Neo-Weberianism, Professional Formation and the State: Inside the Black Box

This paper outlines a neo-Weberian approach to state-sponsored social closure in professional formation. Despite its advantages, state decision-making is not typically well-defined or examined in neo-Weberian analyses. Neo-Weberianism is differentiated from Max Weber’s own work on social action and rationality, which generally provides a more subtle interpretation of state socio-political processes. The paper explores how policy formation can be more incisively analyzed inside the black box of state decision-making from a Weberian perspective. This is exemplified by the passage of the 1858 Medical Act in the United Kingdom establishing the state-supported medical profession. While further work is necessary in filling in the black box, this paper charts an important future path for neo-Weberian analyses of professions, and their relationship with the state.

the trait and functionalist schools had all too readily accepted the benevolent ideologies of professional groups and a less glossy interpretation of their emergence and ascendance was required . More challenging macro-theoretical perspectives on the formation of professional groups were therefore developed, in which the state was central-notably, the Marxist approach and Foucauldianism.
The Marxist approach to professionalization sees professions in terms of the class divisions of capitalism, as opposed to a meritocratic industrial society. However, there are disputes amongst Marxists over where professions reside in relation to the class divide (Carchedi, 1977). Whilst some Marxists see professions as being proletarianized in the labour process under capitalism (Braverman, 1998), many view them as having gained their lofty position from either acting as agents of social control for the capitalist class (Esland, 1980) or being part of the capitalist class itself (Navarro, 1986). Whilst there are more subtle versions of this approach, a number can be challenged because the privileges of occupations like the clergy arose before capitalism (Portwood & Fielding, 1981) and the state is seen as tautologically serving the long-term interests of capital (Saunders, 2007)-resulting in claims about professions immune from counterfactual analysis (Saks, 1995).
Parallel issues afflict some Foucauldian views of professional groups. These are centred on seeing the rise of professions as part of the growing ethos of governmentality based on the institutionalization of expertise in the normalization, legitimation and regulation process in rendering populations governable (Foucault, 1991). On this basis, the rationality of scientific progress linked to professions was critiqued in areas from dentistry (Nettleton, 1992) to geriatric medicine (Pickard, 2010). Johnson (1993, p. 142) argues from a Foucauldian perspective that "the institutionalization of expertise in the form of independent professions was integral to the emergence of the modern state", where the state is defined as a cluster of institutions, procedures, tactics, calculations, knowledge, and technologies related to governance (Johnson, 1995). However, such work has been challenged for being too abstracted and insufficiently empirically supported (Macdonald, 1995). Moreover, viewing professions as an integral part of the state limits understanding of the complexity of state-profession relations (Saks, 2015). Foucauldians are also not always successful in offering cogent explanations of the success of particular groups in professionalizing-it seems more applicable to professions like law than less centrally state-linked groups like architects and osteopaths.

The neo-Weberian approach to professionalization
In considering professional formation with reference to the state, the most helpful macro-perspective is arguably neo-Weberianism. This approach sees professional formation in terms of exclusionary social closure underwritten by the state, based on the interplay of interest groups (Saks, 2010). This conflict-oriented analysis avoids the embedded positivity of trait and functionalist approaches. In addressing the historical and structural aspects of professionalization, it also sidesteps self-fulfilling conceptions of the state intrinsic to many Marxist and Foucauldian analyses. However, as Saks (2016) has highlighted, while neo-Weberianism allows the systematic empirical analysis of professions and professionalization, it has not always been sufficiently evidenced and balanced in its assessment of professional groups. This, though, is not intrinsic to the approach and does not diminish its utility.
Neo-Weberianism of course has theoretical links to the other perspectives considered. This is illustrated by  whose classic neo-Weberian analysis of professional projects owes much to Marxism, while her later discussion of professions is more Foucauldian (Larson, 1990). The neo-Weberian approach, though, is centred on the relations of the market rather than those of production, as in the Marxist perspective (Saks, 2012). Here the focus is on how particular occupations regulate the market in their favour through the state by legally restricting access to socio-economic opportunities to a limited group of eligibles (Parkin, 1979). The strategy of controlling the supply of entrants to occupations to improve their market value within neo-Weberianism is seen as occurring through direct market control of services by self-governing professional groups (Parry & Parry, 1976). However, sometimes such market control is derivative-from either legitimate organized occupational autonomy (Freidson, 1970) or producers defining the needs of the consumer and their satisfaction (Johnson, 1972).
A key feature of neo-Weberianism is that occupational status groups "mobilize their members" in face of competition to extend and secure their market position with state support (Parkin, 1982). This involves gaining legal privileges restricting access to resources, which enhances the income, status and power of insiders. This approach has been applied to professions ranging from law (Burrage, 2006) to medicine (Saks, 2015) in the Anglo-American context. It has also increasingly encompassed less successful attempts at full professionalization, including those of nurses and teachers based on the concept of "dual closure" outlined by Parkin (1979). The latter covers both state-endorsed exclusionary closure and usurpationary closure based on defensive unionized strategies linked to the working class. More recently, such tensions within professions have been represented in neo-Weberian work by the concept of "hybridization", reflecting the often contradictory pull of corporatization and professional bodies (Noordegraaf, 2018).
The neo-Weberian approach has yielded many insights into professional formation, including understanding of the interface between different occupational jurisdictions in the system of professions . It has also underlined the importance of gender in professionalization strategies  and the subsequent exclusion, segmentation, and stratification of women in professional projects in fields like law, teaching and management (Bolton & Muzio, 2008). Recent neo-Weberian analyses have highlighted international influences on the politics of professionalization, such as the impact of mutual recognition arrangements and transnational migration in the European Union (Olgiati, 2003). This has linked neo-Weberianism with neo-institutional theory, which depicts professions as battling other parties in an ecological system of institutional forms-from professional service firms and global business corporations to transnational governance organizations and the state itself (Suddaby & Muzio, 2015).
Further mention of the state and professional formation-including professional reformation in a fast-changing modern world (Light, 2010)-reveals a weakness in the neo-Weberian approach. This limitation is the relative lack of attention neo-Weberian theorists have given to the state. States ensure selected occupations achieve professional social closure, but the role of state actors passes comparatively undocumented. As Parkin (1982, p. 101) observes, the "state is a shadowy body that hardly intrudes upon the scene." Consequently, neo-Weberian research on professions frequently minimizes the role of the state-without appropriately theorizing and empirically substantiating its role and that of associated actors. Thus, Gilb (1966) depicts state actors as passively acquiescing to professionals' demands, while Gorman and Sandefur (2011) illegitimately view professional groups as being serially undermined in neo-liberal societies by increasing corporatization and marketization.
As has been seen, this fault is not unique to neo-Weberianism. Marxist writers often do not analyze the inner workings of the capitalist state in examining professional groups in society (Poulantzas, 1975). For Foucauldians too, the governmentality on which the professional ascendance is based may be conceived as a social process independent of the decision-making or intentions of state actors (Johnson, 1993). Thus, the role of state actors in professional formation from both perspectives can remain vague and untheorized. As a result our understanding of profession creation, professional regulation, and profession-state relations may be incomplete. To unlock this, we need to return to Weber's own theoretical work, recognizing he never wrote directly about professions, as the notion had not yet migrated into German (Swedberg & Agevall, 2016). Instead, neo-Weberian writers like Parkin (1979) have simply drawn on key concepts from Weber-particularly "social closure"-to analyze the professions. It is now proposed to go back to Weber's work for a theoretical resolution of state-profession relations and regulatory outcomes.
Drawing on Weber in understanding professions more expansively is not novel (Evetts, 2006). However, neo-Weberian theorists of professions have largely ignored Weber's work on the state and social action. This paper argues that Weberian conceptualizations of the state, social action and rationality shed light on professional formation, especially state decision-making on professional regulation. Social closure theory illuminates why professions seek market and social privileges, and how they endeavor to obtain these perks. However, effective social closure requires state sanction (Saks, 2015). We cannot understand profession formation and change fully without considering the activity of state actors. In the sections that follow we provide a sketch of Weberian theory on the state and social action, and subsequently highlight its utility by applying it to the case of the 1858 UK Medical Act. We contend this approach-in reaching across the macro, meso and micro levels of analysisnot only helps to illuminate the black box but provides a blueprint for future research into state-profession relations. Weber (1968, p. 54) defined the modern state as "a compulsory political organization with continuous operations … [whose] staff successfully upholds the claim to the monopoly of the legitimate use of physical force in the enforcement of its order." Among the state's key characteristics is the possession of an "administrative and legal order subject to change by legislation, to which the organized activities of the administrative staff are oriented, which are also controlled by regulations" (Weber, 1968, p. 56). Thus, the modern state is highly bureaucratized and dependent on the work and advice of experts.

Weber and state social action
However, Weber distinguished state bureaucracy from parliament, state leadership and its advisory, collegiate bodies such as the cabinet or privy council. Thus, for Weber, the state is not a single entity, but a complex of institutions and actors (Anter, 2014;Hübinger, 2009). Within these institutions, state actors form political factions, which may have different interests and objectives, and which may be in tension with each other (Dusza, 1989). Actors working within state institutions, and those participating in parliament, are like social actors generally: people with their own interests, values and ideals, which shape their activity. Although the modern state is, at least in part, a product of rationalization, and is heavily rule-driven, values and interests are still very much a part of state activity (Weber 1968). This duality results in tensions (Anter 2014;Hübinger, 2009), which are particularly evident, according to Weber, within state parliaments where values clash but compromises are reached. Through the clash of values, and tensions between various political and state forces, policies and laws are formed.
For Weber, then, political and state activities are generally tied to social action. Thus, to understand state activity, it is helpful to review Weber's writings on social action. Weber defines social action as behaviour to which actors attach meaning taking into account, and oriented towards, the behaviour of others. For him, the study of social action is the "central subject matter" for sociology (Weber, 1968). Weber's definition of action is broad, such that even failure to act and passive acquiescence are included. He identifies four non-exhaustive types of action. The first two types are particularly relevant as they capture conscious, goal-oriented activity. Here Weber distinguished instrumentally rational action from value-rational action. Instrumentally rational action is pursued to achieve "calculated ends". In contrast, valuerational action is "determined by a conscious belief in the value for its own sake of some ethical, aesthetic, religion, or other form of behavior, independent of its prospects of success" (Weber, 1968, p. 24-25). Value-rational action is therefore tied to values or principles, whereas instrumentally rational action is intended to achieve a specific goal. The other types of action mentioned by Weber are less consciously pursued-affectual action that is emotionally based and traditional action determined by "ingrained habituation" (Sterling & Moore, 1987).
The two types of rational action are shaped by rationalization processes. Weber (1968) identified four different types of rationality: practical, theoretical, substantive and formal. By rationality, Weberians refer to the "means-ends calculations that determine how decisions are made" (Geva, 2015, p. 172). Unfortunately, Weber never elaborated his discussion of rationality; devoting most attention to formal rationality, rather than the other forms (Levine, 1981;Sterling & Moore, 1987). Subsequently, scholars have relied on scattered discussions of rationality in Weber's work to produce a more coherent theory (Brubaker, 1984;Kalberg, 1980;Levine, 1981). As Weber used the term "rational" in numerous ways, there are varying interpretations (Eisen, 1978). The meanings attached to "substantive rationality" are particularly controversial. Here much reliance is placed on the Kalberg (1980) interpretation, but there is significant accord with other Weberian scholars drawing on these concepts (Geva, 2015;Levine, 1981;Ritzer & Walczak, 1988;Sterling & Moore, 1987).
According to Kalberg (1980Kalberg ( , p. 1152, practical rationality involves the pursuit of interests in given social circumstances-thus "a practical rational way of life accepts given realities and calculates the most expedient means of dealing with the difficulties they present" (see also Levine, 1981). In contrast, theoretical rationality is less directly tied to action as it is centred on abstract concepts. It involves the search for meaning in life and may shape action indirectly, insofar as philosophical beliefs can mould goals and behaviour. On the other hand, substantive rationality orders action in accordance with social values or clusters of values-as exemplified by loyalty, ethics and religious beliefs. It has also been tied to broader societal beliefs about "what ought to be", including principles of social justice and gender norms (Geva, 2015;Sterling & Moore, 1987). Individuals acting in accord with value-rationality may do so, even at personal cost, because they "act to put into practice their convictions of what seems to them to be required by duty, honor … or the importance of some 'cause' no matter what it consists" (Weber 1968, p. 25). For Weber, substantive rationality was subject to a "radical perspectivism" (Brubaker, 1984) as what appears proper to some, may seem irrational and improper to others. Kalberg (1980Kalberg ( , p. 1156 illustrates this with reference to professions: "From the point of view of efficiency and productivity in the economic realm … all status monopolies, since they restrict the expansion of the free market, are 'irrational'." Finally, formal rationality is guided by rules, laws or regulations. It is most associated, in Weber's work, with bureaucratic domination in modern societies. The rise of bureaucracy, however, does not eliminate other forms of rational action, which can mutually coexist. For Weber (1968), then, social action is tied to different types of rationality, with practical, formal and substantive rationality directly related to action. Practical and formal rationality are linked to actors' means-end calculations: practical rationality is directly tied to interests, while formal rationality is directly tied to rules, laws, and regulations. In contrast, substantive rationality is linked with values. Individuals may adhere to their values, and act in a manner they believe is proper or just, even if they do not think it will serve their interests or conform to other rules. Individuals may face conflicting ends and goals, and must choose which one to pursue. The different types of rationality may inform each other. So, individuals pursuing their interests, or acting according to their values and beliefs, may shape policy in establishing formal rules (Geva, 2015;Kalberg, 1980). Thus, value-rational action may lead to formal rationality; however, formal and instrumental forms of rationality tend to cast value-rationality as irrational (Brubaker, 1984).
Research drawing on Weber's forms of rationality has focused especially on the tensions and conflicts between formal and substantive rationality (Sterling & Moore, 1987). For instance, Geva (2015, p. 175) has shown how those working in bureaucratic settings may be given instructions and expected to follow guidelines, but may "interpret and manoeuver within broad guidelines" to pursue their own interests, or uphold personal values. Ritzer and Walczak (1988, p. 4) have examined the interplay between formal and substantive rationality within professions, arguing that "the spread of formal rationalization is tending to overwhelm substantive rationality", thereby transforming professional work. The drive for efficiency, combined with changing rules and regulations, threaten to undermine traditional professional values of public service and autonomy. The authors predict that the spread of formal rationality will undermine professionalism, but admit this is not the only potential outcome. Indeed, although Weber highlighted the emergence of formal rationality in many spheres of life (Kalberg, 1980;Sterling & Moore, 1987), he did not predict that it would undermine all other forms of rationality (Anter, 2015;Hübinger, 2009). Rather, Weber believed that social action would continue to be shaped by multiple forms of rationality. Weber is clear that state institutions are mutable, and characterized by "a complex of joint [social] action" (Anter, 2014, p. 86). The modern state is profoundly influenced by formal rationality and trends in rationalization; however, other rationalities and irrationalities are present. As Anter (2014, p. 193) argues, "the state can only be as rational as the action and thought of the humans who staff it and with which it deals." State activity, in this sense, is the product of the activity of the individuals within it. Weber (1968, p. 14) was explicit in this regard: For sociological purposes there is no such thing as a collective personality which "acts". When reference is made in a sociological context to a state, a nation, a corporation, a family, or an army corps, or to similar collectivities, what is meant is, on the contrary, only a certain kind of development of actual or possible social actions of individual persons.
To the extent that individual action is shaped by a multiplicity of values, the same is true for the actions or activities of collective actors. For Weber, associations, like professions, usually pursue their members' interests and/or are motivated by their "adherence to a set of common values" (Weber, 1968, p. 41). Nevertheless, individuals within these collectivities will differ. Political social action is similar. Weber (1968, p. 55) distinguished political action-the "actual organized action of political groups"-from "politically-oriented" action, which was organized social action aimed at "exerting influence on the government of a political organization, especially at the appropriation, expropriation, redistribution or allocation of the powers of the government" (Weber, 1968, p. 54). Therefore when a professional group lobbies the state for regulatory privileges it is engaged in politically-oriented action. When state actors respond, they are engaged in political action. In character, both types of action are similar-shaped by rationality and guided by values, interests, and goals.
Weber's ideas on the state, action, and rationality can be brought together to inform our understanding of professional projects, state activity, and state-profession relations. Neo-Weberian accounts of the creation of professions have focused on professions' efforts to obtain social closure to improve their market share and increase their incomes. Adopting the social action approach of Weber (1968) provides a more fulsome view of professional projects as activity shaped by practical rationality (means-ends calculations), formal rationality (guided by rules and law), and value rationality (including ideals of public service, honour and prestige, ethics, and the value of science), as well as interests and other factors. Profession creation reflects a variety of rationalities and values, as well as formal rationality.
When state actors pass legislation regulating professions, they are not simply responding to a request from professionals. Neither is it necessarily the case that they do so to pursue their own governmentality projects (as Foucauldian explanations www.professionsandprofessionalism.com Page 7 frequently contend), or seek to protect the interests of capital (on more Marxist lines). Rather, when state actors legislate in favour of, or against, professional groups they may be influenced by the lobby of politically-oriented groups, as well as practical, substantive, and formal rationality. That is, state actors may see personal or political gain in regulating a profession. Conversely, they may wish to regulate a profession because of value-rational principles such as access to justice and the broader public interest. In addition, state actor decision-making may be influenced by factors like formal rationality, including legal precedent based on existing regulation. When professionals mobilize to lobby legislatures for regulatory privileges, they face a complex environment where other groups may be making different claims. Thus, a variety of interests and values combine to shape the process of professional formation.
Adopting an enhanced neo-Weberian approach also highlights the social-historical context since values and interests vary across time and place. Thus, one would expect regulatory outcomes to vary as well. To understand these variations in professional regulation and state-profession relations better, research should seek to identify precisely what values, interests and rationalities appear to shape state actor decision-making in given socio-historical contexts, as well as how other politicallyoriented groups shape parliamentary debates and tensions. In this manner, extending the neo-Weberian approach to professions to encompass Weber's views of the state, social action, and rationality promises not only to enhance our theoretical understanding of profession-state relations, professional regulation, and variations across time and place, but also to inform empirical research on regulation as well.
To summarize, through an enhanced neo-Weberian approach, researchers can move beyond social closure to consider complex rationalities shaping the actions of professional and state actors. The state is no longer a "shadowy" entity, but is comprised of actors in a formal-rational, bureaucratic context, whose decisions and activities are shaped by practical, substantive and formal rationality. To understand professional regulatory outcomes, researchers should therefore explore theoretically and evidentially the interests, values, and formal constraints and considerations shaping state actor activity, and consider when-and the extent to which-the interests and values of state actors coincide with professional groups in policy-making. This kind of analysis is facilitated by some neo-Weberian writers-not least Saks (1995) who has empirically operationalized key concepts such as "self-interests" and the "public interest" in professional decision-making, We now illustrate the value of an enhanced neo-Weberian approach by examining the classic case of the 1858 Medical Act in the United Kingdom.

