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The Future of Prosthetics & Orthotics as a Profession: The Greatest Threat Is...?
By Silvia U. Raschke, PhD, CO (c)  The British Columbia Institute of Technology
(BCIT), Vancouver, Canada, has recently concluded a visioning
report 3,4 and is in the final stages of carrying out a
market analysis on the fields of prosthetics and orthotics. In
reviewing the results of the visioning process, the most serious
threat to orthotics and prosthetics of all those identified appears
to be the lack of certified orthotists.
The problem itself is typically expressed as: There is an
undersupply of certified orthotists, and encroachment into
orthotics is rampant. How are we going to deal with this? Suggested
answers range from strategies for better regulation to advertising
campaigns promoting the certified orthotist as the "expert" in the
field. The focal point in this passionate debate is typically on
the encroachment aspect of the problem. In fact, encroachment is
only a symptom of the real problem: there simply are not enough
certified orthotists. This problem is not going to be solved by
regulation and will be exacerbated by advertising, which, if
successful, will only increase the demand for certified
orthotists.
Besides restricted ability to meet market demands, professions
with small memberships like ours have several other hallmarks
limiting their ability to thrive. Small numbers prevent effective
lobbying and result in most people entering clinical practice, as
opposed to moving into academic roles. Since so few
prosthetists/orthotists go on to PhDs and enter the academic world,
prosthetics and orthotics experts are from outside the profession
by default, thus firmly trouncing any idea that certified
orthotists are the experts in the field.
None of these threats should be considered new. Marty Carlson,
CPO, clearly pointed out the need to dramatically increase the
number of certifees in his 1997 article in O&P Almanac1, and
Dr. Sid Fishman used sound, logical arguments in an article in
O&P Business News to point out that the educational system set
up for prosthetics and orthotics has, in all likelihood, failed to
meet its goals 2 .
Taking all these factors into account, the strategic position of
certified orthotists is weak. They now have little real control
over what actually happens to them-a serious position to be in,
considering today's economy.
What Can We Do?
Acknowledging that the small membership of our profession is a
significant problem is one thing. Dealing with the situation is
quite another. Some possible solutions would include:
- Radically increase the number of students educated. [Editor's
note: Efforts are underway in the US to attract more students to
careers in O&P. Future issues of The O&P EDGE will report
on these initiatives];
- Actively recruit immigration by practitioners who are from
industrialized nations with similar levels of academic training and
have at least one to two years of clinical experience, and grant
them automatic certification or allow them to immediately sit for
the certification examination;
- Do away with [awarding only] single certifications [in Canada],
so that persons who have studied both prosthetics and orthotics are
granted dual certification to practice.
Whatever the solution chosen, unless the undersupply is dealt
with, non-certified orthotists will continue to establish
themselves, building legitimate expertise in the provision of
orthotic devices. Furthermore, the problem will soon begin to
accelerate as the impact of an aging population really starts to be
felt. This is arguably the single greatest threat to the certified
orthotist at this time. All other problems orthotists face with
eventually pale by comparison, unless a strategy to deal with this
issue is implemented in the very near future.
The March issue of Journal of Prosthetics and Orthotics included
a report on a visioning process4 conducted as part of a curriculum
review by the Prosthetics and Orthotics Department at the British
Columbia Institute of Technology (BCIT), Vancouver, British
Columbia, Canada. 5,6 . Many interesting points arose in
the process of the visioning process, but one point stands out with
respect to the ability or inability of certified orthotist to adapt
themselves to the changing marketplace. Of all the threats
identified, the most serious appears to be our lack in numbers.
The problem itself is typically expressed as: There is an
undersupply of (certified) orthotists and encroachment into
orthotics is rampant. At the same time, the aging of the population
will result in an increased need for orthotic devices. How are we
going to deal with this?
It is the issue of encroachment that typically leads to the most
spirited discussions amongst certified orthotists. Many suggestions
and strategies are debated regarding to how to deal with it. Ideas
range from better regulation, in the form of licensing or preferred
provider status, to carrying out advertising campaigns promoting
the certified orthotist as the "expert" in the field. What use
however, is an advertising campaign or preferred providership, if
there are too few persons to perform the service being
advertised?
