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1 - What; Does "Alliec! Heall;h" Mean? A COMPUTERIZED SEARCH of the nation's newspapers for October 1987 found the term allied health in two stories. During the same time, there were 443 references to nursing and more than 500 references to physicians. The individual fields that normally fall under the heading of allied health fared only somewhat better. Physical therapists were mentioned in 21 ar- ticles, occupational therapists in 8, dental hygienists in 7, and medical tech- nologists in 3. The scarcity of such references reflects a lack of public awareness of what allied health practitioners do and the fact that the term means little or nothing to the public at large. Even in the health care community there is considerable confusion about which fields fall under the rubric of allied health. Many of the people who deliver allied health services or educate its practitioners have long been dissatisfied with the term. Yet this dissatisfaction has led neither to a replacement nor to a commonly accepted definition. The only consensus is a distaste for the predecessor term paramedical. Appendix C includes a sample list of job titles and allied health fields that might be included in the broadest definitions of allied health. In the late 1970s, a National Commission on Allied Health Education, supported by a grant from the W. K. Kellogg Foundation to the American Society of Allied Health Professionals, tried to formulate a consensus def- inition. The commission's struggle with the concept is reflected in its def- inition, which follows a six-page discussion: ". . . all health personnel working toward the common goal of providing the best possible service in patient care and health promotion" (National Commission on Allied Health Ed- ucation, 1980~. This definition does not draw boundaries that exclude 15

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16 ALLIED HEALTH SERVICES groups of health care providers, nor does it describe commonalities of task or education that define the fields to be included. Rather, the commission chose to focus thematically on "alliances that need to be built" and "the collaborative approach to providing health services" as part of a team an approach that has value when the overall purpose of the definition is to bind together a disparate group of practitioners. The definition offered by the American Medical Association's Committee on Allied Health Education and Accreditation (CAHEA), a body that ac- credits nearly 3,000 educational programs, suggests the sensitivities in- volved in designating the fields that allied health comprises. CAHEA (1987) defines allied health practitioners as: . . . a large cluster of health care related professions and personnel whose functions include assisting, facilitating, or complementing the work of physicians and other specialists in the health care system, and who choose to be identified as allied health personnel. Definitions of allied health vary due to its changing nature and to the differing perspectives of those who attempt its definition and because certain medically related but traditionally parallel or independent occupations prefer identities in- dependent of allied health: nursing, podiatry, pharmacy, clinical psychology, etc. Other occupations may or may not regard themselves as allied health, depending upon their varying circumstances. e.g., nutritionists, speech-language pathologists, audiologists, public health specialists, licensed practical nurses, medical research assistants, etc. CAHEA's discussion emphasizes that there are two approaches to de- fining allied health: the first describes groups or characteristics of groups that fall within certain ill-defined boundaries; the second relies on excluding groups. In its 1979 A Report on Allied Health Personnel (U.S. Department of Health, Education, and Welfare), the federal government adopted the latter view. It attempted to winnow out from 3.5 million health care workers those in fields that came under the federal purview of allied health. Its criteria excluded health care workers who (1) were treated separately by legislation other than the allied health authorization; (2) had general (rather than health-specific) expertise that could be applicable to other industries; and (3) performed functions that required little or no formal training in health care subject matter. Thus, in addition-to physicians, nurses, dentists, optometrists, podiatrists, pharmacists, veterinarians, and other independent health practitioners, the authors of the report excluded professional public health personnel; biomedical research personnel; natural and social scientists working in the health field;

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WHAT DOES "ALLIED HEALTH" MEAN? 17 nursing auxiliaries; and occupations requiring no formal training (U.S. Department of Health, Education, and Welfare, 1979~. Despite the continuing debate about definition and boundaries, some groups of practitioners have come together and unequivocally call them- selves allied health personnel. The federal programs that supported allied health education provided the impetus for the aggregation of such groups as occupational therapists, clinical laboratory technologists, and dental hy- gienists. The groups coalesced in three major spheres: (1) academic insti- tutions under schools of allied health, to benefit from multidisciplinary interaction and educational efficiency; (2) health services settings, for rea- sons of personnel administration; and (3) the professional associations, to attempt to influence policy, collect information, and publish scholarly pa- pers on issues of interest across the fields. This coalescing is by no means complete; there are many academic pro- grams that lie outside allied health schools, numerous health facilities that, operationally, do not recognize allied health as a useful grouping of oc- cupational categories, and strong allied health professional associations that act independently of each other in the policy arena. Nevertheless, the reasons for the diverse groups to come together under the umbrella rubric allied health remain valid. This committee chose not to engage in the search for a definition. The benefits of making the term allied health more precise are less clear than the benefits of continued evolution. The changing nature of health care makes some practices and practitioners obsolete at the same time it opens up opportunities to form new groups. It is more important for pragmatism to continue to prevail and for old and new groups to draw what benefits they can from belonging to allied health than it is to have an accurate description of common characteristics that define the group. Lacking a satisfying definition of allied health, many groups have tried to impose order with a variety of classification schemes. They have been classified according to their departmental affiliation into such categories as dental, dietary, emergency, diagnostic, and therapeutic. One study em- phasized certain features that cut across different types of work. It rec- ommended classification according to patient, laboratory, administration, and community-oriented groupings (Bureau of Health Manpower, 1967~. A poll of professional associations arrived at three "clusters" according to job function: (1) primary care workers (including medical, dental, and nursing personnel); (2) health promotion, rehabilitation, and administra- tion personnel; (3) and test-oriented workers (National Commission on Allied Health Education, 19801. Clearly, there is no "correct" taxonomy: different classification schemes emphasize different aspects of allied health

