Maloy Das uses Andrew Abbott’s sociological framework to reflect on what the history of ‘non-doctors’ can tell us about present healthcare debates.
In October 2022, Emily Chesterton visited her general practitioner in London for the second time in two weeks (Wooton-Cane, 2024). She’d been walking on a sore, tender calf for a while, and was now feeling short of breath. For the second time in two weeks, she was turned away – anxiety thought to be the cause. A few hours later, Emily collapsed. She died the next day in intensive care. The cause of death? A pulmonary embolism (a blockage in the pulmonary arteries), easily treated if spotted early.
An inquest revealed that a doctor never saw Emily. She’d seen a physician associate (PA) – a healthcare professional who has undertaken a 2-year degree and only assesses patients under supervision.
It is quicker and cheaper to train and employ physician associates than doctors. Governments are struggling to fund accessible healthcare for millions, so PAs arguably provide a valuable service, covering thousands of workforce gaps across many departments. They can assess patients in the emergency department and GP practices, or assist anaesthetists and surgeons in the operating room. But the British Medical Association (BMA) – one of the largest lobbying groups for medical doctors in the UK – say PAs should not be treating patients at all, citing Emily’s case as an example of their danger (Kimber, 2024). Emily’s story is the latest tragedy to be weaponised by doctors in a professional turf war.
Now consider the case of Katie Doyle, a 27-year-old from Dublin. Like Emily, she developed shortness of breath that was attributed to a panic attack (Gallagher, 2024). Like Emily, she died a few days later from a pulmonary embolism. But Katie was assessed by a junior doctor. There have been no lobbies against junior doctors and no legal challenges against their work.
‘Non-doctors’ – not simply anyone who is not a doctor, but rather professions who can do some, or all the tasks we expect of a doctor, such as PAs – have worked alongside doctors throughout history. The aim of this article is not to confirm or refute the safety of PAs, but to question how the conflict between doctors and PAs appears if we looked at it from a medical sociology framework, drawing on Andrew Abbott’s work on the sociology of professions and applying it to three historical episodes. The origin, rise, and demise of each non-doctor role suggests something unique about how the current dilemma might play out.
Professions and jurisdiction
Professions are characterised by their claim over a particular jurisdiction – how they complete for and ensure that claim (Abbott, 1986, 187-224). Abbott’s concept of jurisdiction explains the differences between how the two cases- Emily Chesterton’s and Katie Doyle’s- were responded to. In the former, doctors argue that the mistake was made by a PA stepping outside of their jurisdiction; in the latter, the junior doctor in question was within jurisdiction – and thus required a different level of scrutiny.
The jurisdiction of both doctors and non-doctors is the diagnosis and treatment of illness. But methods of diagnosis, treatment, and the definition of ‘illness’ are by no means stable across time. Non-doctors always have and will continue to compete with doctors. This tension is central to the current dispute– what gives a profession the right to treat patients? What gives one profession the right to tell another how to act? What are the circumstances that lead to a shift in professional jurisdiction?
Beards, barnets and bloodletting
For centuries, surgery was considered the poor relation to ‘physic’ (what we now call medicine). In practice, both were performed side by side under one roof. In medieval Europe, healthcare was largely provided in monasteries; monks carried out operations and prescribed medicinal agents. In this context, contact with blood was seen as taboo, and in 1163 Pope Alexander III banned monks from any surgical operating – exemplifying how societal beliefs and power structures shape the boundaries of professional jurisdiction (Schmidt and Ness, 2006).
With the ban on monks conducting surgery, it was barbers who became the new surgeons. Barbers already frequented the monasteries, keeping the monks clean-shaven, and their shears and razors allowed them to take on the new role. Blood-letting, amputations, and tooth extractions could all be done alongside a beard trim or a haircut (Pang, 2016). Monks were still allowed to diagnose and dispense medications, and thus medicine and surgery evolved separately. The first medical schools sprung up near the monasteries, and medicine became an academic specialty. Barber-surgeons were not permitted entry. When the Black Plague killed off vast numbers of physicians during the 14th and 15th centuries, however, the public turned to barber-surgeons for their health needs (Unsworth, 202), leading King Henry VIII to establish the Company of Barber-Surgeons in 1540, professionalising the role (Unsworth, 2020). The birth of the barber-surgeon illustrates how “professions develop when jurisdictions become vacant” (Abbott 1988, 2). When there is work that doctors either cannot or will not do, non-doctors become essential.
During the ‘Age of Enlightenment,’ when ‘scientific’ and ‘rational’ knowledge of disease expanded, surgery and medicine began to merge. The innovations of barber-surgeons like Ambroise Paré (Friedman, 2018), elevated surgery to an academic discipline and surgeons earned university chairs throughout Europe. Jurisdictional boundaries began to shift once again in response to these scientific and institutional changes, with barbers losing their hold over the surgical craft which began to require extensive educational training. Indeed, the “power and prestige” of a profession’s academic knowledge can sustain its jurisdiction (Abbott, 1988, 53). The practical apprenticeship of barber-surgeons was suddenly viewed as ‘unscholarly.’ Reflecting this, today medical doctors argue that the two-year physician associate degree is insufficient compared to their own five years training.
