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RESEARCH FORUM--Residency Research, Part I:Why Should an Orthotic/Prosthetic Resident Conduct Research?

Terry J. Supan, CPO

ABSTRACT

In 1993, the National Commission on Orthotic and Prosthetic Education established that, as part of an orthotic/prosthetic residency, the resident must be involved with a research project. The intent of this paper is to explain why the resident should conduct research (develop a better understanding of the scientific process; critically analyze published materials; design appropriate research models; and report in a scholarly and scientifically founded manner); how to overcome the anxiety of carrying out research; what the differences between development and research are; how to identify valid research; and why the research should be conducted in private practices as well as institutional practices. Finally, the negative impact a research project can have on the residency is discussed, and suggestions for curtailing this impact are given.

Introduction

The Residency Development Committee of the National Commission on Orthotic and Prosthetic Education (NCOPE) wrestled with the residency research question for some time before it concluded that research and the research process must be part of the resident's clinical education experience.

Research should be a part of an O&P practitioner's training to ensure the survival of the profession itself. The crucial distinction between a professional and a nonprofessional occupation is that the skills characterizing a member of a professional occupation are derived from and supported by a continuously expanding body of knowledge that has been validated via the scientific method (1). All concerned should recognize the mere provision of care is the mark of a half-professional whereas the evaluation of that care is the mark of a full professional (2). Using the residency program to expand the body of knowledge and evaluate the outcome of care will help prepare both the O&P professional and the O&P profession for the challenges of the future.

As it relates to the resident, NCOPE has defined O&P research as follows:

A research project is the scientific or scholarly investigation that leads to a greater understanding of the principles and historical perspectives of orthotics and prosthetics. These projects may include but are not limited to literature reviews, retrospective/prospective studies, outcome evaluations and experimental models (3).

The objectives for the research project are to provide the resident with an understanding and appreciation of the nature of research and the scientific process; the ability to locate and critically analyze published materials in the O&P field; the tools to define a problem, select a sample and design the appropriate research model; and the technique for generating a research proposal outline and report that are scholarly and scientifically founded (3). The completion of a research project is part of the final evaluation (conducted by both NCOPE and the residency program) of the resident.

Fear of Conducting or Supervising the Research Process

Most O&P professionals have some idea, theory or device in the back of their minds that they would like to see proven or developed. The primary fears of these practitioners is that they do not possess the knowledge or the training to conduct true scientific research. They are intimidated by the planning, the process, the statistical analysis or the actual writing of the research report. In reality, the actual problem-solving skills good O&P practitioners use daily are the same ones used to conduct valid research.

Recent graduates of NCOPE-accredited programs, on the other hand, have no such anxieties. The 1993 Undergraduate Essentials (4) require students to complete a course on research and research methodology. In fact, several baccalaureate programs have included research courses as part of their curricula for years. What the residents need is guidance to conduct research that is clinically relevant as well as scientifically valid. This is where the experienced orthotist/prosthetist is required.

Fears of conducting or supervising research are not unique to orthotists and prosthetists. As each allied health career has developed into a profession, it has recognized research as one of the areas that truly helps define a profession. In the late 1970s, the Canadian physiotherapists recognized this, and their journal published a seven-part series on research methodology and applied statistics (2,5-10). This paper is part of a similar ongoing series within this journal to help the clinical orthotist/prosthetist overcome the aforementioned fears (11-22). By better understanding the principles of research, O&P professionals will be less intimidated by the whole process. They will then be able to provide the guidance the residents need.

Anxiety over statistics and mathematics can be one of the major stumbling blocks to getting started with research. Those who worry about mathematics or complicated calculations should understand that the process of selecting an appropriate statistical procedure may involve little or no math. Technical books, such as Reading Statistics and Research (23), are available to help explain how to read, understand and evaluate the statistics in research articles without actually knowing the details of the calculations (10).

For those who want to be further-enlightened, the advantages of taking a statistics course with an applied orientation are threefold: students can gain exposure to the current practices in statistical analyses within their own field; applications to research are emphasized; and the practical examples used in such courses might motivate students to learn the statistical details of O&P (10).