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18 ALLIED HEALTH SERVICES jobs and personnel. The different emphases can be used to serve different purposes. Rather than rely on a single definition or scheme throughout the study, the committee preferred to emphasize the following character- istics of allied health fields. Each paragraph highlights important policy- related characteristics and helps to explain how the fields are affected in different ways by changes in the health care environment. 1. Level of autonomy Some allied health fields have a history of practice without direct supervision; others are struggling for a measure of inde- pendence. Individuals in many fields can work only as employees in su- pervised settings. Practitioners who can attract their own patients can reap the financial rewards of the public's interest in and willingness to pay for their services. However, independent autonomous practice is not possible unless health care payers are willing to reimburse allied health practitioners for their services and unless the practitioners are free of regulation that requires onsite supervision by a physician. 2. Dependence on technology In a health care system that frequently adopts new machines or techniques, individuals who work with only one machine may lose their jobs as new technologies are developed and brought into use. Those workers who become broadly involved in one or more tech- nologies are less vulnerable to obsolescence. Those involved with techno- logical innovations that are coming into widespread use should benefit from a strong demand for their services. 3. Substitutability of personnel Allied health occupations vary as to whether their "turf'' is well marked and protected. If workers from two occupations or two levels of the same occupation can perform the same functions, the workers who are paid more or who are more specialized may be displaced. If more highly trained workers are willing to work for the same wage as those with less education, the lower level practitioner may be displaced. For employers, the ability to substitute one type or level of personnel for another may be helpful when the supply of one type of worker is limited. 4. Flexibility in location of employment Those who can work in a variety of settings are less vulnerable in a job market that responds to altered financing incentives by shifting the location of care or by limiting the amount of care provided in some settings. 5. Degree of regulation If a field is highly regulated (i.e., its practitioners are licensed by the state, required to register with a government agency, or their titles are protected by certification), employers are constrained from hiring anyone but workers from that field to perform a function. These workers are protected from substitution by other personnel. The supply of workers is likely to decrease if the requirements for entry into the field are raised. 6. Inclusion in facility accreditation or certification standards To receive ac- creditation or certification, a health care facility may be required to employ

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WHAT DOES "ALLIED HEALTH" MEAN? 19 practitioners in certain fields. If so, the demand for these workers will respond to changes in the number of these facilities. Throughout this study a major challenge for the committee was both to capture the diversity of allied health occupations and to devise specific yet encompassing recommendations for those who must make policy decisions affecting the role of allied health practitioners in the health care system. Toward this end the committee chose to focus on 10 allied health fields. It used the following criteria in selecting the fields: (1) each field should be large and well known; (2) collectively, they should span the spectrum of autonomy; and (3) collectively, they should include practitioners who work in a variety of health care settings. However, wherever it has appeared suitable for this report, the committee also chose to draw on information about other allied health occupations that was provided to it. The fields the committee chose to focus on are clinical laboratory tech- nology, dental hygiene, dietetic services, emergency medical services, med- ical record services, occupational therapy, physical therapy, radiologic technology, respiratory therapy, and speech-language pathology and au- diology. The final chapter of this report includes an examination of the role of nursing aides in long-term care. Nursing aides often are not included among categorizations of allied health personnel. They are highlighted nere, However, because or one crucial role Inky play In parent care in many long-term care facilities, a role that makes their relationship with allied health personnel very important. In addition, the discussion of aides in the final chapter focuses attention on some groups that are discussed less thoroughly in the remainder of the report than the committee might have preferred. These lower level prac- titioners, often called technicians or aides, are frequently trained on the job or educated in short vocational programs or 1-year certificate programs. Analysis of the present and future supply of allied health practitioners depends heavily on data from educational institutions that are not available for lower level personnel. Moreover, the jobs and tasks of lower level personnel generally are not clearly delineated, and even their job titles can be confusing. The committee therefore was unable to evaluate trends in demand or the forces that determine the demand for and supply of lower level practitioners. The observations made by a commission assembled by the American Dietetic Association (ADA) (1985) to examine their profession help explain why studies of lower level personnel are difficult to conduct. During World War II, high school vocational programs, adult education programs, and hospital education programs began to train dietetic support personnel called food service supervisors. To this array of training sites were added cor- respondence courses developed by ADA in the late 1950s. When it became

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20 ALLIED HEALTH SERVICES apparent that a more highly educated support person was needed, the dietetic technician position was created; these personnel were trained in food service management, nutrition care, or as generalists. The food su- pervisor title was subsequently changed to that of dietetic assistant. A1- though in 1972 ADA published program essentials for both categories and began the formal review and approval of educational programs, in the same year a study commission determined that the tasks of the two fields needed definition (American Dietetic Assocation, 1972~. A decade later an attempt to determine the numbers of dietetic support personnel failed (American Dietetic Association, 19851. During that attempt, many problems were found. For example, workers identified as dietetic technicians were actually graduates of dietetic assistant or other programs. At the same time, the title dietetic assistant was deemed to be inappropriate because often these practitioners did not assist but rather managed. In 1983 their title was changed to that of dietary manager. In the same year, partly because it could no longer differentiate the roles of the two types of support per- sonnel, ADA withdrew from the review and approval program of dietetic assistants' education. A membership association of dietetic technicians and assistant managers took over this function. In sum, dietary support personnel are both formally and informally trained, their roles are ill-defined, and their titles are in a continually evolving state. Moreover, ADA also notes that dieticians often use support personnel for clerical rather than dietary tasks. The committee is aware that aides, technicians, and assistants play an important, if sometimes ill-defined, role in the nation's health care system. By focusing on nursing aides in the final chapter of this report, we hope to give the reader an impression of the vital nature of their work. This chapter briefly introduces each of the 10 allied health fields covered in the report and outlines their evolution.* It also traces the development of two fields perfusion and cardiovascular technology to see whether developing fields tend to follow the same general pathways as the estab- lished occupations. Appendix D offers the committee's best estimates of the number of workers currently in each of the 10 fields. CLINICAL LABORATORY TECHNOLOGY Clinical laboratory personnel perform a wide array of tests that are used to help physicians prevent, detect, diagnose, and treat diseases. The gen- eralist medical technologist is the most widely recognized practitioner in *The description of the allied health fields was drawn in large part from a paper prepared for the committee by Edmund T. McTernan (1987). Where appropriate, other sources are referenced. For McTernan's bibliography, see Appendix H.

