The Future of Prosthetics & Orthotics as a Profession: The Greatest Threat Is...?

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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:

  1. Radically increase the number of students we educate
  2. 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:
    1. granted automatic certification or
    2. 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.
  3. 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:

  1. Blocka, D, et al, Demographic Study of the Prosthetic and Orthotic Profession in Canada, 1990
  2. 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
  3. Neilson, C., Issues Affecting the Future Demand for Orthotists and Prosthetists, NCOPE, November 1996
  4. Raschke, S.U., Visioning Exercise, Prosthetics and Orthotics: Results and Recommendations, BCIT Internal Report, www.health.bcit.ca/P&O/ , 2001
  5. Fishman, S., "The Professionalization of Orthotics and Prosthetics, O&P Business News, June 1, 2001
  6. 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).

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