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A Letter to My Great Grandfather: An Acerbic Look at the 21st Century by a Fourth Generation Prosthetist

Greg Gruman CP has been a long term contributor to the field as a clinician, facility owner and manager, and lifelong volunteer for our national associations. He is a Past President of the American Board for Certification in Prosthetics & Orthotics, the Minnesota Chapter of the Academy and the Minnesota Orthotic & Prosthetic Association and has served on the National Commission for Orthotic Prosthetic Education. As a fourth generation practitioner and President of a 117 year old family business, Greg has a unique perspective on the challenges of the 21st century. In the spirit of Andy Rooney on "60 Minutes", he penned the following letter, which is reprinted here with permission:

A letter to my Great Grandfather

My great grandfather, Lowell E. Jepson, was an original partner in The Winkley Company when it started in 1888. The Company is now 117 years old. Jepson took over when Mr. Winkley retired in 1895. He was President of AOPA from 1932-34. Every once in a while I like to touch base with him in spirit to ask business advice and get reassurance when I have a tough decision to make. I always wonder what he would think of the way we do business in the 21st century as opposed to the 19th century.

Dear Great-Grandfather,
It's been a long time since we talked. I apologize, but I've been busy trying to keep the company healthy and pass it on to a fifth generation. I want to tell you about how we do things these days and about some of the issues we face. As usual, I could use your feedback.

First of all, we don't refer to "artificial limbs and braces" anymore. We call them "prostheses and orthoses". The big words help us to feel more like professionals and raise the status of our jobs. It's more important to actually do a better job but that's harder than changing how we talk. We still do most of the same things but have fancy names for all the procedures. We now have an ongoing debate over what we should call the people who come to us for help. Are they "patients" or "clients"? I think you were right to refer to them as "customers", and everyone might benefit from thinking of them in that same way, regardless of what we call them.

You would be amazed at the inventiveness of the orthotists and prosthetists now. Every year seems to explode with new types of feet and knees and the braces now are mostly made of plastic, not metal. I know your brothers and Mr. Winkley held many patents and can relate to the way that these products grow out of the creative response to customer demands. The manufacturers test the new products on fancy walking simulators nowadays but are still embarrassed when they don't hold up in the real world. So, I guess experience is still the best teacher, just as it was in your day.

One of the major educational thrusts in the 21st century is for more research to prove scientifically that what we make for people really works. The emphasis in education is for students to get Master's and PhD degrees to do substantive studies so that insurance companies can't deny payment for improved technologies by using the excuse that "There are insufficient peer reviewed double blinded prospective randomized controlled trials in the literature to demonstrate the efficacy of this option compared to a peg leg". We never had proof that the OLD methods were effective, but those were paid for. When you had to raise prices in 1910 from $100 to $175, did you run into a lot of resistance and refusal to pay from your customers?

Aside from the payment issue, I feel like we are missing the boat by not emphasizing more basic education for new people entering the field. I think that we are still people who BUILD custom devices for customers. When we lose sight of that, then we have lost the essence of who we are. We have always relied on outsiders to engineer the devices and invent new items for us to offer for sale. The unique relationship we have with our customers is one that will not automatically be improved by getting an advanced degree. I think this relationship is the important difference we offer them and what will continue to sustain our profession in the future. We need to educate and train students to perform the basic skills that customers expect. They expect an orthosis or prosthesis to fit their body, provide the assistance and support they require, and look good at the same time. Skilled technicians and front line practitioners are the only ones who can ensure that these goals are met, just as they were in your era. I understand the need for research, but I think the emphasis should be on supporting the people who brought us to the dance.

I remember seeing in the 1902 catalog that you offered multi-axial ankles with user adjustable heel height. Those features are making a comeback now after nearly disappearing for 90 years. Prosthetists have adapted your ideas about interchangeable adjustable inner sockets by using flexible plastics instead of leather, and instead of a hand-rubbed lacquer finish to reduce shear stresses we use elastomeric gel liners today. Your patented "slip socket" to reduce impact forces, provide rotation and reduce chafing for below the knee amputees is now a shock and torque absorber component placed below the socket.

In your day people would expect to get 10-15 years service from a limb or brace. Of course, they had to come in for regular visits for adjustments, servicing, repairs and overhauls to the device as the parts wore out. Many third parties don't pay for preventative servicing or adjustments today, most people don't want to come back for follow-up, and no one wants to wait more than one hour for anything. With today's intimately fitting designs, we tell folks to expect 3 to 5 years from a device, and that is true only if their body doesn't change. Americans are gaining weight so fast nowadays, we're sometimes lucky to have the fit last six months.