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WHAT DOES "ALLIED HEALTH" MEAN? 21 this field and the one on which this report focuses, but there are many specialities within the field including blood bank technology (the prepa- ration of blood for transfusion), cytotechnology (the study of body cells), hematology (the study of blood cells), histology (the study of human tissues), microbiology (the study of microorganisms), and clinical chemistry (the analysis of body fluids). Practitioners fall into two broad categories: (1) baccalaureate-prepared technologists and (2) associate degree- and certificate-prepared technicians. Technologists perform complex analyses, make fine-line discriminations, and correct errors. They are able to recognize the interdependency of tests and have some knowledge of physiological conditions that could affect test results. They use this knowledge to confirm those results and develop data that aid physicians in determining the presence, extent, and, as far as possible, causes of disease (CAHEA, 19871. Technicians perform routine tests under the supervision or direction of pathologists or other physicians, scientists, or experienced medical technologists. Associate degree-prepared technicians may discriminate between similar items, correct errors by using preset strategies, and monitor quality control programs within predeter- mined parameters. The first clinical laboratory in the United States was established in 1875 at the University of Michigan hospital. Soon thereafter, laboratories were established at other hospitals. Physicians specializing in pathology were responsible for these laboratories, but because the work was often routine, they soon hired nonphysician assistants. By 1900 there were approximately 100 technicians in laboratories around the country. The demand for lab- oratory personnel greatly increased with the expansion of the health care system during World War I. By 1920 there were 3,500 laboratory tech- nicians in the United States, half of whom were women. A census taken 2 years later revealed that 3,035 hospitals had established clinical laboratories. All early laboratory technicians were trained for their role by the pa- thologists for whom they worked. In 1922 a training program was estab- lished at the University of Minnesota. Today, a bachelor's degree with a major in medical technology, biology, or chemistry is the standard prereq- uisite for an entry-level job as a medical technologist. Medical technology programs (offered by colleges, universities, and hospitals) are based on considerable course work in the physical sciences and mathematics often closely resembling the premedical curriculum and at least 1 year of clinical training. Hospital programs are usually affiliated with universities that grant the academic degree. Technologists can also become recognized as such through a federal certifying exam. In 1972 the federal government established its own testing program to certify laboratory workers and make them eligible to provide reimbursable services in Medicare and Medicaid programs. Successful candidates are recognized for Medicare and Medicaid

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22 ALLIED HEALTH SERVICES purposes as clinical laboratory technologists. Medical technicians may be graduates of 2-year programs in community or junior colleges or of 4-year colleges that offer associate degrees; alternatively, they may be graduates of a 1-year certificate program sponsored by a hospital or vocational school. Five states require that medical technologists or technicians be licensed. Other states require that the practitioner register with the designated legal authority. Although professional association certification is voluntary, it is frequently a prerequisite for clinical laboratory jobs and often necessary for professional advancement. Agencies that certify personnel include the Board of Registry of the American Society of Clinical Pathologists, the American Medical Technologists, and the National Certification Agency for Medical Laboratory Personnel and the International Society of Clinical Laboratory Technologists. Concerns over the quality of laboratory testing have surfaced recently, and during its public hearing, the committee heard a number of suggested approaches to address these concerns. One approach proposed by some leaders in the field is the introduction of licensure to ensure that laboratory personnel have received the requisite training. They also support efforts to define the scope of practice for each level of personnel. Others in the field do not believe that licensure ensures quality, nor do they wish edu- cational credentials to be the primary tool for differentiating competencies. According to the American Society of Clinical Pathologists (1987), there were 172,214 technologists and 37,271 technicians registered as of February 1987. The U.S. Bureau of Labor Statistics (BLS) estimates that there were approximately 239,000 jobs in 1986, of which 63 percent were in hospitals. It should be kept in mind that not all people doing work described as that of a clinical laboratory technologist or technician are certified. Individuals with expertise in a science field, as well as persons without a health-related or science-based education, are often hired and given on-thejob training to perform clinical laboratory functions. This is particularly true in settings that are not regulated by the federal government for example, physician office laboratories. Clinical laboratory technologists and technicians are most often women; only about 25 percent of the work force are men. The more highly trained practitioners, graduates of 4-year colleges, are a little older than the grad- uates of 2-year colleges. Of the group of 4-year college graduates, 37 percent are under 35 years old; 53 percent of the 2-year college graduate group fall into that age bracket (Bureau of Health Professions, 19841. DENTAL HYGIENISTS Dental hygienists, working under the supervision of dentists, remove stains and deposits from patients' teeth, take and develop x-ray films, apply

