The Blurring of the Health Professions

Correspondence to:

Eric P. Durak, MSc

Medical Health and Fitness

1074 Miramonte Dr. #1

Santa Barbara, CA 93109

(805) 966-1299

Enter the Exercise Physiologist

The recent growing pains of clinical exercise physiologists trying to get established in therapeutic settings has brought to light a very interesting phenomenon within the health care industry today. It seems that the professionals who work in different areas of health care are in fact, performing similar types of duties in the care of their patients and/or clients.

The profession of clinical exercise physiology was born from physical education curriculums that branched out into cardiac rehabilitation, and general fitness programming. Some worked in other areas of exercise with different types of patients. Today, clinical exercise physiologists specialize in diabetes, cancer, metabolism and weight loss, rheumatic diseases, and pulmonary dysfunction rehab, to name a few.

A Natural Crossover

Many exercise professionals have found employment in diabetes treatment centers, using fitness as one of the three primary modes of treatment for the disease, along with diet and insulin. Again, the clinical exercise specialist is also required to know, in addition to exercise programming, information about insulin regimens, and their administration, effects of food, and exercise on their disposal, timing of injections, knowledge of complications, medical and laboratory diagnostics and assays, patient scheduling and billing procedures, and literature reviews, which encompass a variety of historical, clinical, pathological, and philosophical topics. In this instance, the exercise physiologist performs basic resting measures, once thought to be the sole domain of the nurse, performs patient education, just as the nurse or diabetes educator performs, and helps with some nutritional information, along with the dietitian. It has become clear that the exercise physiologist must become a Jack-of-all-trades, and become well versed in each of them.

However, physical therapists have performed clinical services with many of these types of patients also, from rehabilitative services to office procedures to medical liaisons. The once-clear line that delineated the physical therapist from the exercise physiologist has become blurred in the clinical care that is performed by each professional, and the other responsibilities they are expected to perform.

Another case is the chiropractor, who by virtue of being business owner as well as clinician, performs, in addition to spinal manipulation, soft tissue manipulation, some therapeutic exercises, nutritional consultation, and injury rehabilitation, again blurring the distinction between themselves, and physical therapists, massage therapists, exercise physiologists, and dietitians.

Many allied health professionals are performing different health care procedures. Some MPH graduates in public health are becoming certified in exercise testing and prescription, registered as dietitians, or performing counseling duties and behavior modification with patients with eating disorders, much like clinical psychologists and marriage and family counselors.

Part of the dietitian’s counseling practice is to perform and interpret body composition analysis, once reserved for the laboratory, and program entire wellness packages for their patients and clients.

Nurses, health educators, exercise physiologists, public health specialists, registered dietitians, physical therapists, occupational therapists, and other clinical care personnel are all performing duties once clearly delineated by their educational requirements, and physician’s requests.

Implications of Professional Overlap

Is this type of care good for patients ? Are there any effects from “sibling rivalry ?” To date, there are attempts from some allied health professionals to practice “exclusion” in the hope of maintaining standards in their particular fields.

In a recent issue of the Maryland Bodywork Reporter (1), the American Massage Therapy Association was in litigation with the state of Maryland regarding 50 massage therapists who received “cease and desist” orders from the Maryland physical therapy board. One therapist had received criminal inditement. The charge was practicing physical therapy without a license.

On the other side of the issue, recent information from the American Massage Therapy Association states that both physical and massage therapy can have a major impact on rehabilitation and alleviation of chronic pain and dysfunction arising from long-standing tissue problems (2). The question remains where to draw the line between cooperation between practices, and infringement on professional services.

The area of dietary and nutritional advice is another area of concern and disharmony within professions. A 1986 report sites numerous medical problems occuring from improper advice to clients who had some type of medical condition (4). The response from the American Dietetic Association has been to sponsor legislation to exclude those without the RD credentials from giving advice on nutrition (3). This has prompted a debate from other nutrition societies that many other allied health professionals are qualified to give nutrition advice, and guidelines should be implemented for the professional as a whole, and for the general public to make an informed decision.

An Overview of Overlap

The chart below is an attempt to show some of the many areas of clinical health care, and their overlap with other professions. As time goes by these professions will more and more performing multiple services once reserved for each separate division. Some of these professions are listed below:

Health Care and the World Economy

The terms health care and world economy seem to be separate entities. However, recent television reports (5) have conceded the fact that our notion of what is usually thought of as an “American” product of service may in fact be the product of a global, multi-country effort designed to meet the needs of a changing world economy more efficiently. American cars that are manufactured abroad; airlines which use parts from over twenty countries, manufacturers that use multi-national labor to produce a better and less expensive product – are all examples of an economic base that is changing to meet the needs of many countries in response to demand.

Perhaps the same effort is taking place in health care, where the scope of the problem can be solved not by one leader or care-giver, but by a team of professionals who make up the infrastructure of the health care picture.

As the scope of medical science changes in this decade, so too is the scope of clinical practice. It remains to be seen what the next few years will hold for a country with an overburden health care system, a total reduction in medical school graduates, and an eye on prevention as one means of reducing the burden of illness on society as a whole.

References

1. Maryland Bodywork Reporter. Supreme Court Denies Maryland Request. vol. 2, No. 11, November, 1991.

2. Willert, G. The practice of physical therapy and massage therapy – A cooperative approach. Massage Therapy Journal. 29;3:42-47, 1990.

3. Seelig, M. Nutritionist licensing meeting. American College of Nutrition Newsletter. May, 1991.

4. Rodale, RI (editor). Should nutritionists be licensed? Prevention Magazine. September, 1986, pp. 72-74.

5. KCET television, Los Angeles. Made In America. PBS Public television series. Aired August 27, 1992.