The Residency Experience

A survey of O&P residents provides insight into how residencies have evolved over the years. Introduction For aspiring O&P practitioners, a good O&P residency is where the rubber begins to meet the road. Having spent the previous four to six years in a classroom and/or laboratory setting, residency provides an opportunity for new practitioners to apply the knowledge they have learned in a supervised real-world setting. Residency represents an important continuation of the education process as well as a glimpse into the day-to-day working environment of O&P practitioners. Over the last two decades, O&P education and residency programs have evolved. The purpose of this survey was to investigate what aspects of the National Commission on Orthotic & Prosthetic Education (NCOPE) residency requirements have changed over time, what aspects have remained the same, and what aspects of the residency experience could be addressed for future improvement. History In 1998, William Lifford, CP, conducted a survey of individuals who had completed an NCOPE residency from 1995-1998. At the time, Lifford was a prosthetic resident at Alabama Prosthetics and Orthotics, Montgomery. ( Editor's note: The survey, Best of Resident Directed Studies, was retrieved from www.oandp.org ) The purpose of Lifford's study was to determine the qualities residents felt the "ideal" residency should possess, what areas respondents felt their residencies lacked among the stated "ideal" qualities, the numerical and geographical availability of NCOPE residency sites relative to new O&P graduates, the efficacy of current O&P education, and salary needs and/or expectations. Sixty-two residents completed the survey. While respondents were generally positive about their residency experience, potential problem areas were noted. NCOPE has since implemented several changes to the O&P residency program requirements. In July 2011, a similar survey was distributed to individuals who had completed or were in the process of completing an O&P NCOPE residency between 1999 and September 2011. The survey, which contained 105 questions highlighting topics pertinent to the participant's residency experience, schooling, and demographics, was open for two months. Methodology and Response Rate [caption id="" align="alignnone" width="350"] Figure 1: NCOPE Residencies Completed (509 residencies).[/caption] [caption id="" align="alignnone" width="350"] Figure 2: How Difficult Was It to Secure a Residency Position?[/caption] The survey was advertised predominantly through e-mail (specifically the NCOPE listserv, OANDP-L listserv, online NCOPE residency network directory, and via directors of O&P education programs), and to a lesser extent on various Facebook pages, through the oandp.com website, and by word of mouth. The survey was broken into three parts. The first part consisted of questions pertaining to respondents' orthotic residency experience, while the second part consisted of questions pertaining to respondents' prosthetic residency experience. Respondents who had experience with only one discipline were exempt from answering questions pertaining to the other discipline. The third part of the survey consisted of questions pertaining to education, certifications, and demographics. All questions in the orthotic and prosthetic sections of the survey were mandatory. However, open-ended questions, including asking participants about the strengths and weaknesses of their residency programs, and additional comments, were optional. In the third part of the survey, demographic questions also were optional. The 2011 NCOPE residency survey was completed by 374 participants; partially completed surveys were excluded from the results, as were responses from those who had not completed an NCOPE residency, those who had completed a residency prior to 1999, and those who failed to report significant data regarding the date they completed their residency. Data from the 347 usable responses was used to compile these results. [caption id="" align="alignnone" width="300"] Figure 3: Did You Use the NCOPE Website to Search for a Residency?[/caption] Demographics The 347 respondents had completed or were in the process of completing 509 O&P residencies. Residencies were grouped according to the year the individual was certified. Group one consisted of 49 practitioners who were certified from 1999-2003; group two consisted of 163 practitioners who were certified from 2004-2008; and group three consisted of 297 practitioners who were certified or awaiting certification from 2009-2011. (Figure 1) Results were tabulated for each of these three groups to show changes in the residency program over time. A chi-squared test of independence was used to determine significance among the responses when comparing categorical data among the three groups. P-values less than .05 were deemed to be statistically significant. Education Historically, a post-baccalaureate certificate has been the most common level of O&P education, followed by a bachelor's degree, and then a master's degree. However, as the profession transitions to a master's degree as the entry-level education requirement, there has been an increase in the percentage of people who have earned a master's degree. In comparing Group 3 to Group 1, there has been a 17 percent increase in respondents who have obtained a master's degree in O&P, an 11 percent decrease in respondents who have obtained an O&P post-baccalaureate certificate, and a 5 percent decrease in respondents who have obtained a bachelor's degree in O&P. [caption id="" align="alignnone" width="325"] Figure 4: How Helpful Was the NCOPE Website in Helping You Find a Residency?[/caption] [caption id="" align="alignnone" width="300"] Figure 5: Do You Have a Preference for What Type of Facility You Work?