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WHAT DOES "ALLIED HEALTH" MEAN? 23 fluoride, and make impressions of teeth for study models. They also instruct patients in oral hygiene. In states with less restrictive practice acts, dental hygienists also apply sealants to teeth, perform periodontal therapy, and administer local anesthesia. Most hygienists work in private dental offices, although other employment sites include public health agencies, school systems, hospitals, and business firms. Hygienists should not be confused with dental assistants, who work with the dentist handing instruments, preparing for procedures, and performing other tasks that assist the den- tist's work. . Dentists first began expressing interest in prophylactic care as an adjunct to restorative dentistry in the mid-1800s. By the turn of the century, many had developed protocols for preventive care and were delivering it to their patients. However, these services were time-consuming for the dentist and hence costly for the patient. In 1910 the Ohio College of Dental Surgery instituted a training course for the "dental nurse and assistant." The 1-year program graduated a single class before a coalition of Ohio dentists suc- ceeded in closing it down. Three years later, a Connecticut dentist, Dr. Alfred Fones, convinced his local school board to fund a program to train dental hygienists who would work in the school system giving prophylactic care to children. Fones envisioned dental hygienists working in private dental offices as well, but he placed greater emphasis on the public schools. The profession first gained legal status in Connecticut, which amended its dental practice act in 1915 to permit hygienists to practice under a dentist's supervision. The following year a court ruling in New York held that no existing New York law prevented dental hygienists from practicing. Subsequently, the American Dental Association endorsed dental hygiene legislation, and by 1951 hygienists were licensed throughout the United States. It was not until 1947 that the American Dental Association and the American Dental Hygienists' Association developed the approved require- ments for accreditation of dental hygiene programs. These requirements have been modified several times; to receive approval today, a program must have both liberal arts and science content, and didactic and clinical instruction. Most programs grant an associate degree but often require more than 2 academic years to complete. A smaller number of programs take 4 years and culminate in a baccalaureate. The dental hygiene field reflects some of the ambivalence about education seen in the nursing profession: although 4-year programs undoubtedly have more academic content and presumably prepare graduates for additional career roles, there is only one level of dental hygiene license. All licensed hygienists, regardless of the degrees they hold, are permitted to perform the same range of dental services.

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24 ALLIED HEALTH SERVICES Of the issues facing dental hygienists today, autonomy is the most press- ing. Licensure is effectively in the hands of dentists rather than dental hygienists: in all states, hygienists are licensed by a licensing board that is composed primarily of dentists. At present, there is a strong movement within the profession to gain greater self-determination. One goal is to abolish state laws requiring that licensed hygienists work exclusively under dental supervision. In Colorado, hygienists have already won the right to practice independently, although the move has not been made without controversy. The American Dental Association filed suit against the state demanding the reinstitution of the requirement that patients be referred to hygienists only by licensed dentists. The suit was dismissed, but the association is currently appealing the decision. Dental hygienists are generally young women: only 1 percent of the work force are men, and only 10 percent are more than 44 years old. In 1984 only 13 percent earned more than $25,000 per year (American Dental Hygienists' Association, 19871. DIETETIC SERVICES According to the ADA's 1972 study commission, a dietician is a "trans- lator of the science of nutrition into the skill of furnishing optimal nutrition to people." Although all dietitians share a common interest in the science of food and its effect on the body, they work in many different roles as administrators, educators, researchers, and clinicians. Some supervise large- scale meal planning at companies and school cafeterias; others assess the nutritional needs of hospitalized patients and implement specialized diets; still others advise individuals and groups on sound dietary practices. Die- ticians are also involved in hyperalimentation and the clinical frontiers of parenteral and enteral nutrition. The term dietitian was first coined at the 1899 Lake Placid Conference on Home Economics, but the roots of the profession extend back two decades earlier to cooking schools in Boston, New York, and Philadelphia. One early practitioner, Sarah Tyson Rorer, held classes on nutrition for physicians and nurses before the turn of the century; she later edited a section of an American Medical Association publication called "The Dietetic Gazette." Like many other allied health professions, dietetics expanded during World War I. In England, 40 percent of the 2.5 million men screened for military service were found to be physically unfit, most for nutritional reasons. Good nutrition and food conservation for the public and better health care for the troops, especially those who were sick and wounded, were of great concern at the time, both in the United States and in England. Biomedical advances also helped to stimulate the fledgling profession.

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WHAT DOES "ALLIED HEALTH" MEAN? 25 From its inception in 1918, ADA was active in accreditation, listing hos- pitals that offered reputable dietary internships. By 1927 the association had adopted a standard course for dieticians, the first of several steps toward ADA-sponsored accreditation of educational programs. In 1969 the association established a registry of dietitians. To qualify for registration today requires graduation from an accredited college or university, com- pletion of certain course and experiential components, and passing a na- tional registration exam. In addition, dieticians must fulfill continuing education requirements to maintain certification. The term nutritionist, which was previously reserved for people working in research, is gaining popu- larity with clinical practitioners. It has been proposed that"nutrition" be added to ADA's name, but this chance has not been approved by the ~ ~ . 1 membership. AS of the summer of 1987, ADA members continued to call themselves dietitians. There are several issues of major concern to dieticians today. First, the profession is seeking to extend and strengthen state licensure. Currently, 14 states license dieticians, and a number of others are considering such laws. Second, because there is a slow but steady trend in the field toward private practice, dieticians are interested in obtaining third-party reim- bursement for their services. Finally, ADA is exploring how the field might be divided into subfields. Like several other allied health Professions, the . . . . . . sum total ot knowledge in the field has grown to the point where special- ization seems inevitable. Those dieticians who today consider themselves to be specialists have most often become so through concentrated work in specific health care settings. Thus, it is generally on-thejob training rather than formal education that makes them specialists. At present, an ADA committee Is Developing speciality boards and defining speciality areas. The best estimate of the size of the dietetics work force comes from ADA which reported 44,570 active members at the end of 1987 (American Dietetic Association, 1987~. BLS estimates that there were approximately 40,000 dieticians' jobs in 1986, 37 percent of which were in hospitals (Bu- reau of Labor Statistics, 1987~. The 1984 Study Commission on Dietetics described the "typical" ADA member as a young, college-educated white woman. According to the Com- mission, slightly more than 63 percent of ADA members were under 40 years old, 99 percent had a bachelor's degree, 97 percent were women, and 87 percent were white (American Dietetic Association, 1985~. Little has changed since then. In 1986 fewer than 1 in 10 ADA members was a man. Eighty-six percent of technicians were white, compared with 88 per- cent of active dieticians. Sixty-three percent of active dietician members were under 41 years old, while technicians were a little younger (71 percent under 41~. Forty percent of active dietician members have advanced de- grees, and another 10 percent are working toward such degrees. For 70

