<img style="float: right;" src="https:\/\/opedge.com\/Content\/OldArticles\/images\/2002-08_21\/2002-08_21_01.jpg" hspace="4" vspace="4" \/>\r\n\r\nThe British Columbia Institute of Technology\r\n(BCIT), Vancouver, Canada, has recently concluded a visioning\r\nreport <sup>3,4<\/sup> and is in the final stages of carrying out a\r\nmarket analysis on the fields of prosthetics and orthotics. In\r\nreviewing the results of the visioning process, the most serious\r\nthreat to orthotics and prosthetics of all those identified appears\r\nto be the lack of certified orthotists.\r\n\r\nThe problem itself is typically expressed as: There is an\r\nundersupply of certified orthotists, and encroachment into\r\northotics is rampant. How are we going to deal with this? Suggested\r\nanswers range from strategies for better regulation to advertising\r\ncampaigns promoting the certified orthotist as the "expert" in the\r\nfield. The focal point in this passionate debate is typically on\r\nthe encroachment aspect of the problem. In fact, encroachment is\r\nonly a symptom of the real problem: there simply are not enough\r\ncertified orthotists. This problem is not going to be solved by\r\nregulation and will be exacerbated by advertising, which, if\r\nsuccessful, will only increase the demand for certified\r\northotists.\r\n\r\nBesides restricted ability to meet market demands, professions\r\nwith small memberships like ours have several other hallmarks\r\nlimiting their ability to thrive. Small numbers prevent effective\r\nlobbying and result in most people entering clinical practice, as\r\nopposed to moving into academic roles. Since so few\r\nprosthetists\/orthotists go on to PhDs and enter the academic world,\r\nprosthetics and orthotics experts are from outside the profession\r\nby default, thus firmly trouncing any idea that certified\r\northotists are the experts in the field.\r\n\r\nNone of these threats should be considered new. Marty Carlson,\r\nCPO, clearly pointed out the need to dramatically increase the\r\nnumber of certifees in his 1997 article in O&P Almanac1, and\r\nDr. Sid Fishman used sound, logical arguments in an article in\r\nO&P Business News to point out that the educational system set\r\nup for prosthetics and orthotics has, in all likelihood, failed to\r\nmeet its goals <sup>2<\/sup> .\r\n\r\nTaking all these factors into account, the strategic position of\r\ncertified orthotists is weak. They now have little real control\r\nover what actually happens to them-a serious position to be in,\r\nconsidering today's economy.\r\n\r\n<b>What Can We Do?<\/b>\r\n\r\nAcknowledging that the small membership of our profession is a\r\nsignificant problem is one thing. Dealing with the situation is\r\nquite another. Some possible solutions would include:\r\n<ul>\r\n \t<li>Radically increase the number of students educated. [Editor's\r\nnote: Efforts are underway in the US to attract more students to\r\ncareers in O&P. Future issues of The O&P EDGE will report\r\non these initiatives];<\/li>\r\n \t<li>Actively recruit immigration by practitioners who are from\r\nindustrialized nations with similar levels of academic training and\r\nhave at least one to two years of clinical experience, and grant\r\nthem automatic certification or allow them to immediately sit for\r\nthe certification examination;<\/li>\r\n \t<li>Do away with [awarding only] single certifications [in Canada],\r\nso that persons who have studied both prosthetics and orthotics are\r\ngranted dual certification to practice.<\/li>\r\n<\/ul>\r\nWhatever the solution chosen, unless the undersupply is dealt\r\nwith, non-certified orthotists will continue to establish\r\nthemselves, building legitimate expertise in the provision of\r\northotic devices. Furthermore, the problem will soon begin to\r\naccelerate as the impact of an aging population really starts to be\r\nfelt. This is arguably the single greatest threat to the certified\r\northotist at this time. All other problems orthotists face with\r\neventually pale by comparison, unless a strategy to deal with this\r\nissue is implemented in the very near future.