II. Introduction

In 1995, the American Board of Certification adopted the NCOPE residency standards and changed the post-graduate education requirements from 1900 hours of clinical experience, which did not specify how much or how little experience was needed in any practice aspect, to an accredited residency program. This program’s intent is to provide a structured, clinically diverse post-graduate educational experience and prepare residents for their American Board of Certification exams.

Judging from several professional articles published since 1995, students, educators and practitioners alike are satisfied with these “new requirements”. Mark Edwards (1998), in an article published in O&P Business News, states he feels the new system is superior because residents are assessed and monitored quarterly. This assessment allows experiences to be documented, and the residents can see where they are competent or in need of additional experience. In the same article, Ed Haddon stated the new residency program provides a structure that increases the chances that the participant will receive a diversity of experiences in a reasonable period of time. The tracking and evaluation instruments allow both the residency director and the participant to monitor and document progress toward completion of all required tasks in every skill area. Again in the same article, Scott Hornbeak states that the major advantage of the residency program is the shift of hand-based skills from the primary educational programs and certificate programs to the residency.

Students also provided a positive response to the “new requirements". When surveyed, in the Lifford study (1998), students indicated they preferred the residency program to the 1900-hour requirement because, “ it gives the option to spend more time learning and focusing on preparation for the board exams”. Other students reported the new system is preferable because, “the residency can provide an environment of learning and exploring rather than emphasizing performance right away”.

With changes as significant as these, it is to be expected that adjustments and enhancement will solidify and improve the residency experience. One of those such needs is addressed by Mark Edwards in O&P Business News, May 15, 1998, when he was quoted in as saying, “Students are limited in the number of facilities that offer accredited residency programs”, and continued by saying that the number of qualified facilities must increase. By having an increased number of residency sites a student could objectively choose the residency that offers the educational and clinical experiences that best meets their needs. It is likely that most students will migrate and compete for the top quality programs. In order to increase the number of high quality residency programs, practitioners must first recognize that if they do not choose to sponsor a residency site, they will have to compete in a secondary market, and will be limited to hiring only NCOPE grads that are 12-24 months out of school (Hornbeak, 1998). Mr. Hornbeak’s comment indicates that the best of the best will be hired by residency programs intent on upgrading their employment pool with the brightest students, thereby leaving those applicants who did not receive full time employment offers open to apply to practices that did not offer residency programs. Thus also implying the most productive will already be employed.

The success of the NCOPE residency academia will be a collaborative effort between the residents, residency site directors and NCOPE. If practitioners do their part by expanding their practice to include training students in a residency setting, academia must also do its part by providing the educational foundations necessary for residents to compete for these top training sites. Collaboration between practitioners and academicians can strengthen the existing curriculum of both phases, and likely produce individuals prepared to deliver services independently.

Published studies and manuals have provided the O & P community with information regarding resident’s perceptions and expectations of residency programs (Lifford, 1998). NCOPE has provided a complete description of guidelines for the accredited residency experience. It is this researcher’s intention to poll residency site directors’ (RSD) perceptions and expectations to answer the following questions:

1. What academic foundations are necessary for clinical practice when residents arrive at a particular residency site?

2. What qualities do residents lack in their educational foundations that retard their advancement in a particular residency program?

3. What changes could be made to facilitate efficiency in your residency program?

4. How many active NCOPE accredited programs currently accept new graduates every year?

5. How many years of experience does an RSD have supervising students in a particular program?

The primary purpose of this study is to survey site directors to determine the foundations necessary to equip graduates to succeed in today’s O & P clinical settings, as well as to gain insights from supervisors in the residency programs, which may enhance the curriculum of current academic programs.

In order to understand and appreciate the current status of residency programs, a review of the history of residencies in this country is necessary. An examination of the current literature that follows will be helpful in understanding how medical and allied health residencies have paved the way for today’s new O & P residency program.

Review of Literature:
History of Medical Residency

The history of Residencies stems as far back as the 18tth Century, where most physicians received their training as apprentices to practicing physicians. Formal Academic training occurred on the side as a supplement to the apprenticeship (Anonymous, 1983). Although there were few preparatory schools, and formal education for physicians was not heard of, doctor’s still valued the hands on experience gained in the wards and battlefields of the country.

