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Should orthotic manufacture be dropped from Podiatry training?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Jul 25, 2009.

  1. Members do not see these Ads. Sign Up.
    I hear through the grapevine that there is talk of dropping orthotic manufacture from UK podiatry training altogether!

    I think this would be a disaster of the first order! Without a knowledge of how orthotics are made how can one be aware of how the cast we take informs the final orthotic!? And what of the future? Who will drive research and development of new ideas, new concepts, new materials? Who will test new concepts? Who will innovate new techniques! Commercial labs will only innovate things which make them money!

    Many labs (we know which ones) lean heavily on Root and produce training manuals and run courses based on this an little more. I've been on some. Its not pretty. If we equip undergrads only with this what does the future hold for UK biomechanics? :sinking:

    If we only give them a hammer we can't be surprised when they treat everything like a nail!:craig:

    I'll admit to bias. I am unashamedly what Simon describes as a "lab man". Give me a lab and a grossly deformed foot and I'm a happy camper! But I do feel that unless you've made a few pairs you can't fully appreciate the prescription process!

    For Eg. Take a look at these feet and this insole

    http://davidmhol.proboards.com/index... ad=477&page=1

    Thats not a standard problem. Sam said that

    Now Sam, having passed through my hands, and been trained in manufacture at university, is fully trained and conversant in orthotic manufacture techniques and materials. He knows the difference between poron 92, poron 94, lunar soft and lunar light. Would a podiatrist without these skills have done as well? Would a graduate with experiance only of polyprop shells in various configurations be able to "think outside the box" to treat this patient? I contend that they would not.

    We advocate a systematic approach to assessment based on understanding how the feet work rather than a system of pigeon holes and formulas. Should we not also advocate a systematic approach to prescription based on a full understanding of how orthotics are manufactured rather than a series of tick boxes?

    Is this yet another element of the Biomechanists skill set being trimmed away and snatched up by another group? Are we willing to give up anything which cannot be served with a polyprop shell to the orthotists?:mad:

    I'm not thrilled!

    What say you?

  2. Euan McGivern

    Euan McGivern Active Member

    Robert (and anyone else)

    I am currently an undergrad in Podiatry in the UK (entering level 3 in the autumn) and thankfully have a good component of orthoses manufacture as part of our clinical training from level 1 thorough to 4.

    I agree with the sentiment that experience in the manufacture of foot orthoses will become part of my education which is significant in my future clinical decision making. I may be biased in coming to this conclusion; I have developed an interest in musculoskeletal practice and also happen to enjoy the manufacturing process.

    I also think that having a good knowledge of orthoses manufacture and materials will be useful even if I used 3rd party labs in the future, giving me the ability to evaluate (albeit from a mere experiential position) the quality of the devices made and the processes which the lab uses eg type of positive model used.

    Just my opinion.

  3. Craig Payne

    Craig Payne Moderator

    Be careful about rumours. This come up in the thread on Foot orthoses: how much customisation is necessary?

    We were accused of dropping it, when in reality students are probably doing as much as in the past. They are now doing it in a more streamlined way to improve educational outcomes, within the constraints of resources that we get provided with and balancing that against everything else we have to teach. We continually evaluate EVERYTHING we teach and how we teach it. We get advise from our external advisory committee that consists of representative that WE appoint and the professional bodies appoint.

    The total dropping of manufacturing skills is something that has been an option on the agenda with a whole range of other options for a long time. Just becasue it is one of many options under consideration, does not mean we are going to do it.

    Personally, I think a student should graduate with these foot orthotic skills:
    1. The ability to prescribe
    2. The ability to solve problems (eg adjust)
    3. If they do want to go on and manufacture themselves, then with a bit more work they can (bearing in mind that probably 99% do not go on to manufacture their own).

