O&P Education: Guiding the Transition to Client-centric Training

In 2002, Christopher Hovorka, Robert Gregor, and Mark Geil led a team of educators, clinicians, engineers, and scientists to launch the nation’s first entry-level master’s degree in O&P at the Georgia Institute of Technology. The curriculum was revolutionary at the time, integrating interprofessional science and an intensive research focus with traditional skills-based training. Within a year of the program’s accreditation in 2004, key O&P stakeholders convened a special education summit and reached a consensus that the master’s degree would replace the bachelor’s degree and post-graduate certificate as the national entry-level standard for practitioners. 1 The national transition would be completed within ten years. The Master of Science in Prosthetics and Orthotics curricular framework at Georgia Tech was inspired by the tenets of evidence-based practice, then a relatively new concept that sought to bridge the gap between academic research and clinical practice in O&P. To this end, the curriculum was designed to habituate students to seek out scientific literature and evidence for clinical decisions in areas including device efficacy and in situ data to track patient treatments and outcomes. Providing new clinicians with a background in science and evidence is required to prepare students for the impacts of wide-ranging changes in healthcare, from the reimbursement landscape to technologies, such as 3D shape capture and printing, which are available to the public and increasingly affordable. 2 For example, the ability to collect valid treatment and outcomes data in the clinic could provide ready evidence of efficacy as reimbursement norms continue to change. The ability to evaluate and manage a variety of technologies may also help new clinicians transition their practices away from engaging predominantly in labor-intensive, custom, hands-on fabrication to less labor-intensive and digitally automated techniques for device fabrication, as some O&P practitioners are already doing. Not incidentally, incorporating new approaches into O&P training would be more likely to attract potential students who wanted a greater intellectual challenge and more career opportunities than O&P’s device centrism would be able to provide. The new standard allowed a more flexible interpretation of accreditation requirements. Baylor College of Medicine produced one of the more innovative of these interpretations in 2011, when it announced its 30-month O&P program that combined classroom and laboratory instruction with residency training. The program begins with an intensive 12-month didactic phase, followed by an 18-month, faculty-supervised clinical residency, after which graduates can proceed directly to board examinations and, once licensed, enter the workforce without further delay. 3 Baylor’s classroom-to-workforce time is six to 18 months less than the traditional O&P program’s 36 to 48 months for degree and completion of residency. Startup O&P programs at Salus University in Pennsylvania and Midwestern University in Arizona are developing similar embedded residency training programs. 4,5 In addition to the advantages of allowing instructors and participating clinics to confer on individual student performance, the embedded residency model establishes a novel classroom-to-clinic feedback loop for testing the value and utility of new approaches to O&P training. A Model for Client-centric O&P Some educators are actively investigating one new approach in particular: how best to expand O&P’s role from technical services to a more inclusive, client-centric model of healthcare. Client-centric frameworks are increasingly being adopted by healthcare systems in the United States using the International Classification of Functioning, Disability and Health (ICF), developed by the World Health Organization (WHO) and finalized in 2001, to provide a unifying framework for classifying the consequences of disease. 6 The ICF framework is biopsychosocial, viewing function and disability as a complex interaction between the health condition of the individual; contextual, environmental factors; and personal factors, described as “the person in his or her world” (Figure 1). The language of the ICF is etiology-neutral, emphasizing function rather than condition or disease. It also has been “carefully designed to be relevant across cultures as well as age groups and genders, making it appropriate for heterogeneous populations.” 6-8 There is a growing body of literature on the application of the basic ICF framework to specialized healthcare practices. Outside the US, this literature includes O&P-related subject areas, where it is being explored as a framework for clinical practice and clinical outcome measures. 