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WHAT DOES "ALLIED HEALTH" MEAN? 33 a wide variety of movement disorders soon absorbed the personnel pre- viously needed for the care of acute polio patients. Today, all states require that practicing physical therapists be licensed, and applicants must hold a degree from an APTA-accredited program prior to taking the licensing exam. (APTA directly accredits educational programs independent of CAHEA.) Since 1960 there have been three educational avenues to entry-level jobs as physical therapists: (1) baccalau- reate programs, (2) certificate programs for people who already hold a bachelor's degree in another field, and (3) 2-year master's programs. In 1979 APTA announced its intention to elevate the entry-level requirement for the field to a master's degree a mandate that encountered vigorous opposition, especially from the American Hospital Association, deans of allied health programs, and certain higher education associations. As a result, the mandate has been softened to encourage rather than require a general movement toward the master's degree as the entry-level credential. In 1967 an assistant-level position was created so that physical therapists could delegate more routine tasks and treat greater numbers of patients. Currently, there are approximately 17,000 practicing physical therapy as- sistants. Physical therapists have more autonomy than most allied health practi- tioners. Many are in private practice, and some states allow patients direct access to physical therapy services, which eases the way into independent practice for therapists. Thirty-eight states now permit physical therapists to evaluate patients without medical referral; 11 of these states also permit the treatment of patients so evaluated. Legislation on direct access is pend- ing in about a dozen other states. As the scope of practice in physical therapy has expanded to include services as diverse as pulmonary therapy for critically ill patients in intensive care units, developmental assessment of high-risk newborn infants, home care for elderly stroke and arthritis patients, and industrial consulting to reduce low back injuries, specialization has become a feature of the careers of many therapists. In 1978 APTA established a board for certification of advanced clinical competence that currently oversees the examination and certification of clinical specialists by speciality boards in six fields: cardi- opulmonary, clinical electrophysiology, neurological, orthopedic, pediatric, and sports physical therapy. Thirty universities now offer postprofessional graduate programs (including nine doctoral-level programs) for advanced professional study by experienced therapists. APTA estimates that the number of licensed physical therapists in 1986 was nearly 66,000. Physical therapists are most often women; in 1987 men constituted 25.4 percent of the work force, a little down from 28.8 percent in 1978. On average, women therapists are slightly younger (35 years old) than men (38 years old). The proportion of minority therapists remained

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34 ALLIED HEALTH SERVICES between 4 and 5 percent in the past decade. The 15 percent of the work force who worked full time for themselves were the highest earners, gross- ing nearly $73,000 on average in 1986, compared with approximately $32,000 for the 67 percent who were full-time salaried employees. The educational attainments of physical therapists have increased during the past 10 years. The percentage with master's degrees has increased from 15.2 percent to 21.5 percent since 1978. The percentage with a doctoral degree increased slightly from 1.1 percent to 1.4 percent (APTA, 19874. RL\DIOLO GIC TECH N OLO GY Radiologic services as an allied health field began with the diagnostic use of x rays and the applications of these and other types of ionizing radiation for therapeutic purposes. Originally, radiologic services were provided al- most exclusively by radiologists (physicians) and their technical assistants or x-ray technicians (now called radiographers); in recent decades, how- ever, radiologic services have expanded considerably. New professions have emerged with medical and technological advances. New applications of radioactive tracers led to the birth of nuclear medicine technology; the ~ r .1 _ ~ _ Invention ot therapeutic x-ray equipment for treating cancer resulted in the field of radiation therapy technology; and the development of ultra- sound imaging systems has created a new category of radiologic personnel, the diagnostic medical sonographer. Radiologic technologists and technicians (including radiographers, ra- diation therapy technologists, nuclear medicine technologists, and diag- nostic medical sonographers) held approximately 125,000 jobs in 1986. About two of every three jobs were located in hospitals. Other employment sites included clinics, laboratories, and doctors' offices. Twenty-five years after the discovery of x rays in 1895 by Wilhelm Roentgen, 13 x-ray technicians gathered in Chicago and formed the Amer- ican Association of Radiological Technicians (now called the American Society of Radiologic Technologists). In 1920 a committee of physicians was appointed by the Radiological Society of North America to consider standards for the training of x-ray technicians. Two years later the Ra- diological Society of North America and the American Roentgen Ray So- ciety organized the American Registry of X-ray Technicians (now called the American Registry of Radiologic Technologists). The registry was con- trolled by physicians until 1961 when the composition of the registry board was changed to include technologists. Initially, all training in radiologic technology was done on the job. Gradually, however, hospitals organized schools for technicians, and a program evolved that comprised a year of classwork followed by a year of clinical training. In 1933 the first three programs were recognized by the registry. Today, CAHEA accredits more than 1,000 formal training programs in the field.

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WHAT DOES "ALLIED HEALTH" MEAN? 35 Radiologic technology education changed after World War II, partly as a result of the G.I. Bill. Large numbers of returning veterans were inter- ested in careers in the expanding health care field and, at the same time, wished to pursue formal education under the G.I. Bill. Many administrators of 2-year colleges recognized this new market and established 2-year radio- logic technology programs that granted an associate degree. This devel- opment came on the heels of a growing movement within the field to extend the duration of training programs. At present, there are formal training programs in radiography, sonog- raphy, radiation therapy technology, and nuclear medicine technology. They range from 1 to 4 years and grant a certificate, an associate degree, or a baccalaureate. Two-year programs are the most common. Some 1- year programs attract health care professionals who are interested in chang- ing fields most often, respiratory therapists, registered nurses, and med- ical technologists. Certificate programs also attract radiographers who want to specialize in ultrasound, radiation therapy, or nuclear medicine. Cur- rently, 4-year programs are designed primarily for people interested in teaching or supervisory positions. There appears to be a trend in the field toward programs of longer duration based in institutions of higher education. Because some educators feel that advances in technology have made it difficult to train students adequately in 2 years, a number of associate degree programs are exper- imenting with a third year. Some leaders in the field feel that the slight difference between a 3-year associate degree program and a 4-year bach- elor's program will push the field toward making the baccalaureate degree the educational standard for entry-level jobs. As of summer 1987, only five statesNew York, New Jersey, Florida, California, and Kentucky had licensure laws for radiologic technologists. In 1984 Congress passed the Jennings Randolph Bill requiring states either to establish minimal educational standards for radiologic technologists or adopt extant federal requirements, which call for voluntary compliance. Almost all states have opted for voluntary compliance. The radiologic technology work force is one of the largest among the allied health fields. The Bureau of Health Professions estimates that there were 143,000 radiologic health service workers in 1986, of which approx- imately two-thirds were women and half were under 30 years of age (Bu- reau of Health Professions, 1988~. RESPIRATORY THERAPY Respiratory therapists provide an array of services that ranges from emergency care for stroke, drowning, heart failure, and shock to providing temporary relief to patients with emphysema or asthma. They often treat patients who have undergone surgery because anesthesia depresses breath-

