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Orthoses manufacture

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Adrian Misseri, May 8, 2008.

  1. Adrian Misseri

    Adrian Misseri Active Member

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    G'day all,

    Just a quick question, and probably something which has been brought up a while ago, but I'm just curious as to whether people manifacture their own orthoses or whether they outsource to a lab. I'm lucky enough to have a guy who comes in and does the plaster work and moulds plastic for me so I can get exactly what I'm after, but I do outsource for things like CFA devices, which I use with children quite often as a cost effective solution.
    Just curiosu to see how everyone gets the often interesting and sometimes complicated devices that are discussed about on here.
  2. I'm lucky, i do my own.

    In the NHS i have access to a lab and technician and we are able to manufacture anything we want at far less cost than it would be to outsource, with the added bonus that if i want something exotic i can do it myself and save myself the trauma of trying to communicate the exact requirements to somebody else.

    In Private practice i have a much smaller lab in which i make insoles for my, and recently a few other aquainted podiatrists, private clinics. It cost a bit to set up but its slowly paying for itself and the ability to get EXACTLY what i want is nice!

    I think it would be a valuable CPD activity for everybody who prescribes insoles to spend a few days in a lab making them. Some elements of the process, the cast balancing, the amount of arch fill etc might surprise you!

    Is the actual production of orthotics covered as part of the training outside of the UK?

  3. Ian Linane

    Ian Linane Well-Known Member

    Hi Adrian

    I made my own for about nine years using various materials ranging from EVA through to the laborious techniques of wet-up-lay pure carbon fibre. Had great fun at times but it was labour intensive starting with the negative and ending with the finished product. I think the most I made in a day was nine pairs, although with the carbon fibre type two pairs in a day was pretty good going.

    I started outsourcing about 2 years ago and have been very happy with the results and tend to have more of a life now!! I'm sure Simon and Dave Smith will be able to give you the score on much more modern methods which leave me behind in the days of the Luddites. Strangely enough I came across my rather nice vacuum pump in the workshop today and am debating whether to put it in the skip on the drive or keep it for posterity.

    Last edited: May 8, 2008
  4. efuller

    efuller MVP

    I do my own in my private practice. I also work in a clinic where I order from an outside lab. Recently I returned one patient's device twice before they did what I asked. The first time they did not even put on a top cover as asked. Of course the clinic had contracted with a low budget lab. I would hope this not an industry norm. I also like knowing I will get what I want when I make my own.

    You would think that after several tries you would be able to communicate with a lab to get what you want. Often there is a difference in terminology that gets in the way. You have to learn the lab and the lab has to learn what you mean. You also have to check to see that the lab did what you wanted. There is a learning curve with each new lab. Just hope that the patients you treat do ok while you are experimenting.


  5. Boots n all

    Boots n all Well-Known Member

    We deal with it all in house, they are always finished and ready for pick when l said they would be ;)

    What sort of turn around time are the labs offering?
  6. Trent Baker

    Trent Baker Active Member


    In my practice we out source our orthoses to a great quality lab. I have an excellent relationship with the owner/operator and we rarely get devices back that do not match exactly what we have prescribed. On the odd occasion we do, the lab takes the device without hesitation and follows our instructions to a tee.

    I think there are a few tricks to using a lab though, and I've gone through a few different labs to get to where we are with this process.

    Firstly, building a good relationship with the operator is extremely important to enable efficient communication when ordering variances. Secondly understanding exactly what the operator's interpretation of their prescription form is so you can prescribe appropriately. Finally ensuring your casting technique is consistent and accurate. When you make your own devices you know exactly what you have done with the casting process and any idiosyncrasies you may have in your technique, allowing you to iron out the creases so to speak. However a lab will not make that distinction and make devices from casts at face value (as they should).

    Getting these factors right in conjunction with a good quality lab (and you pay for it mind you) will produce quality devices.