9-15 Medical and O&P training programs, also outside the US, are using the ICF to help students understand the interaction between function and disability, and to develop treatment plans using the whole-person perspective. 16 Then why is the ICF framework not widely taught in the US? In the US, accredited O&P programs must demonstrate student proficiency in design, fabrication, and fitting for several types of custom orthoses and prostheses. The time and resources required to teach these skills can be a significant portion of finite lab and classroom time, leaving little time for training students in ICF’s client-centric framework. Breaking this conundrum will require O&P programs to exercise creative problem-solving as they consider how best to bring the ICF into their curricula without abandoning the hands-on skills for designing and building orthoses, prostheses, and footwear—devices that are still at the core of O&P practice. One potential solution would use the ICF as a framework for the entire client-centric curriculum, including orthoses, prostheses, and footwear. Another alternative, described by Jarl and Ramstad, is a curricular model, the Prosthetic and Orthotic Process (POP), that adapts ICF to clinical O&P processes. 17 In the proposed POP model, aspects of the ICF are conceived as different levels of functioning, which are rated and merged to form a holistic view of the person’s health status. Because participation is ultimately the main goal of O&P interventions, and is realized by achieving activities-related goals, in similar fashion, the patient’s goals related to activities are realized by achieving goals related to body functions and structures. The process begins intuitively with client assessment that informs development of client goals and thus informs development of the O&P treatment plan (intervention) followed by evaluation of treatment outcomes (Figure 2). The model guides the O&P professional and provides a method of implementing the ICF in the O&P field and presents methods in facilitating communication with other rehabilitation professionals. The goal of the POP model blended with ICF framework is to incorporate a client-centric approach to clinical care. Adding CanMEDS to the ICF Framework To further inform transitioning the O&P curriculum from device-centric to client-centric, the combination of the ICF framework and the POP process model could be complemented by the addition of a practitioner-oriented framework designed to enhance training clinical care providers. The Canadian Medical Education Directives for Specialists (CanMEDS) identifies and describes the abilities of physicians required to effectively meet the healthcare needs of the clients they serve. 18 These abilities are grouped as themes in seven roles that all relate to the capabilities and performance of a medical expert. The integrating role (medical expert) is associated with six key attributes, such as being a good communicator, collaborator, manager, health advocate, scholar, and professional (Figure 3). The framework has been adapted in a variety of countries around the world both within and outside the health professions. Applying the CanMEDS model in O&P education adds the provider dimension to ICF by characterizing the core competencies that healthcare providers must exhibit, thereby establishing a template for training students in the knowledge, skills, and behaviors they need to cultivate. To work toward this, the CanMEDS clinician framework could be adapted to fit O&P practitioner training by updating the seven roles that relate capabilities and performance of a medical expert to the capabilities and performance of an O&P expert. Similarly, the six associated key attributes of being a good communicator, collaborator, manager, health advocate, scholar, and profession would all fit well into O&P practitioner training competencies. These attributes could be incorporated into curricula, and by doing so, device design, fabrication, fitting, billing, and related aspects specific to O&P practice could be taught alongside practitioner-specific competencies. Implementing greater digital workflow processes in device fabrication could improve efficiencies and save valuable time. The fabrication time savings through workflow efficiency could allow for the addition of critical content on practitioner training. The CanMEDS practitioner training model, in conjunction with the ICF and POP model, presents a comprehensive framework in which students can learn how to use the ICF for O&P client-centered practice. Collectively they can serve as a framework for the transition from device-centric to client-centric care in O&P, and as a tool for interprofessional collaboration. The combination provides a critical language and structure to navigate the complexities of what it means and what it will take to be a next-generation clinical care provider