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 This is a post in our ‘Advanced Topics in World Building’ series. See this post for an introduction to this series of high-level discussions for the experienced world builder. A master list of these posts can be viewed on the “Free Info” tab. Part 1 of this post is here

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In Part 1 of this series I discussed how complex societies tend to become specialized, and how this includes a status increase for specialists and an organizational move towards credentialing. More on that point follows.

Credentials in Practice

woman studying law booksA credential becomes a necessary validation of a specialist’s ability. It is issued with serious qualifiers and considerations attached. For instance, today one can no longer just “read the law” (studying law books on one’s own, or working as an apprentice to a judge or lawyer) and then start practicing law on one’s own, as Abraham Lincoln did. No, now a person must sit for and pass a test administered by the state. In addition, an aspiring lawyer cannot even take that test unless she has graduated from a school approved (in the U.S.) by the American Bar Association.

On one hand this allows existing specialists to make sure a newcomer actually knows the stuff she is supposed to know. On the other hand, it also gives them considerable control over the aspirant’s education, scope of training, and ability to work in the field at all.

Social Impact of Credentialing

Over the past two centuries we have gone from individuals doing specialized work to many specialist organizations controlling training and work in the field itself. This shift has produced far-reaching social changes in many aspects of our lives. In another post I am writing about medicine, so here as my example I’ll take a look at the effects of specialization and credentialing in this area.

In the 19th century, physicians organized to drive uncredentialed people and “questionable” practices out of the mainstream of medical work. In the process they gave preferential deference to the (then) new and exciting discoveries coming out of scientific research in the field of medicine.

19th c doctorThey succeeded in professionalizing their occupation by a combination of pushing for medical practitioners to have medical credentials, by campaigning for laws to prevent uncredentialed persons from working in their field, and by running a long-term campaign (educational or propagandistic, depending who is telling it) to discredit practices not approved by the gatekeepers of organized medicine.

Midwives were one of the first victims of this credentialing trend, but hardly the last.[1] Natural medicines were largely displaced by manufactured drugs by the mid-20th century. Medical practices that did not stem from within organized western medicine (such as chiropractic and accupuncture) were at first dismissed outright and campaigned against as quackery. Only after many decades of research and institutional resistance is their efficacy just now coming to be recognized by some (but hardly all) elements of the professional medical community.

Medicine, Modern-Style

The effect this rearrangement of the medical landscape has had is vast. It has reorganized how medicine is practiced, who is considered believable and authoritative, what cures are considered valid or invalid, and vested much of the responsibility for healing in the doctor, not the patient. At the same time it has pushed knowledge of natural medicines to the wings and out of the mainstream of current medical knowledge. These changes are virtually invisible to most westerners, who have grown up exclusively in our system of institutionalized, credentialed medicine.

Even so, there is cultural variation in the state of knowledge about natural medicine and the credence given to it, depending upon a nation’s traditions and experience of natural curatives. In Germany, for instance, with its long history of natural and homeopathic cures, doctors still frequently recommend over-the-counter treatments based on natural ingredients, and consumers buy such things themselves because they are aware of them and know they are efficacious. A dental assistant in Denmark routinely tells her denture patients to rinse their mouths with chamomile tea because it is soothing and healing to the gums. Her American counterpart, on the other hand, has not only never heard of such a thing, but may well consider it quackery and advise only use of a drug or medicated cream for denture sores. The fact that the Danish approach is never so much as introduced to the American medical student or technician is a reflection of the institutional framing of acceptable versus unacceptable approaches to healing.

homeopathic medicine

 

Organizational Behavior

Any interest group naturally tends to protect its interests. But once credentialing is involved, the stakes are higher. There is a more authoritative stance to convey and protect, and a higher status to keep safe from challenges. Thus a group that depends on credentialing to help establish its status will tend to ignore input from outsiders, and will execute their specialty only as the in-group members see fit. Highly specialized and credentialed groups (and occupations) tend to become conservative, reluctant to change (unless their work itself requires it) and will circle the wagons to rebuff challenges to their expertise and authority.

On the plus side, this kind of group can also impose quality standards in its specialty; act to ensure the safety of customers, clients or public; promote education and get other large organizations involved in whatever they deem to be a worthy cause.

It is not necessarily a bad thing if a group is specialized, high-status, and uses credentialing to define their position. But groups like this are quirky, and can be a double-edged sword in any society. When there are many groups like this working towards their own ends in a complex society, their cumulative effects can be quite marked.

From the World Building Angle

If your constructed world is complex enough for such groups to exist, be prepared to have them spread like bureaucratic and political kudzu, strangling some occupations and overrunning some other organizations, until their dynamic tension has rearranged the infrastructure of your world. Your more powerful credentialed specialist groups become influential “special interest groups” in our modern parlance. It would be a mistake to think of them strictly as a modern phenomenon, though:  trade and craft guilds in the Late Middle Ages, for instance, were every bit as specialized and influential as the AMA (American Medical Association) today[2]. In a fictional world this niche might be occupied by groups of wizards, churchmen, groups of technologists, or any other specialized group that you decide needs to be interwoven into the power fabric of your society.

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1 “Midwives were one of the first victims of this credentialing trend. . .”:  Although midwives had attended births since America’s colonization, the growing dominance of obstetricians, hospital births, and pressure by the AMA in the 19th century put most midwives out of business by the early 20th century.

It was not until the early 1920s that public health nurses with special training in midwifery started to provide maternity care through Kentucky’s Frontier Nursing Service. The founder of that service, Mary Breckinridge, brought British nurse-midwives to FNS in 1929, marking the start of a trend towards the employment of certified nurse-midwives. Note that although these credentialed professionals were able to work in maternity care, midwives who lacked credentials were driven out of business and out of the public eye by the credentialing requirements that the medical establishment had managed to impose.

NHS nurses from Call the Midwife...midwives1

NHS nurses in 1957 from Call the Midwife…

In the U.K., in contrast, the situation was and is different. Midwives had never really been put out of business there, and in the 20th century the growing trend of certification led to the growth of a respected corps of nurse-midwives who by the 1950s were an essential part of the maternity and obstetric care provided by the National Health Service. For an interesting glimpse into the workings of midwifery as a specialized occupation, I recommend watching Call the Midwife, the award-winning BBC production of the memoirs of NHS midwife Jennifer Worth.

2. AMA: “Critics of the American Medical Association, including economist Milton Friedman, have asserted that the organization acts as a guild and has attempted to increase physicians’ wages and fees by influencing limitations on the supply of physicians and non-physician competition.” See Wikipedia for more.

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NHS midwife nurse teaching prenatal class in 1940

. . .and their historical counterpart, teaching a prenatal class in 1940.

 

 

 

 

2 Responses to Specialization and Credentialing, Part 2

  1. Teramis Teramis says:

    Indeed. Milton Keynes called the AMA a guild, asserting that the organization attempted to increase physicians’ wages and fees by influencing limitations on the supply of physicians and non-physician competition. There are some distinctions between guilds and unions but in today’s world for all practical purposes the end result is the same.

  2. I have often said, the strongest labor unions in the country are the American Medical Association and the lawyers’ association. So strong that few recognize that they are, for all practical purposes, unions.

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