Education in prosthetics and orthotics
J. Hughes *
This is one of the lead papers on Prosthetic/Orthotic Education presented at the Second World Congress. It is hoped that a forthcoming issue of Prosthetics and Orthotics International will carry the other lead paper by W. Kreiger.
At the time of the first World Congress of ISPO a "workshop" was held in Les Diablerets, Switzerland, to attempt to identify needs and establish priorities of action in prosthetics and orthotics throughout the world (ISPO, 1975). In response to questionnaires sent out six months prior to this event, 33 countries, representing nearly half of the world population, provided information on patient population, facilities, professional staff, etc. While there were gaps in the information obtained and although many of the statistics provided were clearly suspect, it was possible to get an impression of the extent of the problem. In the disability types considered, the number of physically handicapped was reported as being over 14,000,000 in a total population of about 1,200,000,000. This suggests that about one person in 100 might require some type of appliance. It appeared that only 1,800,000 have been provided with devices, leaving over 12,000,000 handicapped individuals for whom no appliance had been made. It was estimated that about 11 prosthetists, orthotists and technicians were needed to care for 1,000 patients. Thus, to provide service for the 12,000,000 handicapped presently uncatered for would require the training of 132,000 persons.
Even if these figures are substantially inaccurate, it can be seen that the problem is massive. It is not surprising that in this world survey, in a section for special comment, there were more requests for assistance in education and training than for any other service or facility.
It is apparent that in global terms present arrangements are grossly inadequate for the whole group of medical and paramedical workers involved in this field. The clinic team concept, already proven as the preferred means of treatment for the patient requiring prosthetic or orthotic provision, requires a high degree of professionalism of all its members. The key member in the team in this continuing process and the one whose education and training gives most cause for concern is the prosthetist/ orthotist. It is this problem which is the primary consideration of this presentation.
The emerging pattern of practice throughout the world involves two levels of operatives, the prosthetist/orthotist and the prosthetics/ ortho-tics technician. Job specifications have previously been detailed in a number of documents (U.N. 1968, H.M.S.O. 1970) but the distinction is rather easily understood. The prosthetist/ orthotist is the professional member of the clinic team who is directly concerned with the treatment of the patient. The technician, on the other hand, is concerned largely with the manufacturing and assembly process, working to the instructions of the prosthetist/orthotist. It is inevitable in this field that certain construction or adjustment work will be carried out by the prosthetist/orthotist and, on the other hand, the technician will, from time to time, be involved in working with the patient under the supervision of the prosthetist/orthotist. The two types of staff are, however, quite distinct in function and their selection, education and training must reflect this. To have one individual handling all stages of measuring, construction, assembly and fitting is inefficient in the use of high grade staff and puts excessive demands on the abilities of lower grade staff.
It is recognized that terminology differs throughout the world and that even where the terms prosthetist/orthotist and prosthetics/ orthotics technician are not used, this two-tier structure of working exists. The only importance in formally recognizing its existence is clearly to identify that the two individuals involved would be selected for different attributes and attitudes, would require different entry qualifications and subsequently would be educated to a quite different level.
These statements are not incompatible with the best practice anywhere in the developed world. The training of the technician is broadly craft based and will be adapted to local needs and the skills and resources available. The education and training of the professional prosthetist/orthotist is much more demanding of resources and, moreover, is the key to the massive problem already identified of the world's untreated millions.
Professional education and training
The International Society for Prosthetics and Orthotics has a now clearly developed philosophy in respect of prosthetic/orthotic education and training. This philosophy has been documented in a series of publications which started with the Report of the United Nations Interregional Seminar on Standards for the Training of Prosthetists (U.N. 1968), the so called Holte Report, which was organized by the United Nations in collaboration with the Society's forerunner, the International Committee on Prosthetics and Orthotics (I.C.P.O.). The current status of the Society's views, which have not changed in concept over the years, is now embodied in two documents. The first, already referred to, "Needs in Prosthetics and Orthotics Worldwide" (ISPO 1975) is the report of the workshop held at the time of the first World Congress. In this report it is stated that the Society's "philosophy endorses formal long-term degree-level courses or the equivalent for prosthetists and orthotists". The second document is the "International Study Week on Prosthetic/Orthotic Education" (Hughes, Ed. 1976). The Study Week brought together representatives of most of the major education programmes in prosthetics/orthotics throughout the world to give detailed consideration to the current situation and make plans for future development. This second publication, the proceedings of that study week, spells out in substantial detail the content and format of properly constituted education and training programmes.
