Are New Master’s-Level Practitioners Changing the Face of O&P?

As the new wave of practitioners with entry-level O&P master's degrees stream into the profession, how are they affecting its focus and clinical practice? What will the future bring as their numbers increase? The O&P EDGE asked experienced practitioners, residency directors, and practice managers to share their thoughts on the changing face of O&P.

Although every individual is different, there are some trends the veterans of the profession we spoke with say they've seen among this new breed of practitioner. One of the outstanding characteristics among entry-level practitioners with O&P master's degrees is their focus on the science of O&P care and evidence-based practice (EBP).

They also tend to be a bit more mature and motivated than previous entry-level practitioners, and they bring a broader knowledge base to the table. They understand and speak the language of other healthcare professionals. On the flip side, their educational background seems to indicate a need to augment their knowledge and skills in the technical aspects of O&P. Like any newly minted professional, they still have much to learn about the "real world" of healthcare and their profession. While the current state of O&P, regulatory, and administrative challenges on the profession leave some of our interviewees cautious about the new graduates' employment prospects, others seem optimistic that the mindset, knowledge base, emphasis on EBP to justify care, and enthusiasm will help power the O&P profession past current hurdles into a brighter future.

They Ask the Whys "The master's curriculum and standards help to create clinicians who think outside of current clinical practice and question the relevancy of many of the procedures that are commonly used by bachelor's- or certificate-trained clinicians," says Charlie Kuffel, MSM, CPO, FAAOP, president and clinical director of Arise Orthotics & Prosthetics, Blaine, Minnesota. Kuffel is also vice chair of the National Commission on Orthotic and Prosthetic Education (NCOPE). "The difference that I have seen is their understanding of evidence-based...[practice] to demonstrate efficacy. Many current clinical specialists merely talk about evidence-based practice but fall into routines of fitting devices because that is how it has always been done. The MPO [master's in prosthetics and orthotics] students enter clinical practice knowing the importance of evidence-based practice and do not have the experience or habit of merely fitting a device."

They understand how EBP is used throughout healthcare and enables better-documented outcomes, Kuffel adds. "As billing becomes increasingly tied to successful outcomes, clinical specialists can no longer tell a 'story,' describing how well their patients do under their care, but rather must show documented positive change. The new master's level clinicians will help facilities to evolve the profession into a recognized and relevant component of the healthcare team that is reimbursed appropriately for the care provided."

"Many, like myself years ago, recognized the need to understand the science more and be more objective in how we care for our patients," says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics, Hanger Clinic, headquartered in Austin, Texas. Carroll is excited to see the entry-level master's practitioners coming into the field, especially in the current era of EBP and a more scientific approach to O&P care. "They're asking the 'why' questions," Carroll says. "Experienced clinicians who have been in the field 20 to 30 years often just don't ask questions such as, 'Why are we using this component versus that component? Where's the evidence?'"

"In my personal experience coming out of a master's-level program as well as working with residents out of master's-level programs, I can tell you that there is a level of questioning how we do things beyond just 'expert opinion'-the lowest level of evidence, according to Dr. David Sackett [evidence-based medicine pioneer David Sackett, MD, OC, FRCP]," says Mark Clary, CPO, LPO, FAAOP, the residency program director at Yanke Bionics, headquartered in Akron, Ohio. "These new clinicians research and higher levels of research evidence to justify their patient care decision making." He adds, "Otherwise, third-party payers will continue to question our practices."

"The master's-level professionals are leading the way in not only interpreting and performing evidence-based research, but also in utilizing, communicating, and spreading that information to other healthcare professionals," says Arlene Gillis, MEd, CP, LPO, FAAOP, NCOPE chair and program director of the J.E. Hanger College of Orthotics and Prosthetics, St. Petersburg College, Pinellas Park, Florida. She points to the influx of O&P-related research being presented at national and international professional conventions. "Now we need them to continue that work on to prescribing physicians, insurance companies, CMS [Centers for Medicare & Medicaid Services] and HHS [U.S. Department of Health and Human Services], and the community."