  7. Craig Payne

    Craig Payne Moderator

    The number of podiatrists who manufacture their own foot orthotics in-house has been steadily declining for a while. Many who used to do it, are doing it no longer.

    There are some who argue strongly that more should be doing it, but the number is declining. The Universities have responded by taking emphasis off manufacturing skills and moving more towards prescibing and orthotic adjustment skills. I know some are being critical of that, but the Universities are only responding to what is happening in industry.
  8. PodAus

    PodAus Active Member

    Hi Craig,

    ... and a particularly good approach at that.

    Orthotic manufacture as a scientifically designed and medically prescribed tool suggests tight tolerances and exacting parameters...

    but as we all know, the art is really in the 'how do I review, modify and achieve positive patient outcomes as efficiently as possible'.

    The orthotic manufacture is a baseline - as such, the practical aspects of the implementation and associated medical Practice is where the Patient can really benefit.

    Is the Practitioner better off allocating time to Patient consultation or materials construction?



    Paul Dowie
  9. Adrian Misseri

    Adrian Misseri Active Member

    I dont quite agree with this statement Craig. Certainly the industry is heading towards more lab orthoses, however that means that the basic fundamental knowledge of biomechanics and its relevence to orthotic therapy is just as important. The problem as I see it, is that you can put just about any device under just about any foot and get some degree of relief to the patient. This is how i see prefab devices working, generic countour will suit most simple cases (I know I'm opening myself up for an earful here...). As a result, podiatrists who have a lessor understanding of biomechanics, and especially new graduates who are still getting a feel for biomechanics, are getting away with prescribing less than optimum devices, and are getting positively reinforced as the patient is feeling a bit better (but not as better as they possibly could??).

    Being a relatively recent graduate myself (4.5 years ago), I remember all the orthic manufacturing sessions. I happened to rather enjoy them, and used them as a chance to better help me understand my biomechanics and help get a better grasp on what the foot and device will do to eachother. Certainly other students were less than interested at the time, but I'm sure given an oppotunity to go back and relearn orthotic manufacture, would probably be more interested and get more out of it.

    Perhaps a CE workshop on orthotic manufacture would be useful?

    Thaks for you interest Craig and everyone else who has posted!
  10. CraigT

    CraigT Well-Known Member

    Agree 100%.
    I make all of my orthoses myself, and must have made over 5000 pair.
    I believe I have gained knowledge that I could not have got any other way than by following the whole manufacturing process through from start to finish. You make errors in judgement occasionally, but you can see where this occurs and correct for it with ultimate control.
    These errors become less and less over time.

    You will learn this art more efficiently if you have the skills to control the process from start to finish...
    Do you need to make your own devices? No... but if you can, you have ultimate control, and I believe those that do, learn the process of modifying more efficiently.

    I have trouble comprehending that with Podiatry courses extending to 4 then 5 years, that time to learn manufacturing skills is decreasing... (in Australia that is)
  11. PodAus

    PodAus Active Member

    Hi Craig,

    Understanding orthotic manufacture is an intergal part of Orthotic Therapy. The manufacture process is part of orthotic implimentation, but to clarify, the orthotic shell manufacture is only part of the orthotic prescription. The other components of the top cover, additions, padding are just as important as the shell, and I completely agree with Practioners being extremely well versed and practiced at modifying both shell and 'additions'.

    I don't see how those whom manufacture their own orthotic shells learn the process of modyifing more efficiently. Those whom can and do modify to acheive best outcomes learn the process best...


