O&P Ten Years Later, Part Three: Raising the Bar in O&P Education and Professional Standards

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By Judith Philipps Otto

In early 2009, O&P experts identified trends most likely to impact the profession during the next decade and discussed challenges that lay ahead for its professionals and suppliers. Our three-part follow-up began in January, as we revisited their predictions and reviewed a decade of progress. It continued in March with a focus on the economics of outcomes and the evolution of patient care, and it concludes this month with a look at where major changes in educational standards have brought us and speculations about where our pursuit of higher professional standards is likely to take us in the next decade.

Elevate O&P Professions
Exactly what defines a "qualified provider" continues to be a source of controversy, and the latest (2017) attempt to implement Section 427 of the Benefit Improvements and Protection Act (2000) also met with opposition. 

"ABC [the American Board for Certification in Orthotics, Prosthetics and Pedorthics] and other O&P organizations have specifically reached out to CMS [the Centers for Medicare & Medicaid Services] and offered to work on revised regulations, but we have not been really taken up on that offer," Cathy Carter, ABC executive director explains, although the O&P Alliance continues to look for ways to promulgate appropriate regulations.

She points to the O&P Improvement Act Bill passed in part in February 2018—a "big win" that allows the orthotist's or prosthetist's notes to be considered a part of the patient's medical record. "All of the Alliance organizations are continuing to try to work on distinguishing O&P care from that of durable medical equipment. Currently we are working on the Medicare O&P Patient-Centered Care Act."

Meanwhile, the profession polices itself, supports its certifying bodies in efforts to raise performance standards, and works to ensure that CMS requirements are in the best interests of patient care.

Dennis Janisse,CPed, president and CEO, National Pedorthic Services, headquartered in Brookfield, Wisconsin, applauds the 2007 merger of ABC and the Board for Certification in Pedorthics and joins others in praising the partnership of the American Orthotic & Prosthetic Association (AOPA) and the Alliance. "Together they have learned how to represent our industry, including pedorthic. They do a great job of representing us."

Robin Seabrook,executive director, National Commission on Orthotic & Prosthetic Education (NCOPE), confirms that the pedorthic group came under the NCOPE umbrella in 2009 and in 2015 made the commitment to bring pedorthic educational standards under the Commission on Accreditation of Allied Health Education Programs (CAAHEP) system. At this writing, assistant standards were to be approved by end of July; board approval of associate-level pedorthic degrees is anticipated this fall.

"Our standards are tied to what's happening in clinical practice," she says. "We get that feedback from communities of interest, as well as ABC's practice analysis, and use it to develop the minimum level of education."

Chris Hovorka, PhD, CPO/L, FAAOP, assistant professor, University of Pittsburgh,suggests that standards are needed for products as well as for facility and healthcare provider certifications and education programs. "In our profession the prosthetic and orthotic devices that we provide are essentially the treatments. In another context, we provide a motion-controlling therapeutic tool as the treatment. If that motion-controlling tool is the byproduct of a prosthetist-orthotist patient treatment—then what are the standards for quality of the product? There are virtually none."

The Move to the Master's Degree Requirement
"From ABC's perspective," says Carter, "one of the most important advancements [since 2009] is the change in the orthotist and prosthetist education standard from a bachelor's degree or post-baccalaureate certificate to a master's degree in orthotics and prosthetics.

"ABC certification requirements for practitioners will be changing January 1, 2020, when we'll be requiring a master's degree in orthotics and prosthetics for candidates who are interested in taking the orthotist OR prosthetist exams. Our current requirements are either a bachelor's degree in orthotics-prosthetics or a post-baccalaureate certificate in orthotics and/or prosthetics. That is all rapidly changing."

ABC's certification requirements change as education curricula and standards change, Carter says, so the journey to the master's degree requirement began with NCOPE. Seabrook confirms that NCOPE formally adopted the education standards for the master's program in 2010 and allowed a four-year phase-in period for school programs to complete the transition by 2015, when all programs were enrolling students at the master's level. She adds that changes and upgrades to the original master's standards were approved in July 2017.

