Remarks On "Improving Relationships Between Orthotists, Prosthetists, And Orthopedists"
William E. Kenney, M.D. *
The trend in Medicine for sometime now has been for the development of specialties and subspecialties. The advantages of such a situation carry an inevitable corollary that the specialist soon becomes unaware of the advances in fields other than his own. Those engaged in the profession of making, fitting, and applying braces and limbs are in the process of emerging as an individual and integral part of the field of surgery, and particularly the specialty of orthopedics. In order that the best interests of the patient be served, it is of the utmost importance that orthopedists, orthotists, and prosthetists understand the several basic problems which affect their relationships, one with the other. Such an understanding will create a more efficient and more harmonious cooperation between them with resultant better service to the patient. A presentation of at least some problems may be of help.
Much has been made of the shortage of physicians, but certified orthotists and prosthetists are rarities compared with even such relatively uncommon specialists as orthopedists.
In order for the orthopedist to deal adequately with his patients, he should have access to a certified orthotist. The problem of training and supplying more men in the field of brace-making falls squarely upon the American Board for Certification and the Orthopedic Appliance and Limb Manufacturers Association.
It is not commonly known among physicians that a specialty board for orthotists and prosthetists exists, and that there is a required period of training with regular examinations to be completed successfully. The physician has in mind the brace-maker and brace shop which were (and still may be ) relegated to the basement of the hospital in some dingy, out of the way place. He has in mind the braces produced which appeared crude and cruel, and which were used in some mysterious fashion by "cripples." These poor unfortunates wore braces as a badge of some catastrophe or as a cross to be borne, not as something to aid function and to relieve pain. The correction of this misconception is by education of the physician carried out through the various associations of orthotists and prosthetists.
To men in the appliance field, the types. variations, and functions of braces and limbs are of elementary knowledge, but physicians as a rule are unfamiliar with at least several appliances which are available. Furthermore, many doctors do not clearly understand the functions of different braces, nor do they know just what to expect of any given brace. In general they expect more of an appliance than is possible. They arc ignorant of its weight, its material, its strength, and its exact capacity to aid function and give comfort to the patient. It is up to the appliance maker to educate physicians along these lines.
As a result of the rarity of certified orthotists and prosthetists, and as a result of the usual lack of knowledge on the part of physicians of the several and special appliances available, the physician sometimes turns to a relatively easy solution; i. e. the mail order house and the standard supports. He has available a firm which will supply, for example, low back braces in sizes A, B, and C, small, medium, and large. He can purchase these by the dozen-and does so. Furthermore, he is supplied with a catalogue in which are pictured several braces. If one seems to be almost, but not quite, what he wants, he proceeds to measure the patient, and order the appliance by mail. It is, of course, clear that he is not so skilled in measuring and in choosing as the orthotist or prosthetist, but at least it appears a make-shift solution to supplying his patient with something. The correction of this problem is an adequate number of skilled personnel willing to measure for and produce the proper brace at the physician's suggestion or prescription.
Appliances are expensive, and any physician with a conscience warns the patient on this point. The brace-maker complains that after he has given of his time, and utilized bis material, and adjusted the appliance, it is not, in fact, too expensive. There is no disagreement on this point. Braces are not
too
expensive, but the patient still is faced with an expenditure which to him seems a great deal, in fact sometimes excessive, or even prohibitive. It is a good policy for the physician to know approximately how much a brace will cost. It is good policy then to present the matter to the patient and to refuse to order a brace until the patient agrees to pay the estimated cost, or until some other source of funds is found to cover the cost. Furthermore, if the physician has made a gross error of judgment and has ordered a brace which is unsuitable for the situation, he should pay for the brace himself so that neither the orthotist nor the patient is penalized for his mistake. Such a principle would help the physician to exercise special care in deciding if, when, and what type of brace is indicated. Still in the same vein, it seems only fair that the patient be willing to pay in advance for a brace provided he will be refunded his money if the brace is found unsuitable due to an error in judgment of his physician.