    To be able to do these 3 (and esp 2 & 3), they probably need to have made some devices. The debate may centre around:
    1. How many should the make to get those skills? What is the minimum number?
    2. Are there alternative ways to get these skills, especially given the resource intensiveness of teaching this subject. This is probably where the rumours come from, as we have implemented some alternative ways to get the 3 skills that are more efficient in terms of resources and time and student/staff ratio.
    Last edited: Jul 25, 2009
  4. Craig Payne

    Craig Payne Moderator

    I should also add that we also are informed by the guidelines/outcomes and accreditation documents from APodC & ANZPAC. At our last audit we were complying. The ANZPAC document has been widely consulted and informed by discussion within the profession. These documents are imposed on us by the profession - they tell us what outcomes are wanted and we decide how best to teach to achieve those outcomes (as that is our area of expertise) - the audits are to see if we are achieving those outcomes. I assume there are similar documents in other countries.

    We also happy to take advice and opinion from others, but it has to be informed advice based on knowledge of those external constraints and the internal resource constraints.

    There would not be many teachers of foot orthotics at podiatry schools all over the world that I have not taken the opportunity to discuss what they do and what we do.
  5. Hey craig.

    I am very careful about rumours as you say. And if you look carefully I did say that there was "talk of" dropping it from the sylabus. I didn't say it had happened nor that it would. I suspect that as with you it is just one of the options under examination!

    That's not my point. My point was should it be an option we consider? That's why I phrased the thread in the form of a question.

    As to being happy to take advice from external agents only if they are aware of internal and external conditions, fair enough. I'm not trying to give advice! I'm merely expressing an opinion! Whilst I fully respect that you and the other educators in oz and here have the same goals and far more experiance in delivering them I don't feel that should make this a taboo subject for the rest of us!

  6. Craig Payne

    Craig Payne Moderator

    Has my response put a dampner of anyone else replying?

    How many orthotics (from prescription to manufacture to issue to follow up) do you think students should be involved with?
  7. Sammo

    Sammo Active Member

    From my perspective.. I felt that there was not enough time spent on orthoses manufacture at university for my liking, but on the other hand I feel it is one of those manual skills which needs alot of time invested in the lab to gain the knowledge and develop the motor skills to be able to grind the materials well and choose the right materials for the patient (which I think, like wound care dressings, is a combination of clinical reasoning and practitioner preference) and with regards to how much else was packed into my course, I don't see where the hours needed could have gone. In fact I left uni with the belief that outsourcing insoles was by far the best way, and I didn't really need the skills to make a good set of insoles (I'm a clinician, not a technician!!).

    However, after some time my opinions have changed quite alot and I currently outsource most of my "normal" insoles, and for children and people with funky feet I'll make my own. It works for me.

    I know it is not ideal, but some people on my course really didn't have an interest in developing their biomechanics knowledge beyond the basic needed and were quite happy with the idea of referring anyone they see with MSK issues onwards. I didn't really have a great interest in wound care (although my current job means I see quite alot).

    One thing I thought might be an option is in the final year having a couple of options that the student can choose with regards to topics to be covered in their learning. Clearly everyone needs core competencies in all areas, but pretty much from day one I wanted to go into the biomechanics side.. at uni I would have liked it if there could have been the options for an extra unit in: advanced wound care, advanced biomechanics/orthotics manufacture, dermatology, nail surgery, paeds.

    What do other people think of this?


  8. wear84

    wear84 Member


    You'll find that what you are proposing about choosing different modules in year 3 already happens at some Uni's -

    From Huddersfield uni website -

    Option modules (select two):

    •Starting in Private Practice
    •Care for the Older Person
    •The Foot in Diabetes
    •Dermatology for Podiatrists
    •Paediatric Care and Management
    •Clinical Governance
    •Law for Health Care Practitioners
    •Wound Care
    •Lower Limb Pathology and Care after Amputation
    •Health Economics
    •Sports Injuries for Podiatrists

    Nothing on Orthotics there but some of them have changed since I was there so I'm sure if there was the demand it could be organised.

    With regards to the initial point about making orthotics and being taught these skills I think it is a valuable tool but as Sam said it's difficult to fit enough time in to the course to get enough practice. I enjoy making orthotics but I don't think you learn everythign at Uni. I also think if you happen to work in the NHS the opportunities you have to actually make them (not prescribe) is limited so skills can easily be lost.

  9. Ian Drakard

    Ian Drakard Active Member

    I'm completely with you Robert.