\r\n\r\nThe March issue of Journal of Prosthetics and Orthotics included\r\na report on a visioning process4 conducted as part of a curriculum\r\nreview by the Prosthetics and Orthotics Department at the British\r\nColumbia Institute of Technology (BCIT), Vancouver, British\r\nColumbia, Canada. <sup>5,6<\/sup> . Many interesting points arose in\r\nthe process of the visioning process, but one point stands out with\r\nrespect to the ability or inability of certified orthotist to adapt\r\nthemselves to the changing marketplace. Of all the threats\r\nidentified, the most serious appears to be our lack in numbers.\r\n\r\nThe problem itself is typically expressed as: There is an\r\nundersupply of (certified) orthotists and encroachment into\r\northotics is rampant. At the same time, the aging of the population\r\nwill result in an increased need for orthotic devices. How are we\r\ngoing to deal with this?\r\n\r\nIt is the issue of encroachment that typically leads to the most\r\nspirited discussions amongst certified orthotists. Many suggestions\r\nand strategies are debated regarding to how to deal with it. Ideas\r\nrange from better regulation, in the form of licensing or preferred\r\nprovider status, to carrying out advertising campaigns promoting\r\nthe certified orthotist as the "expert" in the field. What use\r\nhowever, is an advertising campaign or preferred providership, if\r\nthere are too few persons to perform the service being\r\nadvertised?\r\n\r\n<b>Encroachment: Only a Symptom<\/b>\r\n\r\nEncroachment, however, is simply a symptom of the real problem,\r\nwhich is lack of numbers. By attempting to solve the perceived\r\nproblem of encroachment, time is wasted as the problem itself is\r\nnot dealt with-a problem which will be exacerbated significantly as\r\nthe population ages.\r\n\r\nWhen any market is under-serviced by a given group, basic market\r\nprinciples will dictate that others will move in to fill that\r\nmarket need. The longer these other groups have access to that\r\nmarket, the more established they become in that market. In the\r\ncase of foot orthotics, for example, pedorthists, podiatrists, and\r\nsome physiotherapists\/occupational therapists have provided service\r\ninto this market over the past 15 years, to the point that they are\r\nwell-established and are providing a competent level of service.\r\nDue to our historic inability to meet the demand in all areas of\r\northotics, this is now also happening in other orthotic market\r\nsegments, from knee orthoses to upper limb and spinal.\r\n\r\n<b>Educating More Prosthetists and Orthotists<\/b>\r\n\r\nBoth Neilson <sup>4<\/sup> and Blocka1 have highlighted the need\r\nto educate more prosthetists and orthotists. Blocka focuses on the\r\nnumber of students we need to educate to replace those certifees\r\nwho are retiring. Neilson expands the topic by also examining other\r\nfactors, such as the effect of an increasing market size due to the\r\naging baby boom population.\r\n\r\nHowever, no publicly available study has ever been done to\r\nestablish if the population had ever been serviced adequately to\r\nbegin with. Such knowledge is critical if any strategic planning is\r\nto be done, since not knowing if the baseline used is correct,\r\nweakens the power of estimates established using that baseline.\r\nEven without the availability of such a marketing study, it can be\r\nestimated that the market for orthotic services has been\r\nunderwhelmingly served over the past two decades, by simple\r\nobservation of the encroachment from a myriad of other persons and\r\nprofessions into that market. To deal with this lack of information\r\nin doing educational planning, BCIT has engaged a consultant to\r\ncarrying out such a study. It is anticipated that the results will\r\nbe available in mid-2002, and they will be available to all\r\ninterested parties.\r\n\r\n<b>Small Numbers: A Limiting Factor<\/b>\r\n\r\nAside from the purely business aspect of small numbers,\r\nprofessions with small memberships such as ours have several other\r\nhallmarks which limit their ability to thrive. These are that small\r\nnumbers:\r\n<ul>\r\n \t<li>prevent effective lobbying and<\/li>\r\n \t<li>ensure that most people enter clinical practise, as opposed to\r\nperusing an academic career.