“No one familiar with the history of professions can ignore the importance of power in jurisdictional competitions” (Abott, 1988, 139). Physicians stood with the power structures of their day – the church, the monarchy, the universities. In 1858, the UK Medical Act was passed, uniting surgeons and physicians under the General Medical Council (GMC). The barber-surgeon ceased to exist.
Today, doctors have historical institutions such as the Royal Colleges and the BMA lobbying on their behalf. The United Medical Associate Professionals represents physician associates, but has existed for less than two years. Without greater political capital, PAs face the same fate as the barber-surgeons.
Officers, auxiliaries and practitioners
The global spread of European medicine during colonialism is certainly problematic, with European physicians holding a sense of superiority (Bruchhausen, 2020) and displacing indigenous practices in the colonies. The imperial powers built many city hospitals on colonial territory, but were less interested in rural areas (Louise-Clark and Toshner, 2023). These regions were deemed unattractive to Western medical doctors, and creating European ‘Medical Schools’ for locals was costly and time consuming. The solution? Professional non-doctors. Their titles varied: assistant medical officers in Sudan and auxiliaires médicaux in Algeria (Louise-Clark and Toshner, 2023). These non-doctors studied condensed medical curriculums through accelerated programmes, much like today’s PAs. There was a deliberate focus on infectious diseases, which were stigmatised as “native” illnesses (Louise-Clark, 2013). In Algeria, the French government built under-funded, poorly equipped hôpitaux indigènes and the auxiliaires médicaux were employed to keep costs down (Louise-Clark, 2021).
In the colonial world, attitudes towards Western medicine were ambivalent. They imposed healthcare systems that othered locals and perpetuated inequality. Colonial non-doctors bore the brunt, and were viewed by patients as stooges of the colonial authorities (De Craemer and Fox, 1968). They were harassed at work and unappreciated by the public; other medical staff considered their qualifications ‘second rate’ (Thomas, 1963).
Colonial non-doctors are often cited in the argument against physician associates today. Both roles were created to meet shortages in particular kinds of doctors and for both, remuneration is significantly lower than for doctors (Louise-Clark and Toshner, 2023). “When you create two-tier systems for accessing careers in medicine, the “lesser” track will map onto existing inequalities in the surrounding society” (Louise-Clark, Toshner, 2023). Medical school graduates are usually from high income households (Steven et al 2016; Khan et al 2020; Nguyen et al 2023), whilst student PAs disproportionately come from disadvantaged backgrounds (Louise-Clark, Toshner, 2023).
The barefoot revolution
In 1966, Mao Zedong launched the Cultural Revolution – one of the 20th century’s darkest periods. However, healthcare historians also recognise it as a time of remarkable improvement in Chinese rural healthcare (Xu and Hu, 2017; Gross, 2018).
Before 1966, 82% of the population lived rurally whilst 70% of doctors worked in cities (Gross, 2018; Macrotrends, 2025). Mao redressed this imbalance by expanding the role of “barefoot doctors” (Xu and Hu, 2017; Gross, 2018). Over a million farmers and labourers were given a crash course in preventative medicine, infectious diseases, and family medicine, before returning to the villages. Their training blended Western and traditional Chinese medicine, the effects being that drug addiction, infectious diseases, venereal diseases, and infant mortality rates plummeted (Zhu et al, 1989). Life expectancy and the healthcare provider to patient ratio increased (Xu and Hu, 2017). The barefoot doctor is the exemplar non-doctor – a cost-effective movement that improved the health of millions. The model inspired the World Health Organization’s philosophy of primary care (Wei, 2013, 251-280).
Barefoot doctors had a clear remit and a limited scope of practice. Studies assessing how PAs would integrate into healthcare systems have always emphasised the importance of limited scope (Rosinski and Spencer, 1967; Hutchinson et al, 2001). A well-defined scope of practice with distinct jurisdictional boundaries allows non-doctors to become experts – for example, midwives. But such limitations need revision and assessment – by the 1980s, the barefoot doctors had been so efficient that they were no longer needed.
Conclusion
Non-doctors have, and continue to face battles over their agency and autonomy, harassment at work, and restrictions to career advancement. Non-doctors, and healthcare systems more broadly, would benefit from judicious advocacy.
Non-doctors have a rich history, and have often stepped up to provide accessible healthcare to millions around the world. The lines of jurisdiction over patient care are not solely based on what is right for the public, but also along lines of power and class. Medical doctors have retained authority over this jurisdiction for decades, but external factors may change this; as Abbott says: “While power clearly affects jurisdictional conflict, in the long run power alone does not suffice.” (Abbott, 1988, 140).
About the author
Maloy Das is a consultant surgeon with the Saolta University Healthcare Group in the Republic of Ireland. He has previously worked as a doctor in the UK, Canada, and South Africa, and has a lifelong interest in medical humanities, history, and writing.
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