"When candidates coming out of a formal O&P education have a master's degree in orthotics and prosthetics, it's a natural evolution for certification eligibility criteria to also change," Carter explains. "There are no single-discipline programs anymore; so, we're finding that most candidates are taking both sets of exams—both orthotics and prosthetics—to become a CPO."

In ten years, she speculates, ABC will no longer test in single disciplines. "Even if people have a personal inclination for orthotics or prosthetics, they find the CPO certification is more marketable."

The number of schools offering an O&P program remains at 13. "We didn't lose any programs due to the transition, which was one of the fears when we moved to the master's," Seabrook says. "As a matter of fact, several of our programs, including Northwestern, offered more seats than we were predicting they would be able to do."

The master's move also fueled development of a different educational model: Within the last decade, NCOPE approved the addition of the combined 18-month residency program now offered at Baylor College of Medicine, which is being considered by others, as well. "Individuals complete their didactics, then go through an 18-month residency. Then they are eligible to pursue certification immediately following graduation," she notes.

Michelle Hall, MS, CPO/L, FAAOP(D), former American Academy of Orthotists and Prosthetists (the Academy) president, Gillette Children's Specialty Healthcare, St. Paul, Minnesota, recalls that "nationally, some people were really worried that the move to the master's would decrease applicants to O&P schools," but since then, her professor colleagues report having to turn more applicants away from the same number of seats as when they were baccalaureate or post-baccalaureate.

"At the time that the industry changed to a master's level certification, there were concerns," agrees Kevin Carroll, MS, CP, FAAOP(D), vice president of prosthetics, Hanger Clinic, headquartered in Austin, Texas."But without that change, where would we be today? We need this level of educated clinician. It's a real joy to interact and work with today's younger clinicians who have master's degrees, in that they bring so much to the clinical environment."

Enhanced professional credibility is another bonus consequence of the master's degree upgrade, Hall says. "Legislators often ask what our educational level is. Now we can say it's entry-level master's degree with a one- to two-year residency; we're educated similarly to PT, OT, and other allied health professions. It's just the way we provide care that's different. That starts to resonate and will help us move forward."

Improving Education for Better Patient Care
Of primary concern to many respondents was the need for more research to support evidence-based practice, and knowledge about how to use it.

"Looking back on the last ten years," Carroll reflects, "one great positive has been seeing how we have anticipated the needs of the clinician of today to be well versed in the science of prosthetics and orthotics, and especially the evidence and research element. It's a credit to our universities putting out such high-caliber students, and it's a joy to work with these individuals in the field."

To that end, Seabrook says, NCOPE was motivated to expand the curriculum to introduce future orthotists and prosthetists to research, making them effective consumers of it, capable of implementing outcomes-based practice methods, and feeding that data and information back into the profession, while also expanding patient-care services.

"Within the last ten years, the body of evidence has increased as new research has been conducted and published; and most of the information is accessible," observes Hovorka. "But the bigger limitation has been clinicians' knowledge and awareness of the information and where to find it; and then, once you acquire the information, how to understand it and use it to your and the patient's advantage.

"Although NCOPE requires all of the programs to cover research, they don't offer specific guidelines on how to formulate a question, read information, and integrate it into a plan of care," he says.

Scott Bretl, CPO, program director, Alabama State University, anticipates that the increasing demand for evidence-based practice will create a continuing need for people with doctoral levels of experience with research. "There aren't many PhD researchers with backgrounds in P&O, so they may not be as well prepared to identify what might be most clinically relevant or have the greatest impact on the average patient." 

Hovorka, who played a role in pushing for the master's degree, shares Bretl's concerns. "The entry-level master's degree programs are still maturing and developing. The profession doesn't have much of an employee base of individuals to select from that can step up to provide rigorous graduate-level education. We still lack the human resources with the advanced knowledge to deliver the clinically relevant theory of P&O in the required curriculum. That information is the basis for clinical care.

