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3 Allied Health: An Overview In 1966 the deans of 13 university-based schools of health professions met in Washington, DC, to discuss possible federal actions to bolster the health care workforce. According to David Gale, Dean of the College of Health Sciences at Eastern Kentucky University, a persistent story that has emerged from the meeting is that a secretary at the meeting suggested using the term allied health to refer to the professions and occupations other than medicine, dentistry, and nursing that are essential to health services—and the name stuck. That meeting contributed to the passage of the Allied Health Profes- sions Personnel Training Act of 19661 just 8 months after legislation was introduced in the House and Senate. According to data presented by Gale, the next year Congress appropriated $3.735 million under the act to in- crease the number of allied health personnel and to improve and expand allied health education and training. Between that year and 1979, more than $276 million was appropriated under the act, which is the equivalent of more than $1 billion today. Appropriations were zeroed out in 1980, reappeared in the years 1990 and 2005, and have been zeroed out since. While the term allied health has been successful in unifying very differ- ent occupations and professions, it is not a popular designation, said Gale. Only a small percentage of schools of allied health professions uses the term. However, it is tolerated, Gale added, when federal money is available. Today the term is used in different ways by different organizations. 1 Allied Health Professions Personnel Training Act of 1966, Public Law 751, 89th Cong., 2nd sess. (November 3, 1966). 11
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12 ALLIED HEALTH WORKFORCE AND SERVICES For example, the American Medical Association (AMA) recently published a survey of allied health professionals conducted by the AMA Organized Medical Staff Section in association with the National Association of Medi- cal Staff Services (AMA, 2010). The professionals included in that survey were clinical nurse specialists, nurse anesthetists, nurse practitioners, nurse midwives, counselors, physician assistants, chiropractors, podiatrists, and dentists—not all of whom would commonly be considered allied health professionals, as Gale observed. The following definition of allied health is generally used: Allied health professionals are involved with the delivery of health or re- lated services pertaining to the identification, evaluation, and prevention of diseases and disorders; dietary and nutrition services; rehabilitation; and health systems management, among others. Allied health professionals, to name a few, include dental hygienists, diagnostic medical sonographers, di- etitians, medical technologists, occupational therapists, physical therapists, radiographers, respiratory therapists, and speech-language pathologists. (ASAHP, 2011; DOL, 2010) In its Occupational Outlook Handbook, the Bureau of Labor Sta- tistics lists health diagnosing and treating practitioners as audiologists, chiropractors, dentists, dietitians and nutritionists, occupational therapists, optometrists, pharmacists, physician assistants, physicians and surgeons, podiatrists, radiation therapists, recreational therapists, registered nurses, respiratory therapists, speech-language pathologists, and veterinarians (BLS, 2011). It lists health technologists and technicians as athletic trainers; car- diovascular technologists and technicians; clinical laboratory technologists and technicians; dental hygienists; diagnostic medical sonographers; emer- gency medical technicians and paramedics; licensed practical and licensed vocational nurses; medical records and health information technicians; nuclear medicine technologists; occupational health and safety specialists; occupational health and safety technicians; dispensing opticians; pharmacy technicians and aides; radiologic technologists and technicians; surgical technologists; and veterinary technologists and technicians (BLS, 2011). These listings mix people with very different degree levels and include prominent omissions, such as physical therapists, Gale noted. ACCREDITATION OF EDUCATION AND TRAINING PROGRAMS According to Gale, the AMA began overseeing allied health education in the 1930s. In that decade, the American Occupational Therapy As- sociation, the American Society for Clinical Pathology, and the American Physical Therapy Association all began working with the AMA Council on Medical Education on educational standards. Health information adminis-
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13 ALLIED HEALTH: AN OVERVIEW trators began working with the council in 1943, and radiographers in 1944. In 1957 the AMA did a study of 50 educational programs combined under the term paramedical education. In 1969 the AMA House of Delegates defined allied health professionals as those who exercise independent judg- ment within their area of competence. In AMA documents, allied health was called ancillary and paramedical. “In the early 1970s, the AMA Council on Medical Education and the Association of Schools of Allied Health Professions conducted a major study of accredited schools of allied health, in which it identified seven prominent dilemmas,” said Gale (Rees, 1973). The first was “Should there be accreditation?” to which the report replied that educational programs require some type of monitoring. The second dilemma then became “What form of monitoring is appropriate?” with the ancillary questions of “How shall the monitoring be conducted?” “Who should be responsible for the monitoring?” and “Who will finance this system?” The report did not reach conclusions in any of these areas, according to Gale. The third dilemma— “What are the functions of accreditation?”—was the most contentious. Issues of control and of authority over methods were prominent. Again, the report did not arrive at conclusions or recommendations in this area. The fourth dilemma involved the structure of accreditation. Until the 1950s, groups formed their own accreditation organizations. In that decade the National Commission on Accreditation noted that this practice tended to make professions, including medicine and dentistry, into monopolies. The fifth dilemma turned to the financing of accreditation. The question of whether funding for accreditation should come from the schools or from government still has not been answered, Gale noted. Dilemma six pointed to the validity of accreditation. The study observed that regulatory agencies tend to have a life cycle from gestation to youth to maturity to old age, con- noting a sense of deterioration. Finally, the seventh dilemma asked whether the expansion of accreditation groups should be controlled or restricted. Since 1935, according to data gathered by Gale, 24 accreditation groups were formed. In 2008 he sent a survey to the ones he had identified. Ac- cording to the survey, of 9,000 accreditations that were performed in 2008, only 20 found that programs did not meet standards, with an additional 86 programs put on probation. ISSUES IN ALLIED HEALTH Based on his 40 years of being a dean, Gale drew several broad con- clusions about allied health. First, institutions of higher education tend to “like” their allied health programs, even though they are expensive. Second, career ladders in the allied health professions tend not to be available. They
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14 ALLIED HEALTH WORKFORCE AND SERVICES work best in nursing, but he said that even in nursing only a small number of people who earn an associate’s degree go on to earn a bachelor’s degree. Each accreditation body operates in a silo around its discipline with little regard or even awareness of other professions. Third-party accredita- tion processes and a national accreditation board could help break down these silos, Gale said. The term allied health covers everything from 1-week laparoscopic training to Ph.D. research and postdoctoral education. But most allied health workers are educated in community or technical colleges. The pro- fessions generally are at the bachelor’s level or higher. For example, the clinical laboratory field has associate’s, bachelor’s, and master’s degrees and a handful of clinical doctoral programs. However, it also has a crisis in pre- paring enough doctoral-level faculty and program directors. Gale advocated “letting the body of knowledge do what it needs to do.” Governments, regulators, and administrators need to be flexible to let professions change. The reimbursement systems for many allied health professions are flawed and fragmented, as are scope of practice regulations. When a patient is in need of, for example, rehabilitation services, those professions should direct patient care, Gale said. He also observed that most of the hospital patient record is from the laboratory, yet these workers generally are unable to discuss results with patients. Finally, he listed several pressing questions involving allied health: • W hat is the available workforce in each profession, including age, education, income, and length of time in the profession? • W hat reimbursement mechanisms can appropriately reward prac- titioners for a highly demanding education? • H ow can state practice acts be made current and relevant to the practice of each profession? • H ow can the education system help graduates move up an educa- tional ladder? • H ow can an accreditation program recognize a “school of allied health” rather than duplicating all materials for each program? • H ow can more faculty be better prepared for allied health programs? • W ith professions that have changed to graduate-level entry, how can broken educational ladders be fixed?