The State of the Profession: A Practitioner Population Survey
September 2020 Issue
Caroline Nielsen, PhD, authored a white paper commissioned by the National Commission on Orthotic and Prosthetic Education (NCOPE) predicting that by 2020 only 61 percent of orthotic patients and 64 percent of prosthetic patients would be served at the current professional growth rates. This was reinforced by results of the 2015 Dobson and DaVanzo study that estimated that there would need to be a 60 percent increase in the number of practitioners from current levels to fulfill the professional demand by 2025. This quantitative data, reinforced by the fear of professional encroachment filling the projected vacuum, fueled the perception that the number of O&P students and schools would need to grow. This was reflected in the slogan from the late 2000s, "The Drive for 5," or five new clinical O&P master's programs by 2015.
Indirectly, this also influenced movement toward the "Clinic of the Future." This model envisioned that prosthetists and orthotists would be supported by ancillary personnel such as assistants, technicians, and residents to extend their reach. The clinicians' positions would evolve to a point that technical demands would be greatly reduced, and their main professional functions would be inspection of clinical work, reviewing and implementing outcome-based protocols, and collaborating with other allied health professions on the rehabilitation team.
This was a popular and alluring message for the future. It symbolized the promise of professional growth in O&P from a trade to a scientific and outcome-based profession. It also changed the profile of the students who would be attracted to the profession, and O&P education was subsequently affected. With the de-emphasis on laboratory and technical training, which historically had significant operational costs due to the space and material needed for instruction, greater flexibility was allowed to attract new programs that had curriculums with a decreased expense per student burden on the school.
All these changes and hopes for the future hinged on the premise that there would be too few practitioners to adequately serve the needs of patients by 2020. Having arrived at this unforeseeably turbulent year, the questions are: How are we serving the current demand, and were the projections that initiated so many changes correct? Also, how is this futuristic, now present, model of the prosthetist/orthotist fulfilling or not fulfilling the expectations of the key stakeholders—including patients, new students, schools, ancillary support personnel, and the profession?
To find some of the answers, I conducted a representative interview, or phenomenology, with five practitioners who represented experiential levels at 0, 3, 11, 21, and 31 years of clinical service. Through these conversations, some consistent areas of differentiation were identified as experience, clinical context, certification level, number of patients seen per day, population of clinicians, increasing patient volume, need for additional schools, use of ancillary support personnel, role of single certified practitioners, and professional encroachment.
From these factors, a ten-question survey was created and included an opportunity for additional comments. Some duplicate questions were created to check interrater reliability and possible bias of the respondents. The answers for statements were coded numerically where above three indicated more agreement and below three indicated less agreement. Most of the responses indicated a neutral answer. The survey was posted on SurveyMonkey from January 8 to February 15 with an announcement link on the OANDP-L listserv. The response was quite high compared to my earlier surveys with 396 respondents and a 100 percent completion rate. The average survey time was 3 minutes 47 seconds with 141 additional comments.
While many of the respondents (35 percent) had 26 or more years of experience, clinicians with ten or less years of experience constituted 25 percent of the sample. As to the certification level, 62 percent were CPOs, 18 percent were CPs, and 14 percent were COs.
Most of the practitioners, 25 percent of the sample, were from regional multi-center, privately owned offices; 23 percent were from single-office, privately owned facilities. Only 12 percent were from cross-regional, multi-center, corporate-owned offices. While this was a larger sample group, the corporate-owned clinics were somewhat under-represented in the sample.
The number of patients seen per day showed that 25 percent saw 5-6 patients per day (pts/day), and 25 percent saw 7-8 pts/day. On average, CPs saw 4.9 pts/day, COs, 8.2 pts/day, and CPOs, 7.0 pts/day. By years of experience, clinicians with 21-25 years of experience saw the most with 7.7 pts/day followed by those with 11-15 years at 6.9 pts/day. Finally, regional private clinics saw the most patients with 8.0 pts/day followed by cross-regional private and corporate clinics at 7.5 and 7.4 pts/day. Anecdotally this seems a similar patient load to that of previous years, however the real increase in patient workload may be the compounding documentation, reimbursement, and approval process. In the post-COVID-19 time, the question remains whether this volume will increase or decrease and what the resulting effects will be to work burden.
Looking at the qualitative agreement questions, there was slight disagreement at 2.85 (SD 1.03) that the number of practitioners has not met the need projected in 2002. From the comments, this is seen as dichotomous, in which one group feels that there are too many practitioners and a slightly larger group feels it is the right amount. The neutral group is also quite high, so the aggregate answer to the question is not well defined. The sample group was neutral as to number of practitioners, graduates, and O&P schools. Again, there was a dualistic difference of opinion that balanced the aggregated opinion to neutral. There was slight agreement at 3.16 (SD 1.05) that the clinical and technical team is answering the increased demand. Again, a large minority expressed that there were too many new practitioners, but they were not strong in their opinion.
There was more agreement at 3.46 (SD 1.23) that experienced, single-disciplined practitioners may not be as attractive to hire. This would seem to indicate that single-disciplined practitioners may not have as much market-value even if they are more experienced. The paradox is many practitioners choose an area specialization or proficiency in prosthetics or orthotics, but this may not be as marketable, especially in a job transition.