The end of the Civil War brought with it the opening of US. Medical colleges, which began to award a MD degree to individuals who had less than 6 months attendance in addition to a period of apprenticeship. (Anonymous, 1983). By 1905 the AMA had been created, and a revolutionary push was underway to expand academic and clinical training to 6 years. Although these optimistic forces continue to call for longer and more advanced training for doctors, a 6-year medical training program could not be sold to the growing and more powerful medical community. These same forces continued to support the need for “a year of internship of intensive exposure to patients for whom they could assume real responsibility but still be under the supervision of faculty and hospital staff members”. (Anonymous, 1983). The idea of clinical work with real patients continued to be recognized as a high priority, and many began to encourage the need for postgraduate training involving new graduates with large amounts of autonomy caring for the health needs of the ill.

It took until 1910 for standardized medical education to embrace all colleges and universities. Practically all schools developed a 4-year curriculum, with the first two years of basic science education, the third year consisting of lectures and clinical experience, and a fourth year of eight to ten months of “ward clerkships”. The new graduate would then enter an internship for an unspecified amount of time to study a major clinical discipline. (Anonymous, 1983).

The term “internship” used above was essentially the postgraduate training that physicians received in a desire to extend and supplement their pre-graduate training. The term residencies came to light in the late 1920’s in response to the AMA’s attempt to formalize graduate physician education. (Anonymous, 1983). Soon to follow were accredited residency programs and Residency Review Committees for each discipline in the medical field.

Residency training prospered in the 1940’s. Medical schools were graduating 5,097physicians and there were 7998 internships available. All but 344 (4.3 %) of them were filled, and virtually all the trainees were American graduates (Creditor & Creditor, 1975). The exact number of residency positions offered appeared to be around 5500 and nearly all were filled. The end of WWII sent large numbers of doctor’s back to search out internship and residency training programs. The medical community responded by expanding the residency positions from 7,600 in 1945 to 51,600 in 1973. Since medical schools were graduating around 10,300 students a year, it became necessary to open the training experiences to foreign students and graduates. (Creditor & Creditor, 1975). It appeared, with the increase in clinical settings and the influx of foreign students, that the primary educational purposes of the residency had become subverted to its service function. Concern for the conditions surrounding employment of residents began to emerge. Advocates for quality improvement suggested, “ We do not need graduate-training programs in this country to deliver medical and hospital care. In fact, only about 1500 of the 7000 acute-care hospitals have internship and residency programs. There is little evidence that the teaching hospitals deliver better care in terms of process or outcome and even less evidence in terms of cost benefit”. Creditor & Creditor, 1975, went on to state that it is important to achieve a balance between the number of graduates and the number of clinical residencies available. By achieving this balance it was expected that residencies would return to their educational purpose and labor and demand would take care of salary and work load disbursement.

These same concerns have been debated through the century. These sentiments were echoed earlier in the century by a chief of staff at a large teaching hospital in Cleveland. He said: “If a hospital is of sufficient size and has a proper staff with a proper spirit, it is not necessary in order to obtain interns and residents to offer them more than a nominal honorarium. Such an amount of money as will make the salary feature a deciding one for their coming to that hospital should not be offered either to interns or to residents. They should come and will come for the teaching and the opportunity alone, if the teaching and the opportunity are there…. Training and experience for their own sake should be the features that draw interns and residents to any hospital. ( Wentz, 1984). Dr. Hugh Morgan, Chairman of Medicine at Vanderbilt University School of Medicine, Nashville, Tenn., stated that “ they had decided not to pay house officers because they felt they got much better interns when they didn’t pay them than when they did” ( Wentz, 1984). The topic of providing quality education to graduates at a fraction of the salary that professionals make continues to raise concerns and many in the O & P residency community have expressed their concern that graduates seek out internships for their educational value and not for the external reinforcements.

Allied Health organizations arrived on the scene around 1933 paving the way for the creation of education and accreditation standards. In 1966 the AMA recognized a need to establish a department within the commission to coordinate Allied Health education. In August of 1966 the Department of Allied Medical Professionals and Services was established. Today we call it the Department of Allied Health Education and Accreditation. (Anonymous,1983).

