Thoughts on the Profession
Ira Schoenwald, Ph.D.
The Role of the Profession
While each organization plays a separate
role within the fabric of the profession, they
also must be considered as a whole where
each part is interdependent with every other
part. This "whole" or "profession" should
be seen as performing several major functions, including producing goods and services in O&P, creating and maintaining standards of practice, professional codes of conduct and institutional arrangements that
guarantee minimum levels of competency as
entry into the field. Just as the "Profession"
has many roles to play, each constituent organization must also be concerned with specific areas of responsibility within the larger
picture.
AOPA faces the problems of economic
survival of its members. The Academy and
the ABC respectively focus their attention
upon professional standards of conduct and
the creation of credentialing mechanisms for
quality assurance to the consumers and NAPOE (National Association of Prosthetic
and Orthotic Educators) faces the challenge
of basic and continuing education that is
both relevant, consistent and high quality.
AOPA is continually confronted, therefore, with the problem of attaining balance
within two environments: external and internal. The problems of external balance are
generally assumed to be economic. The
problems of internal balance are chiefly concerned with the maintenance of a kind of
social organization in which individuals and
groups working together can satisfy the need
to create and maintain the formal definitions
of a "profession."
The two major functions of this arrangement are interrelated. The development of a
"profession" and the economic survival of
AOPA members are intimately related and
interdependent within a framework of the
public's trust. AOPA is chiefly concerned
with the maintenance of business practices
and relationships within the field. Its chief
goal is to maintain a profit thus ensuring
economic survival for its members.
The Academy is chiefly concerned with
the role and advancement of individual professionals in the field as well as the maintenance of professional standards and ethics. It
attempts to do this through programs of continuing education. Another important avenue could be the obtaining of exclusive certification rights (and licensure where possible)
while upgrading its membership through
continuing education.
The ABC is primarily concerned with the
establishment and testing of standards for
individual workmanship as well as facilities.
It is also interested in becoming recognized
more widely as the exclusive agency for certification and accreditation by outside professional and governmental agencies.
Each group is completely interdependent
with one another. For AOPA to maintain its
level of business profits, it is dependent upon
(1) the establishment of an acknowledged
profession with widely recognized standards
and accreditation for the exclusive delivery
of O&P devices; and (2) the establishment of
a core of qualified, certified professionals
accountable for their workmanship within
the profession. The "Profession" must be
further recognized to promote high levels of
patient care. These elements will allow the
partial establishment of a "monopoly of
services" by these professionals, certified by
accrediting bodies and supplied and housed
by AOPA member businesses.
Counter-Balancing Forces
But this interdependence is not without
major counter-balancing forces that tear at
this mutual relationship. These forces are
natural and important factors that can be
managed. They need to be recognized simply as normal processes of development and
not threats.
AOPA's profits are being eroded by both
internal and external pressures. Internally,
the recent requirements from the ABC in
increasing certification standards for practitioners and facilities, as well as new recommendations for continuing education, produce direct and indirect costs of doing business on AOPA members who are footing the
bill. In addition, AOPA is also under constant pressure for increased wages of rank
and file professionals. Most recently,
AOPA's profit margins have been cut by the
dramatic change in reimbursement rates,
schedules and availability of funds. Further,
the anticipated across-the-board cuts by
Medicare and the VA in all health care expenditures promise even more difficult times
ahead.
These pressures on AOPA become even
more difficult when it is realized that the
profession has not acquired a nationally recognized status in allied health. If attained
this status would confer a form of "economic
monopoly of goods and services" or establish exclusive professional standing. This status or standing would guarantee some certainty in profit margins over the long term.
Without this "monopoly" by the profession,
there is an increasing pressure upon some
AOPA members to sell to PTs, OTs and
others. These negative forces are destructive
to the interdependent cooperation that is
fundamentally important to the profession.
