Inter-Professional Relationships
William A. Spencer, M.D. *
From a presentation made at the First Annual Roundup, American Academy of Orthotists and Prosthetists, Freeport, B.I., January 1975
"Professionalism" and "being a professional" are concepts that deserve consideration in understanding reasons for successes and failures of professional development and professional relationships among the health-related disciplines. This topic is difficult to engage so as to avoid an argumentative style which is not intended. Analysis of trends occurring in professional development of many kinds locates orthotics and prosthetics as an emerging profession and in the light of a new perspective. Traditionally, the hallmarks of a profession are found in the existence of a defined and unique body of transmissible knowledge and technology. A professional helps develop, use, and transmit this knowledge to others. The tendency today is for almost any technical skill to be considered a profession. Obviously, a professional has to do more than practice the techniques of an art. In the last quarter of a century, particularly in orthotics and prosthetics, there is remarkable evidence of professional development. The transition from simply practicing an art to actively developing new knowledge and procedures and to sponsorship of educational efforts such as this seminar suggests that the capability of the orthotic and prosthetic disciplines to serve handicapped people more effectively is increasing.
Willingham+ has defined some of the operational characteristics of the professional person and his rewards. We should appreciate that there are three principal kinds of professional activities engaged in by professional people. There are practitioners; there are teachers; and there are scholars or scientists. It is interesting that almost every professional body champions the existence of a "compleat"* professional within that discipline-a person who is able to pursue all these activities equally well. The reality is that it is becoming more difficult to accomplish such a balanced and broad professional life; nonetheless, this completeness remains a very worthwhile target. Why is this expectation so commonly held forth for professionals? Willingham points out criteria that many of you have observed during supervision and training of a professional person by the practitioner. Improvement of the skills required by a discipline through observation and demonstration, with a focus on practical problems, is such a criterion. This concept is particularly comfortable to the orthotist/prosthetist. Early involvement in professional affairs such as academies, congresses, and professional associations is sought. There is visible and recognized performance within the profession by certification. Finally, there is evidence of academic competency and of the efforts to improve the quality of the profession.
On the job, the practitioner's standards of success become his leadership characteristics, his certification, his rate of advancement in the area of work he chooses for his practice, and the money he receives for doing it. His patients' gratitude is a major reward. The teacher, on the other hand, depends more on institutional recognition, student and alumni nominations, the judgment of his colleagues, and a leadership role in an academic community to allow him to develop his academic programs as he desires. The scholar/scientist professional is recognized by his tendency to achieve independent accomplishments, that is, accomplishments independent of the current state of the art and knowledge base of his profession. The fact that he does innovative or creative work, makes inventions, and/or uses his creativity in conceptualizing problem areas that need to be solved and finds solutions for those problems are some of his success criteria. The quality and importance of his publications and his academic competency thus define the scholar's professional status. These publications, citations, and awards reflect his eminence in his field. His problem-solving capabilities and the utility of the inventions or discoveries that he makes are substantial evidence of his success (Fig. 1 ).
It is obvious that we mean many things by professionalism, the state of being a truly professional person. We are beginning to believe that the appropriateness of different kinds of activities including those of the practitioner, the teacher, and the scholar/scientist is proper and necessary. Some rare individuals exist among us who have the attributes of several or all of these functions. The crucial question is whether our educational processes and experiences foster these goals of professionalism or hinder their achievement.
