O&P Fabrication Education: Current Trends

Part of every O&P clinician’s education includes device fabrication. Prior to 1949, most professionals entered the profession through apprenticeship and mentoring that began with learning how to fabricate devices unique to O&P and its patients. 1 A little over 20 years later in 1972 the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) created the Educational Accreditation Commission to develop clinical O&P programs with colleges and universities. 1 It wasn’t until 1993 that the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the National Commission on Orthotic and Prosthetic Education (NCOPE) established standards and guidelines for education, establishing the minimum requirements to which an accredited program is held accountable. 2 Since that time, the minimum educational requirement for an orthotist/prosthetist has advanced to an entry-level master’s degree, thereby affecting the various educational institutions, courses offered, and in some cases the content and depth of content in those courses. There are numerous foundational content areas outlined within the core curriculum guide of the CAAHEP orthotist/prosthetist education standards, including technical skills, which are defined as: “The study and supervised practice of psychomotor skills necessary to ensure the safe and appropriate use of tools and equipment to formulate and implement orthotic/prosthetic treatment plans. Strategies include the use of technical/mechanical problem solving to assess, adjust, and direct the fabrication of orthoses/prostheses to meet patient-specific needs.” 2 Furthermore, it is required that students can formulate a treatment plan that includes selecting the materials, components, and fabrication methods to match the needs of the patient. This, combined with the materials science knowledge, mechanical principles, and accurate understanding of the patient presentation, is a complex combination for students. This is especially challenging for many students who enter programs with little to no prior technical experience or those with an undergraduate degree in something other than an applied science. Students have the common interest and goal of assisting patients, but often may not have a full or practical understanding of what will be required of them during the psychomotor and materials science portion of their education. The goal of a master’s level education is to teach these concepts while fostering independence and critical thinking so students can adapt to the various clinical challenges they will face as a certified clinician. Who Are Today’s Students? The O&P student body has changed in recent years and is constantly evolving. Students entering the profession are more diverse than ever, which is a positive step toward having inclusive representation in our profession. According to data sources from NCOPE’s annual reports completed by the CAAHEP-accredited educational programs, the average age for a master’s student in their first year of study is 24 years old. 3 This has remained consistent for the past three years. This relatively young age may indicate that students are enrolling with less professional training and in-depth exposure to the O&P profession. Figure 1 contains NCOPE gender data (required by regional accreditors) showing 62.8 percent of student applicants who used the O&P Common Application Service (OPCAS) are female. 3 This is an increase of 6 percent in the last five years. Two points of note are the 0.8 percent that declined to state gender, and that gender is self-reported in the student application. Depending on how students identify, they may have declined to state gender since the selection options for the years reported are binary. Additional options are forthcoming in future application cycles to be more inclusive. For students enrolled in CAAHEP-accredited orthotist/prosthetist programs, clinical programs are comprised of a similar percentage, 61.67 percent female and 0.17 percent being defined as other. 3 Technical programs have stayed approximately 50/50 with roughly 2 percent defining as other in 2020/2021. 3 Figure 2 shows how enrollment has changed in the past three years in both clinical and technical programs. Comparing this student data to the ABC Practitioner Practice Analysis published in 2015, in which 28 percent of orthotics respondents and 18 percent of prosthetics respondents identified as female, shows how the industry is changing and has changed in the past seven years. 4 As for ABC-certified technicians, a practice analysis in 2017 showed only 7 percent of respondents were female. 5 This large disparity could be due to a variety of reasons, including many technicians not being ABC certified, but does raise questions about gender and fabrication. Unfortunately, gender data does not exist for educators at the various O&P educational institutions, many of whom are teaching fabrication and materials science courses. As an example, at the University of Hartford, the course titled “Material Methods in P&O” changed from the certificate level where projects were related to either orthotics or prosthetics to now including both disciplines. Currently there are three psychomotor projects that include AFO fabrication, a laminated socket with Pelite liner, and a metal bending project with both calf and thigh bands. Developing these projects to their current state has occurred incrementally over numerous years, and for the first time in program history, the course is being led by three female instructors. Along with age and gender, there is more racial and ethnic diversity within the O&P student body. Figure 3 shows ABC and NCOPE data for the percentage of O&P practitioners and first-year enrolled students by race and ethnicity. 3,4 The 2020-2021 academic year shows the percentage of Caucasian students declining with many of the other racial backgrounds increasing. Comparing the NCOPE data to overall ABC data shows a significant increase in diversity since 2015. With the most recent ABC Practitioner Practice Analysis results currently being analyzed, there will soon be another data point for comparison. Instructors must be sensitive to the fact that students from diverse backgrounds may have diverse needs and prior experiences that could influence their comfort level and performance in a fabrication environment. Practice (and Theory) Makes Perfect There are many other ways instructing fabrication has changed independent of student and faculty demographics. Students at the master’s level must not only learn how to fabricate but also understand the theory behind each project and how to appropriately use the material in a clinical setting. Accredited O&P programs teach either a combined course including engineering concepts/materials science and fabrication or have them as part of two separate stand-alone courses. Regardless of course organization, most start by teaching safety and orientation to the equipment used in our profession. Many students have an undergraduate degree in an engineering discipline where they may have utilized lab equipment such as band saws, table saws, and various hand tools. This does not always translate to confidence and appropriate use of this machinery specific to O&P fabrication. For every student, regardless of demographic, the equipment used in our profession must be understood so that students feel confident in how to use each safely, for the appropriate application, and with confidence. Most tasks within the fabrication courses are psychomotor based, but students must also learn how to select the appropriate materials to achieve the desired patient outcome. Due to many students being unable to shadow in clinics or gain work experience during the COVID-19 pandemic, they may lack context or understanding for the actual application or appropriate patient scenario. As a result, an incremental approach is often used. As an introductory step, students perform a task or skill for basic familiarity. Next the theory and engineering principles are learned with the aid of some contextual experience. Lastly, students have the opportunity to practice that skill or project again, ideally numerous times throughout the duration of their educational programs. This helps in developing psychomotor skills while reinforcing the underlying concepts to build a level of fluency that can be employed in clinical situations. Another important consideration is the distinction between psychomotor skills and fitting skills. They do, of course, relate but are not always assessed in tandem as part of a materials science course. CAAHEP standards dictate students demonstrate entry-level competence with prefabricated and custom-fitted orthoses. 