The Pedorthist Education Debate
November 2010 Issue
All Those in Favor of Increasing the Pedorthic Education Requirement?
Pedorthic education is in a state of transition. In October 2010, the Committee on Pedorthic Education (CAPE) released a survey aimed at getting input on proposed new education standards for the pedorthist. The proposed standards would require that all National Commission on Orthotic and Prosthetic Education (NCOPE)-accredited pedorthic education programs be housed within-at minimum-a two-year college, essentially transitioning pedorthic education "from a course to a formalized education program within an institution of higher learning," according to Robin Seabrook, executive director of NCOPE.
"Much has changed with the profession over the years, and it is...a natural progression to increase and expand the education to meet patients' needs," Seabrook says.
That being said, the proposed change is, for some, a prevailing political hot button. Some industry insiders consider it a no-brainer: upping the prestige for the profession could only enhance the reputation pedorthists command in the allied healthcare industry, leading to more referrals. And from a business standpoint-and most pedorthists are forced to develop their share of commercial savvy-many claim that increasing the pedorthist education requirement is a sound up-front investment that would provide ample pay-offs once trainees transition into practice. So what's really at stake?
Pedorthic Education: Now and into the Future
The pedorthic profession developed a standardized curriculum, thanks to efforts made in 2003 by the Board for Certification in Pedorthics (BCP) and the Commission on Accreditation of Pedorthic Education (CAPE), to move pedorthist education into a competency- or outcome-based model that all schools would include. The Pedorthic Education Alliance (Pedorthic Alliance) took these guidelines and created a curriculum that was then shared by all certifying schools, according to Rick Sevier, CPed, chairman of the Pedorthic Alliance. In January 2009, CAPE dissolved as a corporation and became a committee under NCOPE.
Current NCOPE-approved educational standards for pedorthists require two to four weeks of training using a competency-based curriculum that consists of three levels or modules. Programs typically include a hybrid of live class time and online learning and cover a broad range of subject matter from anatomy and biomechanics, to shoe modification, casting, and insert manufacturing, as well as patient and retail management. According to Seabrook, NCOPE "has not reviewed any new materials, self-studies, or curriculum since [CAPE] transitioned under us."
To be eligible to sit for the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) pedorthic certification exam, individuals must "possess a high school diploma, GED, or college degree; successfully complete Levels 1, 2, and 3 of an NCOPE-approved pre-certification pedorthic education program; and document a minimum of 1,000 hours of patient care experience in pedorthics obtained either before or after completion of the pedorthic education course," according to the ABC website (www.abcop.org). The Board of Certification/Accreditation, International (BOC) website (www.bocusa.org) lists its eligibility requirements as demonstrating "successful completion of the NCOPE-approved pedorthic pre-certification education requirement...[and a] minimum of 1,000 hours...of supervised patient fitting experience."
Regarding the current pedorthic education program requirements, Seabrook says, "students who attend [this training] do not receive any type of college credit for attendance and completion. Some of the courses offered are not associated at all with an educational or academic institution." The proposed new standards, which were "drafted as a result of the Pedorthic Education Conference held [April 10-11, 2010, in Dallas, Texas,]" Seabrook continues, address this issue. Because the proposed new standards would house pedorthic education programs within at least a two-year college, students completing the program would earn college credit. Under the proposed standards, students who complete the pedorthic education program would earn a minimum of a certificate of completion, but, Seabrook says, "it could become a part of a curriculum that already exists," meaning that a pedorthic certificate could be rolled into a two-year associate degree in a complementary discipline.
Jennifer Richards, CPO, CPed, FAAOP, vice chair of the NCOPE board of directors, stresses, however, that "while the new proposed standards do require the program to be housed at a two-year college (or greater), they do not require a two-year degree." She adds, "I'm not sure everyone understands all of the...different types and lengths of programs-and thus certificates-institutions can offer. I know I didn't until recently."
Seabrook explains, "The reasons for this shift into the academic arena is twofold. First, it allows for prospective students who are entering community college to learn and hear about this allied health option known as pedorthics. The way in which the courses are run now, there isn't the ability to appeal to a broader base of prospective students...."
Second, she says, "the level at which pedorthists practice in today's healthcare arena-including retail-[have brought about] a need to expand the curriculum. The 120-160 hour course length is not appropriate to cover all of the required knowledge and skills needed to enter the profession."