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36 ALLIED HEALTH SERVICES ing and respiratory therapy may be prescribed to prevent the development of respiratory illnesses. The majority of respiratory therapists works in hospital settings, although increasing numbers are being employed by nurs- ing facilities and home health agencies. Since the 1800s, doctors have prescribed oxygen therapy for individuals with cardiopulmonary problems, and until recently the task of actually administering treatment fell to attending nurses. After World War II, however, much of the equipment for administering oven became so O , O . . . sophisticated and expensive that aclm~n~strators began assigning respiratory care tasks to orderlies who became known as oxygen orderlies. These first respiratory therapists, although usually employees of nursing departments, frequently developed direct relationships with physicians and often came to know more about gas therapy than their immediate supervisors. The field's first professional organization, the Inhalational Therapy As- sociation, was formed in Chicago in 1946. Now, several decades later, the organization is national in scope and is known as the American Association for Respiratory Care (AARC). As the field and its body of medical knowledge evolved, the range of tasks performed by respiratory therapists widened to include both the mundane and the highly complex. As a result, in the late 1960s, leaders in the field promoted the idea of developing an entry-level position so that respiratory therapists could be relieved of their more routine tasks. In 1969 the first inhalation therapy technicians were certified. Today, training is offered at the postsecondary level in colleges and universities, medical schools, trade schools, and hospitals. To be accredited by CAHEA, programs for respiratory therapists must be of at least 2 years' duration and lead to an associate or baccalaureate degree. Technician pro- grams usually last 1 year. Certification is voluntary and available through the National Board for Respiratory Care. As of tune 1987, respiratory care personnel were licensed in 18 states, and licensure bills had been introduced in 10 others. Members of the field currently are concerned about issues relating to competition with other health care workers. They are alarmed by incursions into the field that have been made by other health care workers, especially nurses, who in the early years performed the functions (or the precursors of the functions) that are usually handled by respiratory therapists today. To halt these incursions and protect the quality of respiratory services, therapists are seeking licensure in all 50 states. It should be noted that AARC, unlike many other allied health organizations, is not currently striv- ing to achieve greater independence from physicians for its membership. The AARC leadership anticipates that respiratory personnel will continue to work under the direction of physicians.

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WHAT DOES "ALLIED HEALTH" MEAN? 37 BLS estimates that there were more than 56,000 respiratory therapy jobs in 1986, the majority of them in hospitals. AARC suggests, however, that administrative positions were excluded in the BLS count. Two-thirds of respiratory therapists are under 30 years of age, and unusual for an allied health field almost 40 percent are men. SPEECHLANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES Audiologists and speech-language pathologists held approximately 45,000 jobs in 1986. Slightly more than half of these positions were in elementary and secondary schools, universities, and colleges. Hospitals, nursing homes, speech-language and hearing centers, and private physicians provided most of the remaining jobs. Unlike most other allied health professions, the speech-language-hearing profession does not function exclusively or even principally in the medical world. Moreover, the care provided by these professionals was not previously supplied by physicians. The development of these fields took place in the educational sector. Early in this century, educators became interested in introducing speech correction services into the public schools. The Chicago school system was the first to offer these services, hiring 10 speech correction teachers in 1910. Within 6 years, Detroit, Boston, New York, and San Francisco had followed Chicago's lead and were also employing speech correctionists. University education of individuals interested in speech correction was initiated in the United States around 1915 at the University of Wisconsin. Most early speech correctionists saw themselves as specialized teachers of elocution and belonged to a large organization known as the National Association of Teachers of Speech (NATS). In 1925 a group of speech correctionists decided to form a semiautonomous organization under the auspices of NATS to serve their professional interests, and the American Academy of Speech Correction (AASC) was born. Among the goals of the fledgling organization was raising "existing standards of practice among workers in the field of speech correction" and securing "public recognition of the practice of speech correction as an organized profession" (Paden, 1970~. During the next several years, the academy grew, but with growth came dissatisfaction over its close connection with NATS. The traditional dates of the annual NATS meeting apparently were not convenient for a number of AASC members, many of whom felt that AASC should be affiliated with groups in the medical world rather than with NATS. After 25 years, AASC separated from NATS; today, the organization is known as the American Speech-Language-Hearing Association (ASHA).