Common Errors
There are a group of common errors which plague both the orthotists and the orthopedists. Careful attention to detail can help to reduce the frequency of such mistakes. For example, a brace may be applied to a shoe, the sole of which has of necessity been increased in thickness. The opposite normal sole remains of the original thickness. A discrepancy in leg lengths has resulted where attention to detail and some forethought would have prevented the situation from having occurred. At times a brace is applied to a shoe with the obvious intent of preventing fool-drop beyond 90 degrees with the leg. The caliper is inserted in the heel so that motion is present, sufficient in degree, to defeat the purpose of the brace. Sometimes braces are inserted into the heel in such a manner as to exert an undesired rotary force upon an entire extremity which the patient complains of and which is quite difficult to detect. Repeated breakage of an appliance is annoying to the patient and physician and wipes out the profit of the orthotist. The value of the attention to detail is obvious.
One of the most important roles of the orthotist and prosthetist is being developed in clinics, rehabilitation centers, and training centers. Attendance at such clinics and training centers many times is regarded as a very unpleasant chore by the orthotist. and he frequently has upsetting, frustrating, and distasteful experiences in such clinics. All too often he is treated by the physician in a disdainful and haughty manner. Sometimes he is requested to produce a brace which he knows is inferior to one with which he is familiar, but he may not dare to suggest the alternative to the physician. It is all too common that the physician will criticize a brace, its functioning, and the brace-maker in front of the patient with or without the orthotist present. Amelioration of the situation can come only by understanding several facts by physicians and orthotists.
First
, the physician should take the responsibility of the total care of a given case. It must be his final decision as to when, if, and what type of brace or prosthesis is to be used. In making that decision, the physician has a fund of facts about the individual patient which the orthotist does not usually have. The physician might be aware of a deep-seated psychological resentment on the part of the patient against the type of brace which would be conspicuous, or he may know of certain family conflicts regarding braces where father and mother are divided over acceptance of bracing, or disability, or even the diagnosis of a child's condition. The physician may have knowledge of the family's finances unknown to the orthotist. The physician should have a better knowledge of the disease process or disability and its possible future developments than the orthotist. In making his decision, then, the physician should draw upon several facts. His decision may seem arbitrary and somewhat stupid to the orthotist but (please be tolerant), if all the facts are known, the decision might appear more rational.
Second
, physicians are human beings upon whom extraordinary responsibilities are not infrequently tbrust and as human beings they can be distracted by worry regarding not only the case they are presently seeing but also by several other cases which are simultaneously on their minds. Consequently, at times, the physician appears to be short tempered, and if he is abrupt in dealing with an orthotist, remember that the doctor may be acting so merely because of anxieties rushing in upon him.
Third
, the doctor is very conscious of maintaining the confidence of the patient in him as a doctor and in the program of treatment prescribed. Nothing should be allowed to cast doubt in the patient's mind about the competence of his doctor or the treatment program. If an orthotist suggests a brace different from the one prescribed, particularly if done in an undiplomatic manner and in front of the patient, hostility on the part of the doctor can be expected. A peremptory order that so and so be done may be anticipated by the orthotist.
Fourth
, it is well to realize that physicians are not trained in brace work and in types of braces. Education of doctors by orthotists along these lines skillfully done, diplomatically carried out and almost insidiously suggested might do a great deal for improved relationships. A poor choice of appliance might mean nothing more than his own ignorance of available products, and some of his quick temper might (understandably ) be on the basis of his feeling of insecurity in the appliance field.
Fifth
, realize that doctors, as a rule, are unaware of the time and type of training necessary to qualify as an orthotist and prosthetist. It is up to the individuals in the profession to make these facts known to the medical profession, particularly to orthopedists, and by individual standards of behavior to demonstrate themselves as of professional level ready to do service and not simply as salesmen ready to increase their business.