The transition from tradesmanship to professionalism is more than the existence of a unique body of knowledge or skills. It is the development of a field, the transmission to other people of what was learned, and a kind of life-long commitment of the professional person to his own self-development. The requirement of professionalism is competence, both conceptual and technical. How well the person can think out what it is he wants to do and why he wants to do it, as well as how well he does it, is crucial. The simple difference between tradesmanship and professionalism is found in the characteristic of the professional who is interested in why as well as how. Trends in the application of scientific methodology indicate that attention to the why is essential if we are to devise better hows. It is also true that for professionalism to flourish, factors in the physical and social environment of the individual must be reinforced. The professional needs to have personal attributes of competence, willingness, and motivation to develop creativity, and ability to communicate and collaborate with other people. Yet, if he is not in the proper environment with colleagues to model and with helpful physical resources, these attributes may not be expressed. If there are no supportive personal and behavioral relationships which promote opportunities for personal decision-making by the student and encourage sharpening of analytic skills through recognition and problem-solving, the self-growth and developmental process is starved. A developing individual needs not just supervision but consultation and guidance. He especially needs persons to emulate, to respect, and to model, as well as sources of accurate information. Without these intangibles, it is difficult for professionalism to be nourished and to flourish. It is probably in this aspect that the requirements of inter-professional relations can be found. The older professions, such as medicine, have a tremendous responsibility to newly emerging professions, such as orthotics and prosthetics, to provide or stimulate the kind of behavioral climate that the orthotist and prosthetist needs. I do not believe this is widely appreciated. Intra-professional relationships usually are concerned with gaining and transferring knowledge that is appropriate to share among professions. Seminars, including other professionals, special publications, demonstrations, and teaching efforts, do provide examples of your organizational commitment to the development of new people in your field. Inter-professionalism is mostly thought of as teamwork; yet I have a great deal of trouble with that word. The reason is that most of the accomplishments of inter-professional development have not been done by a "football team." It is not a question of a quarterback calling signals and the linemen taking their assigned positions. What we mean is the circumstance where people can, together and simultaneously, perceive a problem or need and solve it with the harmonious and orchestrated interaction of their collective competence. Teamwork, thus, is not putting together a group of incompetent or partially competent people and hoping it will add up to one competent activity. It is putting together different competencies which are equivalent in quality. It includes the sharing of responsibility and even transferring of responsibility back and forth to one another.
Most professions (and I include medicine in this allegation) currently try to differentiate the uniqueness of what they do. This is a kind of territory-defining that means we are not supposed to cross one another's boundaries-as if problems were neatly compartmented into isolated pieces! This kind of behavior absolutely destroys the opportunity for teamwork. It is a dreadful problem, but it is happening in academics, in business, in industry, and in bureaucracies of all kinds. The current vogue is to try to define one profession's body of knowledge so uniquely and so rigidly circumscribe what the professional does that no one else can do it or be involved. Thus, an attitude which is the whole antithesis of teamwork is created. Teamwork is actually an inter-personal attitude which encourages learning from each other, giving credibility to each other's point of view, and recognizing that willingness to use each other's knowledge to solve a common problem more complex than any one person can handle is not piracy but a privilege. Putting together a "martini" of "X" number of proportions of orthotics, prosthetics, medicine, engineering, psychology, etc., is not the way to go. Multiple professions should be used when the problem solution requires it.
I have never seen professional education or training of any kind which insures or guarantees that a person will know how to be an effective team member or colleague. This quality is much more defined by the attitude and manner of the person, his willingness to learn from other people, his willingness to share responsibility, and his opportunity to have shared responsibility, than it is by professional or technical training. I defined professionalism before I got into the topic of inter-professional relations because, depending upon personal attitude rather than the kind of profession, inter-professional relationships can be developed by learning how to improve and strengthen professionalism. We need to develop our personal and individual insight into those activities we do which are self-gratifying, self-rewarding, and, at the same time, can contribute to our profession and help the growth and development of others. We have to ask ourselves, "Is what I am doing improving myself and improving my profession or only one or the other?" We want to maximize on doing both. There is a personal responsibility to seek an environment which is supportive rather than repressive of professionalism, whether in private practice, institutional practice, or even academic activities. Each of these entirely different functions can be very supportive of professional development or very inhibitory of it. Each professional person has an obligation to teach for more reason than just transmitting knowledge-how much do I know that I can give to someone else. It is the test of usefulness of knowledge in the teaching situation. Teaching tests not only the quality of skills and techniques, but the quality of ideas. Students are particularly adroit at testing this capability. They are increasingly more interested in the "why" as well as the "how" of what they are learning. It is also perfectly proper for the orthotist or the prosthetist to question the physician's clinical decision process and for the physician to question the selection or choice of a device solution if both parties have the correct attitudes.
