American Academy of Orthotists & Prosthetists

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The Changing Face of O&P Education: Can We Make a Better Practitioner?

William J. Barringer, MS, CO
Susan Kapp, CP
Charles H. Dankmeyer Jr., CPO
Darrell Clark, CO
Terry J. Supan, CPO
Robin Seabrook

ABSTRACT

The National Commission on Orthotic and Prosthetic Education (NCOPE) has re-evaluated O&P educational philosophy for the past 18 months. Important decisions have been made concerning both primary education and postgraduate training.

Primary education will now focus on clinical knowledge with the technical aspects de-emphasized. Postgraduate education will be structured and essentials will be written to address the clinical and technical skills necessary to educate competent practitioners.

O&P education is now recognized by the American Medical Association as a legitimate allied healthcare profession, and NCOPE has become a member of CAHEA, the major accrediting agency for health-related occupations. This affiliation has forced NCOPE to rewrite and upgrade its primary and certificate programs' accrediting procedures.

These are important advances for O&P education. This shift in educational philosophy will produce more competent practitioners for the future.

Introduction

Education does not stand alone as an unchanging entity; it constantly reflects on history and tradition to determine its future. When NCOPE began its journey in July 1991, the commissioners brought with them a "sense of history" as it related to the O&P profession. Each of us realized the history and tradition of orthotic and prosthetic education had shaped our individual perceptions of the profession and served as our own personal rites of passage to orthotic and prosthetic maturation. But this knowledge of history and tradition also leads us to question if our current educational process provides future practitioners with that same rite of passage.

The "jewel in the crown" of any profession is the quality of education it provides. Each of us as guardians of our profession must look at higher education and ask serious questions about why history has led us to where we are and whether we should change our course for our future well-being.

History

Orthotics and prosthetics is a late bloomer in the garden of allied health and medical education. Until World War II, formal education for practitioners did not exist on any university campus. This is in stark contrast to medical education, which has existed for more than 400 years. During the early part of this period, surgeons were not considered doctors or even highly educated; they worked under the supervision of physicians. They were often called in with bloody aprons and tools to do work beneath the physician's level of knowledge and training. This tradition persisted until surgeons elevated their status through education, thus redefining themselves and their specialty.

Orthotics and prosthetics has reached a similar crossroad and must prepare for the future by embarking on a new educational pathway. It will not be a pathway concerned with new information, but one that will redefine and change our educational philosophy. This new pathway will also alter the demands we place on practitioners, provide for the mastery of an ever-growing body of knowledge necessary to administer the best care and secure our place in the medical community.

EAC Task Force

In 1972 the American Board for Certification in Orthotics and Prosthetics Inc. (ABC) created the Educational Accreditation Commission (EAC) to confront the O&P profession's need for an institutional accreditation program. That same year the EAC set out to establish criteria to assess and compare O&P curricula. These criteria, called "Essentials," were developed and revised to meet the profession's needs. Through the Essentials EAC created written rules and regulations for short-term courses, certificate programs, baccalaureate programs and required clinical hours. It also established and modified common application and site visit processes.

Despite the EAC's accomplishments, several problems remained. Accrediting bodies operate best when they are politically and administratively independent from the educational and professional arenas they serve. Political separation is usually defined as including both financial and programmatic independence. Financial independence was achieved in 1988, but full programmatic and administrative autonomy was not.

In April 1990, the EAC recognized that problems existed and established a five-member task force that included representatives from the American Orthotic and Prosthetic Association (AOPA), ABC, the American Academy of Orthotists and Prosthetists (AAOP), the National Association of Prosthetic-Orthotic Educators (NAPOE) and the O&P National Office.

The EAC Task Force set forth to accomplish the following goals:

• Investigate and evaluate the relationship between O&P training curricula and patient needs.

• Coordinate a needs assessment considering such things as patient care availability in relation to educational funding.

• Report facts, findings and conclusions regarding the investigations and studies to the commission and make specific recommendations.

In March 1991, the leadership of AOPA, ABC and AAOP formally accepted the task force recommendation to reorganize EAC and hire dedicated staff. The leadership and profession had made a firm commitment both financially and administratively to the EAC.