Advertising and promotions are very much the same as before 1900. We advertise in print media and in pamphlets promoting the company and inviting comparisons with the competition. Some even use television and computer web sites to advertise. I would explain those, but it would take too much time. The ads are not as vicious as in the old days, but people still are eloquent self-promoters, and every new product is "The Best" for all our customers. Just as it was 100 years ago, we need to be wary of the claims made for new products and carefully weigh the benefits to our customers before adopting the amazing new gizmo with the slick marketing claims and glossy color brochures.

In the old days every product had the company label on it, telling all who saw it where it was made. After hearing customers say that they didn't want our name on their body part, we stopped doing that half a century ago. Now some companies are using this again, especially when some competitive advantage might be gained from public exposure.

Help me out on something, Great Grandfather. I realize that there were NO physical therapists at the turn of the last century but they help people learn how to use their braces and limbs better. In your day, I think the nurses used to do that type of work as the patients recovered. Physical Therapy as a specialty was invented some time after World War II. Now the therapists' national organization is saying they are qualified to provide the full range of orthotic and prosthetic care. For many years this company has provided FOR FREE the two hour O and P training to the therapy students in three local Universities. I don't think they even take an examination on their O and P knowledge, but today they want to refer patients to themselves without a doctor's prescription and to be licensed to do our jobs. As their field has gotten squeezed financially, their reaction is to try and encompass other related fields to make up for lost revenue. Would you suggest that I hire a therapist...or a lawyer?

Many manufacturers and private facilities have "professional" amputee models demonstrating and endorsing products in ads and at conventions. Winkley had these, too. Everyone is amazed at the mountain climbing, parachuting and running that takes place. They seem to claim that these remarkable achievements are due to the company that made the device or credit the new foot the person is wearing. I have pictures on my wall from the turn of the century showing men roller skating and skiing, bicycling and working. I remember pictures in the A.A. Marks catalogue from 1875 demonstrating the proper technique for boarding a moving streetcar. Lou Trautman had a radio show in the 1950's called "Mender of Men". These promotions aren't new at all. It's amazing how far we haven't progressed from the old days. Maybe it is just that we are all still pretty gullible.

Business is very competitive now. Just like in the 1890's, we have employees leaving and starting up their own practices up the street. We compete with everyone over contracts and each surgeon's referrals. One thing different now is that we have to compete with tax supported public entities like the Veteran's Administration and charity hospitals. It is pretty difficult to compete with a company that doesn't have to charge for its services. I know that contracting with the government for Civil War amputees was a big part of your early success, but now veterans' care amounts to less than 3% of our prosthetic revenues.

In the 1800's, the market would generally influence the prices you charged. If your prices were too high, folks would find a different limb company. Now the government sets the market rate and determines when we can get a raise in reimbursement. Medicare guidelines affect more than half of our sales and are affecting more sales dollars every year. We cannot pass along increases in our costs and must absorb them, leaving smaller margins and an owner who wonders if he could get a better return on his investment with a bank savings account. I know you survived the Bank Panic of 1895 with personal savings, the Great Depression by bartering, and other hard times. I promise you I will find a way to keep Winkley afloat through this most recent squeeze.

Great Grandfather, I know that the old days are generally criticized for using traveling salesmen who scoured the papers every week for new accidents and potential customers. They would take casts and measurements in the person's home and mail the order to the home office for fabrication. This really got a bad name due to questionable ethical practices by some firms. Now, in 2006, many companies send orthotists and prosthetists out of the office to see patients in far away cities. This practice is called an "Outreach Clinic", and we admire the individuals for servicing those who have difficulty traveling. Either way, the result is greater market share and increased sales.

Today, instead of taking a plaster cast, we can take a digital image or scan the limb electronically. The impression is then emailed over the Internet to the fabricator and the device is shipped back overnight for fittings at the patient's residence. Big advances! It seems that we're not inventing new ways of doing business so much as just using new tricks to perform the same functions. [I'll explain what email, the Internet, UPS, digital cameras and non-contact scanning are some other time.]

I know you wrote your Master's Thesis in 1900 on "Where and How to Amputate". It seems strange that physicians would still need help with this subject, but many do. They still fail in too many instances to give the patient the type of remaining limb most suitable for using a prosthesis successfully. Even with all the advances in surgery in the past century we still see patients with poor results that leave them no option but more surgery to correct problems from the first operation.

I guess that the most important thing I can tell you, Great Grandfather, is that the essence of our business hasn't really changed since you were in charge here. We continue to be focused on the customers, although it is somewhat of a cliché now. We still serve people who have been clobbered by accidents, disease or warfare. They still need specialized help to return to their former lives. They still count on our skills to help restore their mobility and function. I still try to treat them as valued customers and know that they are the key to my future and to the success of our company. That is one thing I hope never changes.

Thanks for the visit, and for listening to my frustrations from the twenty-first century. I'll be in touch again sometime soon for more of your wisdom.

Your great grandson,
Greg Gruman, C.P.

To browse or download a catalog (as a PDF) from Mr. Jepson's era, visit www.winkley.com .