Without recognition of the field as having
an exclusiveness in the delivery of O&P services through licensure, AOPA's dilemma becomes more troublesome. It comes from the
smaller profit margins caused by long-term
changes in Medicare and short-term increases in the cost of doing business with the
very organizations that have been established to create a "profession" with exclusive
rights to access.
From AOPA's perspective, the justification for the development of these professional requirements for quality of service, education and ethical codes of conduct rests in the
acknowledgment of a "profession" in the
eyes of patients, third-party payers and government agencies. The establishment of a
profession and its accompanying mechanisms of professional standards and certification would grant recognition to an individual
who has met certain predetermined qualifications specified by that profession. These
standards can be used as restrictions of access to others and confer a "monopoly of
services" to those certified. This "monopoly" protects the public by assuring it that
accepted high standards of conduct in workmanship and ethical standards of patient
care will be enforced. In return, professional
and business interests are assured a maintenance of a monopoly by certification or licensure. A balance is created between the
association's roles and responsibilities.
However, there is an imbalance in the present set of relationships. AOPA is shouldering both the major load of increasing pressures that are cutting the bottom-line as well
as carrying many of the burdens of support
for professional and educational interests in
the field.
Some of these pressures come from the
way the field has developed historically.
AOPA's historical role as the only organized
group in the early days of the field have
placed it at the center of many non-economic
issues that should be the rightful burden of
the other associations. At the same time,
many professional developments have not
occurred that are overdue. However, as
gloomy as this description seems, a coordinated vision and strategic plan of action can
still fulfill the promise of professional quality
and economic viability that we are all working toward.
This vision requires a general understanding of the roles and functions of each of the
major organizations in the profession and an
acceptance of the legitimate spheres of influence and activity for each group. Conflicts of
timing, personality, and turf will continue to
be a natural part of daily association life.
However, these should occur within a general framework or balance that achieves a reasonable assured profit, improving quality of
service and professional standards while obtaining recognition from other allied health
programs.
"Getting there from here" is not an easy
process. It requires AOPA to accept the
somewhat lessened but continued pressures
from ABC toward increasing standards of
professional practice and certification and to
accept the Academy's movements toward increasing professional standards and wages,
as well as increasing requirements for continuing education. While these dynamics
continue, AOPA must refocus its activities
primarily toward its economic interests
through lobbying efforts with government
and development of other avenues of reimbursement. On the other hand, AOPA
should expect the Academy to increase its
efforts toward attaining exclusive certification (and licensure where possible) and the
ABC to increase its efforts in becoming recognized more widely as the exclusive agency
for certification and accreditation by outside
professional and governmental agencies.
While initially this will further increase the
cost of doing business internally (at the very
time that external pressures are growing) a
coordinated structure of relationships can be
created. This coordinated structure of relationships would allow AOPA to devote its
energies to attracting new economic opportunities while the other organizations assume their full responsibilities in helping to
obtain a professional monopoly of services
by fulfilling their roles.
The Role of the Educational Programs
What is the role of the educational institutions in this coordinated structure of relationships? Their most immediate and direct
role and function (plus one year of experience) is to provide entry level education and
training. The educational programs plus the
mandatory year of experience in the field
must meet the specified requirements set
down by the EAC (Educational Accreditation Commission) as the minimum requirements for entry into the field. This preparation for entry level must be done independently to preserve the integrity of the process. The educational institutions should also
play a cooperative role with the Academy in
continuing education.
The educational programs must be accredited by a legitimate credentialing body that
speaks for the field. These accredited educational programs then serve the important
function of independently guaranteeing the
quality standards of graduates entering the
internship phase of the entry process. This
process is necessary for recognition of the
profession as credible by patients and third-party payers as well as being the profession's
mechanism for transferal of accumulated
knowledge and values of the field to the next
generation.
The accredited educational programs
should also play other roles. These additional roles should include the development of
clinical and experimental research, implementation of programs of continuing education, the development of teaching facilities,
the creation and application of new technologies to the field, the development of standards and tests of product liability and further development of the standards of entry
into the profession, in cooperation with the
other organizations.