    I found the time spent making orthotics invaluable, and gave me an appreciation of material properties and choices, manufacturing techniques etc

    Where possible we were encouraged to make the orthotics that we had prescribed and being able to see the whole process through was great. It really helped to see when when you got things right (and was probably even more useful when you got things wrong ;) ).

    It's not that everyone is going to go on to make all their own orthotics -just the beneficial effect on prescription writing and thinking more about the atypical cases.

    anyone else find the idea of choosing modules on an undergraduate course a bit odd?

  10. It does seem a bit early to be specialising. That said, I suppose if you have a strong interest in a particular area it allows you to focus your training whilst you still have access to expert lecturers.
    Fully agree, especially with the last! Whenever we have students on rotation I always tell them that if I can't find something to critique them on, they're not learning. I HATED the lecturers who used to do this to me, but with hindsight they are the ones from whom I learned most!
    Depends on where you work.
    That’s a fair question.

    I think it is a matter of variety, rather than numbers. I can see no benefit to a student making 20 STJN polyprop devices over 5. I think the student should make enough to be reasonably competent in the methods involved (doing it till they do it right.) Rather than numbers overall I would suggest that they should be exposed to different types of insoles and methods so that they A: feel confident in their use and B: have a broader "palette" of techniques available to them. So for example (and I don’t propose this as an exhaustive list)

    At least a few polyprop devices with a variety of intrinsic and extrinsic skives and posts. That way if they want to order (for e.g.) a device with an intrinsic forefoot post they know what it will look like and how that shape was arrived at.

    At least a few simple devices using a spread of materials. I know Simples are not "fashionable" but they can be very effective and COST effective. They are also within the realms of possibility for a private pod to do themselves.

    At least a few Shank dependant casted devices, so that they can experience the issues of shoe fitting and the shaping of the underside.

    At least a few of any of the above where the positive cast must be substantially modified (PF groove, skive, intrinsic etc) so they can experience how that looks / feels / works.

    At least a few of any of the above using "standard cast correction" such as most labs apply.

    At least a few using foam and at least a few using POP.

    That may seem a long list but many of those would cross over. Also when I was training we would "buddy up" for manufacture so that several people would have the experience of a single manufacture.

    So far as internal resource constraints are concerned, I am acutely aware of the costs of running a Lab as I am responsible for maintaining both an NHS and a private Lab. However there are areas where costs can be easily cut. In extremis why not simply charge patients a nominal fee for their devices? I won't go into costs on a public forum but with a little compromise on selection material is rarely a substantial part of the cost.

    I know I'm just "blue sky-ing" here but thats my view. And to return to my OP it is one thing to debate what level of training should be offered and another to discuss dropping the manufacture training altogether. Granted there will always be dissonance between what people like me want and what is plausible but is a complete lack of lab training something which should even be countenanced (if, indeed, it were to be?;))

  11. pgcarter

    pgcarter Well-Known Member

    This is a controversial issue. My experience is that people who don't do it completely have limited insight into the benefits. There are clinical skill issues that result from a more in depth and complete experience of making things for people with real trouble. There are economic issues in relation to setting up your own practice,(if you don't have the skills to make things at a commercial standard your overheads are going to be higher), there are sphere of practice issues (if you can't do something then you can't chose to pursue a particular kind of job).
    There are expense issues in public health, if a device is made by a factory then the invoice price will be higher than the costs of it being made efficiently in house, which will often result in the patient being charged more for it.
    I would be curious to know if any of the podiatrists consulted in Victoria actually continue to make things. Saying that only very few people do it and that because of that it is not all that important ignores the issue of why more people don't do it. Most of them can't do it and never had skills good enough to be truly efficient, so that is used as a justification for not putting the time and effort in to be better/faster at it.
    The income issues are a classic. This past weekend I made 9 pairs of orthoses, if I had a factory do it for me my income would be about $900 dollars less for that week or so. Now you might say that I gave up my w/e for that, but I also did a bunch of other stuff so it does not feel like that. I have the skills to do this so I can choose to do this or not. If you don't have the skills you don't have the choice, you just plain can't do it. That state of things is much less flexible or desirable in my opinion.
    regards Phill Carter
  12. Lawrence Bevan