    Paul Dowie
    Last edited by a moderator: May 13, 2008
  12. Craig Payne

    Craig Payne Moderator

    The curriculum is always under pressure. We always get comments like "You have to teach more or this" "You have to teach more of that" ... everyone has advice for us on us teaching more of their "pet" subject. Its all about meeting competing demands on the limited time that we have in a degree program. We talk to a lot of people and discuss this amongst ourselves ad nauseum as to what the balance should be. Our students are taught the manufacturing process and do manufacture some themselves....but this is only in the context of learning the key skills of being able to prescribe and adjust. They are taught and practice up to the level of manufacturing that if they do want to go on and make their own, that with a bit more work that they can. We are training Podiatrists, not orthotic technicians.
  13. pgcarter

    pgcarter Well-Known Member

    I could not resist......Latrobe had said at faculty meetings that it was intended to remove orthoses manufacturing from undergrad training as early as Nov 2005. As far as I'm aware the profession was not consulted....what's driving the whole thing is money....it is expensive to run a clinic....whoops...that's gone too.....it's expensive to teach specialty 4 yr courses....lets make it happen in two years.......it's hard to make orthoses and nobody on the faculty has ever done much of it....and has not the foggiest idea of the gains to be made by doing a lot of it......and to admit this would mean they have to admit that they themselves did not try that hard to acquire those skills....but those skills aren't worth much anyway if you don't believe so......they are something lowly "techs" can do.........
    What's wrong with this view?.....it limits the choices practitioners have in the work place...they can't choose to do something they can't do......nett result?......lower quality of service to patients who can't pay....show me a public health centre or hospital who provides devices to patients at any where near the raw materials cost.....which should be about $20 for a pair of cast orthoses. If you don't have an invoice from a lab you don't have to charge the patient for it........those that slip through the cracks are getting more numerous because the cracks are getting wider.....and the Universities are not driven by ideals..........its all about the money.
    Phill Carter
  14. Sounds like a little bit of bitterness, Phil. Are you then saying that Universities are not providing a good education to their students but are, instead, just collecting fees without educating? I'm sure that your opinions may not sit well with those faculty members that put their heart and soul into teaching for what they perceive as less income than they deserve for the number of hours they devote to teaching.
  15. Matthew Oates

    Matthew Oates Member

    The teaching of the manufacture of orthoses is an interesting debate. The decision at La Trobe to migrate away from countless hours spent making devices was based on a number of reasons and some of these have already been identified by previous postings to this discussion thread.

    It was felt that education should reflect dominant professional practice (ie. develop the student's skills to accurately take a plaster cast, to interpret the findings of their clinical and biomechanical assessment, to formulate an appropriate prescription to achieve the desired effect and their skills to troubleshoot and modify the devices they have prescribed in response to problems that might present following the issue of the devices).

    As an educationalist thinking about the way students learn, it is in the orthoses lab that you develop an appreciation for Howard Gardner's multiple intelligences. This is also evident in the student clinic where students are asked to 'present' their patient to the supervising clinician (but we can leave this for another discussion at another time). The manufacture of devices favours those with bodily kinesthetic intelligence - i.e those that can visualise how the device will contour to the foot and how plaster additions will change things, those that can manipulate equipment with ease, etc. For those students who struggle to do this, orthoses manufacture can be a frustrating exercise with very few outcomes. I can certainly remember peers when I was at university who experienced this. We need to recognise that repetitive manufacture of orthoses does not necessarily lead to the achievement of learning outcomes (i.e understanding of biomechanics, etc.).

    That is not to say, that we shouldn't acknowledge that there are some students that enjoy and learn from the orthotic manufacture process and in our new curriculum we will cater for these people through elective and advanced practice subjects. I also believe that the Prosthetics and Orthotics Department will offer graduate certificate opportunities in orthotics and I'm sure podiatrists will be one of their target audiences here.

    The other obvious constraint has been the availability of appropriate resources to teach this. We are under pressure to increase the number of students we take into the course for our own financial viability. Orthoses lab space can't increase and so with the safety of students paramount, it becomes impossible to have large groups of students in the lab for the time needed to manufacture devices.