The Educational Imbalance
At the present time, the educational institutions have not fully developed the capacity
to accomplish these added roles. This is a
function of both their development historically and of the vulnerable nature of all allied
health programs in the country. The history
of the development of most of the O&P university and school programs has been
through small developmental grants arranged through the Department of Education. The expensive nature of our O&P educational programs, relative to other academic programs, have hindered our growth within large institutions in size and number. Nationally, allied health programs have not
been well supported. There has been a
movement away from federal funding for all
of allied health in the `80s that has seen the
virtual elimination of major university
Schools of Allied Health within this decade.
(University of Pennsylvania, University of
Michigan, Emory University and Stanford
University have closed allied health schools
and programs.) More recently, the funding
crisis in O&P makes the acquisition of additional roles by our educational programs unlikely for the near future.
With the inability of our educational institutions to take on these other roles, there is
an important imbalance created in the field.
This is most important in the areas of applying new technology, the development of relevant research, and faculties for our profession. In addition, the educational programs
do not have much independent capability to
respond to changes in the field as they are
bound by the requirements for accreditation
placed upon them by the EAC.
The profession needs to develop and absorb the new technologies and research created in other disciplines. The systematic development of a scientific basis for treatment
and practice is an essential aspect for maintaining the professional quality and integrity
of the profession. If this is not done under
the auspices of the established professional
institutions, then the future of the profession
is threatened. Other disciplines, which can
create and apply new technological developments to the field, will decide our future. In
other allied health fields, it is the university
related programs that serve this function
through Ph.D.'s and other research-oriented
graduate training programs performing research in the field.
Where are the new developments in the
field coming from and how are they applied?
If major new technologies are not being developed internally, then our field is not in
charge of its own future.
Another important need of the profession, that is equally important as the development of new technologies and the conduct
of needed research, is determining the future
requirements and skills for new members of
the field. While the ABC and Academy are
endeavoring to solve this problem with continuing education, more attention is needed
by the universities in direct consultation with
other elements of the profession to gain a
consensus upon future roles of education
and the mechanisms to support them.
The educational institutions presently are
caught between mixed messages and multiple demands from the profession. One set of
demands stem from a need for increased
technical skills from new graduates. The other set of demands focuses upon increased
skills in diagnostic and patient management
skills of our new graduates.
The focus upon increased technical skills
is, in part, a result of shortages of new graduates that elevate entry-level salaries to the
point where facility owners would need to
get a faster "return on investment" from the
new graduate and place them in clinical situations more rapidly than they might have.
The other set of demands upon education
stems from the increasing need to respond to
new and sophisticated techniques that will
change the very nature of the professionals'
daily role in the future. While educators
must respond to all these important messages from the profession, we must maintain
a plurality of educational delivery systems to
meet these varying needs of the profession.
Continuing education presents a particular area of concern for both the Academy
and the educational institutions of NAPOE.
Overall, continuing education's role in our
profession is to be a delivery mechanism to
ensure professional competence and currency in a fast changing technical profession.
Recent surveys indicate that this field is especially interested and likely to participate in
programs that present much information in
recent developments, new techniques and
materials. Here we face a need for a greater
variety of delivery vehicles for professionals
in rural and geographically distant areas.
While the national conventions and regional
association meetings have been bearing the
primary burden of continuing education in
the past, alternative programs of delivery
must be sought to provide professionals
more immediate and accessible forms of acquiring continuing professional education.
While I have not covered all the important
issues facing the profession, I have attempted to demonstrate a need to view the field's
problems as fundamentally inter-related and
interdependent. Issues of Medicare reimbursement, quality patient care, credentialing requirements and basic and continuing
educational directions are interdependent.
The major associations representing the various constituent parts of the profession have
begun to work toward this view. Further coordination among the associations is vital.
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