    Lawrence Bevan Active Member

    Doesn't it all depend on whether its worth making custom devices when pre-fabricated are as good? :D

    Dont you all feel ashamed at being part of an industry that persists in the branding of these "arch supports" as something special?? ;) :D:D
  13. cpoc103

    cpoc103 Active Member

    Firstly to Robert, I completely agree with you, "Should manufacture be dropped from Pod training completely in the UK" no it should not, how can a pod appreciate what they are prescribing if they dont have a basic understanding of A. what the device looks like/ what materials are used and why, and B. how can they fully understand what the function is of these devices what are they prescribing and why. Only my opinion, but unless you are subjected to materials and a basic knowledge of how they are made you cannot fully understand how they work.

    I graduated 4 years ago, I wont name the university but we did very little/ almost no orthotic manufacture, we did get to play with some materials and do some POP casting, but never shown a +ve mould pour and device made from. I was a little bit more lucky than my colleagues having already been used to this method from working within the Ski industry, however the reason for attending uni and pod course was to extend my skills and learn the medicinal/ biomech values. The uni I attended were fantastic at wound care and medicine, but I just felt they were missing the basic picture, and still do now.

    Secondly to Phil you hit nail right on the head, CHOICE how can choose whether to make your own devices in house or send to a lab if you dont know how to make.

    And finally, sorry getting a bit long winded now but as you can probably tell I have a bee in my bonet over this..:bang:..to Lawrence congrats on the recent paper BTW very good reading...I only have 1 criticism with your statement, when you say prefabs are you saying straight from the packet with no add ons or no modifications made by the Podiatrist issuing?? doesn't all good prefabs these days come with extrinsic posts you can add on or grind off, and you can also heat modify most of these deivces now. So if this is in fact the case you are almost issuing a custom device no??

  14. Craig Payne

    Craig Payne Moderator

    There are plenty of other ways to get that knowledge and those skills without actually making devices.

    99% of practitioners do not make their own devices....
  15. Lawrence Bevan

    Lawrence Bevan Active Member


    My tongue is firmly in its cheek when I say what I said. ;):D
    The comments relate to the discussion on the orthotic customisation thread.

  16. cpoc103

    cpoc103 Active Member

    This is very true, and I appreciate that as I had to go down this route for the best part of my learning, but I fully believe orthotic manufacture has got to be a part of the curriculum to sit alongside the biomechanical teachings and clinical application of such teachings...:drinks

    Sorry Lawrence I didn't actually read the other thread, I shall make it a point to read. :D
  17. Lawrence Bevan

    Lawrence Bevan Active Member

    Perhaps it would be better for the profession if 99% did make orthotics? Or at least worked in group practices with in-house production.
  18. :good:

    Never happen of course, but there is a difference between recognising an ideal and thinking it can Happen.

    99% of people break the speed limit, drive without due care and attention and eat whilst driving. But you'd still fail your test if you did that. You LEARN to drive assuming you live in a world where you do "best practice". That way we know that everyone who passes CAN drive well even if they don't.

    I think its a similar situation.

  19. N.Knight

    N.Knight Active Member

    Been a recent grad from northampton, we spent 1 day every 4 weeks in the lab for years 2 and 3. We didnt make many casted orthotics (made a few but not many), it was mainly functional insole made with poron, EVA, celron etc will stil had really good results.

    I still wanted more time in the lab. It would be terrible if they took it off the sylabus, personally it helped me learn why we put a valgus pad in, why a functional hallux wedge. Now with that knowledge I believe I could treat a pt better. Yes in the NHs and most private jobs the orthotics are made off site, however the training gives you the knowledge to what to put in orthotic and which materials are best for different pts. Jus tmy views from a recent grad.

    The only nag I have is that I am not to hot on is RF posting as I hardly done it, is posting dieing out? (apart from in the pure biomechanical pods)

    any how it is something I am ready up on.at the moment.
  20. Nope. Alive and well in Kent at least!;) Its just another modification in the pallette available. I'm guessing you mean intrinsic posting right? Not much to learn about extrinsic!

    Always nice to get a fresh Grad perspective, its a bellweather of what is being taught to undergrads. I am curious to know therefore what you mean by functional insoles rather than casted.