However, O&P residency mentors have a responsibility to help residents put into practice the concepts they have learned, stresses Matthew Garibaldi, CPO, assistant clinical professor and director of the Orthotic and Prosthetic Centers for the Department of Orthopaedic Surgery at the University of California, San Francisco. "Most of the [MPO] students I've taught have had strong interest in the concept of research and analyzing the current literature as it pertains to evidence-based clinical decision making. Unfortunately, I haven't seen their interest translate to practice without prompting from mentors or supervisors." He adds, "While in school, [MPO] residents are introduced to research and the tremendous impact it can have on our profession, but it's the student's residency mentor who will be responsible for emphasizing the importance of literature review as an essential tool in providing appropriate clinical care."

Mature, Motivated Carroll is impressed when he teaches in the master's-level O&P programs. The students are generally a bit older than students in bachelor's-level programs, with a more mature mindset, he observes. "They've made up their minds early that this is what they really want to do. This is a big investment for them in time and expense. They're very motivated, very driven, and hungry for knowledge."

The master's-level O&P practitioners are already having a positive impact on the profession, says Tom DiBello, CO, FAAOP, regional director of Hanger Clinic's Texas Gulf Coast and the company's central zone residency director. "They are much more mature, more engaged, and more serious about their work," DiBello says. "As time goes by, the field will benefit substantially from them. They are more willing to take on projects related to research and nonprofit work outside the office, doing things for the good of the community."

Expectations related to O&P practitioners' clinical evaluation skills are changing dramatically, DiBello adds. "Their ability to understand the problem enables them to better design the orthosis or prosthesis to solve the problem. That's an area that requires a lot of attention, and you see that improve with an advanced degree."

The new master's-trained clinicians have a greater eagerness for knowledge as they enter the profession, Kuffel says. "The MPO students have invested a considerable amount of time and money to complete their education and want to make a change within the profession." Although he sees the current state of O&P as stagnant due to administrative burdens, he says the master's-level practitioners will help push the profession over the hurdle with their increased knowledge of EBP and greater understanding of how O&P fits into the larger healthcare environment. "MPO graduates bring new energy and new ideas to a practice and can provide the catalyst for organizational change."

Carroll points out an elevating effect of moving to the entry-level O&P master's degree on the profession as a whole. Advancing levels of education from the most highly educated previous level causes all levels to rise, he notes. "For instance, when individuals started coming with bachelor's degrees, many persons with associate degrees jumped on board, went back to school, and got their bachelor's. And now with the entry-level master's, many men and women with bachelor's degrees are going back to get their master's as well." This parallels what is happening in other allied healthcare professions, he adds. "For instance, when physical therapy moved to a master's degree, many physical therapists with bachelor's degrees went on to earn their master's. And now the physical therapists have a clinical doctorate [degree available]."

Knowledge Base Widens Kuffel comments that a benefit of the new O&P master's standards and the influx of practitioners at this level is the knowledge base they bring into the profession. "Although new graduates may lack the clinical experiential piece, I believe they make up for it in an increased thirst for knowledge and a wider base of initial knowledge."

The transition to an entry-level master's degree has come at an appropriate time, Clary says. "The way in which O&P professionals fit into the healthcare system has changed dramatically, as it has with most healthcare professionals. The scope of knowledge needed to be successful has increased, and requiring a master's-level education is fitting to deal with these changes."

New O&P professionals with a master's-level education will be better prepared to meet the upcoming challenges presented by the changing face of healthcare, Gillis says. "With the additional training in business practices, materials, advanced technology, and research, they will be well versed in documenting and justifying O&P services and able to prove quantifiably that we provide quality-based care that creates successful patient outcomes."

A wider knowledge base helps clinicians "speak the language" of other healthcare professionals as well, interviewees noted. There is a large amount of science involving O&P care that is affected by many other disciplines, Carroll points out. "We need to not only speak the language but understand it, for instance, such things as physiological and neurological aspects involved."

"The advancement of the educational requirements will greatly benefit the profession and allow clinical orthotists and prosthetists to communicate and practice on an even playing field with others in healthcare," Kuffel agrees.

