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The continuum cleft is a costly and precarious gap that divides professions on the health professions’ continuum. It is an interprofessional phenomenon that is encouraged because health care professions protect their members in professional silos and isolate competing professions in professional cysts. This article uses case studies of the allopathic, osteopathic, naturopathic, and chiropractic professions to contemplate the existence, consequences, and possible mitigation of intraprofessional silos, cysts, and clefts.
An ordinal scaling method has been used to position health care professions objectively and systematically on a 2-dimensional, rainbow-like continuum based on scopes of practice and philosophical values. The resulting health professions’ continuum has enabled interprofessional comparisons that have been helpful to students selecting health care careers, patients selecting health care providers, and policy makers seeking to regulate the health care professions.1
Organizing the health care professions in that way reveals a sparsely populated gap or cleft in the health professions’ continuum that represents the distinctions between the conventional and the complementary and alternative health care professions. That gap has been referred to as the continuum cleft and is illustrated in Figure 1.
The tendency of patients to secure services simultaneously on both sides of the cleft without informing their conventional or CAM providers of those consultations is thought potentially to disrupt the continuity and cost effectiveness of health care for more than 70 million Americans, at a cost of more than $7.7 billion annually.2
The cleft is an interprofessional phenomenon that becomes visible when ordinal comparisons are made among health care professions on the basis of scope of practice and professional philosophies. The cleft is intensified as health care professions protect their members in professional silos and isolate perceived antagonists or competing professions in professional cysts. If intraprofessional silos and cysts occur within individual health care professions, it is conceivable that they may precipitate the formation of intraprofessional clefts that could compromise the continuity, efficiency, and effectiveness of the professions.
In the process of professionalization, it is likely that all health care professions undergo periods of transformation that may be accompanied by intraprofessional discord and the formation of intraprofessional clefts. Case studies of the allopathic, osteopathic, naturopathic, and chiropractic professions, based on transformative events in those professions, are described in this article. Evidence of intraprofessional silos, cysts, and clefts is examined.
Specialization has been described as a common but advanced step in the professionalization process that often results in the formation of new professions.3 Specialization within conventional, Western medicine began in Paris, France, in the 1830s.4 In the decades following the 1911 Flexner report, in which the qualities of US medical schools were assessed, US medical education experienced a heightened emphasis on scientific and biomedical content that favored the advancement of medical specialties and diminished the attractiveness of general practice.5 By the end of World War II, it had become increasingly apparent that general practice would need to redefine its scope of practice and reestablish itself as a medical specialty to survive.6
To the existing medical specialties, general practice became an antiquated practice that warranted encapsulation in a professional cyst to protect patients requiring specialized care. To the existing general practitioners, a perceived need arose to erect a professional silo that would protect them from the specialists. The debate and the division persisted within the allopathic medical profession during most of the 1950s and 1960s. In 1969, after 2 decades of deliberate outreach and thoughtful negotiations, the American Medical Association (AMA) approved family practice as its 20th specialty.7 Family practice and the allopathic medical profession have since flourished.
Within 2 decades of the Flexner Report, the American Osteopathic Association permitted the integration of pharmacology into the curriculum of colleges of osteopathy.8 Although controversial to many doctors of osteopathic medicine (DOs), that action facilitated efforts by associations of osteopathic physicians in multiple states to seek practice parity with medical doctors (MDs) in their respective jurisdictions.
Those efforts were strengthened during World War II when many medical doctors were commissioned in the US military to care for troops, whereas osteopathic physicians remained at home to assume much of the United States’ domestic health care. By the end of the war, the osteopathic medical profession provided a disproportionately large share of the United States’ general health care in which the medical profession had begun to lose interest.9
By 1960, California was more heavily populated by osteopathic physicians than other states, and those physicians were politically positioned to negotiate professional parity between the state’s MDs and DOs. Despite opposition from the rest of the osteopathic profession, the California Osteopathic Association merged with the California Medical Association in 1961. The provisions of the merger and the state’s referendum that followed required that existing California DOs become MDs and that DOs be prohibited from future practice in the state.
The merger contributed to a predictable division within the osteopathic profession in which California’s osteopathic physicians were derisively labeled as little MDs. The division was ultimately repaired when the osteopathic medical profession united to successfully persuade legislators to reauthorize the practice of DOs in the state. The osteopathic medical profession has since flourished, and California is currently the home of 2 colleges of osteopathic medicine.10
The pharmaceutical advancements that occurred during and immediately after World War II caused the US therapeutic pendulum to swing from natural remedies toward synthetic, drug-related interventions. The naturopathic profession was especially jeopardized by that trend until the drug abuse of the 1960s and the Controlled Substances Act of 1970 stimulated a resurgence in consumers’ demand for safe, natural, noninvasive health care.