The new EAC met in July 1991 and changed its name to become NCOPE. Already NCOPE has addressed issues critical to O&P education, assumed the role of O&P accrediting agency, and with the support of the profession, will continue to grow and mature.

The New Essentials

Primary O&P education is currently conducted in one of two formats: bachelor's degree and postgraduate certificate programs. Programs were offered originally at New York University, Northwestern and University of California at Los Angeles. Today nine accredited programs (four bachelor of science and five certificate programs) are offered at these and other institutions. These programs are governed by a set of Essentials that outline the minimum requirements for accreditation.

As the profession has experienced more rapid change, it has become apparent that the Essentials should reflect a maturing profession and the changing roles of practitioners. Patient evaluation and treatment methods now play a more significant role in the duties of practitioners. Most technical tasks are completed by technicians, and an increase in the number of central fabrication facilities and prefabrication systems allows practitioners more time for patient contact. Also, the economics of today's health delivery system require certificants to devote the majority of their time to direct patient care.

Coupled with these factors are recent advances in O&P technology. The use of computer-aided design and manufacturing and new materials requires continual education on the part of the practitioners. As these techniques become integrated into common practice. they will need to be taught during undergraduate or postgraduate education.

The previous Essentials called for a mix of didactic instruction, laboratory experience and clinical affiliation. The lab component was tightly defined with a list of specific fabrication projects and skills that must be taught. Little time remained in the curricula for the addition of classes that might reflect the state of the art in current practice. Such topics as radiology, computer science, business practice and pathology were not easily integrated into curricula designed around the old Essentials.

The EAC Task Force identified several common concerns:

• A need to include more clinical and practice-related education in the undergraduate component.

• A desire to decrease the time and cost of laboratory projects in undergraduate education.

• A need for an organized postgraduate experience.

Because most universities have credit-hour limitations, expanding curricula to include topics such as computer science and pathology could not occur unless the necessary hours were available within the prescribed credit limits. Shifting laboratory projects from undergraduate training to residencies could free up the necessary hours.

NCOPE realized undergraduate and residency Essentials would need to be developed concurrently to provide a smooth transition. The committee developing the undergraduate Essentials considered decreasing or eliminating the laboratory content and developed Essentials to allow flexibility for schools and the development of new curriculum and programs that introduce new technologies and practices while still ensuring quality education.

NCOPE is providing a transition phase from the previous Essentials to the revised ones. Currently-accredited programs will maintain their accreditation under the "old" Essentials and not be required to phase out the teaching of lab skills for a set time. This time will be used for implementing the new Essentials and constructing a new program. In addition, the 250-hour per discipline clinical experience requirement will be maintained until the transition to the new Essentials can take place and residencies are available for all students. Draft proposals of the undergraduate and residency Essentials are being developed.

The Residency

The Residency Development Committee is creating minimum requirements, curricular objectives, evaluation forms and an application process to assist in selecting training sites. The Accreditation Committee will work closely with the Residency Development Committee to develop an accreditation program similar to the current process.

A New Phase

The development of Residency Essentials is the most important task facing NCOPE. The genesis of a new educational phase where none previously existed is a difficult task. The Residency Essentials will contain guidelines for:

• Where a program can be housed.

• How long the program will run.

• Qualifications for teaching staff.

• Resources necessary for teaching students.

• Due process procedures.

• What the resident must be taught clinically and technically.

The Residency Essentials outline clinical and technical requirements that a student must fulfill. Clinical experience will be divided into acute, rehabilitation and chronically ill patients with further subdivisions according to age groups: pediatric, adult and geriatric. Within each group the resident must achieve technical competence in upper- and lower-limb prosthetics or upper-limb, lower-limb and spinal orthotics. Permission to house a residency program will not be granted unless sites can demonstrate availability of the aforementioned categories.

The curricular objectives state the resident must be qualified for independent practice upon graduation. The curricular objectives, taken from the ABC Role Delineation Study, are the essence of what must be taught within every residency program. NCOPE will help facilities teach residents by providing a curricular guide and evaluation forms.

Accreditation of each program will be important. Accreditation sets standards and lends credibility to educational programs at any level, and as part of this process, a program of self-study, evaluation and site visitation will be enacted. NCOPE will monitor programs and residents to maintain quality educational standards.