The Occupational Therapy Association participated in setting original standards for Allied Health practitioners. Physical Therapists and Occupational Therapists played an instrumental role in the history and development of the Allied Health accreditations. It took until 1976 for the AMA to vote to establish a committee, which would have representation and accreditation decision-making power over Allied Health. In 1980 this new body became known as the Committee on Allied Health Education and Accreditation. (Anonymous, 1983).

O & P standards and accreditation procedures did not begin to emerge until much later. IN 1972 the American Board for Certification in Orthotics and Prosthetics Inc. (ABC) created the Educational Accreditation Commission (EAC) (Conkling, 1992). Standards were set for educational institutions and written rules and regulations were created, termed the “Essentials”. These “Essentials” standardized training in the different educational arenas as well as set required clinical hours. These “Essentials” governed the different educational institutional programs by setting forth rules that all must follow. (Lunsford, 1992) The 1900 hours, or a year of postgraduate training became known as a residency. This residency was designed to prepare graduates with clinical skills to interact professionally with the patient population and serve as a valuable member of the rehabilitation team of Allied Health and medical professionals.

The 1900-hour residency requirement was designed with good intentions to provide quality training. However, as seen with the medical model of internships and residency, the 1900 hour model was criticized by students and professionals as being too unstructured and focused on production, instead of being educationally oriented (Linn, 1997).

Considerable progress was been made in the O & P field since the enactment of the EAC in 1972. However, it was in 1988 that the O & P field received a tremendous boost when they earned financial independence from educational and professional bodies giving them full political separation. (Barringer, 1992).

In 1993, O & P adopted new education standards, laying the groundwork for an improved curriculum with mandatory course work in biomechanical, research and diagnostic procedures. (Conn, 1995). The residency model forces site directors to follow a preplanned structure with quarterly rotations, exposing students to different patients, populations and diagnostic groups. Residents can now feel a freedom to focus on providing a “thorough experience in clinical patient management and fabrications, or hand skills. (Conn, 1995).

Judging from the review of literature it is interesting that internships and residences have been a source of contemplation and debate for a century. Many concerns center on the need for clinical training in “real environments”, providing responsible services to the patient population under the tutorage of a licensed or certified professional. This may sound simple, but history indicates it is difficult to leave education to the private sector without guidelines and rules to regulate training in a consistent manner. It seems it is also difficult to maintain an atmosphere of training without expectations centering on productivity.

The new O & P residency model appears to take into account the prior problems of medical residences by attaching standards and clear expectations to the residency experience, however the “new essentials” have been adopted slowly over the last 6 years and the time is ripe to detect future problems that may inhibit the growth and success of this new program.

It is this researchers intention to determine if Residency Site Directors have perceptions and expectations of the residents and the N.C.O.P.E. residency program, which may bring light to the future success of this program. One may question if there is a reason that accredited residency site numbers have not grown at a sufficient rate to keep up with the number of prospective residents. Are new graduates being prepared adequately to enter a residency program and are site managers prepared to provide for their added training in addition to running a clinical practice? Researchers need to know what site managers need from the educational institutions and from NCOPE to maintain a competitive level of knowledge in order to keep up with the changing demands of the O & P field.

1. Residency Site Directors will report that incoming graduates need a solid foundation in anatomical and biomechanical knowledge coupled with a thirst to learn, a willingness to accept direction, and social maturity.

2. Site managers will report that younger students have more difficulty relating socially to patients and to staff and have insufficient knowledge related to work ethics.

3. RSDs will feel that NCOPE should provide local and regional clinical continuing education workshops (along with CEU’s) on topics related to student evaluation, teaching techniques, and the current educational curriculum.

4. 80 % of the NCOPE accredited programs registered with NCOPE are currently accepting new graduates.

5. RSDs will have an average of 5 years experience supervising students.
Specific objectives:
This study will survey 197 Residency Site Directors to determine what foundations they feel are necessary to equip graduates to succeed in today’s O & P clinical settings, as well as to gain insights from supervisors in the residency programs which may enhance the curriculum of current academic programs. The study also hopes to provide RSDs with a venue to describe the type of training and support they feel they need to maximize the residency experience for both graduates and the site supervisors.

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