The intent of a curriculum review is to determine whether an educational program’s curriculum is current and relevant with respect to providing students with entry-level skills for the workforce. It involves examining the current scope of practice and competencies of the profession in question and then reflecting back on the curriculum to determine whether these competencies are being taught adequately. Visioning attempts to determine not what entry-level skills graduates require but, instead, what knowledge and skills students need to meet the challenges of the workplace approximately 10 to 15 years into the future.
At the British Columbia Institute of Technology (BCIT), the visioning process consisted of two steps: 1) focus groups with a variety of stakeholder groups (ie, any group with an interest or concern in the provision of the prothesis [eg, amputee, surgeon, prosthetist, social worker, component manufacturer, and spouse and children of the amputee]) and 2) a paper-based survey of all certified prosthetists and orthotists in Canada. The focus groups carried out a series of exercises and discussions that focused on getting participants to review their positions critically and to “think outside the box.” Thinking outside the box is a part of lateral thinking and involves generating new ideas outside of the normal context in which they would be used in an effort to create a shift in thinking about a certain issue. 1 The focus groups were run over a 2-year period and ranged in size from five to 26 participants. They encompassed the following groups: orthotic and prosthetic examiners for the Canadian certification examination; orthotists and prosthetists with higher degrees, or a qualification such as professional engineer, who are involved in university-level education or in research and development; physical medicine specialists and orthopedic surgeons from across British Columbia; BCIT graduates, 2 months post graduation; certified pedorthists, who specialize in foot orthotics; orthopedic technologists; biomedical engineers and technologists; and the British Columbia Association of Prosthetists and Orthotists.
In the focus groups, all persons who attended were encouraged to participate, and those who came, came voluntarily. The intent of the focus groups was to develop a sense of how prosthetists/orthotists are perceived by persons outside the professions and to determine how certified prosthetists and orthotists perceive themselves.
The focus group sessions were followed by a paper-based survey sent out to all Canadian certified orthotists and prosthetists. Of 353 surveys sent out, 82 replies were received for a 23% response rate. The survey included a wide range of questions, the intent of which was to allow all members of the profession both to comment on their perceptions of current and future trends and to reflect on their past educational experience and current educational needs.
Several key points of interest arose from the visioning process, a number of which could act as catalysts for significant changes to the professions as we now know them. BCIT intends to use these points as a focal point in the planned curriculum review and redesign. It is hoped that the new curriculum will prepare future graduates to be successful in navigating any of a number of changes which may arise from the pressures currently being exerted on the professions by the key points identified.
The key points were as follows:
- There seems to have been a substantial increase in the orthotic marketplace in Canada over the past 15 years to which orthotists seem not to have responded.
- There are too few orthotists and, potentially, too few prosthetists.
- Orthotists are often perceived by referral sources as providing the more expensive, more complex, and permanent types of orthotic devices.
- The business and marketing skills of both orthotists and prosthetists are poor.
- Prosthetics could potentially be at greater risk than orthotics.
- Opinions of referral sources about the services offered by prosthetists and orthotists vary.
- A significant overlap exists between the competencies and activities of orthotists and the competencies and activities of competing groups.
The first key point is that there seems to have been a substantial increase in the orthotic marketplace in Canada over the past 15 years, an increase to which orthotists seem not to have responded. The number of devices, especially in the area of knee and foot orthotics, seems to have increased dramatically since 1980. Although orthotists played a significant role in the supply of most orthotic devices in the early 1980s, their share of the market has decreased in the past two decades. Approximate representations of the changes are illustrated in Figures 1 and 2. Groups such as occupational therapists, physiotherapists, podiatrists, pedorthists, pharmacists, orthopedic technologists, and kinesiologists are all now involved in the assessment for and supply of orthotic devices (Figure 2).
Various studies have been performed in an attempt to determine how many graduates Canadian schools need to produce to maintain the number of practitioners at a given level 2 and what effect the aging of the population will have on the need for service. 3 No comprehensive market review has ever been done using epidemiological data to determine how many persons currently need our services at any given time, and no calculations have been done to determine the ideal number of practitioners actually required to meet the needs of the population. BCIT is committed not only to developing a curriculum that best meets the needs of students and patients but also to attempting to produce the numbers of graduates required to meet the current needs of the population.
