A minor profession on the move; what does it take to arrive? BUTEYKO in America.

I suggest that the only books that

influence us are those for which we are ready,

and which have gone a little farther

down our particular path than we have yet gone ourselves.

E. M. Forster, 1925

There are six clusters of questions which the literature of professional formation reports as very telling of whether a group is a profession already, or at least on its way to becoming one.  The challenge is that advocates of the orthodox biomedicine establishment have little tolerance for newcomers and control the entry gates to professional formation. Let’s consider Buteyko Breathing, a remarkable approach to respiratory care, which is gaining adherents not only in North America, but also globally. A quick scan of the literature of the professions … that is, the books, articles and studies about professional groups and how they take shape in civil society … can begin to answer these questions.

First, the questions.

1. What exactly is a profession and does the Buteyko educator/ practitioner community constitute a profession? what are the characteristics of the socialization process for new entrants to the Butyeko Breathing profession?
2. What are the educational foundations of professional preparation?
3. Has the Buteyko profession achieved social closure as a profession and converted specialized, codified knowledge into social and economic rewards?
4. If the Buteyko educator/practitioner community is a profession, is it a major or minor profession? Who or what decides?
5. How does the scope of practice of Buteyko breathing differ from other similar respiratory care groups?
6. What is meant by “professional education”?
7. Is the Buteyko profession required to ground any codified body of knowledge in scientific principles? What is the role of research in that process?

 The literature of the professions includes numerous, related factors about the emergence, development and sustainability of groups wanting to be recognized as professionals. The very word “profession” in terms of the highly competitive U.S. health care marketplace asks two further questions, the answers to which are very telling: is the group self-regulating? And, does it have voluntary clientele? The literature goes beyond, say, the nature of health professional expertise (Papa, Stone & Aldrich, 1996; Bordage & Zacks, 1984; Norman, Rosenthal, Brooks & Muzzin, 1989; McGaghie, McCrimmon, Boerger, & Ravitch, 1994). It embraces scholarship about professional expertise, professional formation, and intra-professional competition.

The concept of social closure in professional formation is also very important. Along the way in the evolution of Buteyko Breathing education as a professional activity, there is the issue of the bifurcation of the profession into practitioners and educators. The Buteyko Breathing Educators Association (BBEA) had to do this in order to ward off annoying attacks by licensed biomedicine practitioners who would insist that BBEs (Buteyko Breathing Educators) cannot “practice medicine without a license”.  Thus, yet another question: is Buteyko Breathing a form of “medicine”?   

The positivist foundations of professional curriculum embrace what Schon (1987) calls a “normative curriculum”. Do the BBEA (Buteyko Breathing Educators Association) and its TIBE (Training Institute of Buteyko Educators) have a normative curriculum tradition? The literature of professional formation also calls attention to the recurring theme of marginalization in professions and to aspects of a “hidden curriculum” which contribute to the oscillation among those who would embrace scientific medicine as more important than patient-centred medicine.  Is Buteyko Breathing “medicine” at all?  Is it scientific? Is it patient-centered?  In response to these two latter questions in particular, the BBEA would answer “yes” and “yes”. 

 Social closure and the making of professionals

Larson (1977) explains how the social sciences provide a framework for describing and understanding the concept of the professions in civil society, and how an occupation tries to “translate one category of scarce resources – special knowledge and skills – into another – social and economic rewards” (xvii). Richardson (1985) insists, “it is axiomatic that professionals possess a complex set of techniques which requires time and training to master” (p. 45). A profession takes shape, he adds, around its ability to codify knowledge and standardize the training of its practitioners (p. 45). Murphy (1988) demonstrates how “social closure” and “monopolization and exclusion” ensue for professional groups successful in structuring, transmitting and codifying their knowledge and specialized skills. In addition, Larson (1977) discusses how symbols legitimize professional practice, manifesting in career paths and the regulation of groups with specialized training and skills who, ideally, as indicated above, have a voluntary clientele and are self-regulating. The marketplace gets crowded, though, and there have to be screening processes which keep out triflers (in the interests of safety and credibility) and encourage new approaches which ameliorate the complex and unfortunate dominance of biomedicine by pharmaceuticals.

Richardson (1992) later added to this view of the professions by pointing out the “scales of professionalization” and typologies which accommodate the “semi-professions” (p. 44).  Thus the question, is Buteyko Breathing a “semi” profession? He explains that “the success of a profession can be determined by the degree to which it has successfully closed access to a particular set of market opportunities for its own members” (p. 45). This process of social closure is what MDs have done. They have been very successful in dominating bio-medical science, generating in the process a number of “minor” professions (a term coined by Glazer, 1974) in the same field.  This creation of a category of minor professions accompanies another aspect of professional formation, the differentiation of the core professional group. Are Buteyko Breathing Educators/Practitioners a sub-set, say, of respiratory care practitioners and respiratory therapists, or an abbreviated specialty of pulmonologists? The former two are not MDs, but whose specialized training is accredited and credentialed; the latter category is a specialty, usually of licensed physicians, focused on health concerns such as asthma, COPD, trauma, acute lung injury, and so on). But who's the boss?