Applying the neo-Weberian perspective to professional regulation: A case study opening up the black box
The events leading to the landmark Act to Regulate the Qualifications of Practitioners in Medicine and Surgery in 1858 in the United Kingdom resulting in a statesupported medical profession have been considered from various macro-theoretical perspectives-including the Foucauldian and Marxist schools that have been critiqued. Foucauldians see this mid-nineteenth century medical legislation as embodying the institutionalization of expertise to support modern governance and extend governmentality (Johnson, 1995). Marxist writers like Navarro (1978) view the emergence of the medical profession as reflecting capitalist class relations, given its contribution to capital accumulation by the bourgeoisie in addressing the disease and diswelfare generated by capitalism. However, both these approaches are flawed. While Foucauldians highlight the interests of state actors, they are limited in ascribing to them simply one driver-the use of expertise to enhance governance. Marxist writers similarly are too fixated on the influence of the dominant interests of the bourgeoisie over the state under capitalism to the exclusion of other parties. Some neo-Weberian contributors, though, have focused on the wider patterns of agency www.professionsandprofessionalism.com Page 8 involved.
For neo-Weberian scholars the 1858 Medical Act represents a successful collective mobility project in which medical practitioners-including apothecaries, surgeons, and physicians-pursued and organized social closure to reduce competition in the crowded marketplace for medical services in a modernizing industrial society. This was largely focused on enhancing their income, status, and power, with a successful outcome after many years of lobbying the state (Parry & Parry, 1976). For other related contributors, such as Berman (2006), a neo-institutionalist, this case shows how different interest groups organized themselves sufficiently coherently to accomplish professional projects. She argues that, to understand how medicine obtained regulatory legislation after numerous attempts, we must consider the structural locations and organizational acumen of the medical groups involved. On their own, however, these neo-Weberian and interlinked neo-institutionalist perspectives are not able to fully account for the 1858 Medical Act. Neo-Weberians tend to focus on how professional actors positioned themselves to obtain regulatory legislation, paying less attention to the state actors who passed that legislation. Drawing on Weber's theories of rationality and social action, we argue that wider interests shape state and professional activity.
The drivers of the medical profession in seeking regulatory legislation in the midnineteenth century are well-documented in historical and sociological literature (Saks, 2015;Waddington, 1984). Closer examination of the parliamentary legislative debates surrounding the 1858 Act, however, provides a broader neo-Weberian perspective on the range of interests involved, particularly of state actors-and allows a more penetrating look inside the black box. When members of the Houses of Commons and Lords discussed medical legislation in 1858, they displayed a plethora of values and principles, practical concerns, and formal-rational considerations influencing regulatory outcomes, in terms of Weber's work. The final legislation was not simply the product of the medical profession's demands, or even state actors' political goals, but rather a range of principles and interests, from substantive-rational concerns for public well-being to formal-rational concerns for standardization and practical concerns about expediency and cost in a developing liberal democracy. It is only by examining all these interests, and the interplay between them, that regulatory outcomes can be understood.
When members of the House of Commons debated medical legislation in 1858, they were wary. Bills to regulate medicine had been proposed on eight previous occasions from 1841 without success (Parry & Parry, 1976). As Abbott (2005) argues, the Act of 1858 was partly politically motivated. The provision of medical services had become a state concern, because various state initiatives involved medical doctors. During the 1858 session, state legislators also discussed amendments to public health legislation, university reform, the health of the armed forces, public sanitation, and the expense of public medical officers. These all referenced the medical profession. Establishing a uniform system of qualification was a concern for the state. That the major medical colleges, associations, and universities shared an interest in regulatory legislation, provided an opportunity for state actors to seize the moment.
When introducing the bill in 1858, William F. Cowper clarified its aims. It sought to establish one qualification across the United Kingdom, to enable the public-and the state when granting public offices-to distinguish the medically qualified from the unqualified. Medically qualified practitioners would be named on a national register maintained by a council containing representation from different medical colleges, associations, and universities. The bill was said to serve the interests of the medical profession, the public, and the state. The medical profession "would derive the benefit of an organization [the Medical Council] which it never had before" (Cowper, 1858, p. 651), while the public-particularly the "less educated portion of the community"-could "ascertain what practitioners were really qualified, and in what the nature and extent of their qualification consisted" (Cowper, 1858, p. 648). Cowper offered two advantages for the state. First, it would facilitate governance as "there were a dozen Acts of Parliament concerning the medical profession always referring to qualified persons, but none settling what the qualification should be" (Cowper, 1858, p. 649). Second, since medical doctors filled appointments "connected with the army, navy, friendly societies, or other institutions," clear qualifications were needed to prevent the appointment of unqualified persons (Cowper, 1858, p. 648-649).
In addition to the political and governance goals of the state, the 1858 Act was advocated on the formal-rational grounds of standardization and efficiency in Weber's terms. One priority for state actors was to supersede the inefficient and confusing situation in the United Kingdom: in England the criteria to practise in London differed from the countryside; licensing power was held by colleges in some areas and universities in others; and licensing practices differed between England, Scotland, and Ireland. The existing laws were, therefore "in many respects obsolete" producing "anomalies" and even "absurdities-with regard to the privileges conferred" (Walpole, 1858(Walpole, , p. 1411. Standardization was lauded as the solution based on countrywide criteria and qualifications for entry to practice. This argument was advanced on value-rational and rational-legal grounds, as existing statutes-in some cases dating back to Henry VII and Henry VIII-were deemed outdated and "inapplicable to the times in which [they] lived" (p. 1411). Some legislators saw these statutes as historically valuable (Cowper, 1858, p. 649), while others dismissed them as "a nuisance to everybody in London and seven miles around it" (Duncombe, 1858, p. 1419). Most legislators agreed, however, that medical legislation needed regularizing and updating.
Practical-rational concerns were also clear from a Weberian perspective in legislative debates about the medical bill. Given that prevailing regulation was not working, one solution was to start again-eliminating existing colleges, and the infighting between them, and establishing a new, more efficient, regulatory system. Cowper (1858, p. 650), however, rejected a radical approach as he thought it would be "wise to make the least amount of change that was necessary". He argued that previous legislative attempts had failed due to their complexity and challenge to existing practices. Therefore, Cowper (1858, p. 650) claimed that: The best course would be to leave the examination to be conducted by the present licensing bodies, under the general control and supervision of a general council, to whom power should be given to decide upon what examination should be required, or what certificates should be produced before any person could be placed upon the register.
Most Members of Parliament (MPs) speaking on the bill felt it was more practical to work with existing institutions, and implement incremental change to appease medical associations and universities, and to minimize public confusion. Legislators also demonstrated practical interests in debates around the cost of regulation. MPs saw the 1858 Medical Act as the most expedient, low-cost, solution.
Substantive-rational considerations are also evident in legislative debate on the 1858 Medical Act. Various principles and considerations of fairness were raised by MPs in an emerging liberal democratic society. In its second reading in the House of Commons the Home Secretary, Spencer Horatio Walpole (1858Walpole ( , pp 1414Walpole ( -1415, summarized the government's view that successful medical legislation had to meet three principles-"reciprocity of practice, a register of ascertained duly qualified practitioners, and a supervising council"-if it was to "accomplish their object without causing a great disturbance in the profession." Following these principles, Walpole felt it would meet other goals, including minimizing conflict within the profession and giving more confidence to the public. He explained that even this minor reform would "elevate the profession, give satisfaction to the public, would be a safe and prudent step to take, and would not introduce any serious impediment in the way of any further legislation which it might be found necessary to adopt" (Walpole, 1858(Walpole, , p. 1417. From a Weberian perspective, other principles related to those outlined by Walpole underlining the substantive rationality of the state are evident in legislative debates on the medical bill. Walpole, Cowper, and many other MPs argued that the public in a liberal democracy should have the ability, indeed the right, to know who was and was not qualified to practice medicine. At the same time, the public should be free to choose practitioners. In the words of Cowper (1858, p. 648), it was important "to guard the right of private individuals to consult whomsoever they pleased, whether they happened to be learned or unlearned." Legislators also discussed the standard of services provided where the need for modernization was also expressed: new standards should be "maintained up to the standard of modern science and practice" (Cowper, 1858, p. 648). There was concern that prevailing standards were too low, and it was suggested legislative change could result in "more skilful treatment" and "reducing the competition of those who underbid one another from the want of remunerative practice" (Cowper, 1858, p. 650). Many legislators agreed with the goal to "elevate the profession and secure a more efficient body of practitioners" (Brady, 1858(Brady, , p. 1410, but not all MPs were convinced the proposed bill would be successful in practice (Black, 1858;Walpole, 1858). Nonetheless, the principles of public choice and access to high-quality services were often raised in, and shaped, legislative debates on the bill.
Many different views, though, were expressed by MPs during such debates in the House of Commons and the House of Lords. A minority supported a free market in medicine. For example, Thomas Duncombe (1858, p. 1418) argued that MPs "ought to leave the public to take care of themselves in medical matters." However, most MPs favoured the legislation underpinning the Medical Act, with all of its benefits for the profession, public, and state.
This analysis of the 1858 Medical Act reveals that state actors considered a wide span of concerns and interests when debating the legislation. While these included political issues and governance, as well as the interests of the various medical subgroups, legislators also had many practical, formal-legal and substantive-rational concerns and interests in Weberian terms that impacted the outcome. The regulatory solution implemented in 1858 sought to meet multiple concerns and values. Its passage cannot, therefore, be fully understood without employing Weber's theories of the state, social action, and rationality. Notwithstanding the need to avoid the theoretical and methodological bear traps of confusing subjective preferences with objectively defined interests (Saks, 1995), the records of the parliamentary discussion of the 1858 Medical Act indicate the significance of the practical, formal and substantive dimensions of thinking of state actors, in addition to other better documented aspects of the neo-Weberian analysis of professional formation through social closure.

Conclusion
Agreement is lacking on how to theorize professions and professional regulation and all too often accounts of professional formation downplay the importance of state actors. Proponents of neo-Weberian social closure have focused on the efforts of professional groups to restrict access to socio-economic opportunities to outsiders with the assistance of the state. Such accounts, though, risk treating state actors as passive recipients of their claims, rather than actors with their own interests and goals. Some scholars seeking to theorize the state have turned to Foucauldianism, but this does not necessarily capture the complexity of legislators' interests and activitiesnor does the work of many structural Marxists. This paper argues that research into professional formation should follow an enhanced neo-Weberian approach based on the importance of exclusionary social closure, but incorporating a broader underwww.professionsandprofessionalism.com Page 11 standing of social action shaped by formal, substantive and practical rationality, especially for state actors.
We believe this provides a more incisive approach from a neo-Weberian perspective. In our case study, the British Medical Association (BMA) did indeed influence legislative outcomes (Vaughan, 1959;Waddington, 1984). However, medical regulation was not simply the result of such doctors' lobbying as the BMA did not feature directly in official reports of legislative debates about the 1858 Medical Act and many of its proposed reforms were not supported (Parry & Parry, 1976). None of the medical colleges and groups were entirely satisfied with the Act (Berman, 2006). Nevertheless, it protected many of the rights and privileges of existing medical institutions, and secured a privileged market position for doctors through a de facto monopoly centred on recognized qualifications, despite calls for a free market in medicine (Berlant, 1975). Here the Act appears to have met key goals and interests of both state actors and medical doctors-and can only be understood as the product of their interplay, informed by seeing state players as agents whose social action is shaped by rational, substantive and practical rationality.
In this paper, state actors-and, to a lesser extent, incipient professions-are seen as key stakeholders in shaping professional regulatory outcomes. However, to fully understand professional formation, other stakeholders must be considered. This is highlighted by the related neo-institutional approach which sees additional parties like consumer groups, business leaders and other occupations and professions influencing the type of regulation put in place (Saks, 2016). Our extended neo-Weberian approach based on Weber's work can be applied to these groups too, allowing us to explore the social values, interests and practical concerns driving their activity in sculpting regulatory arrangements. Attention to the broader socio-political context is also needed in understanding the interplay between stakeholders (Meyer & Jepperson, 2000).
The main point of this paper, though, has been to go beyond the frequent depiction of state actors as passive assessors of professional claims within the neo-Weberian perspective and do greater justice to the complexity of state decision-making. This is vital if the dynamics of professional formation are to be better grasped with deeper penetration into the black box of state sponsorship of professional monopolies. Although more work is required in opening up the black box of state decisionmaking in particular cases of professional social closure, this paper provides the conceptual tools to take the field forward from a neo-Weberian perspective.
The populist challenge to professions and professionalism, particularly as a direct challenge to experts and to the very idea of evidence-based decision-making and policy, has grown considerably (Moffitt, 2016). Famously during the Brexit referendum campaign, then justice secretary Michael Gove declared in an interview for Sky News with Faisal Islam, that the British people "have had enough of experts" (Islam, 2016). The authority of traditional trustworthy sources of information are challenged, not by careful alternative analysis, but by declaration. Donald Trump declares climate change reports and even estimates of numbers attending his inauguration, to be fake news. He tweeted "Any negative polls are fake news" (Trump, 2017). This undercuts the authority of evidence-based or knowledge-based communications and practices. It undermines trust in professional advice and discourages reliance on professional services. So pervasive has this been that "post-truth" was declared the Oxford Dictionary's international word of the year for 2016 (Oxford Dictionaries, 2016). Collins' phrase of 2017 was "fake news" (Collins Dictionary, 2017). Both refer to circumstances where emotional appeals are more influential in shaping public opinion than verified or verifiable information.
According to Susskind and Susskind (2015), traditional professions and professionalism are challenged by the access that new platforms allow for practical experience and technical knowledge to bypass traditional professional expertise delivered face to face. They enable networked experts, self-help services and crowd sourced practical expertise to be acquired through machines. However, those technological innovations that threaten professions, also encourage populism. Social media and the Internet allow expanded exposure of individual moralities and particular populist likes and hates, thereby to challenges to professionalism. Here we analyze the populist challenge by juxtaposing populism and professionalism across certain attributes through which thought-provoking connections can be made.
It may seem odd to compare populism and professionalism. Populism is widely regarded as a political phenomenon, analyzed in relation to democracy (Canovan, 1999;Thompson, 2017). Professionalism is associated with work relations and market forms, and has been specifically compared with managerialism and consumerism Faulconbridge & Muzio, 2008;. However, both are widely regarded as ambiguous, complex and contested. Some question the analytical value of populism (Collier, 2001;Jansen, 2011) and of professionalism (Bourdieu & Wacquant, 1992;McCulloch, Helsby & Knight, 2000;. Many concepts are widely regarded as ambiguous, complex and contested. They generate large literatures, which follow deep paths within particular academic journals, stimulating self-reference juxtapositioning to their own literature trails; their own academic silos.
Here we suggest a way to cross these silos, encouraging interdisciplinary working and potentially raising the analytical value of each concept as well as offering an approach to further develop other ambiguous, complex and contested concepts.
We begin by examining definitions of populism to develop comparative dimensions for juxtapositioning with professionalism. We introduce the distinction between ontological and ontic definitions and judge the latter as more appropriate for juxtapositioning. After reviewing definitions of professionalism the two phenomena juxtaposed according to five related elements of their ontic definitions: Manichean distinctions, political intermediation; morality v. ethics; emotionalism v. rationalism; and openness or transparency. We conclude that to meet the challenge of populism, professionals and their institutions can:  directly challenge populist assertions,  adjust to populist criticisms and, more controversially,  adopt certain of populist attributes.

