Last-Century Job Titles

Why healthcare workforce titles still reflect an outdated model of care

This two-part essay builds on a question first raised by Bulela Vava*, a South African oral health activist and founder of the Public Oral Health Forum. His insistence that workforce language matters not symbolically, but structurally, shaped the argument that follows. Bulela joins this piece as a guest author to reflect that shared line of thinking, which unfolds first as a diagnosis of how professional titles encode hierarchy, and then as a reflection on what different ways of naming work might make possible.

Why do the names and titles used in the dental team still sound as if they were designed for the last century? That question did not arise in an academic seminar or a workforce review committee. It emerged from conversations within South Africa’s Public Oral Health Forum, where debates about health workforce, scope of practice, supervision, and recognition are not abstract. They shape daily work, determine who is allowed to do what, and ultimately decide who receives care and who does not.

The question is deceptively simple. Titles sound technical, even neutral. But in health systems, names are not labels. They are infrastructure. They encode identity and hierarchy, allocate authority, and quietly stabilise power relations long after the conditions that produced them have changed.

Dentistry offers an unusually clear illustration of this problem. Across countries and contexts, members of the dental team are still described using terms such as auxiliary, mid-level, allied, assistant, or support. These words do not describe functions or competencies. They describe proximity to the dentist. This is not just a matter of tone or connotation; it is built into the grammar of the titles themselves. Terms such as mid-level or assistant presume a unidirectional relationship: someone is always assisting, supporting, or positioned in relation to someone else. The logic does not ask who, in turn, is responsible for supporting them. It normalises a professional order defined by subordination rather than partnership.

In dental assistant, assisting is not a task but an identity: the grammar defines the role by subordination rather than by expertise or responsibility. People are defined not by what they contribute to oral health, but by what they are not.

The contrast with dental hygienist is instructive. Unlike assistant, hygienist is a function-describing title. It names a domain of work centred on hygiene, prevention, and maintenance, and signals accountability for that function. Whatever the limits of scope, autonomy, or remuneration attached to it, the title itself positions the role in relation to work rather than to another profession. Within dentistry, this difference makes visible how language can either anchor expertise or anchor subordination.

This linguistic logic is not unique to dentistry. Similar patterns appear across healthcare wherever roles are named relationally rather than functionally. Titles such as medical assistant, pharmacy assistant, or laboratory assistant follow the same structure. They define a role through assistance rather than through a clearly articulated domain of work. The object of assistance is implicit, hierarchical, and rarely reciprocal.

This stands in contrast to professions whose titles already name their function or modality of care: physiotherapist, occupational therapist, radiographer, or speech therapist. In these cases, the title signals what the professional does and what they are accountable for. Relationships to other professions exist, but they are secondary. The function comes first. Where assistant-based titles dominate, the relationship comes first and the function remains vague, assumed, or negotiable.

This distinction matters because it shapes how work is governed, valued, and rewarded. Roles defined through assistance are structurally positioned as supportive rather than contributory, regardless of the skill, judgement, or responsibility involved. Their scope may expand in practice, but their autonomy rarely does. Career progression often requires leaving the role altogether rather than deepening expertise within it.

This language made sense in a particular historical moment. Twentieth-century healthcare, including dentistry, was largely procedure-driven, professionally siloed, and organised around singular figures of authority. Workforce terminology evolved to protect professional boundaries, manage delegation, and formalise supervision within that model. Hierarchy was not an unintended by-product. It was the organising principle.

What has changed since then is almost everything else. Disease patterns have shifted towards chronicity and preventability. The evidence base for population-level prevention is strong. Primary health care and universal health coverage are now explicit policy commitments. Task sharing is no longer experimental but necessary. Team-based care is no longer aspirational but unavoidable.

If titles shape what is imaginable, then outdated titles limit the futures that can be built.

What has not changed is the grammar of the workforce.

The persistence of outdated titles is not just a semantic quirk. It has material consequences. Language structures governance. Governance structures scope of practice. Scope of practice determines autonomy, remuneration, career progression, and who can respond flexibly to population needs.

This has direct implications for task shifting and competency-based workforce design. Task shifting requires roles to be defined by what people are trained and authorised to do, not by whom they assist. Competency-based job descriptions require clarity about functions, responsibilities, and decision-making authority. Relational titles undermine both. When a role is defined as assistant, expanding its scope appears as boundary transgression rather than system optimisation. Competencies become negotiable exceptions rather than recognised assets. Task shifting becomes politically charged precisely because language has already decided who is entitled to autonomy. Where roles are named by function, as with dental hygienists, competency-based expansion is at least imaginable; where roles are named by assistance, it remains structurally contested.

None of this requires bad faith. Health systems reproduce the hierarchies they were built with. Titles follow time spent in initial training rather than contribution to health outcomes. Regulation follows historical power rather than contemporary need.

The result is a persistent paradox. Health systems claim to prioritise prevention, access, and integration into primary care, yet maintain a workforce language designed for a narrow, interventionist past. Reform and innovation are endlessly discussed, but the vocabulary through which teams understand themselves remains frozen. Professional labels do not merely describe functions; they assign identity and position within the system.

If titles shape what is imaginable, then outdated titles limit the futures that can be built. A system that keeps speaking in last-century terms should not be surprised when it struggles to deliver twenty-first-century outcomes.

Part II will ask what becomes possible when healthcare teams are organised around contribution and responsibility rather than proximity to professional authority.

Dr Bulela Vava is an Atlantic Fellow for Health Equity at Tekano and Founder of the Public Oral Health Forum, a volunteer network committed to advancing oral health equity in South Africa.

Artwork by Canva