Research or Development?

In general, orthotists and prosthetists tend to use the terms research and development interchangeably although they are quite different in their methods and final outcomes. Research must follow strict scientific methodology to prove a hypothesis or establish a relationship. Development is undertaken to provide a solution to a problem. Individuals who develop devices with various componentry (i.e., orthoses and prostheses) are much more comfortable creating engineering designs. As with other engineering processes, orthotic and prosthetic design development has not necessarily followed the strict scientific processes of research.

For development work to meet the goals of a research project as defined by NCOPE, it must adhere to a structure similar to that of research. The resident needs to prepare a design proposal (approved by the adviser), perform a literature review for similar designs, work on the prototype, establish ways of testing the design and report the results. Heyd's development of the Oklahoma ankle joint during his residency is an example of this (24).

Validation of the care orthotists and prosthetists provide is more in line with traditional research. Outcome studies, comparisons of orthoses or prostheses, and patient satisfaction surveys are all examples of this type of resident research project. The resident must identify a problem; conduct the literature search; develop a hypothesis; design the methods of collecting the data; record the results; and finally, evaluate the data to come to some conclusion or recommendation. If the hypothesis is proven, then the orthotic/prosthetic intervention is validated. The Wagner study comparing different types of prosthetic feet (25) is an example of this type of resident research project.

Whether residents conduct development or research as their research project, the body of knowledge available in the O&P field will be expanded.

Credibility of Literature

After the adviser and the resident decide on the research project, the resident must conduct a literature review. A good literature review places the research project in context and supports the rationale for its methodology and conclusions.

During the process of collecting and evaluating materials, the researcher gains invaluable information that will assist in the design of the proposed project (8). As the resident reviews the literature, he/she must not only determine if the material is germane to the research but also verify the previous research is credible.

The resident also must recognize the fallacies of poorly written or conducted research. In Anatomy of Research in Allied Health, Stein states that "...strong arguments that are used to convince researchers and clinicians to accept the findings of a study or the efficacy of a treatment method, the fallacies of irrelevant conclusion, appeal to authority, false cause, ambiguity and generalization must be recognized by consumers of research as totally unacceptable means of advancing knowledge" (26).

One of the underlying goals of the NCOPE Residency Committee was to improve both the quality and quantity of the research being conducted. The resident orthotist/prosthetist should develop a better understanding of the scientific process and also strive to improve the credibility of O&P literature. Should not both the technical/clinical and the research literature be written by the orthotist/prosthetist?

As O&P literature becomes less technical and more research-oriented, O&P professionals must keep in mind that the type of research published can have a greater impact on how others perceive the quality of O&P care. In 1986, Sackett published a methodology including rules of evidence for expert committees to apply when generating recommendations for clinical management of patients (27). Although Sackett's levels of evidence" (see Table 1 ) were developed as a way of evaluating the effectiveness of antithrombotic medicines after cardiac surgery, they also should be used to help quantify the type of research being done in orthotics and prosthetics.

Recommendations are made concerning the type and number of studies that fall into each level of evidence. A grade "A" recommendation is supported by at least one, but preferably more, level I randomized trial; grade "B" is supported by at least one, but preferably more, level II trials; and grade "C" is supported by evidence from levels III-V.

When Stuberg reviewed the current literature on the effectiveness of orthotic intervention of cerebral palsy while at the ISPO Consensus Conference on Orthotic Management of Cerebral Palsy (28), he noted the majority of the articles were either at level V or could not be ranked. Therefore, the majority of the aims of orthotic intervention were graded at a "C." Based on the published literature alone, orthotic management of cerebral palsy does not "make the grade."

In reality, the condemnation should not be of the treatment as much as it should be of the type of research conducted and the literature printed. What this means to the resident and the adviser is the selected research project should be at the highest level practical for the limited time and resources. If the resident uses Sackett's levels of evidence to develop the project, his/her research can have a much greater impact on both the O&P body of knowledge and the O&P profession. The same can be said if the resident uses the levels of evidence to help evaluate other researchers' recommendations/conclusions or a manufacturer's claims.