Defining Populism
According to Laclau (1977, p. 143) "few [terms] have been defined with less precision' than populism. For others, it is "notoriously vague" (Canovan, 1999, p. 3) and contested (Barr, 2009). Some despair of finding a single comprehensive definition (Germani, 1978): "to each his own definition of populism, according to the academic axe he grinds" (Wiles, 1969, p. 166). A substantial subfield of populist studiesanalysis of definitions-has emerged (Taggart 2000). Following Laclau (2005, p. 2) we distinguish: a) Ontological definitions-derived from a theoretical perspective providing an "explanation" for phenomena in terms of their "essence". b) Ontic definitions-identified empirically from materials produced by populists and commentators; associated with dictionary definitions containing sufficient information to impart understanding.
Ontological definitions are occasionally proposed in opposition to ontic ones; referred to as "folk definitions" and judged "inadequate for social scientific analysis" (Jansen, 2011, p. 76-77) or the politics of the pub (Mudde, 2004). We contend that ontic definitions are preferred for the purpose of juxtaposition with another complex, ambiguous and contested phenomenon like professionalism. We are not looking to adjudicate among definitions to discern the true essence of the phenomenon or the connection with a particular general academic theory. The value of ontic definitions is that they can handle multiple versions without generating seriously threatening contradictions. There is no need to adjudicate the one truth as implied by ontological definitions. They can connect more widely with unanticipated comparators.
We may structure sets of ontic definitions by distinguishing a core of elementsalmost always included-and a periphery of "fuzzy" elements-occasionally included. Fuzzy refers to concepts for which certain defining characteristics apply only to a certain extent or with a certain magnitude of likelihood, or where boundaries of application vary according to the way the concept is used or the conditions in which it occurs (Zadeh, 2013). Therefore the distinction between core and fuzzy is not a strict one. "Closeness" to core of any element among ontic definitions depends on how frequently it appears, which will change as new definitions are proposed.
Full analysis of ontic definitions is beyond the scope of this paper. Here we distinguish elements of populism according to how well they can be juxtaposed with professionalism; they may be core or peripheral elements. For example most ontic definitions would identify the Manichean distinction: People v. the Other as common core (Jägers & Walgrave, 2007;Deegan-Krause & Houghton (2009;Hawkins, Riding & Mudde 2012). Further elements are contained in fewer definitions, such as the people being homogeneous or the other being the elite and further that this elite is a conspiracy. A sizable source for peripheral elements is the 24 characteristics of populism identified by Wiles beyond his base definition (1969, p. 167-171). Most were specific characteristics of the "Other" (10 of the 24) or the "People" (4 of the 24). These were often expressed in emotional terms, the People being "fundamentally nostalgic"; the Other referring to "demonology". Individual elements also included:  "moralistic rather than programmatic"  "throws up great leaders in mystical contact with the masses"  "loosely organized and ill-disciplined"  "anti-intellectual and abhors science and technology"
www.professionsandprofessionalism.com Page 4 Up to the 1960s, views of professionalism among sociologists were primarily positive: a force to counter individualism in an acquisitive society (Tawney, 1921); serving "public need" (Freidson, 1994, p. 13); altruism and service orientation for citizenship (Marshall, 1950). Associated with this is the ontological definition of professionalism: an occupational value (Parsons, 1939; characterizing knowledge based occupations where knowledge is abstract, systematic and often esoteric (Torstendahl, 1990). Definitions of professionalism of this type are often published by professional associations in a "grey" literature of limited distribution newsletters and in member-only sections of websites. Associated with these definitions are elements contained in professional competency standards and ethical codes (Friedman, Daly & Andrzejewska, 2005). The ontic core for this approach would be based on the more frequently mentioned obligations in ethical codes or the more frequently mentioned characteristics of professionalism identified by the trait or attributes approach (Greenwood, 1957). Millerson (1964, p. 5) examined 23 traits in 21 academic accounts and found the three most frequently mentioned were: "adherence to a professional code of conduct" (13 of 21); "organized" (13) and "skill based on theoretical knowledge" (12). Some of the peripheral traits were: "best impartial service given" (2); "loyalty to colleagues" (1) and "independence" (1).
A second, critical view of professionalism gained traction from the 1970s, based on the ontological definition that professionalism is a form of occupational control . Professionalism is "strategies and rhetorics employed by members of an occupation in seeking to improve status, salary and conditions" (Hoyle, 1975, p. 315). It is founded on professionalisation: an occupational mobility project leading to market closure through barriers to entry . Proponents of this view consider theirs to be correct and the former view false. The ontic core in this view is striving to achieve legal closure. Peripheral elements would be specific restraints on trade such as prohibitions on advertising and restrictions on referrals as written into ethical codes up to then (Bloom, 1977).
A third view of professionalism is as discourse or style, used by management to responsibilize professional autonomy (Fournier, 1999;Troman, 1996). A variation on this is "hybrid" professionalism: professional/managerial combinations (Noordegraaf, 2015).

Juxtapositioning concepts
Juxtaposition is usually thought of as a literary term by which two things are placed side-by-side, or at least in common view, for the reader to draw out links between them; generally in the form of metaphor. This can be extended as an analytical technique for considering multiple relations between those things. It can also illuminate neglected aspects of each. Metaphor has influenced organisation studies (Morgan, 1998). It has long been regarded as important in philosophy (Lackoff & Johnson, 1980), political studies (Mio, 1997) and recently been applied to analysis of the professions (Liljegren & Saks, 2017).
We interpret ontological definitions as examples of a particular kind of juxtaposition; containment. Defining populism as an ideology is to treat it as an example of a family of concepts with common characteristics. However, for some populism is so different from other ideologies as to classify it as a recognizable subtype: a thincentred ideology (Freeden, 1996;Mudde, 2004), lacking characteristics of the prime exemplars. A similar argument could be made of populism as movement or strategy. We can interpret ontological definitions of professionalism as different forms of containment too; as forms of occupational values or occupational control.
Juxtapositioning is pervasive. New versions of familiar concepts are commonly identified with prefixes: neo (neoliberalism); post (post-industrial, post-modern) or new (the New World). All language involves juxtapositioning one word beside another, but metaphor has come to refer to a particular effect from juxtaposing certain www.professionsandprofessionalism.com Page 5 words or concepts. Metaphors can stimulate new insights that build on ambiguities and complex facets of concepts, that is, on their fuzzy edges. Here we use juxtapositioning as a way to link two concepts that are not normally considered together to reveal analysis possibilities and particularly to analyze responses to the populist challenge affecting professions and professionalism

Elements for juxtapositioning populism and professionalism
We can connect populism and professionalism through the core and fuzzy elements we identified for populism. These have been chosen for: clarity of comparison with professionalism, potential for furthering understanding how compelling is the challenge to professionalism fuelled by the current wave of social and technological change; and demonstration of the possible effectiveness of different responses to the populist challenge. The populist elements chosen are: 1. The core Manichean distinction between the People and the Other 2. Disintermediation of structures between the People and the populist leader 3. Moral expressions. 4. Passion and views expressed emotionally, 5. Open politics based on common sense solutions Asymmetric comparators from professionalism ontic elements are: 1. Manichean-like distinction between qualified and charlatans and between professional services and self-servicing 2. Intermediation in terms of pluralism and technocracy 3. Focus on ethics and ethical codes. 4. Objectivity, impartially, cool and considered rationally 5. Behind the scenes influence and opaque processes.

Manichean distinctions
One way of juxtapositioning populism and professionalism would be to take the core element of populism definitions, the Manichean distinction: People v. Other and juxtapose it with a distinction sometimes included in professionalism definitions: being qualified as distinguished from the unqualified and sometimes those claiming falsely to be qualified: charlatans (Goode, 1960).
A second distinction for professionals is between people being serviced by qualified professionals and self-servicing. Not taking professional advice as well as the risks of self-medicating and self-servicing have often expressed by professionals (Ruiz, 2010), though opposition is not part of a core definition of professionalism even if it is implied in the second, more critical, view of professionalism. Occasionally it is opposed with vigour publicly, as when it is presumed to endanger the public good (rejecting inoculation). However views toward refusing medical advice have changed; from the early 20th century view of those who do comply with professional advice on tuberculosis as "ignorant" and "vicious", giving way to a less harshly judgemental view of patients who did not take new antibiotics for tuberculosis following World War II being labelled "recalcitrant" (Lerner, 1997) or non-compliant. More recently some recommend a more balanced view of patient relations to be more of a partnership with the concordance medical model (Vermeire, Hearnshaw, Van Royen & Denekens,2001). However, this balance will arguably tip further away from professional monopoly of expertise if the trend towards AI-enabled servicing without individual encounters with professionals continues as predicted by Susskind and Susskind (2015). Arguably in future professionals will need to be retrained to act more like coaches or consultants to support clients and patients armed with information gleaned from the Internet or social media. We can see this coming with the rise of coaching as a motif for servicing clients and patients. There is now a plethora of organisations training people to become coaches and traditional professions are introducing coaching skills to their qualifications and continuing professional development subjects (for example new Chartered Institute of Personnel Development coaching qualifications). This is one way to meet the populist challenge that professions disempower people by imposing their definitions of what clients need (Illich, 1977).

Political disintermediation, pluralism and technocracy
Populism favours disintermediation between leader and the people: free from political party, government bureaucracies and other agencies (Canovan, 2002;Weyland, 2001)-unless they are directly connected to the leader-rather than providing checks and balances (Barr, 2009). This means countering or bypassing party machines and media whose messages clash with or criticize the populist leader. A clear example is the use of Twitter by President Trump. Professionalism is not directly a target of populists here unless it is professional journalists and professionals who generate and support the policies of parties opposed to those of the populist leader. These would be key targets for the charge of unjustified influence from "pointy headed intellectuals" (Taggart, 2000, p. 94). More generally populists attack institutions that force obedience to rules and regulations that get in the way of the People living their lives, naturally.
The issue of intermediation in party political processes is not directly of concern for professionalism and it is not a common theme in sociological treatments of professionalism. Particular leaders of individual professions tend not to lobby for forms of political activity to achieve representative power for themselves, or for a party to represent the professions. This may be a weakness in Anglo-American professionalism. However, sensitivity to political intermediation does encourage attention to the ways professions engage with party politics. Rather than attach themselves to a particular party they agitate politically primarily at particular moments to win support of the law to protect their job territory or jurisdiction. Some professional associations get involved in specific political campaigns concerning their subject area, developing position papers arguing for certain policies to be pursued by whoever wins power, in fact studiously avoiding linking too strongly to any one political party as they will need to maintain their influence whichever party comes to power.
Professionalism is implicated more directly in populist concerns to de-institutionalize politics and society. However, here is a case where the professions could meet the challenge of populism by entering political debate concerning the way professions are organized. Professionalism is commonly underpinned by long-lived professional associations. They act as interest groups as part of pluralist society, even if they rarely officially argue as professions for pluralism. Instead they may be interpreted as arguing for technocracy. They aim to be treated as dispassionate rational purveyors of impartial knowledge that can underpin policy decisions. They aim to distinguish themselves from other interest groups who bid for government resources to support their causes. Rather the professions position themselves as providers of evidential bases for policies. This can raise their reputation and that of their subject. Individual professional associations not only publish research findings in their journals, but many fund research projects that will bear on policy issues (Evans & Abela, 2019;CIMA, 2019) There is no direct debate between populism and professionalism on these issues. Populists argue trenchantly for disintermediation of politics and deinstitutionalization of political and social life, for uncluttering the people from rules and regulations and from rule makers. The professions account for populating these institutions, advising those in positions of authority in them and, through their associations, are part of society's institutions. However, there is no professional voice on these issues because professionalism is not expressed in these terms at this macro political level. This may be a way that professionalism can be mobilized to meet the populist challenge. It would require professional associations to lobby, preferably collectively, on the macro political level for professionalism. However, there is a danger of losing legitimacy as dispassionate purveyors of reliable evidence if profession become embroiled in party political matters.
This aspect of juxtapositioning can contribute to understanding by highlighting different trajectories towards ideal political states for populism compared with professionalism. The ultimate ideal for populism would be for all communication channels involving power to be focused on the leader. Policy decisions would be confirmed through perpetual referenda. People would vote through their personal devices either hand held, or worn, or even hard wired into their brains. The professional political ideal would be some combination of technocracy and associative democracy (Hirst, 1994). In a more fully pluralistic society, different associations would have formal access to propose and amend legislation, but unlike the US Senate or the UK House of Lords, this would not be organized through political parties. The presumption would be that interest groups with most influence would be ones that have been sanctioned as having adequate training and skill behind them. New ones would have to apply for legitimacy perhaps in a two stage process, such as achieving first a Charter and then statutory protection.

Morality and Ethics
Some consider morality and ethics to be interchangeable (Copp, 2006, p. 4) or that they should be elided. We distinguish them. Morality concerns personal ideas or feelings of right and wrong; ethics concerns social norms of right and wrong. Making this separation can illuminate the distinction between populism and professionalism as between populist morality and the ethics of professionalism.
Populist leaders take a high moral position (MacRae, 1969). "Populism is moralistic rather than programmatic" (Mudde, 2004, p. 544). The core propositions of populism are expressed in terms of moral appeals (Müller, 2016). Taggart notes that it is the ordinariness and naturalness of the People that has moral value. The Other is immoral. It is abnormal and unjust (Hofstadter, 1964). According to the People's Party the nation was on the verge of moral, political and material ruin, due to the moral decay of the conniving elite (Taggart, 2000). They oppress the people by drawing more than their fair share of society resources, by imposing high taxes and complex rules on the People. Use of moral terms is often left out of lists of populism definitions; it is a fuzzy element. Ethics is differently connected to professionalism. For the positive interpretation, ethics is core and almost always mentioned. Ethics is either absent from the negative interpretation, or it is regarded as a sham, a smoke screen for self-interest (Parker, 1994) or as mere window dressing and ineffective, though the charge is mostly made against corporate ethical codes (Bowie, 1979). Taking both interpretations of professionalism together, ethics can be regarded as a fuzzy element.
The morality/ethics distinction in professions has changed. Eighteenth and early 19th century British professionalism was focused more on gentlemanly morality than ethics. Gentility was assumed to come with breeding; a gentleman would know what is right or wrong instinctively. For populists, ordinary people have this capacity. Ethical codes were not common in Britain up to the mid-20th century due to the tenacity of the gentlemanly presumption of professionals (Millerson, 1964). They have been more a feature of the professions in the USA Abbott, 1983). Over the years, as entry into professions has become more formalized and as complaints and disciplinary procedures have developed requiring law-like adherence to the code, the distinction between morality and ethics has grown, thereby moving further from sharing this ground with populism, even if the nature of the morality was always different.
We can relate morality/ethics juxtapositioning to differences in institutionalisation. Without a strong and sustained organisation to express and continue commitment to populism, it seems unlikely that an ethical code would be developed let alone enforced. This does not imply there are no rules to populism, rather that rules are not formally expressed in written codes.
Professional associations need to create a community infused with ethics as well as knowledge and competence. This is not a natural condition; individuals have to acquire professionalism, and increasingly professional associations have recognized this has to be maintained through continuing professional development policies and programmes (Friedman, 2012). For populists morality is a natural thing. It is inherent in the People and absent in the Other. It needs to be recognized, but not created or maintained.
Professionalism is clearly expressed by the nature of the obligations specified in codes as well as to whom they are owed. Ethical codes vary among professions and have changed over time. In the past obligations mainly concerned bringing the profession into disrepute, owed to other members of the profession and the professional association (Millerson, 1964). More recently obligations also concern integrity, competence and benefits to clients/patients, employers and the general public (Friedman, Daly & Andrzejewska, 2005). The basic morality of populism has not changed substantially except for a general movement from the morals of the People identified with those who work the land. There is a distinction between left and right wing populism in terms of who are the Other and what is the nature of their immorality. This is reflected in the recent rise of right wing populism.
This morality/ethics distinction may go some way to understanding the recent rise of populism and comparative decline of professionalism. Nowadays it seems more popular to express strong personal morality rather than what is taught in institutions like churches, schools, and universities as evidenced by social media. Brady. Wills, Jost, Tucker and Van Bavel (2017) found in a sample of 563,312 social media communications, that moral-emotional words in messages increased diffusion "by a factor of 20% for each additional word" and this "moral contagion was bounded by group membership" leading to "expanding models of social influence and group polarization as people become increasingly immersed in social media networks" (p. 7313). Personal morality, particularly expressions of moral outrage has been facilitated in this age of extended private space. People express themselves in the enclosed privacy of their cars, in bedrooms in front of screens and in private communion with their I-phones, less encumbered by social norms against vitriol (Crockett, 2017). Populism encourages people to raise personal concerns in media where they will be at one level removed from physical reactions. On the Internet and in social media platforms local groups are fed information shaded to cater for their prejudices and morality. Moral prejudices are "heard" more sympathetically within these groups, reacted to and thereby reinforced. There are now so many different sources of morality which are valorised by the ubiquity of "likes".
A strategy for dealing with the raised influence of morality compared with ethics can be to incorporate moral elements more clearly into ethical codes as well as for professional associations to raise moral issues more forcefully on social media. Courage is one moral issue that can be emphasized around ethical obligations to support whistleblowing (ICAS, 2015).

Passion and emotionalism versus cool rationality
Though not emphasized in many ontological definitions of populism, it is commonly noticed that populism is associated with high emotions, primarily hate directed against the Other, but also nostalgic emotionalism for the People (Saul, 1969). The populist style is to "radicalize the emotional" constructing a moral struggle between people and other (De la Torre, 1992, p. 400). "Peronism is a question of the heart rather than the head" (Peron, 1952).
There are two ways of thinking of high emotion. One is as passion: strong and sustained feelings of extreme affection or hatred. Populists love the People, their customs and common sense approaches to life and decision-making. These are regarded honourable. They hate the Other as the elite for being corrupt and undeserving. They also hate immigrants and minority groups who are regarded as living off the hard work of the People and in many cases as purveyors of dangerous practices, unnatural mores and ultimately terrorism. A second way of thinking about high emotion is as irrationality: populism as a pathology characterised by the spread of irrational fears: "negative demonizing imagery of pointy headed intellectuals" (Taggart, 2000, p. 94).
Professionalism is associated with low emotionality, with objectivity and "cool": dispassionate objectivity. Professionals are meant to give advice and make service decisions based on evidence and experience rather than emotion. They must guard against emotional connections with clients/patients; often grounds for disciplinary procedures. They are obligated to treat clients/patients fairly, to the same standards as they would their friends and relatives; foreigners to the same standards as their fellow country folk. Professional associations emphasize the importance of professional standards to be applied to all.
Juxtapositioning populism and professionalism in terms of emotion can be seen as an antonymic relation, depending on how emotion is interpreted. Emotion as irrationality distinguishes populism from professionalism from the professional perspective. Mudde (2004, p. 542) suggests it is common to regard populism as opportunism "rather than looking (rationally) for the "best option"".
Emotion as passion can be regarded as antonymic by populists against professionals. The phrase "No drama Obama"-originally coined by his own political advisor (David Axelrod)-has been taken up by the conservative media to defend Trump. Hillary Clinton was labelled as a cold fish during the presidential campaign. "Their [experts] lack of emotion, which was originally so crucial to their authority, opens them to attack for being cold and selfish" (Davies, 2018, p. 60).
Emotion as passion can help understand the rise in populism compared to professionalism. The general tendency in society towards celebrity is substantially founded on expressions of passion by ordinary people, such as in their public singing and dancing or their support of sports. A problem for professionalism is that it can become associated with emotional neutrality and interpreted as lack of caring. Professionals playing by laid down rules can be regarded as insensitive to individual situations. As with morality, the new celebration of passion can be taken on as way of meeting the populist challenge. More can be made of the passions involved in pursuing a vocational "calling". Professional associations could do much more in emphasizing the thrill coming up with exciting solutions to difficult problems as well as the passion for caring so strong in many professions without crossing the boundary with misconduct for "inappropriate relations".

