restricted access 6. The Redivision of Labor,1950-1980
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6 The Redivision of Labor, 1950-1980 Until the 1950s the allied occupations accepted their subordination to medicine because they perceived this relationship as beneficial and necessary. With the professionalization of groups such as chiropractors, and with the proliferation of new "therapy" workers such as corrective therapists, physical therapists wanted more protection oftheir territory than the medical profession provided. While physical therapists turned to state governments for protective licensing legislation, occupational therapists, for a variety of reasons, did not. Since the mid-1950s the allied groups have tried to increase their autonomy vis-a-vis physical medicine and the medical profession. The enlarged federal role in health care during the 1960s created a more competitive market situation. Programs like Medicare and Medicaid and the Allied Health Act of 1966 supported the trainingof health workers and spurred the drive for autonomy by creating new service markets in hospitals, nursing homes, and home care. By the early 1970s, however, various forces in the medical profession, the state, and the private sector aligned to prevent further increases in autonomy by allied occupations on the 123 grounds that fragmentation had to be stopped. Nonetheless, physical therapists prevailed in this struggle and entered the 1980s with a secure and sizable market for their services. In fact they were so successful in the medical marketplace that other occupations have called the APTA to find how physical therapists accomplished this. By making a number of market mistakes since World War II, occupational therapists have been much less successful in their quest for autonomy. The rise of allied occupations, especially physical therapy, in the rehabilitation division of labor has been paralleled by the fall of physical medicine as the dominant specialty in this area after World War II. Moves by physical therapists to assume increasing responsibility for treatment and diagnosis without dependence on physicians have not been countered by physiatrists. Attackson physical medicine by other medical specialties have further weakened physiatrists' domain and control over rehabilitation work. For the most part, physiatrists assumed a defensive posture in the marketplace over the last thirty years and failed to develop a market approach that might have prevented their displacement in the division of labor, if not their possible demise in the future as a medical specialty. Pursuit of Autonomy The Rise of Physical Therapy Beginning in 1946, the APTA encouraged legal recognition of the physical therapy profession through the enactment of physical therapy practice acts that would legally license or register therapists. The association furnished advice and guidance to the state chapters regarding legislative activity and encouraged its membership to take "an active and informed interest" in the state licensing issue.1 "Sound ground work for future legislation" will only be laid, claimed the APTA president in 1951, if therapists "continue to give unsparingly of their time and energy. Protective legislation is vital if physical therapy is to progress!"2 THE REDIVISION OF LABOR 124 Those state chapters which sought licensing faced opposition by traditional competitors, such as osteopaths, chiropractors , and masseurs, as well as by newer competitors, including naturopaths, reflexologists, herb dealers, and even some beauticians. To counter this opposition, and to increase the likelihood that state legislators would pass their bills, physical therapists sought the support of the more powerful lobby of state medical societies and nursing associations as well as private foundations such as the National Foundation for Infantile Paralysis and the Cerebral Palsy Association. In addition, physical therapists in some state chapters registered themselves as lobbyists, and in several states, lawyers, who were also legislators, were retained to sponsor physical therapy licensing legislation.3 In 1954 physical therapists demanded representation on medical examiners boards and an end to the requirement that certain medical specialties serve on the boards.4 The former demand indicated a desire to gain influence vis-a-vis medicine , while the latter reflected a wish to alter physical medicine 's control. The APTA called in 1957 for its local associations to press for state laws that would create "Boards of Physical Therapy Examiners" composed of two physical therapists and one physician. If this met with resistance, the APTA was willing to settle for an advisory group of physical therapists.s By 1959, 31 states passed licensing laws for physical therapists .6 Thirteen states had Boards of Physical Therapy (with 8 being composed entirely of physical therapists) and 18 had Boards of Medical Examiners (with 13 having advisory committees of physical therapists). A total of 15 states had "mandatory " laws that forbade use of...