    These are some of the challenges and I know this disappoints the enthusiasts in the profession who enjoy the orthoses manufacture process.
  16. Adrian Misseri

    Adrian Misseri Active Member

    I always believed that my time spent in the orthotic labs at university was some of the most productive class time that I had in regards to my undertanding of the application of theoretical biomechanics in a physical theraputic sence. I understand foot biomechanics better today for the time spend in playing with orthotic casts and shells at university. I also believe that my skills in manufacturing and modifying orthoses, NCIs, CFAs, and other shoe padding and OTC devices, learned at university, have been fundamental in my application of biomechanics in my patients, and instrumental in the best clinical practice that I can give to my patients.
  17. CraigT

    CraigT Well-Known Member

    Hey Paul
    No arguments from me there.
    I would have to disagree... I think the other additions are more like icing on the cake. The shell can influence the foot the most, and can also do the most harm if not appropriate for the individual.
    I am speaking about the wholesale modification of design- this would include altering plaster work and re-pressing. Having control of the whole process from start to finish, and seeing directly the influence of what you have made is, in my opinion, invaluable.
    Certainly the art of modifying orthoses at the clinic level as also extremely valuable. I am disappointed if I discover that some Pods send there devices back to a lab to get even the most basic changes made...

    Hi Matt
    I agree- and you probably mave a few people contributing here who have high 'bodily kinesthetic intelligence'- they are the ones that enjoyed orthotic manufacture ;)
    Surely the developement of this is part of understanding biomechanics and the effect of an orthosis-
    So if this is difficult for some people, surely having them 'get their hands dirty' will help them at least to some degree.
    This ability is of paramount importance to a Podiatrist who uses foot orthoses... and is also a hallmark of a biomechnical mind.

    They also have to evaluate whether the lab is actually providing them with a device which is what they prescribe, and if not, is it because of the lab, or the prescriber? Again, if you have a more detailed understanding of the effect of the prescription variables, then you can critique the orthoses more efficiently and effectively.
  18. PowerPodiatry

    PowerPodiatry Active Member

    For my two cents worth I'm old enough to say that when I started in private practice the
    option was make the orthotics yourself or let me think "I'll make it myself". So the many hours in rural practice making orthotics late at night after the kids went to bed taught me that making orthoses can become a nearly Zen like pursuit. The art of the foot can be taught in many ways and spending many hours sniffing glue and grinding plastics is but one of them. Do I still manufacture my own , No.
    I have learnt to meditate a different way. My new fear is the New age Podiatrist that invests in High tech data acquisition (force plate, scanners) orthotic solutions and must feed these hungry beasts and hopefully the software will tell them all they need to know about the art/science of orthotic prescription.

    Colin Power
  19. RStone

    RStone Active Member


    I'm certainly not mechanically minded but I've made my own orthotics for a number of years & having to fix orthotic devices that didn't work certainly taught me a lot about biomechanics in addition to how the devices work with different footwear and feet. There is a lot of motivation to understand a device and to get it right first time when it's your own "relaxation" time you're spending fixing them! I have worked with a number of podiatrists who don't know how to fix an orthotic that corrects the patient's foot but doesn't fit into a single shoe! Constantly telling a patient they simply have to buy a different shoe (again) or they simply have to get used to some discomfort from their orthotic does not reflect well on our profession.

    Just Curious:
    Who trains most of the lab technicians?
    In my experience orthotists prescribe orthotics with fundamentally different aims and proposed outcomes when compared to podiatrists - why is this or is this just my own special unique experience?

  20. Atlas

    Atlas Well-Known Member

    Are you saying that money doesn't dictate what most of us do, at an individual and organisational level?

    Lets not confuse bitterness with honesty Kevin. We should welcome it. It raises the bar. We are here to debate the issues and we need as much substance/input on the table. Much more John Lennon and much less Olivia Newton John? Imagine that.

    I think Phil raises some interesting points in the debate. The man has passion and experience relating to the orthotic manufacturing process at several levels (education, private practice, public practice and retail).

    Incidently, I thought Matt's response was quite good. I must not have good "bodily kinesthetic intelligence" in view of my 1st presses not looking/functioning like I often want them to.