Open politics based on common sense solutions vs opaque influence, nuanced judgements, and confidentiality
The populist style of political discourse is direct and in full public view. "Populists love transparency and distrust mystification" (Canovan, 1999, p. 6). Professionalism does not have a clearly recognized style of its leaders. However, style can be inferred from the logic of professional association political practice. This is largely behind the scenes, lobbying through personal influence with selected politicians and civil www.professionsandprofessionalism.com Page 10 servants, thereby feeding charges of conspiracies (Hawkins, Riding & Mudde, 2012, p. 3).
Professions' traditional opacity has many probable causes.
1. Professional association activities have been regarded primarily as internal to the profession, particularly to their own members. 2. Professional associations guard against those who would use professional techniques superficially, not understanding limitations and consequences of their application; thereby potentially devaluing qualifications. 3. Competition among professional associations for members, reputation and influence has encouraged reticence to make activities open to competitors. 4. The ethical obligation in many codes to maintain confidentiality of privileged disclosures can spill over to wider information. 5. Professions have often been pilloried in the public media. They have been reluctant to publicize disciplinary procedures-to expose their dirty laundry in public-for fear the few bad apples will be taken as representative of the whole profession.
Opacity of professional association activities has contributed to public perception of mystery and possible conspiracies which can easily be fanned by populist leaders. The path of knowledge development towards variegation and specialisms has encouraged individuals to display a "specified ignorance" of symptoms or factors not covered by specialist occupational standards (Merton, 1987). Medical specialists have been accused of not treating the whole person and prescribing drugs that though effective for treating particular ailments, collectively may have harmful effects (McKee, 1988). For Illich (1977) the professions have replaced citizen politics and the authentic felt needs of ordinary folk. Participatory politics has withered and been replaced by "self-centered competencies, a self-accredited elite which claims incommunicable authority to determine how needs will be shaped and served" (p. 16).
Populist leader style can be purposely imprecise, relying on rhetorical techniques, such as using metaphor and repetition rather than explanation; Trump's characterization of Hillary Clinton as tricky and dirty. Populism as a matter of the heart rather than the head can be interpreted in terms of greater imprecision or fuzziness. While fuzziness can be used as a strategic method by populist leaders, fuzziness in professionalism is different. The language of professionals is meant to be logical and precise. However, the opacity of professional processes, both the internal workings of professional associations and behind the scenes lobbying and other contacts with stakeholders, leads to fuzziness in the popular mind as to what professionals are up to. Here fuzziness through ignorance of what is in ethical codes for example, has been assisted-even created-by professional associations making it difficult, in some cases almost impossible for the general public to read. Codes have sometimes been placed in member only sections of websites or been difficult to find (measured by how many clicks it takes to reach them from the homepage of websites (Friedman, Daly & Andrzejewska, 2005). This is clearly something professional associations can amend. In addition greater transparency over disciplinary processes and outcomes can help meet the charge of the professions as elites protecting their own.
There is fuzziness in the public mind as to what precisely is meant by terms used by populist leaders arising from a metaphorical style of rhetoric. This seems to have been particularly effective. With professionalism, fuzziness arises from lack of discourse with stakeholders, particularly aimed towards the general public on what professionalism is and how it is intended to achieve the aims of its leaders and institutions. In part this is a common outcome of bureaucratic institutions. There is a difference between assuming things are known without saying for professionalism, and assuming things need to be said loudly and repeatedly, but in a fuzzy way for populists. The professions can go some way to meeting the populist challenge of being a www.professionsandprofessionalism.com Page 11 "self-accredited elite which claims incommunicable authority" by improving communication with external stakeholders.

Conclusions
The touchpoints developed here for juxtapositioning populism and professionalism provide insights into different ways professionals and their institutions can meet the challenge of populism; in terms of fighting it head on, (directly countering populist positions, fake news, post truth), adjusting to reduce the import of the criticisms (improving transparency and taking more of a coaching role in practice and supporting self-management) and perhaps most controversially, adopting some populist elements (morality and passion).
Some professional groups have been arguing for various ways of directly opposing claims of fake news with clearer evidence to the contrary, and hate directed against conspiring elites, as well as against other groups such as immigrants, by emphasizing parity of access to professional services (Speed & Mannion, 2018). However, we contend that this straightforward response to the populist challenge is likely to be of limited success unless it is supplemented by other approaches.
Personal morality has grown as an influence in modern life compared with the notion of duty implied by ethics. This is tapped into and enhanced by populism. It is difficult to fight as it reflects the strongly ingrained individualism of Western culture which has been buttressed not only by the presumed triumph of free market economies and free market policies, but also by more recent technological developments which encourage expressions of personal morality on social media. Professions could respond by incorporating certain features associated with personal morality into ethical codes. This is beginning to happen with the introduction into ethical codes of obligations to show courage, following from concerns about the fate of whistleblowing.
On emotionality/rationality, though there are clearly limits to certain expressions of emotions which would compromise professional obligations to fairness, impartiality and independence; other expressions would not be so compromised. Some clients/patients may be reassured if professionals demonstrated emotional enthusiasm for the services they supply. Professionals can be, and many are, passionate about their work; regarding it as a "calling" as opposed to being passionate about particular clients or patients. More could be made of this publicly through more open celebration and promotion of such attitudes by professional associations. Connecting to young people's desire to "make a difference" through the exercise of professional expertise could be emphasized more; highlighting work of Médecins Sans Frontières and similar agencies for other professions such as the less well-known Engineers Without Borders (https://www.ewb-uk.org/) or Professionals Without Borders (https://www.seattleu.edu/pwob/). In addition, incidences of Pro Bono schemes for the poor, particularly from professions other than the well-known schemes for lawyers could be publicized more.
While morality and passion represent common populist themes that professionals can adopt, or at least adapt, the populist charge of elite conspiracy may encourage a change in the traditional way of undertaking politics and a change in the level of transparency among professionals and professional associations. This is to some extent occurring. In recent years professional associations in the UK have been putting their ethical codes one or two clicks from their website home pages rather than being buried in members only sections. Disciplinary decisions are being made public. The rise of populism may have contributed to this change. Arguably professional associations need to raise efforts in this direction by making continuing professional development requirements more publicly available and to clarify means by which qualifications are being kept up to date. The public perception of such changes by indiwww.professionsandprofessionalism.com Page 12 vidual professional associations would be substantially enhanced if they were to pursue these strategies jointly.
New media provide platforms for practical information; providing alternative information sources to direct practical expertise from professionals, thereby threatening professionalism. Social media has obviated some of the net around communities controlled or at least developed by professional associations. This has led to rogue centres which lend themselves to the kind of "maverick" personalities that are populist leaders (Barr, 2009). One response is for professional associations vigorously to challenge rogue Internet sites such as those offering professional qualifications for payment without requiring training and assessment. Another is to step up professional associations' own presence on social media.
These influences on populism and professionalism may be limited in future. The Internet and various social media platforms have become dangerous places; used to trap people into financial and sexual snares. According to Susskind and Susskind trust in those who deliver professional services will not be so important in the future as the need "for a reliable outcome" (2015, p. 237) for which they claim new machine technologies are well suited. However, inauthenticity threatens Internet reliability as an information source. Tim Berners-Lee, thinks that the world wide web he created is now broken (Schulze, 2018). Concerns about cybersecurity and authenticity may raise demands for professionalism in these areas. A response of the professions could be to develop accreditation for Internet site authentication.
Finally, juxtapositioning encourages attention to the strategies and customs of enduring institutions that support professionalism. In the UK this includes not only professional associations but also an increasingly complex range of regulatory bodies (Friedman & Hanson, 2010). Their relative neglect is striking compared with the interest of academics and journalists in trade unions. Addressing the populist challenge to professions and professionalism encourages attention to these organisations as more than merely expressions of professionalism or concerned only with strategic jurisdictional battles among themselves .

Andreea Ioana Alecu
Putting a Face to Institutions: Professionals and Generalized Trust Abstract: The central role institutions play in the development of generalized trust is well established by previous research. Yet, the role of the professionals employed in these institutions has received considerably less attention. This paper explores whether confidence in welfare state professionals is important in maintaining a high level of generalized trust in the Norwegian context. It is hypothesized that professionals may influence people's generalized trust both via their formal role as gatekeepers and in informal settings as part of social networks. The results are based on novel cross-sectional data, and indicate that confidence in welfare professionals is correlated with generalized trust, while the presence of welfare professionals in a social network is not significantly associated with generalized trust. The relationship between confidence in professionals and generalized trust indicates that alongside good institutions, good service provision is important in maintaining a high level of generalized trust.
Keywords: Professions, generalized trust, welfare institutions, social networks This paper investigates whether trust in the competence of welfare state professionals has broader societal implications by studying its' association to generalized trust 1 . Generalized trust is associated with numerous desirable outcomes. In general, a high degree of generalized trust facilitates collaboration and reduces transaction costs. At the macro level, a vast body of literature has reported that high levels of generalized trust are beneficial for democratic institutions, economic growth, and democratic stability (Bjørnskov, 2012;Knack & Keefer, 1997;Putnam, Leonardi, & Nanetti, 1994;Putnam, 1995aPutnam, , 1995bPutnam, 2001;Zak & Knack, 2001). Alongside the beneficial economic consequences of trust, a lack of trust in expert systems may erode ontological trust, thus affecting the foundations of society (Giddens, 1991, p.136-41). The quality of institutions, such as health care, education, or the police, is bound to the competence and moral integrity of the professionals employed in these institutions. A trusted police force and an impartial judicial system are considered necessary to maintain a high level of social trust (Rothstein & Stolle, 2008). Interactions with police are not routine for most citizens in developed countries. By contrast, interactions with health care professionals, educators, or social workers occur more often. The provision of these services is universal in Norway, and these 1 The terms: generalized trust, and social trust are used interchangeably.
professionals safeguard both the interests of the clients and those of the state. Breaches of trust in any of these sectors may reduce the trust level in the society and in turn the costs of collaboration, as well as the economic and democratic stability of the society. These claims are investigated with the aid of Norwegian cross-sectional data. Two of the most prominent explanations of generalized trust revolve around the role of institutions and that of social networks. The institutional scholarship shows that impartial and efficient institutions foster generalized trust (Delhey & Newton, 2005;Rothstein & Stolle, 2008;Rothstein & Eek, 2009;Rothstein, 2011;Svallfors, 2013). Alternatively, it has been proposed that generalized trust arises from engagement in social networks and voluntary associations (Paxton & Glanville, 2015;Putnam, Leonardi, & Nanetti, 1994;Putnam, 1995aPutnam, , 1995bPutnam, , 2001. The institutional literature seldom explains how confidence is maintained at the individual-level, while social networks explanations seldom account for interactions with the state. For example, Rothstein (2011Rothstein ( , 2013 theorizes that citizens most often interact with professional practitioners, not institutions. Yet, this has rarely been tested or explicitly theorized (with a few exceptions: Kumlin & Rothstein 2005;Rothstein & Eek, 2009). By drawing upon the sociology of professions and the generalized trust literature, this paper aims to investigate the correlation between the perceived trustworthiness of welfare state professionals and generalized trust. This paper explores whether the perceived trustworthiness of welfare state professionals in the Norwegian context is linked with generalized trust, also when accounting for one's confidence in institutions and whether they are acquainted with welfare professionals. In doing so, this study discusses a potential link between trust in abstract systems (such as institutions) and generalized trust (a form of interpersonal trust). Additionally, it discusses why trust in welfare state professionals is not only important for the professional groups but may also be important for a well-functioning society.
By using two underexplored indicators-confidence in welfare state professionals and being acquainted with professionals-the study aims to contribute to current scholarship in two ways. First, disaggregating confidence in institutions and professions offers insights about the role of professionals in the institutionalist framework. Second, by controlling for being acquainted with welfare state professionals, it also accounts for the social nature of interpersonal interactions with these professional groups.

Literature review: Generalized trust between state, society, and culture
The extant theoretical explanations of generalized trust revolve either around the role of institutions, that of society, or of cultural norms. These explanations are partly competing and inform of the context and key factors that may influence the level of generalized trust. The institution-centered theory of generalized trust has become increasingly dominant in the literature (Nannestad, 2008;Rothstein, 2011). It focuses on the link between citizens and the state as a way of generating and maintaining social trust (Knack, 2002;Netwon & Norris, 2000;Paxton, 2002;Rothstein & Stolle, 2008;Rothstein, 2011). Rothstein (2013) and Rothstein & Uslaner (2005) posit that social trust is embedded in the political context and in legal and political institutions. Although the trustworthiness of the government is important, interactions with authorities at the local level are more important in maintaining generalized trust (Levi & Stoker 2000, p. 495-496). Many of the explanations for why citizen have a certain degree of confidence in institutions, are linked to the institution's performance and responsiveness (Norris, 1999;van der Meer, 2010). One of the conditions for trust discussed by Kumlin & Rothstein (2005) is that people infer others' trustworthiness via their perception of public service bureaucrats. However, as discussed in the following section, this hypothesis can be extended to welfare state professionals also when accounting for one's level of confidence in the institutions.
Alternative theories highlight the importance of either social or cultural factors. In the society-centered approach, Putnam, Leonardi & Nanetti (1994) and Putnam (1995aPutnam ( , 1995bPutnam ( , 2001 have emphasized that informal interactions and civil society engagement are among the main drivers of generalized trust. Membership in voluntary associations, and other face-to-face interactions with people from different backgrounds, lead to increased trust (Putnam, 1995a(Putnam, , 1995b. The empirical support for approaches concerning the role of social networks is mixed (Newton & Norris, 2000). However, several studies suggest that in societies with dense social networks, as well as good institutions, virtuous spiral form, leading to high levels trust (Levi & Stoker, 2000;Netwon & Norris, 2000;Paxton, 2002).
A third perspective is presented by Uslaner (2002Uslaner ( , 2003 who has focused on the importance of cultural norms developed via interactions. Uslaner's approach entails that the levels of trust are relatively stable, as they are influenced by cultural norms transmitted through socialization processes (Uslaner 2002). From this perspective, latent features of the individual, such as optimism or other norms transmitted through socialization, explain variations in generalized trust.

Welfare state professionals in Norway
This study focuses on the case of Norway, one of the most trustful and egalitarian countries. Corruption and favouritism in the Norwegian public sector occur very seldom (Rothstei,n 2011). At the aggregate level, cultural factors such as Protestantism and low-income inequality are associated with high generalized trust (Bjørnskov, 2007;Uslaner, 2002) and explain the comparatively high levels of trust found in Norway. Furthermore, most of the welfare state good provision is based on universalistic principles, which are associated with high generalized trust (Rothstein 2011(Rothstein , 2013. However, the presence of these factors does not exclude that additional mechanisms might be present at the individual-level, nor does it fully explain differences in trust between groups of individuals. Norway has one of the most extensive welfare states with well-developed institutions, and employs a large number of professionals (Statistics Norway, 2015). The low levels of corruption and historical high levels of trust (Delhey & Newton, 2005) make this case least likely to solely capture the effects of petty corruption, and most likely to capture additional mechanisms that might mitigate trust. This case, thus, offers the opportunity to explore mechanisms that may otherwise be blurred by either corruption, or under-developed institutions. Many of the professions within the welfare state are licensed, or require a formal authorization, thus the state becomes a warrant of the competence of the professionals employed within these institutions (Drange & Helland, 2019).
This study focuses on the following core welfare institutions and the main professional groups employed within health care, education, social work, the judiciary, and law enforcement. These are the main professional groups employed within the institutions shown to be most relevant in maintaining generalized trust (Levi & Stoker, 2000). In Norway, these professional groups are mainly employed in the public sector, and are central in implementing public policies, either in their capacity as public employees, or as contractors to local, regional, or national government authorities. Against this backdrop, the next section discusses whether and how welfare state may influence generalized trust.

Welfare state professionals and generalized trust
Generalized trust refers to a form of interpersonal trust, which can be extended to strangers (Glaeser Laibson, Scheinkman, & Soutter, 2000;Nannestad, 2008). The conceptualization of generalized trust employed in this paper refers to the individual assessments of others, based on the individuals' previous personal experiences and conditional on the trustworthiness of others (Cook, Hardin & Levi. 2005;Hardin 2002;Paxton & Glanville, 2015). Inter-personal trust is an important component of generalized trust, which captures whether individual A trusts B to do X (Hardin, 2002). As discussed by Schoorman, Mayer & Davis (2007), interpersonal trust is also a function of previous experience. Experimental research shows the empirical validity of this approach. In trust games, players base their actions on whether their trust was reciprocated in previous games (Ostrom & Walker, 2003). Finally, in a trustful relation, individuals who trust a professional are willing to be vulnerable and submit themselves to the treatment or follow the advice of the professional (Grimen, 2008;Parsons, 1951).
The departure point for many institutional explanations of social trust is that "good" institutions that are fair and treat their clients in an equal manner are important in maintaining trust in a society (Levi, 1996;Knight, 2001;Rothstein & Stolle, 2008). However, the experiment conducted by Rothstein and Eek (2009) in low corruption/high trust Sweden and high corruption/low trust Romania shows that individuals in both countries base their decisions on the trustworthiness of others by assessing the behaviour of professionals. Individuals in the experiment who were assigned to scenarios where the professional engaged in favouritism-helping a patient upon receiving a bribe-exhibited lower levels of generalized trust. This implies that not only institutions but also the professionals employed therein should be "good" to encourage generalized trust, suggesting a direct correlation between trust in professionals and generalized trust. While the link between perceived procedural justice or fairness, and political trust is widely documented, as shown by Grimes (2017), the role of professionals remains somewhat unclear in relationship to generalized trust.
Implementation-side institutions such as the army, the police, and legal institutions have been shown to be of more importance to generalized trust compared to political ones, such as parties, parliaments, and cabinets (Levi & Stoker, 2000, p. 495;Rothstein & Stolle, 2008, p. 444;Rothstein, 2011;Rothstein, Charron, & Lapuente, 2013). One potential reason is that citizens account for their political preferences, when they evaluate encounters with officials from political institutions (van der Walle, Kampen & Bouckaert 2005). Thus, this study will focus on implementation-side institutions.
Additionally, I argue that one should distinguish between implementation-side institutions and the professionals employed within these institutions. Although this distinction is not new, it is often overlooked. David Easton's (1965) seminal model implies a differentiation, amongst others, between institutions and their incumbents. More recently, Grimen (2012) showed that trust in professionals cannot simply be equated with trust in the institutions in which they are employed. Thus, differentiating professionals from institutions is necessary from both theoretical and empirical points of view. This differentiation allows the exploration of differences between institutional policy and the trustworthiness of professionals.
Professionals in their formal roles also provide a face for the system and represent what Giddens (1990) describes as "access points". If the public views professionals as "access points", it should be expected that the perceived trustworthiness of welfare state professionals is positively correlated with generalized trust, even when confidence in institutions is controlled for. Direct encounters with institutions have been proposed as a trust-fostering mechanism (Kumlin, 2002). However, Christensen and Laegreid (2005, p. 504), found that trust is of a general nature, and the differences between those who have experience with the services and those who do not are negligible. Although an individual does not know the professional she is going to visit, she knows that the professional belongs to a group defined by a shared normative identify, much like ethnic or social groups discussed by Warren (2017).
Professionals grant access to the welfare state's goods and services. Ultimately, they either provide certain goods or decide the services to which the public is entitled (for a further discussion see Lipsky (2010)). In the case of sickness, they decide what treatment is to be administered and whether the patient is entitled to sick-leave. Welfare professionals are often in relatively autonomous positions and have some discretionary powers. The relationship between these welfare state bureaucrats and the public is a possible mechanism linking systemic trust to inter-personal trust.
Professionals may inspire the public to draw inferences about the trustful behaviour of other individuals. If a professional bound by ethical rules of conduct fails to follow these rules, it might be that strangers that have no such constraints will have little or no intention of being fair or helping others. I argue that when accounting for one's view of welfare institutions, trust in welfare professionals may be linked with one's level of generalized trust. At the same time, it cannot be excluded that the quality of institutions, such as health care or the police, is bound to the competence and moral integrity of their professionals. Putnam (1995bPutnam ( , 2000 provides an alternative framework to the institutionalist framework, which focuses on social network factors. In this framework informal interactions with others, such as dinner parties, or membership in voluntary associations influence whether one is trustful. As welfare professionals make up a large part of the workforce in Norway, they may be part of many individuals' social networks, and in turn may influence these individuals in private settings, as suggested by Putnam (1995b). In 2015, 8% of the labour force was employed in the education sector, and 20% in the health and social care sector in Norway (Statistics Norway, 2015). In the data used in this study, around 50% of interviewees reported that they had friends or family members who were nurses, and 60% knew teachers, 26% police officers, and 24% social workers. These individuals may be informed about the functioning of the system and service quality via informal channels, such as dinner parties or work or family gatherings. Individuals may be able to mobilize their acquaintances easily, and access accumulated knowledge of the system if they experience any wrongdoing.
Meetings in informal settings may facilitate the exchange of information regarding the quality of institutions and professional services, however it is unclear whether they can shape influence one's social trust. Nevertheless, it is important to account for whether individuals are welfare state professionals, or have acquaintances who are professionals, in studying the relationship between social trust and trust in welfare professionals. In doing so one can at least partly differentiate between two potential mechanisms: social factors such as informal meetings or dinner parties that may inform the public regarding the functioning of institutions, and trustworthiness of professionals in their formal roles.
Drawing inferences from the behaviour of professionals is arguably a cost-effective strategy of examining the functionality of the system, as well as influencing one's level of generalized trust. Thus, a first hypothesis is that the overall level of confidence in welfare state professionals, employed within healthcare, education, social service, police and judiciary is associated with generalized trust. The second hypothesis is that, as these professionals may be part of an individual's social network, thus affecting how the individual perceives the profession in general, it is expected that having acquaintances, friends, or family members employed in these professions is associated with generalized trust.