The pace of consumers’ renewed interest in naturopathic medicine surpassed the development of educational and regulatory standards and within a decade, multiple classes of individuals calling themselves naturopaths existed. Most naturopaths were educated in accredited, residential programs with supervised clinical training and eligibility for state licensure.11 Others received instruction through minimalist distance education programs in the relative isolation of their homes, and some simply hung up a shingle and declared themselves naturopaths.11
Some were singularly dedicated to the use of natural remedies, whereas others embraced many of the practices of conventional medicine. Notwithstanding their dissimilarities, each used the title naturopath and the credentials naturopathic doctor (ND or NMD), and they protected themselves in their own professional silos and sequestered the others in professional cysts.
To uninformed health care consumers and policy makers, the discord among the various naturopathic professions resembled intraprofessional clefts, aggravated by intraprofessional silos and cysts. When residentially educated and clinically trained naturopathic physicians sought legislatively authorized practice rights, naturopaths educated through distance learning assembled to oppose the legislation, often confusing the policy makers or at least providing an excuse for inaction. Although the confusion has subsequently diminished with the closure of the largest distance learning naturopathic college,12 the perception of fragmentation within a single naturopathic profession has contributed to the slow and incremental recognition of naturopathic medicine in a growing number of jurisdictions.
Divisions within the chiropractic profession emerged within a few years of its establishment in 1895.13 They remain today as perhaps the most enduring and disabling clefts among the health care professions and have prompted leaders of the profession to consider multiple scenarios for mending the clefts.14
Contributing to those clefts are intraprofessional silos and cysts occupied by groups of practitioners who have focused scopes, medium scopes, or broad scopes of practice.15,16 That intraprofessional fragmentation has resulted in intraprofessional confrontation in such public venues as scope-of-practice hearings in state legislatures and reauthorization hearings of federal, educational accreditation associations.
Clefts in the chiropractic continuum occur in both the horizontal or philosophical continuum and the vertical or scope-of-practice continuum (Figure 2). The cleft on the philosophical continuum separates chiropractors who base their practices on vitalism and the anecdotal evidence that supports it, from those who base their practices on mechanism and the clinical evidence that supports it.
The cleft on the scope-of-practice continuum separates chiropractors that focus their practice on a narrow range of conservative spinal-adjustment techniques, including the treatment of subluxations, from those who desire to use a broader range of diagnostic and therapeutic measures, including a conservative use of drugs and minor surgery.
Many attribute the subdued growth of the chiropractic profession and the limited reimbursement of its practitioners to the fragmentation caused by the intraprofessional chiropractic silos, cysts, and clefts.
Just as the health professions’ continuum is fragmented by interprofessional clefts that may compromise the efficiency and efficacy of health care collaborations, intraprofessional clefts can also compromise the efficiency and efficacy of health care professions. The ability of a health care profession to thrive and to contribute optimally to the larger continuum of health care may depend on its ability to minimize its silos and cysts and manage its intraprofessional clefts.
Multiple strategies for mending interprofessional clefts have been described.17 Some of them may also have utility in managing intraprofessional clefts. The following strategies are suggested for intraprofessional cleft mending. They appear to have value based on the author’s experiences acquired from the study of professions described above.
Intraprofessional organizations with divergent aspirations must communicate with each other in ways that are professional, respectful, and beneficial to the greater good of the profession. The allopathic general practice cleft required 2 decades of deliberate outreach and thoughtful negotiations by those who favored and those who opposed the formation of the family practice specialty to achieve a common consensus. The merger of the California medical and osteopathic associations that resulted in the temporary loss of recognition of osteopathic practice in the state, ultimately served to unify the osteopathic medical profession, enabling those with diverse perspectives to collaborate across the cleft.
Collaborating across the cleft should begin in the professional education process and continue in the activities of professional practice and professional management. It has been said, “Doctors that train together, treat together.” Although that strategy was intended to enhance interprofessional collaboration, educational institutions may diminish the effect of intraprofessional silos, cysts, and clefts by strategically exposing their students and faculty to each other’s clinical instruction.
Each of the case studies of the 4 professions contained intraprofessional conflicts that were based in part on the desire of some members of the professions to preserve while others sought to modify the principles on which the professions were founded. Protecting the historical heritage of a profession as a mending strategy may be more important in managing intraprofessional than interprofessional clefts.
Usually at least 1 of the intraprofessional silos is attempting to preserve some attributes of the profession that are considered to be historically significant. Although it is imperative for progressive health care professions to seek better and more comprehensive ways to continually meet the needs of their patients, it is equally important to preserve the values upon which a profession was initially established. The strategic plans of all health care professions should contain heritage-sustaining measures, ideally at the level of planning the profession’s goals or objectives.