"If you had asked ten years ago, ‘How many people in the U.S. have a PhD and are certified in either orthotics, prosthetics, or both, through ABC?' the answer would be probably less than five. Today, roughly five or ten years later, the answer is going to be probably over 20. That is progress—but the numbers are still small."

Demographic Changes in O&P Education
"The biggest change in education isn't about education itself, it's about who's going to school," says Dave McGill, JD. "The significant influx of female practitioners into the field is a fantastic thing for O&P—a necessary thing. We need as diverse a group of people treating people as the patients they themselves are treating."

Jim Rogers CPO, FAAOP, Academy past president, Pinnacle Orthotics and Prosthetics, Chattanooga, Tennessee, credits this change to a $5 million grant to the Academy from the Department of Education that lasted from 2004 to 2010 and supported development of programs to increase the number of women applicants.

"Within three years of establishing that program nationwide, which included public service announcements on TV and radio, we saw an increase of 50 percent in female applicants to O&P schools, and that has continued. Maybe it's because the recent conflicts, the increased notoriety of Paralympic athletes, and increased publicity about O&P have increased awareness among guidance counselors and student advisors of orthotics and prosthetics as a professional option. We are no longer an unknown profession," Rogers says.

Carter agrees. "I have heard from some of our female candidates that they became more attracted to O&P as a profession when it became more clinical and less technical. Less about plaster and bending metal and more about the clinician's role in the rehabilitation team. Quite a few women have told me they were attracted to that."

She points out that colleges and universities may find that an O&P curriculum dovetails nicely into other programs they have in the rehabilitation spectrum, from occupational and physical therapy to biomedical engineering, kinesiology, and other patient-centered programs. "So, I definitely think that we will continue to see the percentage of females in the profession increase."

Seabrook's data reflects a consistent increase in female applicants from programs reporting through a centralized application service, which jumped from a 58.18 percent share of applicants in the 2017-2018 cycle to 66.67 percent in the 2018-2019 cycle. The statistics themselves are another marked improvement over the previous decade: "We have more data now than we ever had in the past. We even have ethnicity and age information showing that the median age since we moved to the master's has also gotten younger. Post-baccalaureate certificate students tended to be second career seekers—finding a different profession—so the average tended to be a little bit older."

Bretl notes that at his historically black college and university, "there's been a drive to support diversity in the field, so I recognize our responsibility to reach out to more under-represented populations around Alabama; yet our cohort of ten students right now come from nine different states—not because we turned away Alabamans, but because people from all over the country applied."

More of Bretl's applicants are also coming directly from undergraduate programs—which raises another potential concern: "In a clinical healthcare field where you have direct interaction with patients, it's important to develop those interpersonal skills. Students applying to grad school have been just doing school for their entire life and may lack work experiences that have challenged their personal interactions with others. So, it's a priority that educators emphasize and model exactly how to interact with people in a patient care setting—and it should be a clear mentorship responsibility during residency."

"The gender shift in the mix of students graduating from O&P schools is very visible and long overdue," agrees Vinit Asar, CEO, Hanger Inc., pointing to Hanger's Women in Leadership programs, part of diversity and inclusion initiatives developed to address the changing demographics in their workplace. "I believe this issue has not yet been front and center within O&P as a whole, but I see encouraging signs of some organizations like ours paying close attention to it."

Can We Afford It?
The rising cost of education is a barrier that concerns some. "The costs of going to a P&O education program in the U.S. have gone up exponentially in the last ten years," Hovorka says. "Those bills are increasing, and the students are bearing the load through greater tuition and fees."

A troubling related trend he points out is the changing demands of the students and families that support the programs. "Ten years ago, students may have required that education programs have generally pleasing facilities and a really rigorous education. Now many universities have addressed a new demand for aesthetics and luxuries. Those cost money to create. At some point soon," he fears, "the cost of education may exceed the tolerance for students and their families to pay."