Data
To investigate the relationship between generalized trust and welfare state professionals, data are required on both confidence in welfare state professionals, institutions and on whether individuals have welfare state professionals in their social networks. Despite the significant increase in data collection over the past decade, there is little information regarding trust in professionals. This is especially striking when one considers the considerable amount of information regarding trust in institutions 2 . To overcome this, the study employs novel data taken from the Norwegian ProTrust survey, which combines information about confidence in welfare state institutions and trust in professions. The survey has a response rate of 41% 3 and includes 4007 respondents between 18 and 80 years of age, weighted to represent the adult Norwegian population in terms of age, gender, education, and geography. The survey was carried out electronically in October-November 2015.
Analyses of the dropout and response rates show that the group with the highest nonresponse rate was composed of individuals under the age of 30 with lower secondary education. Post-sampling weights adjust for this potential representativeness challenge. In terms of the reliability, two main tests were carried out. To avoid any potential bias generated by the order in which the response items are presented for their respective questions, the order of all items was randomized, but not that of questions. Several additional tests were conducted to ensure the reliability of the answers. Furthermore, there is no apparent relationship between the proportion of respondents answering "Don't know" and their progress though the questionnaire. Individuals favouring "Don't know" answers in opinion questions were not statistically different in terms of background characteristics from those who responded.

Variables
Following the standard approach in the literature, both the dependent and main explanatory variables are operationalized as indices. The dependent variable is generalized trust, measured using the standard three-item scale. Respondents chose a score on a scale from 1 (low) to 10 (high) anchored by the following pairs of statements: 1) "You cannot be too careful" and "Most people can be trusted"; 2) "Most people look out for themselves" and "Most people are helpful"; 3) "Most people try to take advantage of you" and "Most people try to be fair". Although this index has some limitations (Nannestad, 2008), at the national level it is strongly correlated to other outcomes associated with generalized trust, such as wallet return (Bjørnskov, 2007), violent crime (Lederman, Loayza & Menendez, 2002), and corruption (Uslaner, 2002;Rothstein, 2011).
The three items have strong internal coherence in the data, with a Cronbach's alpha score of 0.84. The index ranges from 1 to 10 and has an average of 6.3 with a standard deviation of 1.8. The results are in line with expectations based on current research and existing survey material, where in Norway, alongside the other Scandinavian countries, a larger majority of the citizen believe most other people can be trusted than in other Western European states (Rothstein & Uslaner, 2005;Eurostat, 2015).
To capture latent confidence in welfare institutions and in the trustworthiness of professionals, two separate indices were created. An overview of items included in each index is presented in Table 1. Confidence in welfare state institutions is operationalized as an index calculated based on confidence in health care, the education system, social services, the justice system, and the police. For example, the component on the health care system comprises items regarding confidence in public hospitals at the regional and local levels, as well as trust in the Ministry and Directory of Health. The resulting index has a Cronbach's alpha score of 0.91. Removing the latter institutions, such as ministries and directorates and creating a non-partisan confidence in welfare institutions variables lowers the Cronbach's alpha score to 0.85. However, this variable is potentially more precise when estimating solely role of welfare state institutions, as it removes political institutions. The perceived trustworthiness of professionals is operationalized by an index based on the item scores for each professional group presented in table 1. The question asks respondents to indicate the extent to which they trust the competence of different groups of professionals on a scale from '1 (no trust)' to '7 (complete trust)', with a Cronbach's alpha value of 0.87.
Dichotomous variables account for social connections with welfare professions. One variable accounts for whether the individual has worked or works within one in the occupations presented in Table 1. An additional variable accounts for whether the individual has acquaintances; friends or family members employed in each of the occupations presented in Table 1. Individuals with acquaintances in welfare professions tend to be above 40 years old, male and have completed highschool or hold a bachelor's degree.
Alongside institutions, voluntary associations have been considered important in maintaining generalized trust in a society (Putnam, 1995a;Wollebaek & Strømsnes, 2007). Membership in voluntary associations is measured in a similar manner to that presented by Wollebaek & Selle (2003;. There is a distinction between those who have never been members (33%), those who are former members (22%), those who are current members, as well as between active (22 %) and passive participants (23%). Those who have never been members represent the baseline in the regression models.
Following the standard approach in the generalized trust literature demographic characteristics are also included in the analyses: education level (from '0' representing elementary education baseline, to '3' for higher college or university education), marital status, current employment status, 10 year age cohort, gender, self-reported income level, and immigration background. Additional controls include the county of residence and the 'centrality' of the municipality of residence, measured by the number of hours required to drive to a regional center. Trustful and optimistic individuals may be more trustful towards both strangers and professionals, as posited by Uslaner (2002Uslaner ( , 2003. As such, characteristics are latent; they are constructed using latent profile analysis (LPA). LPA is a probabilitybased technique that identifies profiles (groups) of individuals that show similar patterns on several variables. As LPA techniques can be model dependent, several group techniques were tested. The most robust solution is with three groups, one answering generally on the mean (Trustful: average), one higher above the mean (Trustful: Trustful), and the other which is below the mean (Trustful: Reserved).

Estimation strategy
The association between trust in professionals and generalized trust is assessed by using weighted ordinary least squares (OLS) regressions. Recent research shows considerable regional differences in relation to the quality of government and the public perception of institutions in Europe (Rothstein, Charron & Lapuente, 2013). They emphasize that the ease of access to public services and the concentration of public services varies systematically between rural and urban areas. Place of residence is operationalized as the respondent's county and the centrality of the municipality (number of driving hours from regional center). Albeit equal institutional development and access to services within Norway, larger municipalities and regional centers have access to more concentrated resources and deliver more encompassing services. To account for the potential heterogeneity, controls for the centrality of the municipality and county are employed.
The causal nexus between generalized trust, institutions and social indicators is disputed. Even though the data at hand offer a rich description, they are only a snapshot in time. This paper does not make causal inferences regarding trust formation in society. Nonetheless, exploring the associations between institutions, professionals, and generalized trust allows us to explore the relevance of mechanisms linking institutional performance, society, and generalized trust. Additionally, as the interdependence between the forms of trust studied here cannot be excluded, structural equations models (SEM) were also employed (results available upon request). The SEM analyses confirm the intuition from the regression results; that the direct correlation between respectively confidence in institutions and trust in professionals and generalized trust a statistically significant. These analyses also highlight that the correlation between trust in professionals and generalized trust is only in part mediated by confidence in institutions, suggesting that trust in welfare in professional may function as a mediator.

Results
The first step before proceeding to the analysis of whether confidence in professionals is related to social trust is to analyse the bivariate relationship between confidence in professions and in institutions. Notwithstanding the theoretical distinction between professionals and institutions, the public may not differentiate between the two. The correlations between trust in the main professional groups and their corresponding institutions are moderate, but significant, varying from 0.33 (p < 0.000) for social workers and the Norwegian Labour and Welfare Administration, to 0.82 (p < 0.000) between police officers and the Norwegian police. The correlations between confidence in schools and teachers, universities and professors, hospitals and nurses/doctors vary between 0.4 and 0.5. The results are similar to those of Brante, et al. (2015) in Sweden and support the hypothesis that individuals differentiate between confidence in institutions and that in professionals.   Table 2 displays the regression results. Models 1 and 3 serve as baselines and include only the institution, and respectively social network specific covariates. Model 2 and 4 additionally include the full set of control variables, while in model 5 all the covariates are included.
The institution-centered theory of generalized trust has focused on the link between citizens and the state as a way of generating social trust (Rothstein & Stolle, 2008;Rothstein, 2011). The results of the multivariate regressions from Table 2 show that increased trust in welfare state institutions is correlated with higher levels of generalized trust, thus offering additional support for the institutionalist theory. The correlation between trust in welfare state institutions and generalized trust remains positive and significant when controlling for factors shown to be important by the current literature. The magnitude and direction of the coefficient is consistent with the expectations derived from current scholarship. Nevertheless, as shown in Models 1 and 2, the results indicate that trustworthy professionals and institutions, are positively associated with increased generalized trust. This finding is in line with my theoretical expectations and suggests that alongside the presence of "good" institutions (Rothstein, 2011), professionals that are competent and responsible are positively associated with higher levels of generalized trust. The correlations between trust in institutions, professionals, and general trust remain stable when possible confounders are controlled for in Model 3, although there is a small reduction in magnitude.
In the European context demographic factors correlate with generalized trust (Mewes, 2014). Experimental studies also show that individuals from different backgrounds and ethnicities have different trust propensities; however, these are also contextual (Ostrom & Walker, 2003). Even though models 2, 4 and 5 include all available background characteristics captured in the data, it is still possible that the levels of generalized trust are affected by other factors that the present study does not capture. Putnam (1995a) emphasized the role of informal networks in maintaining generalized trust. To capture whether individuals' social networks influence their generalized trust, model 2, 4, and 5 adjust for membership in voluntary associations. The results indicate that only members of voluntary associations who actively participate in the organization are significantly more trustful of strangers compared with the unaffiliated. This finding corroborates previous findings in Norway (Wollebaek & Selle, 2003).
Model 3 shows that having acquaintances, friends, or family members employed in a welfare state profession is not significantly correlated with generalized trust. Although there is a positive relationship between working in a welfare profession and generalized trust, this relationship loses significance when introducing additional controls (in Model 4 and 5). These results do not support the hypothesis that informal interactions with welfare state professionals correlated with social trust. As nurses and teachers are some of the most common professional groups, with around 80% of the respondents having an acquaintance in at least one of these occupations, robustness models were run without these two occupations. When these occupations are omitted, the results remain largely unaltered. Interactions between confidence in professionals and acquaintances in welfare state positions are not significant. However, confidence in welfare state institutions and professionals might also capture the indirect association of being engaged in social networks.
Norway has sometimes been considered a deviant case because of its high level of social trust. Yet the mechanisms leading to generalized trust seem to operate in a similar manner to that elsewhere. As indicated by previous research, resources tend to be positively associated with social trust. The models indicate that greater cultural resources (education) have a larger impact than economic ones (income). As discussed by Stolle (1998), education mitigates scepticism and enhances tolerance. Overall, the findings presented here are similar to those at the European level (Charron & Rothstein, 2016;Mewes, 2014). Voluntary associations, education, and confidence in welfare and law enforcement institutions have a positive association with generalized trust. The results in Table 2 also illustrate that individuals who are trustful of welfare professionals are also more trustful of strangers. This relationship is robust to the inclusion of other potential confounding factors. The statistical significance of the correlation between confidence in welfare professionals and generalized trust is not altered by controls for employment in a welfare state profession or having welfare professionals in one's social network. Unlike Cook, Hardin and Levi (2005, p. 69) who argue that institutions "will work well even if they are staffed by knaves", this paper suggests that both trustworthy institutions and professional groups are of importance in maintaining generalized trust. The analyses provide support for the hypothesis that trustworthy professionals are important in maintaining a high level of generalized trust. This result substantiates the insights from the institutionalist framework and provides possible mechanisms through which this theoretical framework can be connected to the individual levels of trust. A challenge of the institutionalist framework is linking interpersonal trust to institutional trust, while the societal explanations of generalized trust sometimes overlook the role of the state. This study suggests that by accounting for confidence in welfare state professionals in the study of generalized trust may be an efficient way to link the state with society and by-pass some of these issues. In doing so, this paper has shown that the perceived trustworthiness of welfare state professionals is not only important for the professional groups, but has society-wide implications, by being a correlate of generalized trust.

Discussion and concluding remarks
The results also highlight that confidence in institutions is linked with generalized trust, also when trust in professionals is accounted for, thus giving some reason to believe that the institutional and professional aspects of the welfare state, each in their own way may be linked with generalized trust. While the findings also indicate that the association between confidence in welfare state professionals and generalized trust is in part mediated by confidence in institutions, this association is considerably smaller in magnitude. Nevertheless, it points towards the complex nature of trust formation.
Incorporating whether welfare professionals are part of individuals' social networks controls for social factors, and at least to a certain extent differentiates between two potential mechanisms: social factors such as informal meetings or dinner parties that may inform the public regarding the functioning of institutions, and trustworthiness of professionals in their formal roles. This encompasses some of the concerns discussed in the societal approaches to generalized trust. The results show that having acquaintances, friends, or family members employed in a welfare state profession does not correlate with generalized trust, once controlled for confidence in institutions. A limitation of the measure of social networks employed here is that it fails to account for the type of information transmitted in these networks, thus increasing the uncertainty of what the variables capture. Arguably, these results highlight that inferences about the trustworthiness of others are easier to make in formal interactions with professionals. In a formal interaction with a professional, there is an expectation of moral integrity and professional ethos. If such expectations are not met, the individual is likely to infer that this pattern will also hold for the behavior of the public.
The results also show that once controls are introduced for one's predisposition to be trustful the coefficients of being employed in a welfare profession is reduced considerably and so is the correlation between having acquaintances in welfare professionals (Model 3 to Model 4). These findings may indicate that either one's personality traits (such as trustfulness) may affect the interpretation in two ways. It may be either argued that exposure to welfare state institutions (either through their job or network) mediates their view of welfare institutions, or as argued by for example Uslaner (2002) some individuals have a more trustful disposition than others do. If the latter is the case, the observed correlations between confidence in welfare state institutions and professionals would be spurious. Future research could focus on identifying which mechanisms pertaining to personality traits or networks may affect one's evaluations of trustworthy professionals and institutions.
As previously discussed, Norway is a country where individuals have high levels of trust and a wide radius of trust (Delhey, Newton & Welzel, 2011). Petty corruption and favoritism in the public sector are very low (Rothstein & Stolle, 2008), so there may be little to gain from having acquaintances employed in key welfare state positions. Public processes tend to be transparent. The public can access information online relatively easily, so the added benefit of having welfare professionals in one's network is again relatively low. Given the existing institutional landscape and high historical levels of trust, social ties employed within the welfare state are superfluous. However, trust in institutions and welfare professionals can also be the bearer of sentiments such as occupational loyalty and dependence on welfare state (Kjølsrød 2010), where they would be observed through the correlation between trust in professionals and generalized trust.
Although this paper cannot account for developments over time, it is a first step in differentiating between the trustworthiness of professionals and institutional quality. The results highlight that confidence in the abilities of welfare professionals is a significant factor in maintaining a high level of generalized trust. More research is needed to understand the interplay between trustworthy professionals, institutional policies, and generalized trust better. Welfare professionals are on the front line of implementing public policy, and many are in direct contact with the public. Given the increase in New Public Management reforms and standardized routines, the relationship between the population and professionals is under greater scrutiny. Hardin's (2002) thesis that individuals place their trust in those they believe have strong incentives to act in the individual's best interest is becoming increasingly relevant. If individuals lose confidence that professionals will act in their best interest, will this also have an impact on generalized trust, or will they only lose confidence in the institution?
Given the large differences in institutional confidence and the quality of government between countries, comparative research is needed to improve the understanding of the context dependency of the mechanisms linking confidence in professionals with social trust. This study shows that generalized trust is not correlated with the presence of welfare professionals in a network. Nonetheless, in other countries with a different radius of trust, where family and close ties are more important, and perhaps with a less developed public sector, the situation may be different, as individuals may gain additional benefits from having welfare state professionals in their social network.