<\/li>\r\n<\/ul>\r\nThe effect of small numbers on lobbying clout is obvious. The\r\ndanger of having few to no members of a profession involved in\r\npeer-reviewed academic research is less obvious. With less than 20\r\ncertified orthotists\/prosthetists in the world having PhDs, many of\r\nwhom are not employed by universities and engaged in setting up\r\nprosthetic and orthotic research programs, prosthetics and orthotic\r\nexperts are by default from outside the profession. As a result,\r\ndecision-makers, such as government and regulatory bodies, must\r\nturn to medical doctors, podiatrists, therapists, and engineers for\r\n"unbiased, peer-reviewed expertise" in orthotics.\r\n\r\nThese professions, in turn, have become the established and\r\nacknowledged "experts" in the area and are the ones driving the\r\northotics profession and its development. Not being members of the\r\nprofession, they have no stake in nurturing it. This particular\r\nproblem is exacerbated by the fragmented prosthetic and orthotic\r\neducational system in North America, making it difficult for those\r\nwho wish to do so to move into the academic world and to rise\r\nwithin it.\r\n\r\nMoreover, none of this should be considered to be news. Marty\r\nCarlson, CPO, clearly pointed out the need greatly increase the\r\nnumber of certifees in his 1997 (!) article in O&P Almanac2. In\r\nan article in O&P Business News, Dr. Sid Fishman pointed out\r\neloquently, using sound, logical arguments, that the educational\r\nsystem set up for prosthetics and orthotics neither raises us to\r\nthe peer-recognized (medical professionals other than ourselves)\r\nstatus that we aspire to, nor, it can be extrapolated, meets the\r\nneed for supplying the numbers we require 3. In other words, it has\r\nfailed to meet its goals.\r\n\r\nAll the above factors, in combination, result in certified\r\northotists having little real control over what actually happens to\r\nthem-a weak position, in today's economy.\r\n\r\n<b>Possible Solutions<\/b>\r\n\r\nAcknowledging that the small membership of our profession is a\r\nsignificant problem is one thing. Dealing with the situation is\r\nquite another. Some solutions to dealing with this problem would be\r\nto:\r\n<ol>\r\n \t<li>Radically increase the number of students we educate<\/li>\r\n \t<li>Actively recruit immigration to our countries from\r\nindustrialized nations where practitioners have similar or higher\r\nlevels of academic training courses, plus one to two years clinical\r\nexperience. These persons should either be:\r\n<ol>\r\n \t<li>granted automatic certification or<\/li>\r\n \t<li>be allowed to immediately write the certification examination.\r\nInternships and residencies are bottlenecks in the process at a\r\ntime when it is imperative to increase numbers quickly. The\r\nargument is made that we don't "really" know if these persons are\r\ncompetent to "our" standards. However, if the second case in option\r\ntwo is used, the certification exam itself will provide the filter\r\nto ensure that a baseline of experience\/performance is met by\r\ncandidates. If candidates are not competent to practice, they will\r\nnot pass the examination. If they pass anyway, then the exam is\r\ninvalid, and there is a much more serious problem, since there will\r\nalso be certified "locals" who are not competent being set loose on\r\nthe population. This method is used successfully in numerous other\r\nprofessions, such as nursing, engineering and physiotherapy-and\r\nwould work equally well for prosthetics and orthotics.<\/li>\r\n<\/ol>\r\n<\/li>\r\n \t<li>Do away with single certifications [in Canada]. In most cases,\r\nstudents have studied both prosthetics and orthotics. Sound\r\narguments can be made that persons can practice both disciplines\r\neffectively without having to traverse two separate and lengthy\r\npaths towards dual certification. In fact, many other\r\nindustrialized nations do not make the artificial divide between\r\nthe two professions, with successful results. This model has been\r\nclinically proven in other countries. This option also makes sense\r\nfrom a business strategy point of view, as workload planning\r\nbecomes easier and more flexible, allowing immediate market needs\r\nto be met quickly and easily by all members of the profession.