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38 ALLIED HEALTH SERVICES A master's degree in speech-language pathology or audiology is the basic credential in this profession, although there are numerous programs in communications sciences and disorders at the baccalaureate level. Of the approximately 235 colleges and universities offering master's degree or doctoral programs in speech-language pathology and audiology, about two-thirds are accredited by ASHA. Course work at accredited schools includes basic communication processes, the study of speech-language pathology or hearing disorders or both, and related areas such as the psychological aspects of communication. Most persons with a master's de- gree pursue the Certificate of Clinical Competence (CCC), which is offered by ASHA in either speech-language pathology or audiology. To earn the CCC, the individual must hold a master's degree or its equivalent, complete a supervised clinical fellowship year, and pass ASHA's written exam. Thirty-six states require that individuals providing speech-language pa- thology and audiology services hold licenses if they practice privately in clinics or in other nonschool settings. Medicare, Medicaid, and other third- party payers pay for the services of licensed practitioners. In states that do not have licensure laws, Medicare and Medicaid require that speech-lan- guage pathologists and audiologists meet the educational and clinical ex- perience requirements for the CCC or be in the process of accumulating the necessary clinical experience. Increasing numbers of individuals within the field are becoming inde- pendent private practitioners. This trend, while fairly new, is rapidly grow- ing. Like the leaders of other increasingly autonomous allied health professions, authorities in speech-language pathology and audiology are seeking to ensure that standards of practice remain high. ASHA estimates that approximately 86,700 speech-language patholo- gists and audiologists are active in the work force (Shewan, 19884. Ap- proximately 15 percent of the practitioners certified by ASHA are audiologists, and most of the remainder are speech-language pathologists; about 2 percent of speech-language-hearing practitioners are certified in both speech-language pathology and audiology (ASHA, 19861. In 1987 au- diologists earned slightly more than speech-language pathologists. The median annual salary in 1987 for ASHA member audiologists was $28,000 compared with $25,000 for speech-language pathologists (ASHA, 19884. The speech-language pathology work force is overwhelmingly white and female (approximately 95 percent and 89 percent, respectively, in 19881. NEW ALLIED HEALTH FIELDS The committee recognizes that the 10 fields selected for this study rep- resent established, traditional allied health professions. Yet the changing pattern of health care delivery has tended to spawn new allied health

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WHAT DOES "ALLIED HEALTH" MEAN? 39 fields fields that develop as changes occur in the health care system and as technology develops or expands. The committee looked briefly at two fields perfusion and cardiovascular technology that recently have come to be recognized as allied health occupations to see if developing fields tend to follow the same general pathways as those of the established oc- cupations. These two fields developed from core elements they once shared with respiratory therapy. Early academic programs covered heart and lung procedures; as technologies developed, practitioners specialized in one or another area, and separate fields and occupations evolved. Perfusion Perfusionists began in the mid-1950s as pump technicians for heart- lung machines equipment that was designed to withdraw blood from a patient's body, cleanse and oxygenate it, and pump it back into the body. These technicians moved with the equipment from experimental labora- tories into clinical settings as assistants to surgeons and anesthesiologists. Trainees were often drawn from other disciplines, including nursing and respiratory therapy, and were trained on the job until the mid .1970s. By the mid-1960s, perfusionists saw the need to develop a system for certifying practitioners and to establish a minimal base of knowledge for the profession. They formed the American Society of Extra-Corporeal Technology (AmSECT) to organize the profession and provide information and professional services to its members; in 1968 AmSECT began a pro- gram of certification for perfusionists. The American Board of Cardio- vascular Perfusion was established in 1974 to conduct certification as an independent activity. In 1977 CAHEA recognized perfusion as an allied health profession, and the way was paved for establishing accredited schools ~ . . tor training. In the years following the move to certification for perfusionists and prior to the establishment of accredited training programs, technicians trained on the job were allowed to sit for the certification exam. Since 1981, however, when school programs became available, certification require- ments have changed, and no one may sit for the exam without having graduated from an accredited program. Perfusionists work under the general supervision of a physician. Whereas they used to work only with heart-lung machines, perfusionists now man- age highly technical patient monitoring devices in the operating room. In addition, they are no longer limited only to assisting during heart bypass procedures; now, perfusionists also assist during organ transplants. The profession is striving to expand its expertise and not limit its focus to one technology; in pursuit of these goals, it is expanding its scope to include managing patient monitoring devices that have not been claimed by another

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40 ALLIED HEALTH SERVICES allied health field. Perfusion thus is taking a course not dissimilar to that of the older, established allied health professions. Cardiovascular Technology The field of cardiovascular technology involves the diagnosis and treat- ment of patients with cardiac and peripheral vascular disease. It is seg- mented into three distinct areas: (1) invasive cardiology, (2) noninvasive cardiology, and (3) noninvasive peripheral vascular study. As each of these areas developed and as changing technology led to their divergence, tech- nicians in each area were trained to conduct the requisite tests and pro- cedures. The three groups have remained together for the purpose of designing an educational program. Cardiovascular technology has been recognized by CAHEA as an allied health profession since December 1981. Cardiovascular technologists and technicians specialize in one or more of the three areas. Program accred- itation criteria have been developed, but thus far there are no accredited programs for training cardiovascular technicians. Several programs are expected to be available by the fall of 1988. The range of skills and training required by cardiovascular technologists and technicians is broad. Within the area of noninvasive cardiology, for example, procedures range from electrocardiography (EKG), which may be taught in a few hours, to echocardiography, an ultrasound technique that requires relatively extensive training. EKG technicians are often cross- trained on the job in exercise testing, another noninvasive cardiology pro- cedure. The associations that represent cardiovascular technicians who do EKGs and exercise tests have established a separate board to test technicians who want to be credentialed; most technicians are not credentialed. Institutions in which these technicians work encourage credentialing but do not require it. Cardiovascular technicians are employed in a variety of settings including physicians' offices, outpatient clinics, and exercise clinics. They work under the supervision of nursing staff or physicians. Technicians who specialize in echocardiograms are often trained on the job. Only 6 of the 30 schools offering ultrasound training include training in echocardiography, and none of the schools is accredited under CAHEA's new program of essentials for cardiovascular technology. Training in these programs must generally be supplemented by on-thejob training, but not all health care facilities have the capability to train the echocardiography technicians they need. The demand for these technicians is high, and their salaries are rising. They are often drawn from other disciplines, including nursing, physical therapy, and respiratory therapy; few trainees are without a medical background.