To this end, BCIT had commissioned a marketing study to determine the full size of the orthotic and prosthetic markets in Canada. Results will be available in December 2001 and will be used to review the number of students currently accepted into the BCIT’s prosthetics and orthotics program.
The Numbers of Orthotists and Prosthetists
The second key point identified is that there are too few orthotists and, potentially, too few prosthetists. Both the increase in market sizes without significant increases in numbers of orthotists and the reality of encroachment point to a shortage of orthotists. The potential for a shortage of prosthetists is pointed out by Neilson 3 and is related to the aging of the population. With the demographic similarities between the United States and Canada, this then would point to the possibility of a similar shortage of prosthetists occurring in Canada as well.
Professional shortages have the immediately noticeable effect of making professional services more difficult to access—something noticed by the patients. There is a second effect in the area of orthotics that arises from a shortage of professionals. Because there are too few certified orthotists, certified orthotists are typically doing very well in their business. Because of the demand for their services, some certified orthotists do not perceive a threat at all to their livelihood. From their narrow focus it looks as if all is well. At the same time, some market segments are expanding. When viewed from the bigger perspective, many potential clients are in fact being served by competing groups, because there are not enough certified orthotists to meet the current needs of the population.
These groups have in turn become quite skilled in dealing with the assessment for and provision of orthotic devices to the extent that they are now becoming officially recognized by funding agencies as suppliers of orthoses. Gaining in confidence, they begins to enlarge their own scope of practice further and further into what used to be the exclusive domain of orthotists. The result of this is that, within the growing market for orthotic services, the orthotist commands an ever shrinking market share.
The review of class sizes referred to in the discussion of point 1 is also relevant with respect to this second point.
Perceptions of Referral Sources
The third key point identified in the data is that orthotists are often perceived by referral sources as providing the more expensive, more complex, and permanent types of orthotic devices. With changes in plastics technology, the term “permanent” is quickly loosing its significance. Devices that are more expensive and more complex are devices that often require careful assessment, time-consuming manufacturing, and extensive follow-up, thereby reducing the potential profits derived. The lower-cost, easier-to-fit devices, which hold a higher profit margin, are often supplied by the competition and at a lower cost.
BCIT will be reviewing the curriculum with the goal of expanding the curriculum to include more education in both business and manufacturing. This will allow graduates to become more competitive in the lower-cost market, as well as be better able to calculate and justify compensation received for the more complex devices. In addition, it will give the students the skills to quickly apply changes in materials and manufacturing technology to daily clinical practice.
Poor Business and Marketing Skills
The fourth key point noted in the survey is that the business and marketing skills of both orthotists and prosthetists are poor. With respect to business skills, the certified prosthetists and orthotists themselves report that the level of business and management education provided at either of the Canadian schools was not sufficient. When one considers that the majority of prosthetists and orthotists in Canada either own or work in a small- to medium-size business setting, it becomes essential that graduates have some level of entrepreneurial training.
Referral sources commented that orthotists and prosthetists do a poor job of marketing themselves to the medical community. They stated that many persons in the medical community do not have a clear and correct understanding of who and what prosthetists and orthotists are and exactly what services they provide.
The addition of business and marketing courses to the BCIT prosthetics and orthotics programs would provide graduates with concrete skills in making their services known to groups such as referral sources. In addition, graduates would have the business skills that practicing prosthetists and orthotists have reported as missing in their education.
The Risk for Prosthetics
A fifth key point is the concept that prosthetics could potentially be at greater risk than orthotics, despite the fact that the trends identified thus far have concentrated more on orthotics. Current research trends in the area of prosthetics focus on making prostheses available to patients at a lower cost with a shorter turn around time and better biomechanical function. Some examples of ventures in this direction are direct manufacturing (eg, ICEX), initial forays into attachment of “live” donor limbs, recent advances in the treatment of diabetes, computer-assisted design/computer-assisted manufacturing, and osseointegration.