Supplementary material
The supplementary material such as the full specification of Table 2, including all coefficients and additional robustness analyses mentioned in text (the structural equation models, analogous regressions to Table 2 with clustered standard errors on municipality, regressions where acquaintances with nurses and teachers are excluded, construction of the trustful/reserved variable and additional correlations between the variables included in the model) are available upon request from the author.
New and emerging technologies signify a "process of cultural and social redefinition in which the foundations of how we understand the body, the human and the parameters of health are being radically transmuted" (Dolezal, 2016, p. 219). The increased use of digital health technologies in healthcare sectors offers multiple ways for health professionals to be present without physically being in the same room as the patient. This can be achieved digitally through cameras (e.g., Lindberg & Carlsson, 2018) and virtually through avatars, visual representations of a person or a software, such as virtual nurses (e.g., Abbott & Shaw, 2016), where the health professional is virtually embodied: the avatar becomes an embodiment of a health professional. Avatars are used to embody health professionals for several reasones: to perform certain duties usually carried out by human health professionals (Abbott & Shaw, 2016), to empower patients with health literacy (Bickmore, Pfeifer & Jack, 2009), and to build closer relationships between patients and health professionals (McStay, 2018). The use of digital health technologies in which health professionals work through avatars affects and changes health professionalism and health professions regarding identity, work tasks, working conditions etc. (e.g., Abbott & Shaw, 2016;Bickmore et al., Page 2 2009;Hirvonen, 2014). In the case of digitally embodying a health profession (avatar), I argue that the digitized embodiment of the virtual health professional (VHP) 1 affects the ways in which a health profession is understood (cf. Lupton, 2014), where the dichotomy between the real and the virtual is challenged (Hayles, 1999;Johansson, 2014). This is because technologies "play an active role in shifting the traditional social and cultural boundaries of our work-places" (Hansson & Bjarnason, 2018, p. 65). For example, some patients prefer to communicate with a virtual nurse rather than a human doctor (Bickmore et al., 2009), or express VHPs in terms of almost being (human) physicians (Lupton & Jutel, 2015).
Reports have shown how digitalization could result in health professionals gradually losing their jobs (e.g., Fölster, 2015). The Swedish Municipal Workers' Union (Kommunal) stresses how digital health technologies could benefit nursing assistants, the most common profession in Sweden and one that is female-dominated (92%) (Statistiska Centralbyrån, 2019), by improving working conditions through decreasing work-related back pain and increasing the status of the profession (Baudin & Fjaestad, 2017). In this paper, I focus on professionals working in or with health care and how they imagine the digitalization of health care will affect health professionalism.
I argue that the use of VHPs is part of a process of (re)negotiations and demarcations of health professionalism. Hence, the aim of this paper is to explore how health professionalism is (re)negotiated through notions of avatar embodiments of VHPs. How are VHPs made intelligible and professional? How do different categories of professionals 2 argue for or against virtual solutions and how do they express their opinions on how to embody these VHPs? How is health professionalism (re)negotiated through the implementation of new technology? How are notions of humanlikeness and machine-likeness articulated with the embodiments of VHPs?

Research overview
This paper addresses health professionalism and how it is affected by the digitalization of health care. Several researchers have studied how the social and cultural norms affect professionalism, as well as how health professionals are expected to www.professionsandprofessionalism.com Page 3 adapt to societal changes (Hansson & Bjarnason, 2018;Lindberg & Carlsson, 2018;Schnell, 2017). Hansson & Bjarnason (2018) studied how technology affects the work identities of nurses leading to a shift in the traditional cultural boundaries of workplaces. One important societal change in Sweden is the increased digitalization of health care, promoted by the Swedish government (The Swedish Ministry of Health and Social Affairs & The Swedish Association of Local Authorities and Regions, 2016). The increased use of digital health technologies in Swedish health care has therefore transformed health care, implying new patient-health professional relationships and patient discourses (Oudshoorn, 2008), and health professionalism discourses (Hansson & Bjarnason, 2018).
Another crucial societal change that has affected health professionalism is the integration of new public management in healthcare sectors, in which the digitalization of health care can be understood as a shift to new public management (e.g., Lindberg & Carlsson, 2018;West & Lundgren, 2015). Examples of this shift are the marketization of health care (e.g., Dahl, 2011;Glynos, 2014), the focus on individual needs and preferences through personalization, freedom of choice (Mol, 2008;West & Lundgren, 2015), cost-effectiveness and quality (Dahl, 2011) -neoliberal values and expectations that affect professional identities (Evetts, 2009). These new public management tendencies in healthcare sectors are also found in Sweden (Högberg & Sundin, 2014).
Feminist researchers have criticized traditional sociology of professions for being too focused on the profession itself, thus failing to acknowledge the societal and cultural norms on gender and its effects, such as reproducing gender, male privilege and gender-segregated labour markets (Dahl, 2011;Davies, 1995;Evetts 2009Henriksson, Wrede & Burau, 2006). Consequently, feminist researchers call for research into how discourses of professionalism produce and modify gender and gendered subjectivities (Dahl, 2011, p. 143;Hirvonen, 2014) such as patients, health professionals, and VHPs. I adopt this view by analyzing how digitalization affects health professionalism specifically by exploring how VHPs, through avatars, are gendered, ethnified and aged.
Researchers have discussed a process of disembodiment in care work, in which the use of digital health technologies disembodies health professionals (Calnan & Rowe, 2008;Kuhlmann, 2006), where health professionalism has traditionally been understood as embodied (Davies, 1995;Twigg, 2006) and performed by (human) bodies. I argue that health care is highly embodied and gendered, even when performed by digital health technologies (cf. Hirvonen, 2014) because technology is always embodied (Lundin & Åkesson, 1999). Lupton (2014) argues that a digitized embodiment is not merely a reflection of a physical body, but rather it affects the physical body or the way in which we understand the meaning of a physical body. I agree with Lupton that digitized embodiments affect how we understand physical bodies. This is also the case for the way we understand health professionalism. VHPs affect how health professionalism might be understood such as expectations on how health professionals should act, possible new arenas for health professionals and patients to interact, how health care is embodied, and also challenging notions of the (human) professional body.

Theoretical approaches
In this paper, I work with the theoretical concepts of professionalism and embodiment. To analyze how the informants negotiate notions of professionalism and embodiment of VHPs through avatars I turn to discourse theory: how the informants' meaning-makings produce certain understandings of professionalism and embodiment (Laclau & Mouffe, 1985).
I understand professionalism as discursively negotiated (e.g., , where professional work, professionals and professionalism are open concepts whose meanings are produced through articulations. I define discourse as a system of meanings and practices that are fluctuating and contextual, shaped in relation to other discourses (Laclau & Mouffe, 1985). Hence, resulting in discursive struggles over the meaning(s) of professionalism. A dominating discourse of professionalism concerns how professionals are defined by, and expected to possess, specialized knowledge, a service ideal, and autonomy (Evetts, 2003;. Thus, professionalism works as demarcations between different professions, between professionals and non-professionals , in which the demarcations of (non)professionalism are negotiated. However, professionalism is also affected by societal changes and demands (Hansson & Bjarnason, 2018;Lindberg & Carlsson, 2018;Schnell, 2017), such as new public management (Evetts, 2009) and the digitalization of health care (Hansson & Bjarnason, 2018;Lindberg & Carlsson, 2018). I view VHPs as examples of such processes of demarcation and negotiation of professionalism. Hence, VHPs can be positioned in relation to human health professionals in different ways such as professional health tools used by health professionals, potential colleagues and even rivals to health professionals (Abbott & Shaw, 2016;Bickmore et al., 2009)-aspects of the changing discourses of health professions. Hence, even though the VHPs perform certain professional work, they are not necessarily considered being a part of the corpus of health professional work.
By embodiment I refer to the materialization of bodies in line with Judith Butler's (1990) notion of how bodies are embodied through the material and the discursive. In the case of the VHPs' avatars this concerns both how their appearance (material) and their behaviour (discursive) are understood by others. Avatars embody the VHPs with digital bodies. Human health professionals and VHPs-through avatars-are different embodiments of health professionals rather than being a question of being real or fake. Johansson (2014) argues for "a thorough investigation of how bodies are produced and negotiated in specific hybrid environments" (Johansson, 2014, p. 16), where hybridity refers to how online and offline dimensions are intertwined rather than separated. I understand Swedish health care, with its ongoing digitalization, as such a hybrid environment of digital media, online and offline embodiments (cf. Hansson & Bjarnason, 2018).
Health professionalism involves embodiment in several ways: an embodied identity that becomes part of a person's identity (Monrouxe & Rees, 2017), an embodied practice (Hirvonen, 2014;Mol, 2008) where certain skills are embodied (cf. Bergman Blix, 2015), and a gendered practice (Hirvonen, 2014;Twigg, 2006). All of these aspects concern the embodying of health professionalism. The embodiment of VHPs touches upon these aspects of embodiment. Hence, the embodiment of VHPs not only concerns the use of avatars, but also the question of embodying professionalism: how the VHPs should behave and look professional. In other words, the embodiment of VHPs concern both how (virtual) bodies are designed and how they embody values and characteristics that are articulated with health professionalism performing professionalism in certain embodied ways. The (re)negotiations of health professionals in this paper relate to the way in which health professionalism should be embodied and what meanings the embodiments are given.

Method and material
This paper builds on interviews with and observations of researchers and user study participants in two interdisciplinary Swedish research projects called "Like-a-peer" and "Walk Safely", developing digital health technologies. Both project names were anonymized by me. I also made interviews with health professionals and representatives of four Swedish unions and professional associations for nurses, doctors, nursing assistants and physiotherapists: The Swedish Association of Health Professionals (Vårdförbundet,) The Swedish Medical Association (Sveriges Läkarförbund), The Swedish Municipal Workers' Union (Kommunal) and The Swedish Association of Physiotherapy (Fysioterapeuterna). The informants were chosen to enable exploring various perspectives from different categories of professionals who are directly or indirectly engaged in health care. They all worked in or with health care regarding questions of digital health technology and professionalism, but from different perspectives: developing digital health technologies, working with digital health technologies in their everyday work life, or organizing health professionals. The paper's ethnographic design, both interview transcripts, and notes from observations, is well suited to the paper's aim of exploring how health professionals is (re)negotiated through different ideas of how VHPs should be embodied (cf. Hammersley & Atkinson, 2007). This paper builds on nine interviews: four interviews with representatives of the four unions, two interviews with researchers involved in Like-a-peer and Walk Safely, two interviews with nursing assistants trained in welfare technology, and one interview with two user study participants from Like-a-peer. The informants from Like-a-peer and Walk Safely were contacted through the research supervisor of the research groups or directly when meeting them during my fieldwork. I contacted the head office of each union and asked for a representative of the union interested in talking to me about the digitalization of health professions. All informants received information about the study and gave their consent. The interviews comprised openended questions concerning experiences of digital health technology, professional roles, possibilities, challenges and the ethical dilemmas of digital health technologies for patients and health professionals, ideas about professionalism, health and body, and aspects of gender, ethnicity, and age. The open-ended questions also allowed the informants to discuss more freely and elaborate on the themes and questions. The interviews lasted 35-75 minutes and took place at the informant's workplace or over the phone. The interviews, eight performed in Swedish and one in English, were digitally recorded and transcribed verbatim in Swedish and English, with minor edits for readability. All Swedish quotations were translated into English by me. In order to ensure anonymity, personal names and project names were changed, no towns or names of current workplaces were mentioned, with the exception of the four unions. My study was approved by the Regional Ethics Review Board.
Between the autumn of 2014 and the spring of 2018, observations of researchers-mainly from computing science, occupational therapy, and physiotherapyand user study participants in Like-a-peer and Walk Safely were carried out, in which I followed researchers involved in the projects. During the observations, I was invited by the research supervisor to observe and participate in project meetings, seminars, public events at which the researchers presented their research, informal meetings (coffee breaks, lunches) at which their research was discussed, as well as a user study conducted for Like-a-peer. Approximately 20 observations, comprising 50 hours, were performed. During my observations, I focused on how the relationships between the patient and the digital health technologies were discussed, notions of health, embodiments of digital health technology and ideas of professionalism, in which the latter theme is the focus of this paper. Notes of the discussions and presentations that took place were taken during or directly after each observation. I also took photos of avatars involved in the project and for the user study I used a digital recorder and transcribed verbatim in Swedish. The observations gave a deeper understanding of the projects, the researchers' work, and their digital health technologies and it also helped to develop my interview questions and themes (cf. Hammerley & Atkinson, 2007).
The avatars in the projects Like-a-peer and Walk Safely are all utilized to maintain or increase the health of the patients. The relationship between the VHPs, human health professionals, and patients are mainly threefold: the software of Like-a-peer and Walk Safely has been modelled by knowledge, expertise, and experiences of health professionals, health professionals can be "present" in the patients' homes via the VHPs, and the health professionals can access data about the patient via the VHPs' interactions with the patients. The avatars adopted in the software to digitally embody health professionals are all inanimate images of human-like characters: the avatars cannot move or speak, and they communicate with the patient via text-based messages on a screen (computers, cell phones, tablets). These avatars have different genders, ages, and ethnicities, and are all human-like, except for a white poodle avatar in the Walk Safely software. For the Like-a-peer software the avatars had not been decided during this study: starting out with animal avatars and cartoons characters and moving on to more human-like avatars.
The material was analyzed with discourse theory (Laclau & Mouffe, 1985). The analysis was carried out in three stages. Firstly, on an individual level by reading through the transcripts of each interview and observations, identifying central themes, arguments and topics of each informant concerning notions of professionalism and embodiments. Secondly, I compared the findings of each informant with the other informants in order to aggregate the themes and find similarities, differences, and variations in the informants' notions of professionalism and embodiment. Thirdly, from my interpretations of the informants' notions I identified articulations of professionalism and embodiments, and how these articulations reproduce, challenge and change discourses (see Winther Jørgensen & Phillips, 2002) concerning health care, professionalism, and embodiment.

Negotiating virtual health professionals
In this section, I discuss how the informants articulate notions of subjectification, authenticity, and diversity with health professionalism. Specifically how these notions of health professionalism are dicussed in terms of how the VHPs should be embodied. According to the informants, by embodying the VHPs through avatars, the VHPs might seem more human-like and professional-like, while at the same time the informants try to balance this human-likeness and professional-likeness in order not to make them seem too human or too professional.

Professionalism through subjectification: a sense of talking to someone
How is health professionalism linked to subjectification: how are the VHPs negotiated as subjects, "almost-subjects", or non-subjects? The embodiments of VHPs created a sense of interacting with someone rather than something. Three key aspects of the subjectification processes of VHPs were notions of how communication and relations between the avatars and the patient should be designed, and how emotions should be expressed.
Communication was raised as a key feature of the interaction between patients and VHPs. The VHPs must be able to communicate with the patient, where the VHP's avatar was an important communication factor. However, the communication skills of the VHP were also connected to subjecthood: to communicate more like someone than something. This was expressed in my interview with Lisa and Sara, two user study participants for the Like-a-peer project, in which they had a textbased interaction with a VHP: Author: You also mentioned avatars. […] Lisa: Well, then it would be more like… if it's on the computer, an avatar, who is asking these questions. Then it becomes more like you're talking to a person, so it becomes a bit more like talking to someone instead of a [computer]  Sara: Yes, it feels more like you're talking to someone who… actually exists […] and understands.
(Interview, July 7, 2015) Lisa and Sara's thoughts about the avatar making the interaction more like communicating with someone rather than something point at a process of subjectification in which the subjectivity of the VHP is embodied through the avatar. Without the avatar, the VHP might seem less real, more like something than someone, and the patient might feel less inclined to interact with the VHP. The use of avatars not only creates a sense of the patient communicating with a subject, it might also help the patient to know who and what the purpose of this someone is. Eric, a physician, and representative of The Swedish Medical Association, mentioned that the most important function for an avatar is that: In a way, it declares itself [laughing] to […] know that it's this persona or avatar you are communicating with. […] "Now I have an encouraging avatar and it will take me out for a run" and this other avatar who sits and reads and extracts information from a lot of textbooks. (Interview, January 11, 2018) In this sense, the avatar not only embodied a subject in general but specific subjects using different avatars. Lisa, Sara, and Eric linked the use of avatars with a sense of communicating with someone: how avatars subjectify the VHPs in the communication with the users to a certain extent. In other words, the avatars embody the VHPs with a sense of subjectivity. Closely connected to communication was the question of building relationships. Anna, a researcher in physiotherapy, told me that in the Walk Safely project the user can choose between five different avatars for the virtual physiotherapist, where the avatar was used to "create a sort of relationship. And then we thought: another way to create this relationship is to use an image" (interview, November 6, 2015). The avatar itself encouraged the patient to build a relationship with the VHP. Eric expressed a similar idea: "If you are going to have a relationship with something over an extended period, you need an avatar, to which you even give a name: 'Pelle thinks this' and then you build a relationship with Pelle as if it was actually a person with a will, perceptions, and goals" (interview, January 11, 2018).
Another strategy mentioned, of forming closer relationships between patients and VHPs, was emotions. The ability to express emotions was a way of interacting with patients and a way of evoking a sense of subjecthood in VHPs. During a user study for Like-a-peer, Marie, a researcher in computing science, introduced what she called a "set of digital friends" where she presented the seven dwarves from the Disney film Snow White and the Seven Dwarfs as possible avatars for the VHP. The idea was that the avatars embody different emotions, such as being happy etc., but adapted to the situation and the interaction: So whenever the […] responses aren't so happy, then the suitable avatar should be visible during the dialogue. Now, it's a bit monotonous with "text text text". So my next aim is to have these images according to the context so that it improves the user experience.
(Observation of user study, July 7, 2015) Marie used avatars to embody and express emotions that evoke feelings of subjecthood (user experience). In this way, the process of subjectification worked by articulating emotions with being a subject: the avatar embodies emotions, thus makes the VHP more like a subject and a health professional. This is similar to virtual nursing avatars designed to demonstrate emotion-like behaviours, such as appearing emwww.professionsandprofessionalism.com Page 8 pathic to the patient (Abbott & Shaw, 2016;Bickmore et al., 2009)-crucial characteristics of the growing field of emotional artificial intelligence (McStay, 2018). However, regardless of whether the health professionals are virtual or not, emotions and empathic behaviour are still key aspects of health professionalism (e.g., Evans & Thomas, 2009).

