection among functional autonomy, a paraprofession, and the American Physical Therapy Associations Vision 2020 statement in this article. Functional autonomy was used by Freidson to set a standard whereby a health care occupation could be judged to have moved out of a paraprofession status. It is clear, as Domholdt eloquently recites, that physical therapists have more functional autonomy today than they did in 1970, that physical therapy is a profession and the public is well served by it. Autonomy for physical therapists is vital for the future. It is vital because of the importance of autonomy to people who are experiencing disablement. Like today, it will be an autonomy dened by its times and social forces. As long as the profession remains secure in its service focus to people who are experienc-

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Meanings of Autonomy for Physical Therapy ing disablement, looking to a future of disease and injury prevention and in dialogue with its communities, the future of autonomous, professional physical therapist practice is bright for a very long time to come.
DOI: 10.2522/ptj.20050245.ar

References
1 Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York, NY: Harper & Row; 1970. 2 Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books, The Perseus Books Group; 1982.

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