Most health care professions share more common than distinguishing qualities. That statement should be truer within a single profession than between multiple professions. Although it is tantalizing to concentrate on the silos and cysts within a profession, a profession is best-served when the commonalities are celebrated. Professions should critically examine the presence of silos, cysts, and clefts in their periodic analyses of strengths, weaknesses, opportunities, threats (ie, SWOT analyses) and then develop strategic initiatives to overcome and manage them. Common philosophies, values, and beliefs should be regarded as strengths and celebrated in ways that unify a profession.
The osteopathic and naturopathic case studies provide examples of the resistance that occurs when valued professional silos appear to be threatened. Just as interprofessional silos are natural and helpful structures for the advancement of a profession, intraprofessional silos may be natural and helpful in advancing intraprofessional diversity or spawning the emergence of new and needed specialties and professions.
To the extent that intraprofessional silos can peacefully coexist and collaborate, they should be celebrated and nurtured rather than confronted and dismantled. After identifying existing and emerging intraprofessional silos in SWOT analyses, the professions should develop strategies to honor them and encourage collaboration among them. The allopathic and osteopathic case studies concluded by acknowledging the ability of both professions to flourish with dozens of intraprofessional specialty silos.
New and foreign initiatives within a profession are often greeted by cyst-forming skepticism. That phenomenon can be a healthy one that protects the profession and its patients from bogus procedures and fosters the conduct of validating research. Evidence is the difference between a harmful professional cyst and an elevating professional silo.
The presence of intraprofessional cysts suggests that the evidence necessary to justify the practices within the profession requires additional validation. Seeking such validation should be a priority for all of the profession’s members. Professions should encourage investigators from polarized portions of a profession to collaborate in identifying the needed evidence and conducting the research to obtain it. Shortly after the publication of the Flexner report, Leonard W. Ely (chairman of the AMA’s Section on Orthopedics and one of the most revered leaders in US health care at that time), wrote, “So long as a specialty is contributing to the advancement of knowledge, it tends to hold its ground and advance its borders. When it stops, other specialties encroach on it. It must take up new ground to avoid absorption ….”18 That assertion remains true for contemporary professions.
Graphic depictions of interprofessional clefts reveal that one end of the cleft is usually narrower than the other. That fact suggests that portions of the health professions’ continuum are more collaborative and less exclusive than others. The same is probably true of intraprofessional clefts as well. The most collaborative group may be the part of the profession that is most capable of initiating cleft-mending activities. In their organizational assessments, leaders of professions should examine the qualities of intraprofessional silos and cysts and develop cleft-mending strategies that encourage the designation of the highest priority for mending assistance to those professionals who are the most collaborative individuals.
Those individuals who possess the resolve to shape professions typically possess the single-mindedness and strength of personality to win at all costs. When the need to conquer prohibits the ability to compromise, clefts deepen, and cysts and silos are galvanized. It is interesting that the acceptance of pharmacotherapeutics has been a source of discord in at least 3 of the 4 professions in the case studies, but it need not be. When the participants consider that the legal definition of a drug is a chemical substance used to diagnose, treat, or prevent disease, it should become apparent that even the most conservative professions have already embraced their use. The acceptance of pharmacotherapeutics is an example of a recurring argument that has stimulated the formation of unnecessary silos, cysts, and clefts in intraprofessional continua.
The process of professionalization is one that naturally introduces professional silos, cysts, and clefts into the intraprofessional continuum. When professions are able to manage them, those features become transitional symbols of transformation. When they endure, however, and are disruptive to the advancement of the profession, its leaders should consider strategic plans that call for the formation of new specialties or even new professions.
Cleft mending requires courage. Silos provide safety, but the cleft menders must venture into the shadows between the silos on the intraprofessional continuum. There they are vulnerable to criticisms from the inhabitants of all of the silos. Blessed are the cleft menders for they are the peace makers of the continuum.
Just as a continuum of the health care professions exists, on which professions can be positioned based on their scopes of practice and philosophical values, intraprofessional continua are based on similar scopes of practice and philosophical values. Just as professional silos and professional cysts contribute to the formation of clefts in the interprofessional continuum of the health care professions, professional silos and cysts also contribute to intraprofessional clefts. The failure to manage its intraprofessional clefts may diminish the robustness of a profession. Many of the strategies that are known to be helpful in mending interprofessional clefts may also be helpful in mending the clefts of intraprofessional continua. The ability of a profession to thrive may depend on its ability to mend or at least manage its intraprofessional continuum clefts.