[/caption] Securing a Residency Beginning in 1999, an NCOPE residency became mandatory for all graduates of O&P practitioner-education programs. When asked, "How difficult was it to secure a residency position?" respondents gave mixed responses. From 1999 to 2011, the pattern of responses reported was not significantly different. On average, 56 percent of respondents indicated securing a residency position was "straightforward" or "somewhat straightforward." On average, 23 percent of respondents indicated securing a residency was "somewhat difficult." (Figure 2) Personal factors that can contribute to difficulties in securing a residency include site availability in the resident's desired location (for the purpose of this survey, defined as being within a 100-mile radius) and family obligations. On average, since 1999, 85 percent of respondents reported success in finding an available residency position within 100 miles of their desired location, a marked improvement from the 1995-1998 survey results, when about 60 percent of residents were able to do so. A possible explanation for this increase could be the greater number of residency sites that have become NCOPE accredited in response to the mandatory NCOPE residency. From 1995 to 2011, an average of 46 percent of respondents reported having restrictions (i.e., family, spouse's job, etc.) when looking for a residency. These figures correlate well to the 43 percent of respondents who reported having previous work experience in professions other than O&P. This population of residents is more likely to be older and have more familial obligations that influence their geographical search for a residency site. [caption id="" align="alignnone" width="300"] Figure 6: At What Type of Facility Was Your Residency Located?[/caption] Searching for a residency site near an academic institution with an O&P education program may also pose difficulties as the O&P facilities surrounding schools are often saturated with previous residents who have accepted permanent positions at these sites. Another factor that may influence residency choice is whether residents choose to work for a company that requires them to sign a non-compete contract. Although NCOPE states it "does not look favorably on the use of non-competes at any time during residency...[but] based upon legal recommendation, NCOPE cannot ban non-competition agreements...," since 1999, an average of 42 percent of respondents reported having been required to sign a non-compete contract—a 4 percent increase since 1999. According to the survey results, potential residents are sending out more resumés than they did in 1999, and there is a slight rise in respondents who report having more difficulty securing a residency site from 2004 to 2011. One possible explanation for this trend may stem from difficult economic times, and thus residents have to reach out to more companies in order to secure a residency position. Another possible explanation may stem from the increased number of online resumé distribution channels (e.g., e-mail, professional networking sites, job search databases, etc.). [caption id="" align="alignnone" width="320"] Figure 7: Scope of Practice in Residencies.[/caption] In keeping with the premise that potential residents have more opportunities to network through use of the Internet, since 1999 there has been a 26 percent increase in residents who report using the NCOPE website ( www.ncope.org ) to search for a residency. (Figure 3) This upward trend can be expected to continue as Internet technology becomes more advanced and usage increases. While an increasing number of respondents reported using the NCOPE website to find a residency site, since 2004 there seems to be a decline in the percentage of residents who expressed satisfaction with the website compared to 1999-2003. (Figure 4) Of all the resources used to help secure a residency, networking was reported as being the most helpful (on average nearly 50 percent of the time) from 1999 to 2011. Other helpful resources include contacts/information from O&P schools (16 percent), the NCOPE website (15 percent), online search engines (2 percent), O&P professional magazines (1 percent), and other (16 percent). The majority of "other" responses were from those who secured a residency through a current employer. Type of Facility [caption id="" align="alignnone" width="325"] Figure 8: How Much Guidance Did You (or Do You) Receive for Your Directed Study Residency Research Project?[/caption] The majority of residents reported "private practice" or "no preference" as to the type of facility in which they preferred to work; the pattern of responses has not significantly changed over the years. (Figure 5) Correspondingly, a greater percentage of residents reported having completed their residency at a private practice rather than in an institutional setting. (Figure 6) Scope of Practice According to the NCOPE Standards of Accreditation , "Residents must receive exposure to the following patient populations: pediatric, adult, and geriatric. They must also receive exposure in managing congenital, acute, and chronic pathologies." Respondents reported fairly consistently over the years, with an average of 74 percent indicating the scope of their experience was "very broad" or "broad." (Figure 7) These results are consistent with the 1995-1998 survey results, in which 78 percent of respondents indicated their residency's scope of practice was "broad" or "broad enough." [caption id="" align="alignnone" width="350"] Figure 9: How Well Did Your O&P Education Prepare You for Your Residency Experiences?[/caption] In recent years, computer-aided design and manufacturing (CAD/CAM) in O&P has become more advanced and its use more widespread; however, according to the survey results, the majority of respondents reported that they received "no experience" in their residencies with CAD/CAM. This may change in the future as CAD/CAM use becomes more widespread and residents receive more exposure to it. In 2011, NCOPE implemented an online residency tracking website known as Typhon. This website allows residents to keep an online record of their residency experiences. Prior to 2011, residents kept a paper log. Fifty-eight percent of respondents who have used Typhon reported overall dissatisfaction with the reporting system, while 18 percent of Typhon users found it to be a good way to track their residency experience. These results raise the question of whether NCOPE is acquiring data to reflect the residency experience accurately. Research is another mandatory component of the residency program. All NCOPE residents are required to complete a directed research study in their year of residency. Over the years, on average, 52 percent reported receiving "little guidance" to "no guidance at all" on this project. Additional guidance and mentorship from residency directors may help to encourage much-needed O&P research, thereby promoting evidence-based practice. (Figure 8) [caption id="" align="alignnone" width="325"] Figure 10: How Well Do You Feel You Met Your Residency Director's Expectations?