The Residency Development Committee is composed of representatives from all levels of O&P practice, including small private practices, institutional practices and larger, multi-office practices. NCOPE hopes input from these areas will ensure development of a program that is accessible to all. The overall goal is to combine the undergraduate and residency experiences to produce practitioners with a better . well-rounded education at a lower cost to students and the system.

The Accreditation Process

Accreditation of residency sites will include the establishment of standards for evaluation, guidance in the self-study process, program evaluation and reevaluation by qualified authorities, and publication of a current list of accredited programs. NCOPE will help programs analyze their performance and improve their effectiveness. NCOPE also will protect the welfare and safety of the public by ensuring some degree of uniformity among prosthetic/orthotic educational programs.

O&P's accreditation process is not unlike those used by other professions for the purpose of evaluation and accreditation. Requirements include:

• Programs seeking initial accreditation must submit a letter of intent.

• Programs must complete self-study reports, which will be reviewed by evaluators.

• Programs must undergo on-site visits conducted by evaluators.

• Programs will be able to review evaluation reports for accuracy.

• NCOPE will review all reports to determine accreditation status.

NCOPE accreditation ensures all O&P educational programs adhere to basic essentials and that quality education is offered to students. This process encourages programs to incorporate the profession's newly-developed techniques and concepts as they become widely recognized.

The accrediting process will be the keystone for ensuring quality programs. It will also be used for residency program evaluation and to follow the recommendations of the Committee on Allied Health Education Association (CAHEA).

Becoming Recognized

Directors of orthotic and prosthetic programs will need to justify their program and its requirements to the college or university administration. When they identify the program as accredited by NCOPE, they may be asked: "Who is NCOPE and by what authority does it make the decision to accredit?" NCOPE needs to be able to answer that question for each program director and identify itself as a legitimate accrediting organization to the education community.

A search of similar programs revealed many were accredited through the American Medical Association's CAHEA. Programs accredited by CAHEA also meet standards established by the U.S. Department of Education. CAHEA is well known within the allied health education field and is recognized as an accepted accrediting organization.

It was decided that developing a relationship between NCOPE and CAHEA was an integral part of becoming acknowledged as the accrediting body for O&P education. NCOPE applied to the AMA for recognition of orthotics and prosthetics as an allied health profession and to establish NCOPE as a review committee within the framework of CAHEA. The application was approved in August 1992. This step linked orthotics and prosthetics with a respected, well organized accreditation system, which in turn will provide a solid base for our education programs.

Conclusion

Orthotic and prosthetic education cannot evolve one phase at a time. All of the components require growth and development as they become intertwined. Our residency and primary education programs will depend on one another to fill certain voids in student education. The success and credibility of these programs will depend on our relationship with CAHEA and the NCOPE accrediting process. All must develop simultaneously-with an eye toward the future NCOPE must also explore other areas that influence O&P's future as a profession. We must study our technician programs to ensure their readiness to move into the next century, encourage more colleges and universities to offer O&P education programs, and develop graduate O&P programs that offer advanced degrees.

NCOPE will continue to develop orthotic and prosthetic education that draws upon the lessons of history and tradition.

WILLIAM J. BARRINGER, MS, CO, is assistant professor in the department of orthopedic surgery and rehabilitation at the University of Oklahoma, Oklahoma City, Okla. He is also the current chairman of the National Commission on Orthotic and Prosthetic Education (NCOPE).

SUSAN KAPP, CP, is assistant professor and acting director of the prosthetic and orthotic program at the University of Texas Southwestern Medical Center, 6011 Harry Hines Blvd., Suite V.5100, Dallas, TX 75235-9091.

CHARLES H. DANKMEYER JR., CPO, is president of Dankmeyer Inc., 2010 Maryland Ave., Baltimore, MD 21218.

DARRELL CLARK, CO, is director of orthotics at Rancho Los Amigos Medical Center, Downey, Calif., and serves as an adjunct faculty member at California State University, Dominguez Hills, Calif.

TERRY J. SUPAN, CPO, is director of orthotic and prosthetic services and assistant professor of clinical surgery at Southern Illinois University School of Medicine in Springfield, Ill. He is also past president of the American Academy of Orthotists and Prosthetists.

ROBIN SEA BROOK is director of NCOPE and worked previously for the American Board for Certification in Orthotics and Prosthetics.