One Solution
The above problems of relationship between orthopedists and orthotists have been worked out on a practical basis at the Cerebral Palsy Training Center of Fall River. Specific reference is now made to the Cerebral Palsy Training Center of Fall River because at this institution the author has his most intimate contact with an orthotist and because the experience at this training center might suggest at least one way of solving certain of the basic problems under discussion. Undoubtedly many other solutions are possible which may prove either as satisfactory or perhaps even better. Be that as it may, at the Training Center the orthopedist is the medical director, i. e., there is a single administrative and professional head. The majority of the patients are children who have cerebral palsy. Excluding doctors, the staff consists of a speech therapist, an occupational therapist, a physiotherapist, a crafts worker, and a Public School teacher (engaged in special teaching). To this paid staff, an orthotist has been invited. He is regarded as one of us. The first Monday of every month, the orthopedist spends the whole day at the Training Center with the staff checking the patients, noting improvements, redirecting lines of therapy, etc. The entire staff assembles in a room and each individual case is discussed before the patient is brought in. Every member of the staff, including the orthotist, expresses his opinion regarding the patient. At this time the orthotist has every opportunity to state what type of brace he recommends, if any, and his reasons for his opinion. In this way, he can not feel frustrated; he has had a chance to educate the doctor regarding the various appliances available; he has not angered the doctor by an undiplomatic maneuver; he has not endangered the patient-doctor confidence, nor the confidence of the patient in the bracemaker.
The doctor then makes a tentative decision having the advantages of all the opinions expressed. He also defends his tentative decision with his reasons. The word "tentative" is used because examination of the patient may reverse the decision. The patient is then brought in and examined in the presence of the whole staff. If a brace is to be applied, the orthotist then proceeds to measure the patient and to give an estimate of the price. Financial arrangements are made at the time to cover such cost either through agreement of the parents to pay or by application to various charitable organizations for assistance. If there is any complaint regarding the functioning of a brace, or any adjustment to be made, such are carried out courteously, openly, sincerely, and without rancor or recrimination right on the spot with the staff, patient, and orthotist all present.
The Medical Director of the Cerebral Palsy Training Center of Fall River dares to say that the orthotist considers this day a month as a pleasant day in which he has been treated courteously, and during which his knowledge and services have been utilized as a part of a team whose job is better service to the patient.
Every month the parents of the patients and the staff meet at the home of the Medical Director to discuss any general problems which concern the running of the Training Center and any problems they may have individually. The orthotist is of course invited to attend so that he may become acquainted with the parents and so that he may give them advice regarding the braces on their children and what to expect of the appliances, and when they may be ready for use, etc.
Summary
In summary, the group of orthotists and prosthetists are emerging as a special group seeking recognition. Several problems of inter-relationships between them and the medical profession, particularly the orthopedists, have been touched on. To improve the general situation, an understanding of several different viewpoints is needed. The orthotists and prosthetists must understand that: (1) Doctors have many facts in mind when they request a certain brace and that they must take the responsibility of decision; (2) doctors can be burdened by anxiety and some of their abruptness might be sympathetically excused because of it; (3) the confidence of the patient in his physician as well as in the orthotist should be protected by the behavior of both professional groups; (4) physicians are not trained in brace work and diplomatic education by orthotists would be helpful; (5) many members of the medical profession are unaware of the training of certified orthotists and it would be well to inform them of it.
On the other hand, physicians must learn: (1) to treat orthotists courteously as members of a team; (2) not to regard orthotists simply as salesmen, but as people of professional level ready to serve patients: (3) to depend on orthotists for advice regarding types and functions of braces and for the measuring of braces: (4) to expect greater production of skilled personnel; (5) to expect greater attention to detail to combat common errors that plague both professional groups.
Based on presentation made before the New England Regional Council of the Orthopedic Appliance and Limb Manufacturers Association in Boston. Mass., March 1955.
William E. Kenney, M.D.
Dr. Kenney graduated from the Arts and Science course at Harvard and took his degree in medicine at Yale University in 1941. He served as instructor for orthopedic surgery at the Yale University School of Medicine from 1943 to 1946. Since 1948 he has been orthopedic surgeon at Truesdale Hospital in Fall River and Medical Director of the Cerebral Palsy Training Center.
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