<\/li>\r\n<\/ol>\r\nNone of these solutions are popular and easy to implement.\r\n\r\n<b>Obtaining Financial Support<\/b>\r\n\r\nMaking significant increases in enrollment is not a\r\nstraightforward process, and increased enrollment does have the\r\ndesired effect until five to ten years into the future. In\r\naddition, prosthetic and orthotic educational programs are\r\nexpensive to run on a per-student basis. These programs must be\r\nsubsidized either by government\/organizations or by high tuition\r\nfees. Such monies are typically garnered through strong lobbying\r\nsupported by a clear rationale and strategic plan, which becomes\r\nquite challenging for orthotists and prosthetists, due to their\r\nsmall numbers.\r\n\r\nIn his article, Carlson2, proposed a unique solution that would\r\nreduce the effect of the high costs of education: facilities and\r\ncertifees themselves would make a financial contribution of 0.1\r\npercent of their earnings toward supporting prosthetic and orthotic\r\neducation. This is not unlike how the Bundesfachschule [Federal\r\nTechnical School] for Prosthetics and Orthotics in Germany is\r\nsupported. Sadly, it appears no has risen to Mr. Carlson's\r\nchallenge in supporting such a venture.\r\n\r\nFinally, the issue of using for-profit clinics in the schools to\r\nfund the educational programs as a suggested solution must be\r\naddressed. This method of funding brings with it a host of\r\nproblems, ranging from sustainability to issues surrounding\r\nacademic freedom (difficult to achieve if faculty members are faced\r\nwith maintaining a bottom line) and to possible negative impacts on\r\neducational quality. This approach must be approached with extreme\r\ncaution, if at all.\r\n\r\nThe second two solutions listed are unpopular with the general\r\nmembership of the profession as each member of the profession\r\nimmediately sees the specter of "competition"' looming over their\r\nheads as the "floodgates" to perceived outsiders are opened.\r\n\r\nIn an under-serviced market however, the real competition is not\r\nfrom "within," but from outside the profession. This argument is\r\nlike attempting to plug a hole at the bottom of a dam to stop\r\nflooding when there is a breach in the dam above. A bonus of this\r\napproach is that by welcoming more members into the fold-as opposed\r\nto excluding people-lobbying power is expanded.\r\n\r\nWhatever the solution chosen, unless the undersupply is dealt\r\nwith, non-certified orthotists will continue to establish\r\nthemselves, building legitimate expertise in the provision of\r\northotic devices. Furthermore, the problem will begin to accelerate\r\nshortly as the impact of the aging of the population really starts\r\nto make itself felt. This is arguably the single greatest threat to\r\nthe certified orthotist at this time. Not addressing the issue,\r\nwill make all other problems orthotists face pale by comparison,\r\nunless a strategy to deal with this issue is implemented in the\r\nvery near future.\r\n\r\n<b>References:<\/b>\r\n<ol>\r\n \t<li>Blocka, D, et al, Demographic Study of the Prosthetic and\r\nOrthotic Profession in Canada, 1990<\/li>\r\n \t<li>Carlson, M, Offering a "O,1-Percent Solution", O&P Almanac,\r\nSeptember, 1997Fishman, S., The Professionalization of Orthotics\r\nand Prosthetics, O&P Business News, June 1, 2001<\/li>\r\n \t<li>Neilson, C., Issues Affecting the Future Demand for Orthotists\r\nand Prosthetists, NCOPE, November 1996<\/li>\r\n \t<li>Raschke, S.U., Visioning Exercise, Prosthetics and Orthotics:\r\nResults and Recommendations, BCIT Internal Report, <a href="https:\/\/opedge.com\/2659">www.health.bcit.ca\/P&O\/<\/a> , 2001<\/li>\r\n \t<li>Fishman, S., "The Professionalization of Orthotics and\r\nProsthetics, O&P Business News, June 1, 2001<\/li>\r\n \t<li>Raschke, S.U., "Report on Key Points Arising from Visioning\r\nProcess on Prosthetic and Orthotic Education Done at the British\r\nColumbia Institute of Technology," JPO, 14(1)<\/li>\r\n<\/ol>\r\nSilvia U. Raschke, PhD, CO (c), is principal investigator for\r\nthe Centre for Rehabilitation and Technology that Enables (CREATE)\r\nat the British Columbia Institute of Technology (BCIT).