2 For custom-fabricated orthoses and prostheses, a minimum number for each is defined, and students must demonstrate skill and experience with fitting as well as material selection. 1 Figure 4 shows the NCOPE data for average number of devices fabricated in educational programs by academic year. 3 This data indicates that for most devices, with a few exceptions, students are fabricating more than the minimum required throughout their master’s education. If this data were compared to that from the time of certificate programs, it is possible students are being exposed to and performing many more projects across the O&P spectrum. Students often feel frustrated if they are not immediately at a level of proficiency and are conflicted about their grade for a particular project and the desire to improve their psychomotor skills, therefore feedback is also a critical component to a fabrication course and all courses. Instructors (and future employers) would prefer the student to worry less about the grade, but instead focus on the quality of work being produced. Some educators and institutions are moving toward not giving numerical grades but instead focusing on other methods of assessment. Ideally there are specific assessment criteria or rubrics to ensure students clearly understand the expectations. Asking the student, “Do you think this meets quality standards required to be delivered to a patient?” is a strategy employed by many instructors to bring the focus back to patient care. Often students are hyper-focused on the technique or theory and may overlook the clinical application. Fabricating orthoses and prostheses is the intersection of science, technology, and art that allows us to find creative solutions to real-world problems. Instructors quickly observe that each student has an individual approach to certain artistic aspects of a project and must provide honest feedback on how their art has combined the appropriate fabrication methodology and materials. Providing consistent and frequent feedback in a valuable and easily accessible format is a constant and time-consuming challenge but is vital to helping students improve and learn for future iterations. What it means to have “good hand skills” has also changed over time. In today’s O&P profession, it is more than hand-eye coordination and controlling variables. It is also the theoretical understanding of why materials are chosen and how to select the appropriate intervention for each unique patient need. As the profession has moved to more centralized fabrication, clinicians may not be performing each step of fabrication from the casting to the finishing processes. For the sake of efficiency, and in some business models, this is just not possible. This strongly supports the need for new O&P graduates to understand what it is they are selecting on order forms and consider how and what they are communicating with technicians. It is critical for students to understand the skill and effort technicians require to fabricate custom devices, even if they are not personally fabricating the device. In addition to changes in fabrication processes, the rapidly expanding options in technology cannot be ignored. The use of computer-aided technology is included in the CAAHEP standards, but there are other advanced processes such as 3D printing and rapid prototyping techniques that are not yet defined. 2 Exposing and training students on emerging technologies can be a challenge, especially when there may be little evidence-based research relevant to the O&P profession. If a master’s program chooses to go beyond the minimum standards, it must be decided which technologies are appropriate to include, identify the applicable course, find available time, and determine the appropriate level of depth so students can incorporate this knowledge in a beneficial way. As any clinician knows, adjusting fit and solving fit issues is a large part of being a skilled practitioner. It is impossible to teach students how to troubleshoot every potential patient issue. This could consume entire semesters of course work that is not built into most academic programs. The role of an educator is to provide students with a solid theoretical foundation and teach them the way to critically solve problems so they are equipped to enter residency where they will gain exposure to various clinical scenarios. Additionally, there is the concern for being too prescriptive in a way that prevents students from thinking independently. Having students memorize solutions to problems is not likely to assist them in their clinical decision-making. In this new era of centralized fabrication and changes to instructional delivery methods, the need for students to learn and practice necessary psychomotor and fabrication skills are still as important as in the times of apprenticeships, perhaps even more so since hands-on experience can be difficult to find. As our students have received more online and remote instruction, the need is greater than ever to maximize the time spent in the lab to allow students ample time to practice and hone these skills. Student and educator demographics, instructional methods, and fabrication technology will continue to evolve, requiring educational institutions to adapt to the changing needs. We owe it to our patients and future patients to equip their practitioners with the best set of skills and knowledge possible to assist them in achieving their goals. O&P EDGE Lindi Mitsou, MSPO, CPO, is an assistant professor at the University of Hartford and chair of the Fabrication Sciences Society for the American Academy of Orthotists and Prosthetists. She can be contacted at mitsou@hartford.edu . References American Board for Certification. 2022.Our History. https://www.abcop.org/who-we-are/history. Commission on Accreditation of Allied Health Education Programs. 2017. Standards and Guidelines for the Accreditation of Educational Programs in Orthotics and Prosthetics. National Commission on Orthotic and Prosthetic Education. https://ncope.org/index.php/home-page-v2/academic-programs/institution-educator-info/caahep-standards-request-for-accreditation-services National Commission on Orthotic and Prosthetic Education. 2022. [data sets]. Chris Robinson [distributor]. American Board for Certification in Orthotics, Prosthetics and Pedorthics. 2015. Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics. www.abcop.org/publication/section/practitioner-practice-analysis/results-related-to-professional-background-work-setting-and-demographic-information American Board for Certification in Orthotics, Prosthetics and Pedorthics. 2017. Practice Analysis of Certified Technicians in the Disciplines of Orthotics and Prosthetics. abcop.org/publication/section/practice-analysis-of-certified-technicians-in-the-disciplines-of-orthotics-and-prosthetics/results-related-to-professional-background-work-setting-and-demographic-information

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