Independent evaluation of products will foster the reasonableness of questioning the validity of current methods of procedures. The replication by others of what we do (a verification and validation process) has its greatest value in fostering learning from one another. Using the principal analytic rules of science in evaluation is a neutral ground. Understanding the limits of one's competence is another factor which has a great deal to do with inter-professional relations. As a director of an institution, I have great trouble getting people to realize that it is a bigger error to cover up limits of competence for fear of revealing what they do not know than it is to seek advice and consultation. Soliciting advice and assistance at the appropriate time creates a situation to learn and improve what one knows. The orthotics and prosthetics profession has already started by improving the process of certification. I do not know yet that you have approached quality assurance as we in medicine are now being directed to do. This will be increasingly important to your field, as it is in medical care, because both the public and the purchaser of services want to be assured that what they are getting for the investment is provided efficiently and is effective. The personal effort to begin to understand quality assurance and how to carry it out can give your profession a running start on medicine. You can be ready when it becomes mandatory. Usage of any device or procedure that affects physical and emotional well-being of people will undoubtedly be subject to quality surveillance. Certainly, then, you also want to direct quality surveillance toward improving practices, not to policing for failures and errors in practice. The latter approach is a mistake found in many current quality assurance procedures. Most quality control procedures, therefore, are error-detection systems. The focus is on trying to discover poor judgments after the fact, improper actions, and errors of commission and omission. The only way to achieve quality is to increase the level of competence, knowledge, and skills of practitioners in a continuing process. Using quality-control procedures as an educational device can help achieve this quality through a progressive elevation of standards.
Today many of your members are seeking to share and to transfer responsibilities according to needs and particular unique competencies among you. Understanding the difference between consultation and collaboration, and practicing those activities appropriately are important ingredients of this personal prescription for your professional development. The last area which I feel to be significant is the need to understand the trends occurring today in health service delivery. Increasingly our citizens expect all health professionals to have an organized, systematic, efficient, and effective structure in which to deliver individualized and personal services. Defining the proper manner in which to achieve such structure comprises a dilemma of world-wide dimensions. The solutions required are not yet clear. Many experiments have been made in the organization and financing of services. There have been many failures because it was not recognized that the ways activities are labeled or services are financed do not seem to have a great deal of effect on how an individual professional practices. He is conditioned mostly by his educational experiences, his postgraduate education, and his professional self-development.
In conclusion, a few popular (or unpopular) caveats are needed. No profession is totally self-sufficient and will be less so in the future. A profession should not be exclusively self-serving or it will simply return to tradesmanship. The best new development comes through creative and innovative professional practices; but development without accompanying widespread availability and distribution is insufficient for thousands of handicapped people if only the developer himself is able to use it. The problem of how to achieve widescale transfer of complex solutions has not yet been solved, especially when the transfer requires drastic changes in practice. Professional boundaries should be overlapping rather than isolated or atrophy of growth and development of each of us will occur. Failure to incorporate related developments and knowledge from others-whether it be in new materials, appropriate application of engineering science and technology, or developments in new engineering knowledge-must be avoided.
Quality of education has to improve so we can learn the method of applied science. We need to learn how to teach each other and to transfer more effectively so we can expand the educational curriculum into the usage of the principles of life sciences and engineering. The orthotic/prosihetic displine needs to develop master's level graduate programs which even include course work in the behavioral sciences and social sciences. Clinical learning experiences should be developed to be supportive of professional growth and development rather than be limited to the provision of technical training under a certified orthotist or prosthetist. The most difficult lesson to learn is to accept failures as knowledge, too. Discovering that something does not work is sometimes the secret to learning what will work. We can be overzealous in thinking that we must find a workable solution every lime we try, and overlook the most important value of negative information.
Finally, we have to satisfy the needs of the patient in circumstances of his daily life. We cannot be satisfied only with the efficiency with which we can produce devices or the economy we can gain in shop production. If developments we make in the field, either individually or jointly, do not find practical utility in the daily lives of handicapped people, we have satisfied ourselves but have not solved their problems or met their needs. The orthotic/prosthetic profession is at the frontier of a whole new era of scientific development. We are just beginning to understand the requirements for coupling devices to man to sustain, to improve or to restore personal function, and to limit the disabilities and impairments that occur during growth and development. A greater degree of professionalism is essential in solving such complex problems. More science is going to be necessary, as well as craftsmanship and clinical experience. The profession is penetrating this frontier because more and more I hear you asking "why" as well as telling each other "how."
+Willingham, W.W., Predicting success in graduate education, Science. 183:273-278, January 1974. *Apologies to Izaak Walton.
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