Professionalism through authenticity: credibly professional, inauthentically human
Closely connected to subjectification-using avatars to make the VHP embody a sense of professional subjecthood-were notions of what this someone should look like. Hence, in this section, I explore the informants' negotiations of whether or not human-like avatars and professional attire should be used to embody VHPs.
The informants discussed the use of human-like avatars as a way of making VHPs resemble certain health professions, thus making it easier for the user to identify the VHPs. A reason for using human avatars to embody VHPs, expressed by the informants, was that since health professionals are human, the avatars should look human in order to represent certain health professions. Laura 3 , a researcher in physiotherapy and a member of The Swedish Association of Physiotherapists, gave me one example when I asked her if she thought it was important for a virtual physiotherapist to have a human avatar: Yes, because physiotherapists are humans [laughter]. If this [virtual physiotherapist] sends a reminder from your physiotherapist, it's probably good that it's a human and not a dog, or an alien or something. [---] For the sake of credibility. (Interview, March 23, 2018) Laura linked the human avatar to a notion of credibility: the human avatar makes the virtual therapist more credible as a professional, while an alien or a dog is not credibly professional due to their non-human embodiments. However, Laura was also open to the possibility of the patient choosing non-human avatars, like a dog, as a virtual physiotherapist, if the patient "would rather be reminded [of the physical exercises] by a dog [avatar]" if this promotes the patient's "compliance" in following the exercise programmes set up by the human physiotherapist. I understand this to be two different and potentially conflicting notions of credible professionalism through the embodiment of the virtual physiotherapist. The former links human avatars with professional-like credibility in the sense of representing human physiotherapists, while the latter links non-human avatars with credible professional-likeness, focusing on the outcome of the patient's health (cf. Graber & Graber, 2011). The human avatars also engendered concerns and some informants raised the question of (in)authenticity, due to linking being professional with being human. Following this line of thought, the VHP should not be embodied by a human avatar since it is neither authentically human nor an authentic health professional. Anna was one of the informants who argued for non-human avatars: "You shouldn't be able to think of it as a person ... it's not a real person" (Interview, November 6, 2015). In order to make the virtual physiotherapist seem less like a "real" person, Anna has introduced a white poodle avatar, which I understand to be a strategy to dehumanize the virtual physiotherapist, as well as a way of not making it look like an authentic physiotherapist.
www.professionsandprofessionalism.com Page 9 However, even if the informants often clearly argued for using or not using human-like avatars for the VHPs, most of them were concerned with negotiating how human-like the avatar should look. An example of this was Nina, a nursing assistant trained in welfare technology. She thought that technology should not try to look human: "It would feel very unpleasant, someone trying to resemble a human being while not being one" (Interview, February 1, 2018 Here Nina negotiated how human-like the VHP should look and behave: it should be credibly human-like without trying to be an authentic human, in order to be credibly professional-like. This related to the question of communication, emotions and building relationships: in order for the VHP to communicate with patients, express (human-like) emotions and build relationships, it needed a human-like embodiment, to a certain extent, without being too human-like. The question of credibility and authenticity when embodying VHPs was also connected to professional attire-if and how VHPs should be professionally dressed. All informants have ideas of how certain attire symbolizes a profession, such as doctors or nursing assistants. Hence, wearing certain kinds of attire becomes a professional sign, making a VHP more intelligible and credible as a health professional (cf. Timmons & East, 2011). For example, Lisa and Sara mentioned that it might be important for the avatar to look like "someone in a nursing outfit" (interview, July 7, 2015) to make it more professional looking, and Laura believed that professional attire helps the VHP resemble "an authorized health professional" (Interview, March 23, 2018).
However, the informants differed in their arguments and negotiations about whether VHPs should wear professional attire or not. When I asked Nina if it is important for an avatar used for nurses to resemble a nurse, she said: "I don't think it should look like a nurse, because it's not a nurse" (Interview, February 1, 2018). Nina linked professional attire to authenticity: the avatar should not pretend to be something other than what it is by using professional attire and not dress up as a nurse. I understand this to be a strategy to both (re)negotiate the differences between humans and machines, and nurses and virtual nurses. For Nina, the humanization of the virtual nurse through professional attire seemed to become a threat to her demarcations between an authentic nurse (human) and an inauthentic nurse (avatar).
Anna raised an interesting issue about credibility and authenticity concerning professional attire for the avatars when she told me about a discussion she had had with the researchers in physiotherapy in her research group. Anna wanted to avoid professional attire that she thought reproduced stereotypical notions of physiotherapists, while the physiotherapists wanted to use attire they thought represented physiotherapists: Anna: I have been more concerned that it will be stereotypical. Like the smart one always wears glasses. Yes, that makes me anxious. [---] While the www.professionsandprofessionalism.com Page 10 physiotherapists are saying: "But a physiotherapist doesn't look like that!" It's more about their profession. Author: Yes. Anna: It's not dressed like a doctor. Author: No. Anna: And it's not like wearing a pullover. (Interview, November 6, 2015) Anna negotiated professional intelligibility through attire; the physiotherapists want attire they consider will make the virtual physiotherapist easily and credibly recognized as a physiotherapist, while Anna linked this kind of attire to stereotypes-as overly intelligible. For Anna, the challenge lied in handling the balance between professional intelligibility, professional credibility, and professional stereotypes. I understand authenticity to be negotiations regarding what is considered to be authentic, rather than a question of what is "really" genuine (Bendix, 1997). The informants were negotiating how authentically person-like and professional-like the VHPs should look. Some argued that the human-like embodiments and professional attire made the VHP look more credible as a health professional, while others argued that these human-like and professional-like embodiments tended to concern questions of (in)authenticity: they might risk making the VHP appear too authentic.
Here the question of professionalism was negotiated through processes of demarcations between humans and non-humans, and professionals and nonprofessionals-to be sufficiently human-like and professional-like in order to pass as credible health professional.

Professionalism through diversity: the ambivalence of patients choosing the embodiment of (virtual) health professionals
In this section, I explore the choice of the virtual embodiment from two different perspectives of diversity. Firstly, I explore diversity from the perspective of offering a diverse variety of avatars for the VHPs, considering gender, ethnicity, and age. Secondly, I explore diversity in relation to patients' right to (not) choose the avatar of the VHP. I also present how a discursive struggle over health professionalism between a notion of freedom of choice and a notion of diversity might have implications for health professionalism since within Swedish health care it is not permitted to choose health professionals based on gender and ethnicity.
Several of the informants emphasized the importance of a diverse variety of avatars for VHPs. This made it possible to avoid reproducing stereotypes, in which the choice of avatars is a crucial part. For example, Stella, a representative of The Swedish Municipal Workers' Union, argued that it is important to not "programme prejudices [...] for example, not only make females [avatars] [...] or only make males [avatars] that are associated with technology" (Interview, February 9, 2018). Stella linked the embodiment of the avatars to gender norms and gender prejudices connected to health professionalism and technology. She wanted to break these norms by designing and offering avatars that challenge these norms and prejudices, but she also articulated health professionalism as being a gendered and embodied practice (cf. Hirvonen, 2014;Twigg, 2006).
Another reason for offering a variety of avatars is identification, specifically how patients might be more inclined to comply with the VHP if the avatar looks like the patient to some extent regarding, for example, gender, ethnicity, and age.
In that case, it's important that you might be able to choose which one [avatar] you want […]. If it's like, "yes, I identify with this [avatar]", if this is even possible. For us within physiotherapy, it's important to achieve patient compliance for the treatment.
www.professionsandprofessionalism.com Page 11 (Laura, interview, March 23, 2018) Here, Laura connected patient identification of the avatar with compliance: the patient needs to identify with the virtual physiotherapist in order to comply and follow through with the virtual physiotherapist's exercise programme.
Thus far, the possibility of patients choosing the VHP's avatar has been expressed in positive terms such as avoiding the reproduction of stereotypical ideas and promoting patient identification. However, some of the informants also expressed potential ethical problems with allowing the patient to choose the VHP's avatar: ethical dilemmas that might not only affect the VHPs but also the human health professionals. I found this to be a discursive struggle over health professionalism between a notion of freedom of choice and a notion of diversity. The freedom of choice notion was connected to ideas about person-centred health care, with an emphasis on patient choice that connects to neoliberal ideas about the individual (cf. Mol, 2008;West & Lundgren, 2015). The diversity notion, however, was connected to values about the healthcare sector as a place that promotes diversity and equality for both employees and patients.
For Carl, a nurse and representative of The Swedish Association of Health Professionals, the possibility for the patient to choose an avatar for the VHP was motivated by the patient's sense of safety: "To make you [the patient] feel safe with it [the VHP]" (Interview, February 7, 2018), in which the embodiment of the avatar evokes feelings of safety. I understand this as an expression of the freedom of choice notion articulated with the patients' safety, embodied through the avatar of the virtual nurse. However, Carl also discussed how these positive aspects of choosing the avatar based on the patient feeling safe might also result in a conflict with what I refer to as a notion of diversity in the healthcare sector: If we talk about racism and so on, you would usually say that patients should not be able to choose health professionals based on skin colour. But this makes it [the use of avatars] interesting... This aspect cannot be addressed if you want to let the patient create the avatar. Then you may want to affirm these prejudices because then it doesn't really matter. Or does it? [laughing] As long as this [the choice of avatar] leads to a sense of safety [for the patient]. (Interview, February 7, 2018) Firstly, Carl articulated a conflict between choice and diversity in which the patient's choice of avatar is motivated by feeling safe. However, this sense of feeling safe might boost, or be motivated by, racial prejudice. I understand this to be a potential conflict of interest between a patient's right to choose and the right of health professionals to be protected from patients' racism and racial prejudice (cf. Andersson, 2010). Secondly, Carl tried to handle this conflict by differentiating a virtual nurse from a human nurse: to choose an avatar based on the patient's preferences is not necessarily a threat towards values of diversity for the health professionals because the VHP is not a human health professional (cf. Graber & Graber, 2011). Previously, I mentioned how a variety of avatar options for the VHP, based on gender and ethnicity, was motivated to avoid the reproduction of stereotypical embodiments. However, in the negotiation of choicewhether it is a question of patient safety or potential discrimination against health professionalsthis might actually reproduce these stereotypical embodiments because of the risk of patients choosing their avatar based on discriminatory grounds. Or, as expressed by Stella: "We don't want a [health care] where individuality or diversity in health care, which is such a diversity-oriented sector, disappears" (Interview, February 9, 2018)

Conclusion
In this paper, I explored how health professionalism was (re)negotiated through notions of embodiments of VHPs (avatars). I found notions of subjectification, authenticity, and diversity as central themes in the informants' negotiations of health professionalism. Subjectification involved negotiations of VHPs as (non)subjects where the informants expressed notions of the avatars subjectifying the VHPs. The embodiment of VHPs through avatars could create a sense of talking to someone rather than something and declaring who this someone was (e.g., virtual nurse). Closely linked to who this someone was the question of what this someone should look like, where the use of human avatars and professional attire for the VHP were discussed. Some of the informants considered the use of human-like avatars and professional attire to make the VHP more credible as a health professional, while others thought of these embodiments as inauthentic because VHPs are not authentic humans or health professionals and should therefore not be embodied accordingly. However, rather than totally condemning the use of human-like avatars or professional attire, I found the informants mainly negotiating how human-like and professional-like the VHPs should look. In other words, the informants were balancing credibility and (in)authenticity in order to find a way of making the VHPs sufficiently human-like and professional-like, to make them credibly professionally but inauthentically human.
The choice of embodiment for the VHPs was connected to two different notions of diversity: offering a variety of options of different avatars regarding ethnicity, gender, and age, and promoting and protecting values of diversity and equality in health care. The former notion was concerned with how a variety of avatar options could both avoid the reproduction of stereotypes of, for example, gender, and make it easier for patients to identify with the VHP. The latter notion was discussed in terms of how patients who are able to choose the avatar might feel safer with the VHP, but that it might also be a potential threat towards equality and diversity for health professionals. I found a discursive struggle over health professionalism between two notions: a notion of freedom of choice and a notion of diversity (e.g., Andersson, 2010). The former promoted the users choosing the avatar motivated by making the user feel safe and more inclined to participate in health-enhancing activities, while the latter was concerned with the risk of patients choosing what they feel safe with, possibly based on prejudices regarding gender and ethnicity (e.g., Graber & Graber, 2011). Mol (2008) argues that the "logic of choice" is part of a global tendency of person-centred health care focused on patient choice (see also West & Lundgren, 2015). I found this logic of choice being similar to the notion of freedom of choice, in which the patient's choice of avatar was an important part of healthcare work. This logic is an example of how health care has been marketized (Glynos, 2014) through a focus on the needs and preferences of the individual through personalization and freedom of choice (Mol, 2008;West & Lundgren, 2015). However, if the patient's choice of avatar is based on prejudices and discrimination, this might actually result in racism towards health professionals, especially due to the hybridization of health care with offline embodiments (human health professionals) and online embodiments (avatars of the VHPs) and the blurring of lines between these embodiments (Hansson & Bjarnason, 2018;Johansson, 2014). This can also be understood as a neoliberal logic of how quality and the patient's freedom of choice have been articulated together as positive values of health care and are therefore hard to criticize (Dahl, 2011), resulting in a dilemma between freedom of choice for patients and diversity within health care for health professionals (Andersson, 2010). In other words, the patients that choose avatars might actually threaten health professionalism if diversity and equality are discursively subordinated patient choice, resulting in rearticulations of both health professionalism discourses and patient discourses (Hansson & Bjarnason, 2018 I understand the notions of subjectification, authenticity and diversity to be processes of creating differences and similarities between humans and machines, though mainly balancing these processes in order to make VHP sufficiently professionallike. In other words, the embodiments of VHPs were articulated with human-likeness and machine-likeness. Thus, the embodiment of VHPs might challenge notions of what health professionalism could be (e.g., Hayles, 1999;Hansson & Bjarnason, 2018;Lindberg & Carlsson, 2018;Lupton, 2014): expectations on how health professionals should act, how health care is embodied, and challenging notions of the human body and the professional body.
The embodiment of VHPs illustrates how health professionalism is already embodied through notions of professional attire, norms on gender, ethnicity, age, (human) bodies carrying out care work etc. I understand health professionalism to be embodied and I agree with Hirvonen (2014) that health care is highly embodied and gendered, even though it is partially carried out by digital health technologies. Health professionals are very much embodied, even if they are virtually embodied (Hayles, 1999;Lundin & Åkesson, 1999), where the informants negotiated how VHPs should be embodied by avatars: if they should look human, wear professional attire and how the avatars were gendered, ethnified and agedembodied aspects of health professionalism. Thus, it is important to study technologies and what norms they (re)produce (Lupton, 2014).
www.professionsandprofessionalism.com Page 2 fessionals do and how they do it. For example, professionals are increasingly pressured to be available to work anytime and anyplace through their mobile phones and the internet (e.g. Perlow, 2012). The changes affecting professionals are similar to those impacting other workers, but there is reason to believe the implications for professions are different (Livingstone & Watts, 2018). Professionals appear to be losing autonomy and influence more quickly than other workers (Livingstone & Watts, 2018). At the same time, social change threatens to undermine those characteristics that have made professionals historically distinct: discretion, social authority, homogeneity, knowledge, and skill.
These changes and other social trends combine to exacerbate internal stratification within professions (Noordegraaf, 2016;Waring, 2014). Scholars have identified divisions within professions across work setting, authority level, and across gender, race, and immigration status. Differences across age cohort and generation are also evident, but have seldom been explored (Choroszewicz & Adams, 2019). Despite the belief that these internal divisions are likely to grow, and that they have the potential to alter professions dramatically Waring, 2014;Noordegraaf, 2016), few scholars have adopted an explicitly intersectional approach to explore within-profession differentiation more closely.
The intersection between gender and age has been particularly neglected, not only among professions scholars, but in intersectionality theory as well (McMullin, 2011;Choroszewicz & Adams, 2019). Professions, and the organizations in which professionals work, are gendered institutions (Adams, 2000;Britton, 2017;Davies, 1996). Historically, male-dominated professions were designed by men for men, and women have been at a disadvantage-experiencing discrimination, and barriers respecting entry, promotion, and practice opportunities (Davies, 1996;Hearn, Biese, Choroszewicz & Husu, 2016;. Nevertheless, gender advantage and disadvantage are very much intertwined with age, generation, and the life course. For example, research has suggested that differences between men and women become particularly salient during key life course transitions, such as first entry into professional employment (Seron, Silbey, Cech & Rubineau, 2016), or during child-bearing years (Ranson, 2005;Demaiter & Adams, 2009). Moreover, generational differences are evident. In light of substantial change to professional work and workplaces, the experiences of those who entered practice decades ago may be different from the experiences of newer professionals entering practice in recent years. Their expectations of professional careers may differ as well (Ng, Lyons, & Schweitzer, 2017). Although some gender biases have been reduced due to equal opportunity and antidiscrimination legislation implemented across Western countries, professional work is still gendered in a manner that creates challenges for young workers entering professional careers.
In this paper, we show how combining intersectionality theory and life course approaches facilitates the exploration of inequalities by gender, class, and race/ethnicity across generations and age cohorts. We argue that the meanings attached to gender, and the gendering of work, have shifted over time such that the experiences of newer cohorts of professionals differ from those of professionals in previous generations (e.g. Adams, 2019;Choroszewicz, 2019;Cottingham & Dill, 2019). Subsequently, we demonstrate the importance of an intersectional approach by presenting some empirical research findings, identifying how at key life course stages, gender and age converge to confer privilege and produce disadvantage in professional workplaces within Western countries. The examples we discuss include: 1) challenges for young professionals entering and building professional careers; 2) challenges for older professionals facing work intensification and rapid technological advances; and 3) work-life balance challenges within and across generations and age cohorts. These examples highlight a growing need to explore the significance of age and generation to professional work, in intersection with other inequalities. Next, we introduce the concept of meta-work-hidden, invisible and laborious work performed by non-traditional and disadvantaged professionals-through which they endeavour to www.professionsandprofessionalism.com Page 3 cope with structural inequalities embedded in the professions. We conclude our essay with a discussion on implications for further research on professions as well as some ideas for future research on the intersections of gender and age in the professions.