Pedorthists' Growing Role in Allied Healthcare
Historically, pedorthists grew out of the specialty shoe business, gaining skills along the way as a means to address the needs of individuals with foot complications who came through their doors. Those shoe cobblers, shoe repairmen, and eventually shoe retailers, according to Pam Haig, CPed, founder of the not-for-profit Robert M. Palmer, MD, Institute of Biomechanics, Elwood, Indiana, eventually transitioned into the positions pedorthists now hold as integral members of an allied healthcare team. She adds, "The modern day pedorthist can easily find employment in orthopedic and podiatric offices, physical therapy and sports medicine clinics, wound care centers, nursing homes, pharmacies, and with large distributors of foot care products and services as well as national shoe vendors." She says that this shift in employment patterns is a result of the diabetes and obesity epidemics in the United States, as well as the trend toward increased health consciousness in general.
A positive outcome of this shift, according to Roger Marzano, CPO, CPed, Yanke Bionics, Akron, Ohio, is that the profession has "gained more recognition within the medical and allied health community with more employment opportunities available to the pedorthic practitioner in a greater variety of settings." He adds that the 1993 Therapeutic Shoe Bill has provided "greater coverage for pedorthic services among insurers as well as more scientific data to support conservative treatment of those with foot and ankle disorders via pedorthic modalities."
The diabetic patient accounts for close to 50 percent of the primary diagnostic category for the pedorthic practice, according to a 2009 ABC survey. The trend has impacted the profession in myriad ways. As a business model, for one, it makes sense to absorb pedorthists within a healthcare practice with a broad scope. "There's a lot of rationale for having pedorthists help deal with patients before they even enter the O&P stage because far too often, we know by looking at diabetes and other disease stats, that [the patients] are going to be [headed in that direction]," says Tom Derrick, CPed, pedorthic industry consultant. Derrick's argument addresses the need for consumers to enjoy affordable foot healthcare, and for healthcare practices to continue operations in a competitive economy by offering graduated care through such a cost/benefit model.
Kristi Hayes, CPed, president-elect of the Pedorthic Footwear Association (PFA), feels the shoe retailer legacy has, in some ways, sullied the reputation of the practicing pedorthist and claims the "stigma that we are just glorified shoe salesmen," comes from within the profession itself. She explains, "Our forefathers set forth a series of motions which gave what we do a national platform and inducted our work into legislation. Through their hard work and persistence, they pushed the trade away from retail shoe sales and into healthcare. We need to not only honor the pathway others have paved for us, but evolve and change with the times to stay relevant and viable." Hayes says she is a proponent of eventually increasing the education requirement for pedorthists to a two-year degree because she believes these higher standards will keep the practicing pedorthist on top of the latest equipment and knowledge base, and therefore better equipped to serve the patient population.
"Pedorthics is a unique niche in the healthcare industry," she says, "and those who are not focusing on their entire scope of practice are remiss. If people want to have a retail store, that's great, but that's not what pedorthics is-it's about the foot, shoe, and orthotic device working as one unit. It's about correcting gait patterns and improving quality of life, not schlepping cheap or trendy shoes. It's about building community trust in referral sources and patients and backing it up with quality work."
If the System's Not Broke, Why Fix It?
But some educators are happy with the educational requirements as they stand. According to Sevier, who is also the founder of Pro-Learn, Tulsa, Oklahoma, a private school that trains pedorthist hopefuls, "Employers are extremely happy with the level of competence of our students." He adds, "The educators believe that if the current model is not broken and allows for continued upgrades, that it should not be radically changed. The educators have worked for years to create an outcomes-based educational model that all educators currently use. This means we are all teaching the same core material." Of the proponents in favor of eventually transitioning the pedorthic education requirement to a two-year degree, he says, "You have a bunch of people out there who are like, 'My doctors are asking me, well, what kind of experience do you have to have in order to be a CPed?' and these people are embarrassed to say, 'Well, three weeks worth of training and 1,000 hours of experience.'" He adds, "Well, I've got news for you. In the academic world, the difference between that and an associate degree isn't a whole lot.... We're not building rockets; we're not doing brain surgery."
Sevier says he is also concerned about enrollment patterns. Attendance figures have been down over the past two to three years in part because of economic forces, but he sees the 1,000-hour internship as the leading cause, saying that he knows of interns who have completed this prerequisite to certification unpaid. He mentions the disinclination of practicing pedorthists to take someone under their wing who is likely to open up shop and compete against them once the training is complete. As a result, that's six months where the intern will most likely need to relocate. "And these are not 18-year-olds for the most part," he adds. "These are, by and large, people with families."
U.S. Educational Standards Lagging Behind Canada and Australia
Hayes says that the United States is lagging behind other countries in the pedorthic educational arena. Haig agrees. "Of all the countries in the world that teach pedorthics as a certification program," she says "the USA has the shortest program of all countries, with the exception of non-certifying countries."