 David Coburn (1992) helps demystify these issues in another way when commenting on Marxist writing on medicine: “Medicine can only be adequately analyzed by situating it within the larger social formation (Derber 1982, 1984; Navarro 1976, 1978, 1983; Waitzkin 1983; McKinlay 1984).” The larger social formation in North America is a case in point as one learns how difficult it has been for the BBEA to get a regionally accredited credential in place, recognized and supported within the higher education sector in North American states and provinces. Freidson’s (1984, 1986, 1970) ideas help put a strong magnifying glass to the debate between orthodox, evidence-based medicine and holistic, alternative and complementary medicine, if indeed, we consider Buteyko Breathing therapy to be a form of “medicine”. Having a common language and concepts to apply to these phenomena is most useful to those interested to understand how professions arise and take their place in civil society.

 Indeed, with respect to social issues, the positioning of a profession to profit from a social contract of the reach and depth, say, which allopathic medical doctors have achieved in North America (Ludmerer, 1999), is an important historical pattern to be aware of. In this regard, Rue Bucher (1988) has written about the interrelationships among health occupations utilizing the “heuristic device of a natural history”. He helps us to understand better the organizational context within which “the processes of emergence and development of occupations” can occur. Bucher explains that medicine had differentiated early in twentieth century into many specialties, and all of them competed for mainstream status and position. He investigates psychiatry, orthopedic surgery, internal medicine, osteopathy and pediatrics, among others. He also examines some of the causes of the emergence of new occupational groups (e.g. the “medicalization” of human concerns). The point is made that respiratory care is differentiated among specialized medical care and those aspects of care which are delegated to minor professions who take direction from the MDs. 

Where, then, can marginalized professions such as Buteyko Breathing educators fit? Are Buteyko Breathing professionals automatically relegated to non-primary roles? On the other hand, given the determination of the BBEA to evolve Buteyko Breathing into a widely accepted health education profession, the question arises, who will regulate those services? Bucher further explains that there emerge “auxiliary” occupations, in some cases the minor professions Glazer (1974) describes, but nevertheless, “deliberately fashioned lower status groups” who “carry out the work that the ‘real’ members of the occupation are no longer interested in doing themselves” (Bucher, 1988, p. 221).

Another scholar of professional formation, Freidson (1970, 1984, 1985, 1994) writes about the reorganization of the medical profession, focusing in part on the growing dependence of that profession on “services and goods that are outside their own control” (1984, p. 15). Further, as Freidson goes on to explain, there have emerged many other health care professions “under medicine’s shelter” and these professions “have to exist only on what medicine allows them” (p. 19). These “carefully delimited spheres of activity”, Freidson argues, corroborate the notion that medicine has a monopoly and that its control is not diminishing. Nevertheless, medicine is facing, Freidson wrote presciently almost a quarter century ago, “greater rationalization and formalization” such as in functions like the financing, accounting, and organization of care (1994, p. 9).  

 Educational foundations of professional formation

Samuel Bloom (1988) points out that despite a longstanding interest in change, the revolution in biomedical science [over the past century] has entrenched itself in a duality: the reductionist biomedical orientation and the social ecology/humanistic approach in medical education, which Ludmerer expands on so persuasively in his 1999 book, Time to Heal. Bloom explains that the reductionist approach “involves faith in the rational solution of medical problems, disinterested concern for patient and society, and dedication to competence in practice” (p. 297). The approach of social ecology on the other hand emphasizes caring more than curing, community rather than the hospital. 

Bloom further explains that despite an effort “from Carnegie to GPEP” [landmark commissions which heavily influenced allopathic medical practice and preparatory education] to “structure an educational experience with a balanced approach between the what and the how of physician behavior”, change has proven to be mostly “cosmetic” (p.303). Bloom also posits “eight interlinked propositions” which argue that research and education are “rivals and sometimes even enemies”. Medical education, Bloom maintains, is “a consulting profession and not a unified scholarly discipline” (p. 299). The assumption, Bloom declares, “is that behavior follows from knowledge” (p. 233). This kind of insight is especially functional in reassembling what at first appears to be a chaotic debate among medical practitioners and medical academics into a familiar narrative about what Ludmerer describes as the “bifurcation of the profession into practitioners and researchers” (Ludmerer, 1999).

Schon (1987), cited earlier, investigates notions of ‘rigorous, professional knowledge based on technical rationality’ [positivist philosophy] helping link the Buteyko curriculum to the curriculum paradigm of mainstream professions such as medicine, dentistry, and even architecture. Schon explains, “the most important areas of professional practice lie beyond the conventional boundaries of professional competence” (p. 11). His “normative curriculum”, characteristic of most professional schools, is a useful way of understanding the “hierarchy of knowledge” which hugely influences the emergence and maintenance of “professional competence” in any professional program. Schon explains that normative curriculum in every professional training program should likely encompass three elements:

1. basic science
2. applied science
3. practicum [technical skills of day to day practice]

The role of research and the university model in professional formation

Finally, we should not forget how important research is as a key foundational and sustaining activity of a profession. There is pressure on the Buteyko profession from all quarters to generate research. The literature of the professions attests not only to the critical importance of this priority in professional formation in the health care sector, but also to the interdependence of the primary health care professions with suppliers of the products and instruments of medicine which grow out of such research (Ludmerer, 1999). 

A reflective practicum and a reflective curriculum simply do not fit snugly into the existing research system and capacity of the BBEA. With Veblen’s formulation of the ancient hierarchy of fundamental and applied knowledge in mind, but taking into account what Schon describes as “the split between the technically rational world of the disciplines, on the one hand, and, on the other, the reflection-in-action of competent practitioners”, the challenge for the planners and implementers of a higher education, Buteyko program within a college or university is formidable.