Encroachment: Only a Symptom
Encroachment, however, is simply a symptom of the real problem,
which is lack of numbers. By attempting to solve the perceived
problem of encroachment, time is wasted as the problem itself is
not dealt with-a problem which will be exacerbated significantly as
the population ages.
When any market is under-serviced by a given group, basic market
principles will dictate that others will move in to fill that
market need. The longer these other groups have access to that
market, the more established they become in that market. In the
case of foot orthotics, for example, pedorthists, podiatrists, and
some physiotherapists/occupational therapists have provided service
into this market over the past 15 years, to the point that they are
well-established and are providing a competent level of service.
Due to our historic inability to meet the demand in all areas of
orthotics, this is now also happening in other orthotic market
segments, from knee orthoses to upper limb and spinal.
Educating More Prosthetists and Orthotists
Both Neilson 4 and Blocka1 have highlighted the need
to educate more prosthetists and orthotists. Blocka focuses on the
number of students we need to educate to replace those certifees
who are retiring. Neilson expands the topic by also examining other
factors, such as the effect of an increasing market size due to the
aging baby boom population.
However, no publicly available study has ever been done to
establish if the population had ever been serviced adequately to
begin with. Such knowledge is critical if any strategic planning is
to be done, since not knowing if the baseline used is correct,
weakens the power of estimates established using that baseline.
Even without the availability of such a marketing study, it can be
estimated that the market for orthotic services has been
underwhelmingly served over the past two decades, by simple
observation of the encroachment from a myriad of other persons and
professions into that market. To deal with this lack of information
in doing educational planning, BCIT has engaged a consultant to
carrying out such a study. It is anticipated that the results will
be available in mid-2002, and they will be available to all
interested parties.
Small Numbers: A Limiting Factor
Aside from the purely business aspect of small numbers,
professions with small memberships such as ours have several other
hallmarks which limit their ability to thrive. These are that small
numbers:
- prevent effective lobbying and
- ensure that most people enter clinical practise, as opposed to
perusing an academic career.
The effect of small numbers on lobbying clout is obvious. The
danger of having few to no members of a profession involved in
peer-reviewed academic research is less obvious. With less than 20
certified orthotists/prosthetists in the world having PhDs, many of
whom are not employed by universities and engaged in setting up
prosthetic and orthotic research programs, prosthetics and orthotic
experts are by default from outside the profession. As a result,
decision-makers, such as government and regulatory bodies, must
turn to medical doctors, podiatrists, therapists, and engineers for
"unbiased, peer-reviewed expertise" in orthotics.
These professions, in turn, have become the established and
acknowledged "experts" in the area and are the ones driving the
orthotics profession and its development. Not being members of the
profession, they have no stake in nurturing it. This particular
problem is exacerbated by the fragmented prosthetic and orthotic
educational system in North America, making it difficult for those
who wish to do so to move into the academic world and to rise
within it.
Moreover, none of this should be considered to be news. Marty
Carlson, CPO, clearly pointed out the need greatly increase the
number of certifees in his 1997 (!) article in O&P Almanac2. In
an article in O&P Business News, Dr. Sid Fishman pointed out
eloquently, using sound, logical arguments, that the educational
system set up for prosthetics and orthotics neither raises us to
the peer-recognized (medical professionals other than ourselves)
status that we aspire to, nor, it can be extrapolated, meets the
need for supplying the numbers we require 3. In other words, it has
failed to meet its goals.
All the above factors, in combination, result in certified
orthotists having little real control over what actually happens to
them-a weak position, in today's economy.
Possible Solutions
Acknowledging that the small membership of our profession is a
significant problem is one thing. Dealing with the situation is
quite another. Some solutions to dealing with this problem would be
to:
- Radically increase the number of students we educate
- Actively recruit immigration to our countries from
industrialized nations where practitioners have similar or higher
levels of academic training courses, plus one to two years clinical
experience. These persons should either be:
- granted automatic certification or
- be allowed to immediately write the certification examination.