"Our O&P education has never been better," says Rogers, but he agrees that the cost of education is increasingly prohibitive. "Practitioners are coming out with a lot of debt, and the prospect for making enough money to pay that debt off and still have a comfortable lifestyle is diminishing because reimbursement is going down. These realities also diminish the potential for increased diversity. That's an issue we have to deal with as a profession."

One solution Hovorka relays is an offer from some of the schools to reduce student costs by reducing the time it takes to get through the program. Unfortunately, he points out, that affords less time for learning.

"The current workplace is asking the schools to create a talented, skilled, experienced pool of applicants they can hire, and the schools are trying to do that under the constraints of less available time and resources, and it's not possible. So, the schools are falling short in the eyes of the facilities that need to hire practitioners."

Many schools have increased their enrollment as a strategy to survive, he notes, which means educating more students with the same number of faculty, further imperiling the quality of the education the students may receive.

Reshaping Our Future: Trends to Watch—and Influence
Although Rogers agrees that today's graduates are exceptionally well prepared to serve as clinical practitioners, he also stresses that "as a profession we have to document at a very high standard, and we have not yet reached that standard. The documentation differences from one orthotist-prosthetist to another are stark. Some people still handwrite notes that might say, ‘fit prosthesis today', while others might provide five or six pages of comprehensive notes. We will never be accepted as medical professionals if our documentation continues to lag behind other professionals."

Emerging graduates have a better grasp of what's required professionally, he notes.

"All that energy and leadership that's coming out of the schools is a very good trend and it bodes well for the future, but we need to move faster or we'll get left behind."

Hall predicts that as clinicians start to embrace evidence-based medicine, "that will help to move us in the next ten years towards more standardized use of outcome measures as well as more standardized patient care."

She also dreams of futuristic digital simulations to aid teaching. "Among the hardest things to teach are effective alignment changes. It's hard to see that change visually, in real time. Video technology can help us slow things down—and will probably become even more widely used. But what if a really cool digital simulation could show pain in an area when a specific slight change is made? And similarly, from an orthotic perspective, if you mal-align (not purposefully) a knee joint for a KAFO, how will that affect the forces that are adversely applied to a patient's limb?

"It's discussed when we learn it in school, reinforced in residency, probably tested on exams, etc.—but hard to conceptualize. We've tried various methods like the 2D models. This is where a 3D digital simulation is sort of the next step when it comes to teaching."

Practice analysis figures lead Carter to predict that outcomes measures—and the data derived from them—will receive even greater emphasis, especially relative to the achievement of patient goals. "I see more emphasis on the use of research in patient care, and I think that we'll probably start to see an increase of emerging technology, such as 3D printing and new materials."

Hovorka predicts continued and increasingly creative use of prefabrication and reliance on central fabrication. "I wouldn't be surprised to see more savvy designs—particularly in the area of orthotics, where there are more modular systems with a wider range of component sizes that can be assembled to create a finished product. Limitations in prefabricated size availability may create opportunity for central fabrication facilities to customize the design.

"Another emerging trend may be for the clinician to customize the desired device by 3D printing the item."

Bretl also anticipates a new willingness of companies to embrace more technology as the younger generations take over; that definitely includes increasing use of central fabrication. "Even though it has a strong foundation in being an art form, we know that O&P is somewhere in the spectrum between an art and a science. And I think things are moving more in the direction of science."

Hall looks forward to better ways to inform the profession via an accessible Academy database that responds with three to eight summarized articles that answer your question on a critically appraised topic (CAT). "The Academy has been working on it for between five or ten years, and now, increasingly with the master's, we're getting more people submitting. I'm hopeful that ten years from now this database will be available for people to use as a resource."

She chairs an Academy-sponsored journal club that encourages discussions of evidence-based medicine among clinicians and awards CEUs for it. "Read the article, watch the presentation, and discuss it minimally with one other person in the profession."

She also points to the Academy's "really fantastic resource of ‘how to' outcome measure videos" that have been developing over the last decade.

"We're not quite to the point where everyone across the country is standardly using outcomes measures in their practice, but the Academy is creating tools to be able to move to that," Hall says.