Hayes adds, "[Here], pedorthists are not as well-educated as in other parts of the world. We're not incompetent practitioners, we are just lacking when it comes to long-term or more in-depth pedorthic education that you find pedorthists in Canada and Australia receiving. So many healthcare professionals, government agencies, insurance companies, and the public are-rightfully so-demanding better care from foot care professionals." Pedorthists, she says, are "the sum of their education, continuing professional development, experience, and how they utilize shoes, inserts, and modifications to treat myriad pedorthic pathologies. This is not an issue that cannot be overcome. Like many professions before us, we too need to evolve and change. Increasing the academic education as well as internship opportunities moves the profession to be responsible for providing high-quality care to the patients we serve." She adds, "Change is on the horizon."
Following the Pedorthic Conference in April, Haig says her understanding of the discussion was that "an associate degree was the goal," although she says she "came away from the meeting feeling as if it was voted upon to require an associate degree in the upcoming future and that some form of an associate degree would be implemented and targeted for 2012 or 2014." Jerry Wilson, CPed, CFO of ProLearn, says that he had a similar understanding regarding the results of the Pedorthic Conference held this past spring.
"It was not determined if it would be a prerequisite to entering the pedorthic profession, obtained as an associate degree in pedorthics, or if an associate degree of some form (not necessarily pedorthic oriented) would be required during a specific time frame of practicing pedorthics," Haig explains.
Though Haig says she agrees with the decision to require an associate degree by 2012, she adds that this may take as long as ten years to implement. "If pedorthists are to be recognized as part of the allied healthcare team, we need to be academically competitive with similar healthcare professions," she reasons. "Currently, the time spent toward pedorthic education provides no benefit in pursuing a college degree, as the hours of pedorthic education are [classified as] certification [or] non-credit hours. Therefore, the associate degree requirement will set the stage for pedorthists to continue their education by using the credit hours obtained in their associate degree toward a bachelor's degree in a complementary field of medicine such as athletic training or [a] physical therapy degree, etc."
Limits on Access to the Profession
Detractors don't want to limit access to the profession by forcing a degree requirement that may preclude the ability for students to hold full-time employment. Consider the prevailing student body. Many are non-traditional students coming into the training programs from current jobs. Many employers currently see the potential of another income stream in maintaining a certified pedorthist on staff, and will sometimes cover education costs. If the education requirement does eventually move to a two-year model, employers may potentially refuse such an out-of-pocket expense because, Derrick says, "it may not be a high enough grossing position to justify the expense of a two-year program [for them]." While Derrick says he is in favor of pedorthists eventually transitioning to a two-year degree requirement, he adds that under a more involved educational model, the cost burden would necessarily shift to the students themselves. "It's something to think about," he says.
Scope of Practice Issues
As a necessary cog in an overarching O&P patient care plan, Derrick says the pedorthist, "serves as one of the first patient care providers on the orthotics, prosthetics, and rehabilitation chain of delivery," particularly with a patient who has diabetes. He adds that "pedorthists often may be one of the only allied healthcare professionals these patients see for three to four years," and therefore represent the "first line of defense" for many patients receiving clinical foot care.
Derrick is in favor of upping the pedorthist's educational ante because of the increasing drive in the industry to enhance the pedorthist's scope of practice. He sees that part of the issue rests with the dilemma for practicing pedorthists to either broaden their scope of practice by becoming certified orthotists or to establish a niche within a more limited scope of practice (through becoming a diabetic care specialist, for example). He believes, however, that neither of these two options is of much interest to most pedorthists.
Séamus Kennedy, BEng (Mech), CPed, president and co-owner of Hersco Ortho Labs, New York, New York, agrees that the pedorthic profession is in a tricky position. "The educational requirements and standards have been raised considerably over the past 15 years," he says. "This is a good thing. It ensures our standing as a profession and validates our credential as lower-extremity specialists. However, if the educational and financial costs to entering the field are too high, many prospective entrants may choose to become certified orthotists. As orthotists, they can practice pedorthics, albeit with more limited training and experience, and at the same time increase their scope of practice."
To offset these forces, an increased education requirement could enable pedorthists to do what they enjoy the most but also maintain a broader scope of practice, and therefore become better equipped to provide a broader range of care while working with a variety of patient diagnoses. Derrick believes that one crux of the issue rests with "whether or not pedorthists are able to provide AFOs." He says the AFO lies at the heart of "a political matter," and that of the politically active pedorthists out there, "half of them will tell you they have no business providing AFOs and half will tell you that they must be doing them, that they're integral to [their practices]."