Internships and residencies are bottlenecks in the process at a
time when it is imperative to increase numbers quickly. The
argument is made that we don't "really" know if these persons are
competent to "our" standards. However, if the second case in option
two is used, the certification exam itself will provide the filter
to ensure that a baseline of experience/performance is met by
candidates. If candidates are not competent to practice, they will
not pass the examination. If they pass anyway, then the exam is
invalid, and there is a much more serious problem, since there will
also be certified "locals" who are not competent being set loose on
the population. This method is used successfully in numerous other
professions, such as nursing, engineering and physiotherapy-and
would work equally well for prosthetics and orthotics.
- Do away with single certifications [in Canada]. In most cases,
students have studied both prosthetics and orthotics. Sound
arguments can be made that persons can practice both disciplines
effectively without having to traverse two separate and lengthy
paths towards dual certification. In fact, many other
industrialized nations do not make the artificial divide between
the two professions, with successful results. This model has been
clinically proven in other countries. This option also makes sense
from a business strategy point of view, as workload planning
becomes easier and more flexible, allowing immediate market needs
to be met quickly and easily by all members of the profession.
None of these solutions are popular and easy to implement.
Obtaining Financial Support
Making significant increases in enrollment is not a
straightforward process, and increased enrollment does have the
desired effect until five to ten years into the future. In
addition, prosthetic and orthotic educational programs are
expensive to run on a per-student basis. These programs must be
subsidized either by government/organizations or by high tuition
fees. Such monies are typically garnered through strong lobbying
supported by a clear rationale and strategic plan, which becomes
quite challenging for orthotists and prosthetists, due to their
small numbers.
In his article, Carlson2, proposed a unique solution that would
reduce the effect of the high costs of education: facilities and
certifees themselves would make a financial contribution of 0.1
percent of their earnings toward supporting prosthetic and orthotic
education. This is not unlike how the Bundesfachschule [Federal
Technical School] for Prosthetics and Orthotics in Germany is
supported. Sadly, it appears no has risen to Mr. Carlson's
challenge in supporting such a venture.
Finally, the issue of using for-profit clinics in the schools to
fund the educational programs as a suggested solution must be
addressed. This method of funding brings with it a host of
problems, ranging from sustainability to issues surrounding
academic freedom (difficult to achieve if faculty members are faced
with maintaining a bottom line) and to possible negative impacts on
educational quality. This approach must be approached with extreme
caution, if at all.
The second two solutions listed are unpopular with the general
membership of the profession as each member of the profession
immediately sees the specter of "competition"' looming over their
heads as the "floodgates" to perceived outsiders are opened.
In an under-serviced market however, the real competition is not
from "within," but from outside the profession. This argument is
like attempting to plug a hole at the bottom of a dam to stop
flooding when there is a breach in the dam above. A bonus of this
approach is that by welcoming more members into the fold-as opposed
to excluding people-lobbying power is expanded.
Whatever the solution chosen, unless the undersupply is dealt
with, non-certified orthotists will continue to establish
themselves, building legitimate expertise in the provision of
orthotic devices. Furthermore, the problem will begin to accelerate
shortly as the impact of the aging of the population really starts
to make itself felt. This is arguably the single greatest threat to
the certified orthotist at this time. Not addressing the issue,
will make all other problems orthotists face pale by comparison,
unless a strategy to deal with this issue is implemented in the
very near future.
References:
- Blocka, D, et al, Demographic Study of the Prosthetic and
Orthotic Profession in Canada, 1990
- Carlson, M, Offering a "O,1-Percent Solution", O&P Almanac,
September, 1997Fishman, S., The Professionalization of Orthotics
and Prosthetics, O&P Business News, June 1, 2001
- Neilson, C., Issues Affecting the Future Demand for Orthotists
and Prosthetists, NCOPE, November 1996
- Raschke, S.U., Visioning Exercise, Prosthetics and Orthotics:
Results and Recommendations, BCIT Internal Report, www.health.bcit.ca/P&O/ , 2001
- Fishman, S., "The Professionalization of Orthotics and
Prosthetics, O&P Business News, June 1, 2001
- Raschke, S.U., "Report on Key Points Arising from Visioning
Process on Prosthetic and Orthotic Education Done at the British
Columbia Institute of Technology," JPO, 14(1)
Silvia U. Raschke, PhD, CO (c), is principal investigator for
the Centre for Rehabilitation and Technology that Enables (CREATE)
at the British Columbia Institute of Technology (BCIT). 
Table Of Contents - August 2002
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