[/caption] Residency Preparedness An important aspect of any healthcare educational experience is the expectation that students are adequately prepared for residency positions. When students do not have accurate expectations of their residencies, they might have feeling of stress or failure. Fortunately, most residents reported that their O&P training either "adequately prepared" (52 percent) or "very adequately prepared" (23 percent) them for their residency experiences. These response levels have been fairly consistent over the years. (Figure 9) In the 1998 survey, 87 percent of participants reported that they were meeting their residency director/mentor's expectations. These results are similar to the findings reported from 1999-2011, in which an average of 87 percent of respondents reported that they feel as if they met or were meeting their residency director's expectations either "well" or "very well." A small percentage of respondents reported that they felt they met or were meeting their director's expectations "not very well" or "not at all." There is a self-bias to this question, which can be viewed as a limitation. (Figure 10) [caption id="" align="alignnone" width="300"] Figure 11: How Well Is Your Residency Director/Mentor Meeting Your Expectations?[/caption] Conversely, when residents were asked if their residency director met or was meeting their expectations, most reported that their director met or was meeting their expectations "very well" or "well," while an average of 17 percent of respondents reported their directors met or were meeting their expectations "not very well" or" not at all." An effective mentor is a high priority to most residents, and it often plays a huge role in a resident's experience. (Figure 11) Compensation According to the 1998 survey, residents' salaries averaged $31,000. Residents' salaries have increased over the years, with the majority reporting that they earn between $31,000-$35,000. (Figure 12) An average of 62 percent of respondents who completed a residency between 1999-2011 reported that their salary matched their expectations. This percentage has been fairly consistent over time. Preparation for the ABC Exam [caption id="" align="alignnone" width="325"] Figure 12: Salary of Residents.[/caption] Over the course of the years covered in this survey, the majority of respondents reported feeling "very well prepared" or "prepared" to sit for the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) exam; however, there has been a decrease in the number of respondents who report that they felt prepared. Seventy percent of respondents reported feeling "very well prepared" from 1999-2003. By 2009-2011, only 29 percent of residents reported feeling "very well prepared" to sit for the exam. (Figure 13) While it is not clear why residents feel less prepared for the ABC exam, it is interesting to note that pass rates for the ABC exam courses have remained steady, with respondents passing 70 percent of the time, on average. ( Editor's note: Residents were not asked to rate preparedness levels in regard to Board of Certification/Accreditation, International [BOC] certification exams. ) Effectiveness of Residency From 1999-2011, about 80 percent of the respondents rated their experience as an NCOPE resident to be either "extremely beneficial" or "beneficial" to their O&P careers. These results indicate how critical the residency program is for providing a solid foundation for future O&P certified practitioners. Steps should be taken to provide the best experience possible for residents learning to be proficient clinicians. (Figure 14) Strengths/Weaknesses of the Residency [caption id="" align="alignnone" width="300"] Figure 13: How Prepared Did You Feel to Sit for the ABC Exam?[/caption] At the conclusion of the orthotic and prosthetic portions of the survey, respondents were asked for input regarding the strengths and weaknesses of their residency programs. It should be noted that many of the strengths and weaknesses are consistent with those reported in the 1998 survey. Items that were repeated as both strengths and weaknesses for prosthetics residencies included patient diversity, mentors, upper-limb experience, patient volume, independence, technical experience, and technology. Items that were repeated as both strengths and weaknesses for orthotics residencies included patient diversity, mentors, independence, fabrication experience, structure, and pediatric experience. The top four factors that were cited as strengths and weaknesses for orthotics and prosthetics include patient diversity, effective mentors, adequate independence, and fabrication experience. [caption id="" align="alignnone" width="300"] Figure 14: How Effective Was/Is Your Residency in Relation to Your O&P Career?[/caption] When asking residents what they would change in their residencies, if they could, most responses were reflective of what they had stated as being either a strength or weakness. Many residents responded that they would like more structure in their programs, and they would prefer not to do orthotics during their prosthetics residency. Others stated they would do their residency at a different company. It is noteworthy that what residents reported as being important to them has remained fairly consistent over time. Conclusion Results of this survey suggest that there have been many changes in the NCOPE residency since 1999, yet many aspects remain the same. Although overall satisfaction has been reported with the NCOPE residency experience, it is my hope that these results will be used to further improve the residency experience in the years to come. Denise Larkins, MSPO, CO, works for Children's Healthcare of Atlanta, Georgia. She conducted this survey as part of the directed research study for her prosthetics residency. She can be reached at linkEmail('denise.larkins','choa.org'); Due to space considerations, not all of the results could be presented. The narrative for the results presented has been edited for space and clarity. This survey was funded by the author's residency site, Scheck & Siress Prosthetics, Orthotics & Pedorthics, Chicago, Illinois. The National Commission on Orthotic & Prosthetic Education (NCOPE) did not provide funding for this project.

The Residency Experience

In Memoriam: James C. Russ

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