in O&P. Christopher Hovorka, PhD, CPO, FAAOP, is director and assistant professor of the orthotics and prosthetics program in the College of Health Sciences at Midwestern University. He is developing an entry-level Master of Science degree in O&P, which will be a first in the state of Arizona. He has been working in the field of O&P for 30 years, and over the past 23 years has engaged in academia, leveraging his education, research, and clinical experiences in exercise science, orthotics and prosthetics, allied health science, and applied physiology/motor control into developing collaborative O&P practitioner education programs. Acknowledgement: The author wishes to thank Ben Lucas, MSPO, CPO, for his critical input and Denise Caruso, BS, for her critical input and editorial effort. References: Orthotics and Prosthetics Education Summit: Forecasting the Future. Final report (internet). New Orleans, LA; 2005. Available from https://ncope.com/summit/pdf/EDSummit_final_report.pdf Kogler, G. F., and C. F. Hovorka. 2021. Academia’s role to drive change in the orthotics and prosthetics profession. Canadian Journal of Prosthetics and Orthotics 4(2); 21. Baylor College of Medicine, School of Health Professions, Orthotics and Prosthetics Program. Available at https://www.bcm.edu/education/school-of-health-professions/orthotics-and-prosthetics-program/curriculum Salus University, College of Health Sciences, Education and Rehabilitation, Orthotics and Prosthetics Program. Available at https://www.salus.edu/Colleges/Health-Sciences-Education-Rehabilitation/Orthotics-and-Prosthetics-Program/Curriculum.aspx Midwestern University, College of Health Sciences, Orthotics and Prosthetics Program. New Program Application: Arizona Private Postsecondary Education Programs; 2022. World Health Organization. International classification of functioning, disability and health. Geneva; WHO, 2001 World Health Organization. International classification of functioning, disability and health: children and youth version: ICF-CY. World Health Organization, Geneva; 2007. https://www.google.com/books/edition/International_Classification_of_Function/SWFQDXyU-rcC?hl=en&gbpv=1&pg=PR5&printsec=frontcover Allan, C. M., W. N. Campbell, and C. A. Guptill, et al. 2006. A conceptual model for interprofessional education: The International Classification of Functioning, Disability and Health (ICF). Journal of Interprofessional Care 20(3):235-45. Kohler, F., A. Cieza, and G. Stucki, et al. 2009. Developing core sets for persons following amputation based on International Classification of Functioning, Disability and Health as a way to specify functioning. Prosthetics and Orthotics International 33(2):117-129. Grill, E., and G. Stucki. 2009. Scales could be developed based on simple clinical ratings of International Classification of Functioning, Disability and Health core set categories. Journal of Clinical Epidemiology 62(9):891-98. Linder, H. Y., B. D. Natterlund, and L. M. Hermansson. 2010. Upper-limb prosthetic outcome measures: Review and content comparison based on International Classification of Functioning, Disability and Health. Prosthetics and Orthotics International 34(2):109-28. Brehm, M., S. A. Bus, and J. Harlaar, et al. 2011. A candidate core set of outcome measures based on the International Classification of Functioning, Disability and Health for clinical studies on lower-limb orthoses. Prosthetics and Orthotics International 35(3):269-77. Ivanyi, B., M. Schoenmakers, and N. van Veen, et al. 2015. The effects of orthoses, footwear, and walking aids on the walking ability of children and adolescents with spina bifida: A systematic review using International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as a reference framework. Prosthetics and Orthotics International 39(6):437-43. Burger, H. 2011. Can the International Classification of Function, Disability and Health (ICF) be used in a prosthetics and orthotics outpatient clinic? Prosthetics and Orthotics International 35(3):302-9. Kohler, F., J. Xu, and C. Silva-Wiotmory, et al. 2011. Feasibility of using a checklist based on the International Classification of Functioning, Disability and Health as an outcome measure in individuals following lower-limb amputation. Prosthetics and Orthotics International 35(3):294-301. Geertzen, J. H. B., G. M. Rommers, and R. Dekker. 2011. An ICF-based education programme in amputation rehabilitation for medical residents in the Netherlands. Prosthetics and Orthotics International 35(3):318-22. Jarl, G., and N. Ramstrand. 2018. A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics. Prosthetics and Orthotics International 42(5):248-475. Royal College of Physicians and Surgeons of Canada. CanMEDS. Available at https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e

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