One of the few areas of strong agreement, at 3.79 (SD 1.03), was the concern about professional encroachment. This shows the underlying fear that others such as occupational therapists, physical therapists, nurse practitioners, or physician assistants may attempt to fill the growing O&P patient need. Another concern observed during the pandemic is the consolidation of manufacturing and patient care offices.
Forty percent of the respondents entered additional opinions. The predominant theme with 41 of the 141 comments was that the role of the practitioner is greatly changed, driven by clinical economics of volume and profitably. This came with the admission that the increase in patients seen would affect the type of componentry and processes used as well as the increased documentation time. This was correlated with 42 respondents expressing that there did not seem to be a shortage of practitioners although the volume of patients seems to have increased. Respondents differed in opinion regarding the causes of this increased volume, citing use of ancillary support, greater personal patient load, patient ambivalence for fitting, or professional encroachment by physician groups or other allied health professionals.
Other respondents questioned the effect volume-based fitting has had on custom solutions, the availability of residencies, and the diversity of clinical options. They were concerned that the customization of orthoses and prostheses, which differentiates O&P as a clinical service rather than simply durable medical equipment, will be abandoned. The advancement of off-the-shelf products may not produce the most optimal results and consequently allow other professionals to attempt fittings. Respondents also worried that patients, who provide outcomes data, would not know what they are not getting.
From a professional satisfaction perspective, respondents expressed concerns that the economic expectations and needs of the new master's degree students were not being adequately supported. The combination of student debt for a bachelor's and master's degree as well as the time investment for a residency were not being offset by the earning potential of the students, which had not grown appreciably. The number and quality of available residencies was questioned as school programs pushed more of the clinical and laboratory experiences to residency. Consequently, some respondents asked if this created a higher attrition level before and during residencies. Commenters questioned whether there was a "sink or swim" mentality in which residents were not allowed to explore a greater spectrum of fitting options, but rather use mainline solutions, for example where liners are used more often. (A recent survey I conducted did indicate a much greater use of liners for transfemoral patients.) Other respondents voiced concern that many students think they will be conducting research but are disappointed by the realities of primarily providing clinical care.
Discussion and Conclusions
Performing a one-tail correlation analysis to find significant relationships, there appeared to be two
distinct groups within the sample group that disagreed as to whether there was a greater need for practitioners and schools. This was demonstrated by the participants ultimately providing neutral opinions with a wider standard deviation. This could be due to natural opinions within the sample as the profession grows or changes, or it could indicate a disparity gap as to which vision is the most optimal. Ultimately, the aggregate group agreed that the current number of students and schools were meeting the current clinical need as predicted. However, there were differences about whether more schools or students were needed. Another area of agreement was that there is a fear of continued professional encroachment that may continue to drive the profession to match the educational and research levels of other allied health professions.
There were differences among the group regarding patient volume. Orthotists see 40 percent more patients, and the experiential group of 21-25 years sees the most patients. Again, the number of patients seen per day may not be reflective of overall workload, which may include charting and reimbursement responsibilities. What is also interesting is that clinicians with only one to five years of experience see 6.7 pts/day, which seems a bit high compared to more experienced groups. This workload among younger clinicians may indirectly affect the diversity of clinical solutions utilized.
There appears to be anxiety over the current state of the professional demographic, with one group be-
coming disenfranchised while another's economic expectations are not being supported by their market value. There is a perception that qualified single- disciplined clinicians may not be as marketable, even though most clinicians choose an area of specialization in orthotics or prosthetics. This is also an issue within physical therapy, occupational therapy, and audiology circles where experienced and capable master's level clinicians are not seen as favorably as doctoral level entrants. There are simply a larger number of less expensive, master's-level O&P candidates that can fill the niche of the offices. However due to the increased number of these students, their economic market value is not appreciably higher than entry-level bachelor's degree certificate students were ten years earlier.
The deeper correlation analysis indicated a distinct dichotomy within the sample. One group consistently indicated more schools and students were needed to serve future needs, and the original projections were correct. A slightly smaller group believed the opposite. They consistently answered that there may be too many schools and students entering the profession and felt that practical skills were still provided by the clinician rather than ancillary support personnel. As is often the case, some of the interesting information lies where there are no correlations. There were no relationships in regard to clinician population and experience, certification level, or setting. There was only a slight relationship between experience and encroachment.
All can agree that the profession is changing. The good news is that we seem to have answered the need predicted in 2002 with an increased number of highly qualified, research-focused students, a number of new O&P practitioner programs, and the continued growth of ancillary support personnel. However, in doing so, we may have introduced unanticipated consequences in terms of the nature of our work, who we attract to the profession, and the manner in which we clinically educate them. With the narrowing of componentry options and fitting processes to serve a greater volume of patients, the question remains: How do we advance the profession while remaining differentiated within the allied health and rehabilitation?
Gerald Stark, PhD, MSEM, CPO/L, FAAOP(D), is a senior clinical specialist at Ottobock Healthcare, Austin, Texas.
- Nielsen, C. 2002. National Commission on Orthotic & Prosthetic Education, Alexandria, Virginia.
- DaVanzo, J. 2015. National Commission on Orthotic & Prosthetic Education, Alexandria, Virginia.
- Annual Report 2018. American Board for Certification, Alexandria, Virginia.
- Annual Report 2019. Hanger Clinics, Austin, Texas.