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WHAT DOES "ALLIED HEALTH" MEAN? 41 The Society of Diagnostic Medical Sonographers represents echocar- diographers and other sonographers. Two boards currently provide testing for certification in the field. Generally, individuals need to have several years of experience before they can qualify to take the exam. The majority of echocardiographers are not board certified, but interest in certification is growing and growing faster than in any of the other cardiovascular technology areas. The American College of Cardiologists is encouraging certification through only one body, which will probably provide increased impetus for such credentialing. Although echocardiographers have some degree of autonomy, they work closely with physicians. Echocardiography overlaps with radiologic tech- nology, which includes ultrasound technology or sonography. A movement to draft state legislation requiring that ultrasound operators be radiologic technicians is being fought by non-radiologic technicians who work with ultrasound technology. Invasive cardiovascular technologists, as their title suggests, assist phy- sicians in invasive heart procedures. With the development of bypass sur- gery the number of catheter labs has risen, and the demand for technologists has grown. Developments in balloon angioplasty and laser technology may have the same effect. Practitioners generally are drawn from other clinical areas, including x-ray technology and nursing, and typically are trained on the job. Noninvasive peripheral vascular technologists assist in diagnostic studies of the peripheral circulatory system. Ultrasound techniques are used in these studies, and, as in the case of echocardiography, substantial training is required for technicians; in addition, like echocardiographers, nonin- vasive peripheral vascular technologists who conduct ultrasound tests also face competition from radiologic technologists. Equipment manufacturers have been the primary source of training; they have established educational programs in their own facilities as well as providing onsite, in-service train- ing. In its early days, most of the field's trainees were nurses, but it now draws persons from other disciplines. CONCLUSION Allied health practitioners vary greatly in terms of the work they do, the amount of education they require, the types of institutions they attend to obtain that education, and the regulatory control that attends their activities. Yet, the evolution of their professions has followed courses that were com- mon to several if not to all of the fields. The fields developed to meet identified health care needs, often taking over tasks that physicians no longer wanted to undertake. Initially, on-thejob training was the norm, but soon the practitioners of a field formed an organization, defined their

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42 ALLIED HEALTH SERVICES roles, and identified minimum qualifications that all practitioners must possess. The certification of practitioners and the accreditation of educational programs followed. Many allied health fields today use CAHEA to accredit their programs. Others have preferred to keep accreditation within the purview of the field, a decision many groups see as one of the key attributes of a profession. In many of the fields, educational requirements have increased almost inevitably, and licensure often has followed, a develop- ment that serves several purposes including the protection of a practition- er's educational investment. In many of the allied health fields, tensions developed between practitioners and the medical or dental speciality from which the field developed. New professions have sought to control their own destinies while the originating professions have sometimes been re- luctant to relinquish control, in part because they fear competition from the very groups they initially encouraged in order to relieve themselves of unwanted tasks. Some allied health fields (e.g., physical therapy) made the transition from hospital training to baccalaureate education in universities and colleges in the first half of the century. With the community college movement in the 1960s, assistant-level programs developed to meet the growing demand for services and the need to make practitioners more productive. For other fields the transition to education and training in academia was made much more slowly. For example, radiography and respiratory therapy are in the midst of evolving toward requiring the baccalaureate degree; consequently, we now see some 1-year programs giving way, primarily to 2-year and baccalaureate programs. Those individuals with advanced degrees tend to gravitate toward administrative roles. The spectrum of allied health today includes fields at different stages of evolution. This report offers a snapshot of them at one point in time. REFERENCES American Dietetic Association. 1972. The Profession of Dietetics: Report of the Study Commission on Dietetics. Chicago: American Dietetic Association. American Dietetic Association. 1985. A New Look at the Profession of Dietetics: Report of the 1984 Study Commission on Dietetics. Chicago: American Dietetic Association. American Dietetic Association. 1987. Unpublished data. American Dietetic Association, Chicago. AOTA (American Occupational Therapy Association). 1986. 1986 Member Data Survey. Rockville, Md.: American Occupational Therapy Association. APTA (American Physical Therapy Association). 1987. 1987 Active Membership Profile Survey. Alexandria, Va.: American Physical Therapy Association. American Speech-Language-Hearing Association. 1988. Demographic Profile of the ASHA Membership. Rockville, Md.: American Speech-Language-Hearing Association. March 9.

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WHAT DOES "ALLIED HEALTH" MEAN? 43 Bryk, I. A. 1987. Report on the 1986 Census of the American Dietetic Association. Journal of the American Dietetic Association 87(8):1080-1085. Bureau of Health Manpower. 1967. Education for the Allied Health Professions and Services: Report of the Allied Health Professions Education Subcommittee of the National Advisory Health Council. Washington, D.C.: U.S. Government Printing Of- fice. Bureau of Health Professions. 1984. An In-Depth Examination of the 1980 Decennial Census Employment Data for Health Occupations, Comprehensive Report. Rockville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau of Health Professions. 1988. Report to the President and Congress on the Status of Health Personnel in the United States. Washington, D.C.: U.S. Department of Health and Human Services. Bureau of Labor Statistics. 1987. Employment by Occupation and Industry, 1986 and Projected 2000 Alternatives. Washington, D.C.: Bureau of Labor Statistics. Committee on Allied Health Education and Accreditation (CAHEA). 1987. Allied Health Education Directory, 1987. Chicago: American Medical Association. McTernan, E. I. 1987. Allied health professions in the United States: A summary of the origins, development, and potential futures of a selected sample of allied health fields. Background paper prepared for the Institute of Medicine Committee to Study the Role of Allied Health Personnel. Paden, E. P. 1970. A History of the American Speech and Hearing Association. Wash- ington, D.C.: American Speech and Hearing Association. Shewan, C. M. 1987. An update on supply estimates for speech-language-hearing per- sonnel. American Speech-Language-Hearing Association, Rockville, Md. U.S. Department of Health, Education, and Welfare. 1979. A Report on Allied Health Personnel. Washington, D.C.: U.S. Government Printing Office.