    My strong feeling is that the less orthotic hands-on work the students do, the more the labs will get away with (lab-o-phobia). The harder it will be for new-age podiatry students to judge quality and whether the device actually matches prescription. On the flip-side (lab-o-philia), doing the 'hard yards' and getting dirty with plaster, and plastic/eva debris, and getting high on glue fume ingestion, may actually increase an appreciation of what the labs put out, at relatively low cost, with big capital expenditure etc.

    What is the solution?

    Phil is right, in that students need to be have some hands-on experience. Ideally, you would of course want a passionate experienced educator at the helm. Then there is the money issue. My guess is that the materials expenditure at university must be at crazy levels. The last thing we students thought of was making that roll of poron go further.

    Just brain-storming....the solution might be to integrate industry and the education arm of podiatry. Go for the 'win-win'. The industrial wing might be able to 'invest' in a communal/shared laboratory where final year students would "work". Podiatrists might be able to then send their casts in, and "hope" for a decent return. Alternatively, podiatrists might be able to rent machinery time in the shared lab and buy materials.

    What goes against this though is that the labs are doing very good aesthetically finished work at low cost IMO.

    Disclaimer: Phil was more than my orthotics teacher:drinks
  21. Atlas

    Atlas Well-Known Member

    Brilliant post.

    I don't know about the orthotists necessarily having diferent aims. Different means, but same aim I would imagine.. In fact, I think there are some things that they probably do better (forefoot cushioning/forces/inbuilt-additions etc.). Like chiropractors and physios. Like reflexologists and spiritual healers;)
  22. Adrian Misseri

    Adrian Misseri Active Member

    My question to the staff at Latrobe, and no offence intended, is that if the course is essentially shrinking with the new proposed 2+2 years bachelor/masters structure, where do the hours required for learning of the orthotic/NCI/NCR/footwear manufacture/preparation/modification fit in?
  23. Adrian Misseri

    Adrian Misseri Active Member

    Matt, I agree with you. I was one of those students who did spend hours in teh grinding rooms, who had the 'bodily kinesthetic intelligence' of which you speak, and I saw my fellow students who weren't so struggle with device after device. What happened here is that we learned of eachother, and the orthotic labs became very much a structured group activity. Yes there are constraints at the universities, and money doesn't stretch far these days, but if the time was made more productive, and clinical supervisors were available at all the manufacture sessions (which they weren't always), perhaps more students would have benefited more from them. And if some of the supervisors are not comfortable teaching this subject, and lets face it not everyone is great in all areas (we're all human afterall) , by helping those with that 'bodily kinesthetic intelligence' perhaps they may be inclined to come back as lecturers and teach what they know and inspire another student to do the same?
  24. PodAus

    PodAus Active Member

    Hi Craig T.

    How's the tan coming along?

    Definitely - a grinder, full selection of materials and the ability to modify on the spot are invaluable in a biomechanics clinic environment. Hands on I say.

    Whilst an appropriately designed shell is very important, appropriate use of the plethora of additions, modifications and cover materials is also required to complete a functional prescription.

    For example, as there is no direct shell influence during propulsion or forefoot loading, additions such as Met Domes, PMP's , windless wedges (kinetic wedge), etc. can complete the function of the device.

    But most importantly, the device must fit into the patients footwear and be comfortable, for anything else to be relevant...
  25. Adrian Misseri

    Adrian Misseri Active Member

    I think you've nailed it there... As podiatrists, we need to be able to do everything involved in orthotic manufacture and modification. And seriously, how often do we make up a pair of arch cookies on the spot to pop into someones shoes, or make an NCI quickly with the patient in the chair? I do it almost on a daily basis. The skills are not relevant solely to orthoses, but to all of our biomechanical interventions.
  26. Ron:

    Here is what Phil said in the last sentence of his post, "If you don't have an invoice from a lab you don't have to charge the patient for it........those that slip through the cracks are getting more numerous because the cracks are getting wider.....and the Universities are not driven by ideals..........its all about the money."