Some AFOs do not impede on ABC's pedorthic scope of practice, which is defined as "any pedorthic device, modification, and/or prefabricated below the knee orthosis addressing a medical condition that originates at the ankle or below." Falling outside the pedorthists' scope of practice, however, are other, more traditional AFOs that extend up to just below the knee.
Whatever side of the political fence the debate eventually falls, Dane LaFontsee, CPed, president of the PFA says, "Through all the controversy that has gone on over the years...pedorthics is a remarkable and very necessary profession, and we need to band together and make sure that pedorthics is here for our children and our children's children.... I think...we need to understand and need to work with other organizations and other healthcare professionals, to make sure that pedorthics is always in the forefront and always in the knowledge, so that we are utilized as an equal profession."
Pam Martin can be reached at . Karen Henry can be reached at
Editor's note: This article is a revised version of "The Pedorthist Education Debate: All Those in Favor of the Proposed Two-Year Degree Requirement?" (The O&P EDGE, November 2010, pg. 34). This revised version clarifies the proposed education requirement and its origins and corrects technical inaccuracies.
The Trend toward Bucking Trends
Shoe consumers are increasingly finding their way into the hands of foot-care professionals due to mistakes made in both footwear choice and misinformation gleaned about foot biomechanics. Dane LaFontsee, CPed, is a retired ballet dancer, whose practice focuses mainly on patients with sports-related injuries. His patients will read an article in a publication like Runner's World, he says, and will decide that "barefoot running is the absolute way to go." This is a mistake, in his view, since the athletes haven't "eased themselves into it [nor do they have] any real knowledge of their biomechanics." He continues, "They come to me with some pretty serious injuries. His patients used to suffer from things like "plantar fasciitis...but now I see things that are much more severe: anterior, posterior tibial insufficiencies and tears and stress fractures." He adds, "In my opinion there is nothing wrong with barefoot running if you are a biomechanically correct person, but if you have been wearing shoes and you do not have proper biomechanics and you try to do that without training and easing yourself into it, you [are going to have] a huge problem."
LaFontsee has also seen a lot of patients who come in after having purchased shoes with rocker soles. "I was seeing my older population who thought that they could put on this new rocker-sole shoe, and it was going to tighten their abdomen and they were going to get nice little butts and ended up falling and having hip problems because they did not have great balance to begin with and were sold a pair of shoes that are...supposed to help with all of that and again without proper instruction into their use."
The qualified shoe salesman, who is under pressure to make the sale, in his view, should still do more than provide customers with the information given by the shoe company representative. He says, "I think we have a responsibility to those people that think that we are the experts in proper foot care. Whether that be fitting you into a pair of shoes or putting you into an orthotic device, and so I think we have kind of passed a threshold where the retail and the technological pedorthist has to become a little bit more knowledgeable in the clinical aspect of being a pedorthist."
Some of these shoe retailers house "library systems" that they claim replace customized, hand-crafted products, according to Pam Haig, CPed, "such as in the case of feet orthoses and even AFOs; perhaps even custom shoes." She says this is unfortunate. "While pre-fabricated and more elaborate library styles of orthoses can produce relief of symptoms, controlling each patient's foot individually at the axis of where his or her unique deformities are occurring will produce a more optimal alignment for the patient-if range of motion permits realignment-thus not only treating the symptom but also the cause of the symptom, and ideally reducing further degeneration." She feels that some small manufacturers and even national labs are regrettably, "deceiving their customers or patients by using 'library systems' and marketing them as 'custom orthoses' while charging a 'custom price for a non-custom pre-fab.'"
While bemoaning these offenses to the industry, Haig also notes that many of the newer technologies have been beneficial in broadening the diagnostic reach of pedorthists through pressure mapping and scanning systems that measure foot width and length as well as inventory management within these systems. She says, "CAD/CAM technology has been an asset to the profession, and the prices are [becoming] more affordable for pedorthists in private practice."
Séamus Kennedy, CPed, concurs with Haig on the exciting influx of technology and its benefits to the industry. According to Kennedy, "In the last ten years, there has been an explosion of software and communication devices that have helped increase practitioner productivity. As an example, many labs now use scanners, milling machines, and routers to make custom products faster and less expensive than ever before." He adds, "Practitioners are using cell phones, laptops, e-mail, and many other web-related tools to stay in touch with both their patients and their offices, and I think this trend will continue."
Beth Jensen, CPed, Foot Solutions, Denver, Colorado, warns, "As technology changes, pedorthists tend to want to say that the new technology works better than the old. I think as we continue with the new technology, it is becoming apparent...that every technology has its benefits. The more technologies we have available, the more people we will be able to treat because the fact is that each person has specific needs to be addressed and no one technology addresses them all."