Orthotists and Prosthetists: Issues in a Developing Profession
Ira S. Schoenwald, Ph.D.†*
Ruth K. Scott, Ph.D.†*
Larrie Lance, Ph.D.†*
Orthotics and prosthetics as a profession is in the midst of a period of major professional change. Developments in six major areas are causing heated discussion and sometimes acrimonious debate amongst practitioners and facility owners. The six areas are: changes in professional status, certification, business management, patient management, mode of service delivery, and the use of prefabricated orthoses. These developments were felt to be most important by the leaders in the field of orthotics and prosthetics whom we recently surveyed. These leaders included officials of the American Board for Certification in Orthotics and Prosthetics Inc., the American Orthotic and Prosthetic Association, and the American Academy of Orthotists and Prosthetists, small facility owners, and directors of professional education programs. The purposes of this article are to present the results and to discuss the implications of some of our findings.
CHANGES IN PROFESSIONAL STATUS
Orthotics and prosthetics is changing from a profession dominated by small practices and skilled craftsmen to one that is increasingly centralized, and in which the force of technological change has produced a need for more analytical and scientifically oriented practitioners. A major characteristic of this change is the growing need for technical competence and the consequent need for standardized educational requirements. In the past, practitioners were either self-taught or learned their skills as an apprentice. They learned "by doing"óby observing and working long hours with a master craftsman. They seldom had formal post-secondary education. But with new technologies and practices, there developed a need for more depth and far more detailed knowledge of the sciences and allied health care. Training evolved in response to these needs, so that today it has a more "professional" character, requiring standardized educational programs and certification procedures.
Beginning this year, this standardization consists not only of specific topics outlined in the essentials, but the addition of other general educational requirements gained through earning the baccalaureate degree. This important development represents an acknowledgement that prosthetics and orthotics is equal with other allied health fields. That is, increased professional status for orthotists and prosthetists is achieved in part through increased educational accomplishment. It is not possible to participate as an equal of other health professionals if one does not share common values, vocabularies, and knowledge. Further, if the field is to remain in charge of its own destiny and not be overtaken by other professions, it must standardize its education, skills, and practice.
A second aspect of the change in professional status is the issue of practitioner control of who practices, and of what practitioners must know, through formal certification processes. The process of certification has been described by R. A. Chase1, and will be examined in more detail in a later article.
In orthotics and prosthetics, the requirements for certification include, in addition to the bachelor's degree, a year of internship, written, practical, and oral examinations by the American Board for Certification in Orthotics and Prosthetics, Inc. Establishment of a formal licensing program affects both the numbers and types of practitioners in any professional field. The introduction of a certification process enhances the profession's image among its certified peers in the other allied health fields. With the expected consistency of higher level professional standards comes increased confidence and professional status.
But changes in certification requirements can produce feelings of animosity among those certified according to "older" criteria, and those certified according to the new. The rate of change in the field, reflected in the changes in the certification process, can create divisions in the field. Our study indicates that many already established practitioners feel that the newly certified professional does not respect the older professional, who is rich in experience, if short on formal degrees. Among the newly certified, there is a sense that the "old guard" is unable to accommodate rapidly changing technology.
These divisions are a natural consequence of the rapid changes that increased technology is bringing to many of the allied health professions. For example, nursing is still debating over the proper role of the baccalaureate degree while also fighting challenges to its professional identity from "newer" professions, such as physician's assistants. Even the widespread growth of medical specialties among M.D.s has caused much division and debate.
It is not new to those of us who work in the medical fields that the costs of health care continue to grow at a rapid rate. Recent attempts to cut costs through government programs, increased competition from other "providers," and changes in the field itself have increased the pressure on small and large practices to become more efficient and more concerned with being good business managers. Our survey substantiates the concern by many practitioners for the need to improve managing skills, and to increase their knowledge of reimbursement options and other techniques to improve cost effectiveness. "If we are not business minded, we go broke" is a common theme from the field.
But along with the increased concern for business practice come other problems of patient management. Because the orthotist/prosthetist is likely to have more direct patient contact than in the past, it is often necessary to discuss billing with patients, a skill which few in the profession report comes easily. Professionals contend that part of the discomfort lies in the question of how to justify billing for professional services, the major component in the cost to the patient, when the patient expects to be billed for a device that is, in the end, constructed of relatively inexpensive materials.
An ironic twist in this issue is that other health care providers, who in large part bill patients solely on the basis of professional services, are often unsympathetic. They also view the device as the end-product, as the only legitimate element in a wide spectrum of services that include professional consultation, patient analysis, prescription, education and problem-solving, as well as fabrication and fitting. In fact, manufacture of the physical device may require the least technical expertise in the entire process.
PATIENT MANAGEMENT SKILLS
The growing need for business skills is coupled with the need for patient management skills. The services provided by today's orthotist/prosthetist are largely patient-oriented in nature. Practitioners must deal directly with a wide variety of patients and an even wider variety of patient conditions. They may aid a patient who needs help in finding funds for their medical needs, engage in patient follow-up, grieve with a recent amputee, and deal with defensive patients who are unwilling to accept a permanent disability. Our survey respondents stated an urgent need for communication and patient management skills that go beyond the technical aspects of their expertise. There is an increasing recognition of the need for workable interpersonal techniques to better manage the day-to-day patient encounters that orthotists and prosthetists face.
CHANGES IN MODE OF SERVICE DELIVERY
Two trends are emerging in service delivery. At one level we can see the development of larger group practices with centralized fabrication facilities utilizing cost efficient manufacturing principles, while at the same time, small, solo practices are proliferating. Each has different implications.
Larger, centralized practices may be conducive to peer review at the expense of a loss of fabricating and technical skills, while the smaller solo practice may give the practitioner more direct "hands on" fabrication experience, but at the expense of valuable collegial interaction. This dual process is not without precedent. Witness the recent growth of large centralized group medical facilities and health maintenance organizations in many parts of the country, while smaller, more general practices develop as well.
A final development noted by those we surveyed is the increased production and utilization of prefabricated orthoses. Practitioners are now faced with competition from "drugstore orthotists," who dispense prefabricated devices that are far cheaper for the patient. Although the drawbacks of their use may seem apparent to the practitioner, there are no good data to tell us whether or not these devices meet patient needs, even though in an era of economic stress thay may be the only option for many.
Practitioners in our survey raise important questions. For what conditions are they, or should they be, used? Should they be controlled in the same way as prescription drugs? If so, who should dispense them? Is it possible to train pharmacists and others to fit them without damaging the status of certified professionals? Are dispensers of prefabricated orthoses "skimming off" patients who would otherwise consult a professional orthotist?
This trend toward "over-the-counter" orthoses, then, challenges all other developmental areas that we have discussed in this article, including quality of patient care and management, professional status of the practitioner, economic interests of the profession, type of service delivery, and the meaning of certification. These challenges were seen as major ones by those we surveyed.
Leaders in orthotics and prosthetics have enumerated a number of professional concerns which are presented here as a series of developments in the field. We have attempted to present their concerns, and to discuss some of their professional implications. We hope that our efforts here will lead to increased discussion and debate. Consensus may never be complete, but it certainly cannot begin until we have a clear understanding of the issues that confront the professional orthotist/prosthetist. As we continue to examine these developments, we invite the active participation and cooperation of all who work in orthotics and prosthetics. Your support is most welcome, and your active feedback is invaluable.
- R.A. Chase, "Proliferation of Certification in Medical Specialties: Productive or Counterproductive, "New England Journal of Medicine 294, February 26, 1976: 498.