    To me, statements such as "the Universities are not driven by ideals..........its all about the money" is indeed bitterness, that does not reflect the truth. I have many colleagues that teach at LaTrobe who I know are great instructors. Are you and Phil saying that these professors are also "all about money" since they are part of the "University"?

    I have been a faculty member at the California College/School of Podiatric Medicine now for 24 years and making statements such as this that the individuals that are part of the University are "all about money" is not only wrong, but also is myopic. Statements such as this, in my opinion, show a complete lack of understanding of what goes into the decision-making process of using X number of dollars to run university program. Sure, I would have liked to have seen CCPM/CSPM spend more of their dollars/time toward teaching biomechanics and orthosis therapy, but I also realize the importance of teaching surgery and the basic medical sciences, for example.

    Please don't denigrate our colleagues that put their time and emotional energy into teaching podiatry at the Universities by saying they are doing it just for money without giving them any credit for possessing a much higher ideal of trying to educate students to make them more effective podiatrists and clinicians. This is not fair to them or their students.

    If you want to make things better for the students, then get involved in the decision-making process at the University level. Better yet, since money and ideals seem to be the topic of the conversation, why don't you go ahead and be more idealistic and volunteer a day a week to teach at the University for free to give the students a better education than what you perceive them to receive. Certainly, it would certainly carry much more weight with me and others if those that claim that Universities are all about money and not about ideals, would spend some of their own free time to help the Universities teach the subjects that they feel need to be taught, without any monetary compensation. How ideal are you??
  27. Atlas

    Atlas Well-Known Member

    Kevin, try reading what I posted. Where did I agree that it was "all about money"? I said that Phil raised some interesting points and was entitled to do so. I actually found Matt's response quite enlightening. Do we need a pHD or belong to some intellectual clique to have a say?

    You're not objective enough Kevin. To be frank, I might not be with Phil either since I have known him personally. That is why I will always add a disclaimer of my personal relationship. Transparency.

    What a tangent!

    I am sure I posted this line. "Are you saying that money doesn't dictate what most of us do, at an individual and organisational level?"
    'Us', I thought, means 'me too'. Nothing too idealistic about that.

  28. Ron:

    Just making some observations, as usual. I stand by my arguments and have never suggested that others should not join in on the discussions. In fact, I wish some more of the faculty from LaTrobe would join in on our conversation to discuss whether, as part of the University faculty, they teach only for monetary gain. After all, it is all for the money....isn't it?;)
  29. pgcarter

    pgcarter Well-Known Member

    Hi Folks,
    What a storm in a tea cup.....No Kevin there is no bitterness invovlved. And yes I agree you will know a lot about what you do.....but this is dangerously like writing a critique of a movie you have not seen. You have not worked in Aus, or at Latrobe or in the Aus health system, either public or private as far as I know. Your insights here will be interesting but of limited relevance.

    The statement that a Uni and more specifically Latrobe is being run pretty much as a business and that money is dictating many\most of the decisions does not mean that the individual faculty members approve of that or that it is somehow their individual fault. When a dept has a chance to outline it's requirements for doing the best job possible, the Uni does not say "great, how much do you need, we'll put it in the account tommorrow"
    What pretty much happens is someone outside your own department decides how much money you have to play with....and you are forced to cut your cloth accordingly.Compromises all the way.

    This sort of thing is driving the evolution of our profession. It is not the professional body saying lets make it all fit into two years, call it a masters and while we are at it lets raise what it costs for the training.

    The result of loss of in house skills in the podiatry work force is causing a significant increase in the cost of services to those who can least afford to pay within the public health system in Victoria. When a podiatrist can make a device themselves the device can be provided to the patient at a fraction of the cost of the invoice from a lab.