Technical Know-How, Hand Skills Gap? Even though in-house technicians and central fabrication facilities may fabricate all or most devices, practitioners still find that knowledge and experience in the technical aspects of O&P are essential when recommending and designing the optimal prosthesis or orthosis for the patient's needs and communicating with technicians and central fabs.

Kuffel notes that the level of fabrication and technical knowledge of master's-level clinicians is different from that of bachelor's degree and certificate practitioners, many of whom have worked as technicians or worked their way up from technicians to clinicians. "Although the new MPO graduates are exposed to a comprehensive educational environment, the profession still remains experienced-based," he says. "New MPO graduates bring increased knowledge regarding the 'why' but still require clinical experience to understand the 'how.'"

Some of the more experienced practitioners do feel that the new master's-level practitioners are less trained in the technical aspects of O&P than in the past, DiBello concurs. He also observes, "I think one reason we're seeing that difference is that very few students today have previously worked in the industry. In the late 1970s and early 1980s when I was in school, the vast majority of students had worked in the field for years and had a very high technical proficiency." He continues, "So although sometimes people assume the curriculum today does not emphasize technical skills enough, the actual number of hours spent doing technical tasks in a current master's program compared to a certificate program is about the same. If students apply themselves in a master's program, they're able to achieve a good level of technical proficiency, which will augment their clinical skills to create a good package."

In terms of developing skill sets, especially technical skills, "I think for decades it has been a case of whether the student or resident has had experience in the field outside of the school setting," Clary says. "For instance, did they work as a technician before going to school? Did they volunteer hours at an O&P facility during high school or college? Have they had other jobs that required mechanical skills or interaction with patients? These are valuable skills that can be developed no matter what their educational level is."

Growing Professionally Since practices must look increasingly at the business aspect of providing care, Kuffel points out that the new O&P master'slevel practitioners cannot look solely at how a particular patient can be helped but must also know how care can be provided while showing evidence-based outcomes to help ensure proper reimbursement.

"They need to gain interpersonal skills and a maturity level that helps them realize that they are a professional with many important responsibilities," Clary says. "Everyone will need to gain experience in terms of treating patients, but more importantly they need to take on a personal responsibility for their actions. They are now in the 'real world' and ultimately responsible for the well-being of their patients as well the overall wellbeing of our profession."

Employment Outlook Interviewees' perspectives on the employment outlook for the newly emerging O&P master's-level professionals ranged from bleak to bright.

On the more somber side, Clary believes the current regulatory audits and reimbursement issues are dampening employment prospects. "Many companies are hesitant to hire new employees due to all the unknowns in the market. I believe stability and growth are harder to come by because of the current environment in healthcare. Students must have the ability to express their value and worth to a company. And companies must be willing to take risks on new hires with the hope that our profession can continue to thrive."

Coming to a mutually agreeable salary for entry-level clinicians is another challenge, Clary points out. "One would think that potential employees with a higher level of education would demand higher salaries, but the current state of our profession may not reflect that in many cases. From a business perspective, that may be one of the biggest challenges in finding and obtaining the best talent in our profession."

Garibaldi sees a mixed employment picture. "Job opportunities as a whole are more difficult to come by for seasoned clinicians due to their high salary demands in a struggling reimbursement environment, but I haven't seen the same limitations placed on residents and young professionals. Typically the private sector has felt the effects of CMS scrutiny far more than those of us in public institutions, but this has definitely had a significant impact on us all."

DiBello and Gillis paint a rosier picture. "Hanger has a significant need for quality practitioners," DiBello says. "If you have good skills and have interviewed well, have done well in school, and have good recommendations from your instructors, you're not going to have any trouble finding employment."

"Master's-level O&P graduates will have a wider variety of employment opportunities as the increased education will open doors for them at universities, [at] research labs, and [in] product engineering and development," Gillis says. "With increased knowledge of business practices, materials, and engineering, employment opportunities are endless."

Looking ahead, Carroll says, "People are worried about change, and yet change is part of our makeup, especially in today's environment. The clinicians coming out of the schools will be a great benefit to us all; we can be confident going into the future that our profession is going to be sound and stable. It's going to be an exciting future."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at linkEmail('miki.fairley','gmail.com');

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