A typical objective in many ongoing research projects in the above-mentioned areas is the reduction or elimination of the prosthetist altogether. In the domain of technology development, it makes sense to drive development in this direction because people-hours in any manufacturing process are typically expensive hours. It might be added that most of the research and development work is not being done by prosthetists and is therefore is not constrained by the concept that the prosthetist is a necessary part of making and delivering a prosthesis. An additional spin-off of some of this research is that the outcome will result in a higher quality of life for the patient as well. Although many of these concepts are still in the early development stage and some will never bear fruit, with the exponential rate of technology development, it is a certainty that one or more researchers will eventually be successful. Once this occurs, the field of prosthetics could change overnight.
Increasing the number of engineering-based courses in the BCIT curriculum, such as materials science, design and design processes, and manufacturing methods, will allow graduates to better assess and integrate new materials and technology into clinical practice. We anticipate that this will allow graduates to practice at the vanguard of technology development rather than continually adapt in response to it. Graduates will then have the skills to play a role in the development of these areas.
Opinions of Referral Sources
A sixth key point was a collection of comments and opinions of referral sources about the services offered by prosthetists/orthotists. Some physicians commented that prosthetists, and not physiotherapists, should be doing amputee gait training and that orthotists should be providing gait training as a part of their service.
Any major curriculum revision at BCIT could result in the students being given the educational foundation which would allow them to incorporate gait training into the clinical services they provide in future clinical practice.
Overlap Between Orthotists and Competing Groups
The seventh, and final, key point is that a significant overlap exists between the competencies and activities of orthotists and the competencies and activities of competing groups. At this point in time, it may be well worth it to formally align with these groups, both at the educational level and the professional association level. This would increase the lobbying power, the ability to provide continuing education, and the ability to fund research, and it would provide a larger pool of young people who might choose to continue their education and actually carry out the research.
In reviewing the key points identified in the study, the BCIT was able to identify that the current curriculum being offered is divergent from current trends. In particular, the BCIT acknowledged:
- The seeming incongruity between the size of the orthotic market and the small number of certified orthotists available to service it;
- The fact that most graduates eventually work in a business environment and yet receive little to no business and marketing training as part of their education; and
- The conflicting goals that arise from new technology and treatments for our patients being developed and assessed by persons outside our professions.
The purpose of the visioning process undertaken by the BCIT was to take a “big picture” view of the practice of prosthetics and orthotics and to reflect upon how the curriculum offered at BCIT is preparing our students for this environment. This process has provided a vision that is somewhat incongruent with current directions in prosthetics and orthotics education at BCIT and therefore indicates that changes in the curriculum must be made to ensure life-long career options for graduates. BCIT can play a role in providing skills to graduates that will allow them to adapt to the changes in a flexible manner so that their careers are ensured regardless of what direction the professions eventually take.
A number of the key points identified in the study are issues rooted outside the profession. For this reason, they must be responded to, as outside pressures are rarely limited by the constraints professions set upon themselves. Thus, efforts to maintain or reinforce the status quo run the risk of having little long-term effect. In such an approach, the prosthetic and orthotic practice of the future will bear little resemblance to the practice of today. Until the key points are addressed, orthotists, in particular, will in all likelihood play an ever-decreasing role in the provision of orthotic devices.
BCIT is optimistic that by changing the curriculum to address the needs of the professional setting, we will provide students with the skills and knowledge not only to weather the changes but to actually play a role in driving the changes. BCIT will be making recommendations for changes to the curriculum based on the results of the visioning study. A full copy of the report will be available on the prosthetics and orthotics homepage located on the BCIT Web site (http://www.bcit.ca) in late 2001.
1. De Bono E. Lateral Thinking. London: Penguin Books; 1970.
2. Blocka D, Lawson L, Miller T, et al. Demographic Study of the Prosthetic and Orthotic Profession in Canada; 1990.
3. Neilson C. Issues affecting the future demand for orthotists and prosthetists. National Commission on Orthotic and Prosthetic Education, November 1996.