    To sat that we can allow the P&O folks to pick up this part of what has been podiatry is to hand away part of the sphere of practice. In the early days of setting up your own private practice the ability to make your own devices is worth $90-120 a pair.......enough to pay for the groceries if patients are a bit thin to begin with. When phasing out orthoses manufacturing was discussed back in 2005 the idea of selling it as a post grad course for an extra fee was also discussed.
    To say that because some people are more particularly suited to learning this particular set of skills and then work to remove it from the course is not necessarily a good thing for the profession as a whole. Just because some people find it hard is not a reason to stop. The implications are significant. There are very few things that the profession of podiatry has in Australia that are not also done by
    other professions. Our profession is a very small one which suffers from workplace politics and competition all the time. Nursing wants to do much of what we do, Physio, P&O.....nail technicians coming in at the bottom (not that I am much against that).....now is not the time to be making our profession smaller or less flexible.

    As far as the level of investment goes....for about $5000 10 YRS ago I have made hundreds and hundreds of pairs, for myself and for a hospital that did not have a workshop, for various community health centres where I have worked, the one where I now work......

    A complex set of issues without any simple resolution......the big question for the future of the profession is....Just exactly what are we going to be the recognized experts at?....and how is the current change in educational format ensuring supporting the profession...as opposed to living with pressures from the educational institutions?

    regards Phill Carter
  30. PodAus

    PodAus Active Member

    How long does it take the average Podiatrist to make a pair of prescription devices, when billing their time at $100+ per hour? Particularly practitioners with many, many years of experience...

    The lab is by far the cheapest place for orthotic manufacture isn't it?


    Paul Dowie
  31. Craig Payne

    Craig Payne Moderator

    I have always based it on the assumption that there is a one hour of labour going into making a pair of custom made foot orthotics from a negative plaster cast --- maybe less if working on more than one pair at a time; obviously labs have a huge efficiency of scale as they working on multiple pairs at the same time.
  32. PodAus

    PodAus Active Member

    I have to assume the cheapest outcome for the patient is to have a professional lab manufacture the devices as best possible to my prescription.

    I just cannot see how time and materials can be amatised without the labs leverage...

    :hammer: :butcher: (pun intended...) :dizzy:
  33. Matthew Oates

    Matthew Oates Member

    Hi Everyone,

    I'm sorry I haven't been active in the last few days. I read with great interest your postings to this discussion thread and I am enthused by the healthy and passionate debate that continues.

    I would like to make a couple of points. As a producer of graduates, podiatry schools have to inevitably make decisions about the skills and competencies of the entry-level practitioner or new graduate. Traditional professional courses, like podiatry, have been plagued by over-crowded curricula which attempt to flood the student's brain with everything they could possibly need to know and the skills to do everything they could possibly need to do (Our previous Dean would refer to this as "just in case" medicine). This is usually at the expense of developing higher cognitive skills - problem solving, analysis, reflection, synthesis.

    Modern curriculum design suggests that if you allow students to develop these skills using a carefully selected gamete of pathologies, cases, etc. (in fact, some graduate medical programs now limit their curricula to 98 core pathologies that are considered over the duration of the program) then you do much more to prepare students for the challenges of the workforce. That is, they learn how and where to access information when something unknown presents to them, they can make informed hypotheses in the absence of a certain answer, they can test these to formulate a diagnosis, etc.

    In our new curriculum, authentic clinical cases will dominate and be used to develop the student's ability to research, to seek out answers and knowledge and to come up with answers as we use an enquiry-based learning model. Skills classes (and this is where casting, orthoses prescription, limited manufacture, modification, etc.) will support their exploration of cases. We hope this will engage our students and enhance their motivation and foster a greater sense of independent learning.

    I would like to point out that reducing the amount of manufacture because this learning process suits a limited number of students is not our intention. We would like to provide alternatives for students to learn about orthoses and how they work. We have created an Orthoses Learning Session program here at LTU which combines small group clinical tutorials complemented with opportunities to get dirty in the orthotics lab much like a problem-based learning program. The feedback has been quite positive and it appears to be catering for various learning styles.

    More food for thought.

