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Over the past decade, different parties in the health care field have developed and disseminated clinical practice guidelines as part of evidence-based medicine. These formal tools based on a scientific evaluation of the research literature purport to tell health care professionals how to practice medicine. Because clinical practice guidelines shift the knowledge base in the health care field through standardization, they remain controversial within and outside medicine. In this paper, we evaluate the predictive accuracy of four medical professionalization theories-functionalism, Freidson's theory of professional dominance, deprofessionalization theory, and the theory of countervailing powers-to account for (1) the shift from pathophysiology to epidemiology with guidelines, (2) the creation of practice guidelines, and (3) the effects of clinical practice guidelines on the autonomy of health professionals. In light of the mixed predictive record of professionalization theories, we conclude with a need for "evidence-based sociology" and a recalibration of basic premises underlying professionalization theories.
According to Freidson (1994), "The most pressing need confronting the study of professions is for an adequate method of conceptualizing knowledge itself" (p. 43). This diagnosis from a pre-eminent professionalization scholar is surprising because for decades Freidson has put knowledge and its authority at the core of his theories of professionalism. Following Everett Hughes' characterization of a professional mandate to control its work (Hughes [1945] 1971), Freidson emphasized that professions are distinguished from other occupations by the legitimate control they hold over their work. Such control does not need to be total; what matters most is that the profession itself determines and evaluates the technical knowledge used in its work; economic control is secondary (Freidson 1970a). Other professions scholars concur with the centrality of knowledge to professional identity and autonomy (Abbott 1988; Goode 1960).
If, as Freidson suggests, we should think of knowledge as the currency to be mobilized by professionals, how do new, contested formats of knowledge relate to what it means to be a professional? In the last decade, the health care field has been under the spell of evidence-based medicine-a social movement aimed to strengthen the scientific base of health care and determine the effectiveness of clinical interventions (Sackett et al. 1996). The turn to evidence-based medicine was made, in part, because studies documented the persistent variation of practice patterns,...