Intersectionality and life course perspective
There is a sizeable body of research exploring the significance of gender to professional employment (see, for instance, Davies, 1996;Hearn et al., 2016;. Research has explored the movement of women into traditionally male-dominated professions (Adams, 2010;Choroszewicz & Kay, in press), as well as women and men's different experiences of career entry, career progression, professional practice and identity, and work-family reconciliation (see for example Choroszewicz & Adams, 2019). Despite the feminization trend in Western professions, gender equity social policies, and other social change, there is evidence that gender still shapes experiences of professional employment in important ways (Britton, 2017;Hearn et al., 2016). However, it has also become clear that a gender lens is often insufficient as social inequalities across a range of dimensions, including class, race/ethnicity, sexual orientation, and citizenship, intertwine to shape experiences (Choroszewicz & Adams, 2019;Holvino, 2010). Intersectional theoretical perspectives provide analytical tools to understand how gender, class, and race, and other structured sets of social relations (and identities) intersect to shape experiences, advantages and disadvantages, and opportunities (Acker, 2006;Choo & Ferree, 2010;Crenshaw, 1989;Holvino, 2010). Yet, intersectional theory too often neglects age, contending that as a dimension of inequality it is fundamentally different from others, and hence cannot be incorporated under an intersectional lens (Acker, 2006). As a result, the significance of age, cohort, and generation to men's and women's experiences of professional practice too often remains unexamined.
In our recent book, Gender, Age and Inequality in the Professions, we argue that combining an intersectional approach with a life course perspective helps to illuminate the intersection of gender and age (and other dimensions of inequality) (Choroszewicz & Adams, 2019). Gender and age are important, co-constructed, and structural systems of inequality. They gain meaning in particular organizational, institutional, and socio-historical contexts. Within professions, gender and age intertwine (in combination with race/ethnicity, social class, etc.) to shape opportunities for employment, working conditions, career promotion, and experiences of private life. The life course perspective can inform our understanding of these intersections by drawing our attention to the impact of social-historical context on our experiences of key life transitions, and how these affect our longer-term life trajectories.
Life course scholars focus on the social pathways that individuals traverse as they live their lives from birth to time of death (Shanahan & Macmillan, 2008). These social pathways are structured by social institutions, norms, and social interactions that vary across time and place (Elder et al., 2003;Shanahan & Macmillan, 2008). Along these pathways there may be many key life events (transitions and turning points) that shape subsequent life trajectories (Shanahan & Macmillan, 2008). Key transitions (such as entry into first professional job, or transition to parenthood) are structured, and shaped by social norms, institutions, and interactions. As a result, social-historical context is crucial in shaping experiences and opportunities.
Individuals whose pathways have commonalities, due to shared norms, shared experiences of major world events, and shared social contexts, often develop similar outlooks and attitudes (Parry & Urwin, 2011). Age cohorts, or generations, can be meaningful in this light. In Western countries generations have been divided into four over-arching categories: Traditionalists (born 1925-1945), Baby Boomers (born 1946-1964), Generation X (born 1965-1979) and Generation Y/Millennials (born 1980-2000). Although the experiences of people within these broad categories may differ, those sharing a generation may have distinct experiences due to the social contexts in which they grew up, were educated, and entered the labour force. These experiences have been said to shape working habits, commitment to work, and outlook.
Adopting a life course perspective illuminates potential differences in work experiences across cohort. In light of the substantial change in professional work over time-changing entrance standards, labour market opportunities, organizational change, shifting policy contexts and so on-one would expect that the careers of Baby Boomer professionals and their Millennial counterparts would differ in meaningful ways. For example, young professionals face a more precarious labour market than their predecessors did; higher education, and advanced training no longer offer protections from unemployment as they did in the past. Moreover, experiences of key transitions, such as challenges at professional entry, may lead to widely varying career trajectories, and even different visions of how professions should be practiced. Age differences within professions may be meaningful sources for division.
These age and generational differences intersect with gender in a variety of ways. Experiences of key life transitions not only vary by age, but by gender: research has documented differences in career entry, for example, across gender as well as other sociodemographic factors (Adams & Kwon, 2019;Francis, 2015;Kay, 2019). Men and women are still paid differently, they are promoted at different rates, and the birth of a child affects men and women's careers quite differently (Colley, 2017;Ranson, 2005). Nevertheless, in light of organizational and national policy changes, having a child does not impact women's careers today in the same way it affected women generations ago. Given the impact of career entry on broader career trajectories (Kay, 2019), these differences might lead to distinct experiences of professional careers. It is important to consider the intersection of gender and age to understand social experiences, and how they differ across individuals and over time. Gender norms also vary across generations. For example, members of younger generations valorize gender equality norms and policies more than their colleagues from other generations whose lives were to a greater extent influenced by norms of gender difference both at home and at work (Niemistö, Hearn, & Jyrkinen, 2016). Looking at just age differences or gender differences in isolation obscures the complex ways in which gender and age intersect to shape the work and personal lives of professional workers.
Combining intersectionality and life course approaches provides a framework for exploring how advantages and disadvantages vary across gender and age, and moreover, how experiences of key life course events and transitions differ in meaningful ways. In the next section, we illustrate the utility of this approach by focusing on three such transitions or life course stages: career entry, late-career challenges, and experiences of work-family conflict.

1) Challenges for young professionals entering and building professional careers
Entry into professional careers involves a complex mix of advanced education, practical training, and mentorship. Access to education and training opportunities is highly competitive. In light of labour market challenges and increasing precarity, access to employment and mentorship is also more complicated than in the past. Young workers entering professions face many challenges that at least some members of earlier cohorts did not. They also increasingly find themselves in strong competition for scarce prestigious jobs. In some environments younger workers may be favouredfor instance in high tech firms or large law firms (Corbett, 2019;Kay, 2019). However, even when job opportunities are available, young workers may struggle to adjust to the physical, mental, and emotional demands of professional careers (Adams, 2019;Cottingham & Dill, 2019). Young professionals may also be stereotyped as uncommitted, unreliable, low-skilled, disrespectful, or overly demanding in terms of work-life balance, leisure time, as well as interesting work assignments and promotion (e.g Foster, 2016;Laird, Harvey & Lancaster, 2015).
Research has highlighted significant gender differences among early career professionals, with men having more work opportunities and more positive experiences. Young men are often paid more, indicating that the gender pay gap begins in the early stages of careers and takes place both in the public (Colley, 2017) and private sectors (Dinovitzer, 2015). Young women entering male-dominated professions may face hostile working environments, discrimination, and skill discounting (Adams, 2019). Over time, professional women learn to ignore everyday sexist comments and micro-aggressions from male co-workers. Others decide to exit hostile work environments in search of more positive ones-a strategy that sometimes takes women out of professional workplaces all together. Exit or 'opting out' of hostile and inflexible workplaces remains one of the most common coping strategies among women in male-dominated professions. Some research shows that exit can be also an empowering experience for professional women and provide them with individual agency needed for opting in to more sustainable work options (Biese & Choroszewicz, 2019).
Young women in male-dominated professions may face extra challenges acquiring the expected professional demeanour, including specific emotional capital, resistance to stress and so-called soft skills. Women are more likely to feel uncertainty, negative emotions and inadequacy due to being young and inexperienced (Cottingham & Dill, 2019). This may be particularly the case for young women today as notions of identity, professionalism, and skills expand to cover personal attributes, behaviours, and attitudes (Bailly & Léné, 2013;Choroszewicz, in press;Grugulis & Vincent, 2009). Emotional labour-and manifesting the appropriate feeling states on the job-is more pronounced and explicit today (cf. Hochschild, 1983). Professionals need to demonstrate empathetic behaviour towards clients and provide personalized service to them while at the same time they have to fulfil organizational performance requirements, which might contradict in terms of time and end result. The capacity to manage both one's own emotions but also the emotions of others is becoming increasingly central not only in female-dominated professions (Cottingham & Dill, 2019) but also in male-dominated professions (Choroszewicz, in press). Young professionals are expected to draw on their personal competences and flexibility to show interest and enthusiasm for their job, to collaborate with colleagues and clients located across the globe, as well as to be attentive to clients' needs for customized service. Generating client rapport and building trust are highly valued, but young professionals are often left alone in developing these skills.
Today's emphasis on individual responsibility, resilience, and self-management can be especially challenging for young professionals who are launching professional careers (Olakivi & Wrede, 2019). Young professionals-especially those coming from more disadvantaged socio-demographic backgrounds, and those with insufficient mentoring-might be vulnerable to subtle acts of exploitation and marginalization that degrade their well-being. They may feel the need to work harder to prove their competence, or make career choices to minimize discrimination. For example, Adams and Kwon (2019) find that young women, especially from Asian-Canadian ethnic backgrounds, entering medicine face particular challenges to find supportive mentors and to choose specialties that allow for work-life balance. As young professionals do not receive enough support, understanding and mentoring from their older colleagues (Cottingham & Dill, 2019;Choroszewicz, 2019), they may need to rely on cultural and social capital forged in part through social class. Aspiring professionals from working-class backgrounds sometimes struggle to ac-quire the capital needed to succeed (Waterfield, Beagan & Mohamed, in press). Social class also matters for entry to the elite law schools (Sommerlad, 2016) and to the prestigious first jobs (Kay, 2019). Young professionals who lack the privileged social, cultural and economic background may feel like 'strangers' in their professions (see eg. Behtoui & Leivestad, 2019).

2) Challenges for older professionals facing intensifying work pace and rapid technological advances
Older workers are also subject to stereotypes and disadvantages in some jobs. Older professionals can, for example, be stereotyped as possessing outdated skills, and therefore to be less effective at their jobs (Scheuer & Mills, 2017). This appears especially salient in technology and computing jobs where older workers-men and women-have more negative experiences compared to their younger colleagues (Corbett, 2019). Stereotypes vary across profession. For example, academia may value older age as evidence of accumulated work experience and knowledge, while in other fields, older workers may be cast as out of touch, and unable to learn new things (Riach, 2007). There is also evidence that people who enter professional practice later in life face particular difficulties landing first jobs (Kay, 2019). In this manner, organizations employing professionals may disadvantage older workers by offering them fewer opportunities.
Older workers may also experience different opportunities. In some fields they may be promoted into management, which brings a new set of challenges: different work, different skills, and work intensification. Contemporary hyper-competitive professional cultures in which continuous connectivity and availability through mobile phones and the internet is the norm, may be particularly intense for professionals in managerial positions. Like workers in other fields, professionals who lose their positions late in life, may have greater difficulty finding new jobs (McMullin & Berger, 2006).
Perspectives on aging also differ for men and women (Krekula, 2007). That is, research shows that while older men are rewarded with higher respect, authority and salaries; older women are often viewed as less competent, and their skills are downgraded (Adams, 2019;Jyrkinen & McKie, 2012). Older professional women also face more pressure to look attractive and young (Jyrkinen, 2014). Women's experiences of being the 'wrong age' are fairly common. Young women may be deemed unattractive employees due to their capacity for childbirth, and when women reach their 40s, they risk being considered as 'old' (Jyrkinen & McKie, 2012).
Still, many older professionals are advantaged in professional labour markets. Their accumulated work experiences may provide them with professional resources-skills, knowledge and networks-enabling them to benefit from current professional structures and cultures. However, they are also affected by emerging precarity. Little research has explored how labour market changes affect professional workers differentially by gender and age.

3) Work-life balance challenges within and across generations
The intersection of gender, age and the life course can be seen quite clearly in research on work-life balance within professions. Having a child is a major life course transition that has a profound impact on life and career trajectories, but the impact on men and women has traditionally been quite different. Men tend to increase their work hours and career commitment after having children, while women traditionally cut back on their work hours (Fox, 2009;Plickert, 2019)-a practice that can negatively impact professional career advancement. Still, there is evidence of variation across generations. For example, younger men appear to be more engaged in childrearing than their predecessors, making work-family conflict more of a concern for them (Burnett, Gatrell, Cooper, & Sparrow, 2013;Ylikännö, Pääkkönen, & Hakovirta, 2014). Furthermore, it is not clear whether child-rearing negatively impacts younger women pursuing professional careers, to the same extent it did women in previous generations.
Still, research highlights how work-family conflict continues to affect the careers of men and women professionals, and its impact appears to vary by age and generation. Young women and men professionals who want to adopt more fluid gender roles in family life and careers may find themselves constrained by traditional gendered assumptions about career commitment in their work environments. As professional ideals and structures continue to prioritize career demands over private life, young professionals struggle to reconcile both. Young male professionals, like professional women, are increasingly torn between intensive parenting and the world of professional work, which may negatively affect their opportunities to build new narratives of themselves as involved fathers (Choroszewicz, 2019). Their older male colleagues, whose personal experiences aligned with traditional gender roles in family and work, do not necessarily understand the different attitudes towards work-life balance and social pressures around involved fatherhood. The use of mobile technologies has also elevated work expectations in many demanding careers, particularly in terms of around-the-clock accessibility, benefitting professionals with a spouse at home to uphold family responsibilities. The research shows that the challenges of work-life balance are often individualized leading more disadvantaged professionals to make career choices that are conducive to family life and in which they are less prone to discrimination (Olakivi & Wrede, 2019;Adams & Kwon, 2019). While some young professionals without parenting responsibilities associate long work hours with professional behaviour, fun, and enjoyment (Sturges, 2013), they may also experience work-life challenges even though their right to 'downtime' is largely overlooked. A study on young to middle-aged childless and solo-living professionals shows that their dilemmas are linked to the lack of legitimacy of their need for flexible work schedules in workplaces as well as the assumption that their nonwork time is solely leisure time and thus less important than the downtime of those with family care responsibilities (Wilkinson, Tomlinson, & Gardiner, 2017).
Currently, organizational policies reward those who can devote long hours to professional work; such policies disadvantage those with care responsibilities. Changing gender roles mean that men and women, across age cohorts, experience such pressures differently.

Meta-work
Many professional workplaces appear designed for an ideal worker-one who is middle-aged (with work experience), middle-class, dominant-ethnicity, and most often male. Those professionals who do not neatly fit these categories need to invest extra time and energy to develop individual strategies and tactics to cope with professional pressures in and around their work. We call this extra work meta-workdefined as the hidden, invisible and laborious work performed specifically by young non-traditional and disadvantaged professionals through which they endeavour to cope with structural inequalities embedded in the professions (Choroszewicz & Adams, 2019, p. 267-268). Meta-work is intrinsically linked to the traditional and normative ideals surrounding professional roles and identities, and therefore is intimately connected with professionals' sense of self and sense of belonging to professional communities.
The meta-work is often invisible to others-especially those in privileged positions. This work is laborious because it places additional strains on those marginalized by gender, age, ethnicity and so on, to work harder to prove their ability to conform to traditional professional assumptions. It can put particular strains on young professionals from less traditional socio-demographic backgrounds who need www.professionsandprofessionalism.com Page 8 to do more meta-work to present themselves as competent. On the one hand, they need to do more work to comply with professional ideals that might be at odds with their worldview, class background, and social and cultural capital. On the other hand, they might have less access to mentoring, at school and at work. Some studies show that professionals with migrant backgrounds may feel like 'strangers' in their professions due to a lack of powerful and resourceful networks and lack of cultural fit (Behtoui & Leivestad, 2019).
We consider meta-work, and the tactics and strategies that result from it, important coping mechanisms for some professionals, enabling them to deal with rapidly changing work realities, a lack of collegial support and barriers to professional development and career progress. At the same time we note that meta-work can also put marginalized professionals at a disadvantage, as they must work harder and in different ways, than their more privileged counterparts. Meta-work can help professionals cope with structural inequalities such as sexism, racism, and ageism on an individual level, but it does nothing to alter the structures that marginalize them in the first place. As a result, meta-work can be a burden that accumulates over a career, reducing opportunities for promotion and advancement (Ferree & Purkayastha, 2000).
Nonetheless, the impact of meta-work may differ dramatically across age, gender, and other structured social inequalities. The impact on a young minority woman undertaking meta-work throughout her career, would be different than the meta-work done by an older man who engages in meta-work late in his career, but who has more resources accumulated throughout his career to fall back on.

Future Research
To conclude, we would like to highlight several areas for future research on the intersections of gender and age in the professions. Drawing on intersectional and life course approaches, and recent research on age cohorts and generations, we have argued that the experiences of men and women entering professions nowadays are quite different from those entering decades ago. Professions have also undergone significant changes in recent years, including the expansion of employment in large organizations, increased precarity, de-regulation, and increased competition, to name only a few. There are still numerous questions to which research on professions has to find satisfactory answers with the help of an intersectional life course lens. Below we focus on only a few.
While we find the concept of meta-work specifically fruitful for further research on professional work and social change affecting professions, we still know little about how meta-work changes as professionals age and progress in their careers. Does meta-work lead to cumulative disadvantages or do professionals with experience find they accumulate resources that actually minimize meta-work over time? How do outcomes vary by gender, race/ethnicity, and other dimensions of inequality? It is possible that meta-work could lead to professionals developing alternative solutions for work in which they feel less disadvantaged, and which legitimate their own sense of self as professionals. These solutions may expand professional landscapes beyond traditional professional workplaces and practice modes. While the meta-work concept provides an analytical tool to capture individual strategies for navigating professional workplaces, it is not clear whether these strategies have any ability to reduce structural inequalities within professions. Thus, we recommend that further research focus on meta-work, and its impacts, over time.
We have highlighted that different age cohorts and generations have their own challenges that are linked to their socio-cultural and historical contexts. These contexts differ across countries and change over time. For example, in some countries traditional gender norms in workplaces and family life are confronted by progressive family policies that empower fathers. We recommend more comparative research to explore the impact of these policies on professional careers and workplaces across and within age cohorts or generations for different genders. This research should also take sexuality and the situation of transgender people into account.
Finally, we know little how the changing professional landscape impacts the career trajectories of different age cohorts and generations outside of Western countries. Do professionals in non-Western countries face similar trends of organizational change, rising insecurity, and proletarization, and if so, and how they cope? Some recent research on academia in Ghana shows that young women are highly disadvantaged in this strongly patriarchal Sub-Saharan context that privileges seniority (Forson, Calveley, Shelley & George, 2017). Violating norms of a deep reverence towards age maturity can be almost treated as deviant behaviour in Ghanaian academia (Forson et al., 2017). There should be more research on the intersection of gender and age beyond Western countries to include for example South Africa, India, Taiwan, Baltic and Eastern European countries.
To conclude, we appeal to professions researchers to adopt an intersectional life course lens, which will enable them to capture the diversity of professionals' experiences, and to understand the changing nature of professional work. We expect that intersectional inequalities and life course issues within professions will continue to shape professional development profoundly in the come years. In addition, we also appeal to researchers already conducting the intersectional research to incorporate age, generation, and the life course when possible to account for changes in intersecting inequalities over time and across socio-cultural contexts.