The Study Week Proceedings recognized that a wide spectrum of approaches exists ranging from the formal university course to the "guild" based. Irrespective of the approach however, the essential ingredients of any course leading to professional qualification were specified as:
Teaching of theoretical subjects.
Closely supervised practical instruction.
Structured and controlled clinical experiences
The theoretical subjects range over the basic physical and life sciences and the application of these to prosthetics and orthotics and related medical and social topics. It is not possible to specify a curriculum in absolute time allocations because of national variations in educational practice and conventions. The specification of degree level or equivalent establishes on a national basis such things as entry qualifications, total time content and educational level.
Closely controlled and supervised practical instruction in a laboratory or classroom situation was agreed as being essential to any of the various forms of training courses and a detailed minimum number of experiences was identified. These covered all the main prosthetic and orthotic devices and would take place in an instructor/student setting apart from the normal service clinic environment.
The normal clinical experiences required by the student which would take place during the course and the related internship were also identified as requiring structuring and control.
Without attempting to impose a uniformity of approach, this specification still sets the boundaries of any reputable course. The course with which the author is associated follows the formal university course pattern. This three year course leads to a nationally recognized award, the Higher Diploma, of degree equivalent status. The hourly breakdown of education and training is as shown in Table 1. It will be seen that the theoretical teaching amounts to about 2,160 hours. The students have university entry level qualifications and this establishes the duration and type of course which is required to bring them to degree level. The closely controlled and supervised practical instruction amounts to another 2,415 hours. It is difficult to imagine that the experiences identified under this category by the Study Week Group could be covered in the laboratory situation in any less. The duration of a course using an alternative approach would require to be adjusted accordingly. However, it would still need to include both these elements and so would inevitably be longer—there can be no shorter path than concentrating both elements together.
Although flexible, there is nothing ambiguous about the ISPO philosophy. The educational level is clearly specified—degree level or equivalent. The educational aspects must be completely integrated with a clinical training programme which, in the controlled environment of laboratory or classroom, provides the trainee prosthetist/orthotist with a specified minimum number of experiences relating to the whole range of devices he will encounter in his clinical career. It hardly needs to be said that throughout the programme proper examinations and assessments would be carried out, records kept and gradings allocated. Standards must be maintained and one would expect to see similar wastage rates applying to this course as to any other university or college course. Within this flexible philosophy, courses or systems of education and training which do not conform to these outlines cannot be considered acceptable.
In consideration of the duties of the professional prosthetist/orthotist, it is difficult to visualize any different situation which would satisfy his needs, the needs of the clinic team and, of prime importance, the needs of the patient.
The world need
It was suggested in the introduction that there was a requirement to train 132,000 prosthetists, orthotists and technicians. This figure may not be very accurate. It does, however, indicate the size of the problem.
In January 1974 ISPO carried out a survey of established prosthetics/orthotics schools. Eighteen were identified of which it must be said that several, perhaps as many as ten, do not satisfy the criteria, already described, of providing a professional qualification. The existing schools are not even sufficient in number or size to deal with natural wastage. Since that time it does not appear that any new educational facilities have emerged—the situation is static. Yet even if the provisional estimates of need are exaggerated, and there is no reason to suppose that they are, the need is desperate. New schools should be developing. Existing schools should be inundated.
There is an urgent requirement for international agencies to channel resources into education and training—and education and training at a high level. As an ideal, the rehabilitation of the patient requiring prosthetic or orthotic assistance must be of similar standard, regardless of the part of the world where this treatment takes place. This infers an eventual move towards uniformity of education and training standards and subsequent qualification. This is part of the ideal of ISPO. The practical expression must come from the national and international groups who are responsible for committing funds. An investment made now in educating and training a prosthetist/orthotist will not mature for at least four years. An investment in an instructor may take twice as long. For the patients who need our services, a decade of Rehabilitation can only follow a decade of Education and Training.
Hughes, J. Ed. (1976) International Study Week on Prosthetic/Orthotic Education. HMSO, Edinburgh.
International Society for Prosthetics and Orthotics (1975). Needs in Prosthetics and Orthotics Worldwide. ISPO, Denmark.
Scottish Home and Health Department (1970). The Future of the Artificial Limb Service in Scotland. HMSO, Edinburgh.
United Nations (1968). Report of the United Nations Interregional Seminar on Standards for the Training of Prosthetists, Holte, Denmark. United Nations, New York.