  34. CraigT

    CraigT Well-Known Member

    Hi Paul
    It's a bit hot to work on the tan now- it is around 40C every day, and it is not summer yet...
    It is for sure the cheapest outcome- but I always billed more than what I lab would charge for my work. That was when I was in private practice.
    Currently I am in a salaried position, and part of my work time is manufacturing. It is more time efficient, and cost effective to make the devices in house here than if we used an external lab. We are now looking at ways to make this process as streamlined as possible without compromising practitioner control.
    How many Pods actually pass on the savings of making the device to the patient? How many Pods charge less if the find a lab that charges them $20 per pair less? Generally Pods charge a set fee for othoses, and the costs in producing them effect the bottom line for the Podiatrist rather than the patient.
  35. pgcarter

    pgcarter Well-Known Member

    If you do enough orthoses and can make a pair in about an hour?..........and is it always about the money Paul? And I have not been talking about average podiatrists.....just what might help make better ones
    regards Phill
  36. Adrian Misseri

    Adrian Misseri Active Member

    Not to sound idealistic or have a go at anyone, but what about the best outcome for the patient? If a pair of labbed devices is about $100 or so, and a pair costs to make approx $20 in materials and about an hour of time (approx $110, given 2 x30 min consults at $55 each) so $130 all up, is it worth sacrificing $30 profit out of a pair of devices to get a exactly the device you need for a patient, as opposed to getting something that may not be 100% what your after but your going to go with it anyways because it's too time consuming to return it to the lab to have it corrected?
    I guess at the end of the day we all wish we could do this for free but unfortuntely we all have to earn money to survive :bang:
  37. PodAus

    PodAus Active Member

    Craig, SPF 60++ mate.

    Is there an external lab within cooee? The alternative to out-source may be logistically challanging...

    How many Practitioners charge excessively for inappropriate, ineffective and unhelpful orthoses? Not through anything else but inexperience? Does the Practitioner charge the patient more for a positive outcome? Does the Patient not pay, if the outcome is not positive?

    The fee should reflect the outcome to a point.

    At the end of the day, consulting patients takes time and making othoses takes time - how the Practitioner allocates their time will ultimately determine just how many patients can be helped.

    I would not turn a new patient away in Private Practice because I had to spend the time making orthoses, particularly when these is a professional lab available. Just as I have reception services, a book-keeper, practice manager, etc. to assist in leveraging my time.

    If you run a good business, gather lots of experience with providing successful outcomes for patients, then your Practice can help more patients.


    Paul Dowie
  38. pgcarter

    pgcarter Well-Known Member

    I agree that you can outsource a variety of services and that lab made devices are as good for a range of patients.....and that after a pod has spent some undefined and variable amount of time actually doing it all (100? 200?....) then using a lab for some of them is reasonable. The issue about end cash cost to the patient in public health remains though. The factors in private and public are not always the same.
    And now being in a situation as you describe, in a rural setting where some folks may not have access to service if you don't see them, then making more consulting time makes sense.
    The other aspect is that some of us may prefer doing lab work some of the time....and if the future pods are not equipped with those skills they cannot make that choice. Having the skills makes for more choices.
  39. PodAus

    PodAus Active Member

    I strongly agree these skills are required and are important for direct use in in clinic every day... for orthotic prescription and modification.

    They must be maintained as part of the education of all practitioners whom associate with Orthotic Therapy.

    However, I don't see the cost benefit to Patients with manufacturing orthotic shells from scratch, rather than using a good Lab.

    Is there any research to show Practitioner manufactured devices give significantly better outcomes than Lab manufactured devices? I'd suggest the outcome is Practitioner dependant, not manufacturer dependant.

    Paul Dowie
  40. Adrian Misseri

    Adrian Misseri Active Member

    All the more reason for apropriate tuition in universities with regards to orthotic theory, production and management. It's up to the universities to attempt to educate the best podiatry students and turn out the best podiatrists they can, given the available staff and resources to educate.

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