Private vs. Institutional Residency Research

In 1951, Conant stated, "Science as a profession, we must remember, is a recent invention. Some of the most important advances in the early development of physics and chemistry are made by amateurs" (29). The same holds true for orthotics and prosthetics today. Many of both the historical and recent developments in O&P have been the direct results of work carried out at private clinical facilities or manufacturing companies. It is now time for research to move from the university to the private orthotic/prosthetic facility.

Validating the orthotic/prosthetic care provided can have a direct impact on any practice. As more outside groups (DMERCs, MCOs, etc.) look at the costs of orthoses and prostheses, it behooves any facility to be in a position to prove the care it provides directly benefits the patient. Having a resident conduct outcome studies or patient satisfaction surveys will either validate the quality of care the facility provides or will identify areas where improvement is needed. In either case, it will have a positive effect on the facility's relationship with outside agencies.

The institutional practice may be a better location for research that involves experimental data collection or long-term prospective/retrospective studies. Within such a practice, the apparatus and instruments needed to conduct these types of studies is more readily available. Multiple resident research projects could build on each other at this type of facility.

Time, Money and Mentors

The three main reasons usually cited as arguments against conducting research during residency are insufficient time, lack of financial support and too few mentors. Although these obstacles may appear to be insurmountable, solutions have been found to all three.

Large projects like those conducted at Southern Illinois University (25,30,31) could never be completed in the one-year time frame of the current residencies. Since 1993, the projects have been downsized to allow the resident adequate time to complete the project. This is in keeping with the philosophy of master's theses and doctoral dissertations.

Another factor affecting the time a resident can devote to research is the limited amount of time the resident has for clinical skills development. Time management and establishment of priorities are critical so the resident neither "short changes" the clinical experience nor the research. However, since the resident is still in the "student mode," he/she usually devotes extra time to studies. At Southern, most of the time spent on the research project is after normal business hours.

The financial support of the research project may be a more difficult problem to overcome. If the project will have a direct positive impact on a company, the corporation may be more willing to underwrite the cost. If the project is one the adviser is truly interested in, he/she would be more likely to seek support for it. Manufacturers have been known to provide financial and/or in-kind support for research evaluating their products. Finally, if grant funding already exists at the facility, the resident's research could be made a part of that funded project.

Finding enough experienced mentors for residents is the most difficult problem to solve. The very small number of O&P practitioners who have earned master's or doctoral degrees has created this problem. As indicated earlier, anxiety over conducting or supervising research may scare away practitioners who have the experience and the problem-solving skills that would be of great benefit to residents. Undertaking a development project or establishing an affiliation with an institutional/university practice would help alleviate some of those fears. The small practice that could meet all of the other requirements of the NCOPE residency essentials would be an excellent location for the resident. Residency programs already conducting research can help new resident advisers overcome their lack of experience as mentors.

Conclusion

There are no shortcuts for the truly professional orthotist/prosthetist. Research must be part of the O&P resident's clinical education. That time period provides residents with a golden opportunity to develop hypotheses, techniques or devices that are much more relevant to the patient's clinical needs than the textbook information residents acquire during their undergraduate education. Although the short duration (one year) of the residency prevents the resident from conducting a long-term project, the resident can conduct research on one segment of a much larger project.

While institution-based residencies may be better suited for experimental research, the private-sector facility has proven to be just as good or even better in development of clinical research. Outcome studies and patient-satisfaction surveys could have strong impacts on the validity of orthotic and prosthetic care. The best situation may be the sharing of the research experience as part of an affiliation agreement between an institutional and private facility.

Although time, money and a lack of experienced mentors can have negative impacts on the implementation of resident research projects, these problems can be overcome. The expanded body of knowledge, the validation of the care provided and the professional development of the orthotist/prosthetist are worth the extra effort.

TERRY J. SUPAN, CPO, is director of orthotic/prosthetic services and associate professor of the Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, P0. Box 19230, Springfield, IL 62794-9230. Supan also was the first chairman of the NCOPE Residency Development Committee.

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