  21. cpoc103

    cpoc103 Active Member


    From what I remember of uni we didn't have a lot of study on biomechanics let alone orthotic manufacture. Speaking to the studnets who come on placement with us here in our NHS trust this still seems to be the case....

  22. Unless you want podiatrists to no longer be considered as the medical experts in foot orthosis therapy, then hands-on training in orthosis manufacture needs to be continued in podiatric medical education. Since foot orthoses are mechanical devices, unless the podiatrist can fully understand the complex mechanics of foot orthosis therapy, then they will not be able to fully appreciate all the physical manipulations that may be made to foot orthoses to optimize their function for the patient.

    In order for the podiatry student to understand and be able to effectively and safely accomplish the physical manipulations of foot orthoses, hands-on training in all aspects of orthosis manufacture, including negative casting, plaster pouring, cast balancing, plaster additions, thermoforming, posting, glueing and grinding must occur during podiatry school. The student does not need to make 100 pairs of orthoses to get a better idea of these processes but does need to be exposed to them and make a number of orthoses themselves from start to finish to gain a minimum understanding of the process and develop a minimal level of the fine motor skills necessary to accomplish the required tasks. I estimate that a minimum of 5 pairs of orthoses is necessary for each student to attain this better understanding and attain the minimum skills.

    The goal of this hands-on training is to help the podiatry student understand the mechanical process of what goes in to a well-made orthosis and to allow them to have the time to develop the fine-motor skills that are required to safely and successfully adjust either their orthoses, another podiatrist's orthoses or adjust prefabricated orthoses to optimize the therapeutic benefit of the orthoses for the patient. Saying that podiatry students don't need to make orthoses themselves to become proficient in custom foot orthosis therapy is like saying that automobile mechanics only need to learn from a book or classroom or video how to repair an automobile safely and successfully. The necessity for the development of proper fine-motor skills in a podiatrist who wants to be an expert in foot orthosis therapy is no different than the necessity for the development of fine-motor skills required by an individual who wants to become a master mechanic. There must be hands-on training. The more hands-on training, the more likely that the podiatrist, or mechanic for that matter, will become a master in their trade.
  23. N.Knight

    N.Knight Active Member

    Yer I ment intrinsic and extrinsic.

    By functional insole I mean, that we take a template of the pt foot and shoe ( the old lipstick technique) then choose what you want the insole to be used for and materials made fom.

    Before the in sole was made we would make a temp in sole from Semi compressed felt, to check that the design would work. From the temp we would make the perminant in sole. For example,

    EVA base with a 12mm D filler with high point under the navicular (the 12mm made up of 6mm TTP then 6mm Poron) all with a medial flange. Then a EVA cover

    Depending on the pt depends what materials we used.

    We had a very high success rate at uni, I am not saying that it is better than casted as there are too many factors to consider, and there is some pt at uni that needed a casted device but it worked for us.

    I beleive we done it that way at uni is I THINK that my lectuer once had a pt who had casted devices and could nt get a pts condtion to get better so they tried soem semi compressed felt and it worked so tried and tried again and found it worked so carried on doing it. THATS WHAT I THINK ( don't quote me on that)

    Any that is the way we done it at UNI. I think that it does not matter what we do as long as the pt has the same result.

    The job I have just got uses casted devices, so am doing my reading up at the moment as not many practices I know of using the same methods I used at uni.


  24. CraigT

    CraigT Well-Known Member


    I think it could be valuable for the students to make devices for themselves, with different prescription variables-
    You take multiple casts (you do need the practice) and make 1 or 2 of each-
    - modified root
    - blake inverted- 5, 15, 30 degrees
    - medial heel skive- 2,3 5mm
    - wedge device (no heel cup, plantar lateral addition)
    - others?
    This would be done irrespective of what prescription may be appropriate.

    The student tries the devices and looks at what the effect of each change has on each other (you would have agood variety of feet) as well as on themselves.
    You could then add addition such as pl fascia accom, pl flexed ist ray accom to the models, and see how thes mods change function.

    Perhaps they also get a couple of devices made by different labs to be able to critique and compare.

    So how many?- 20? - and this ignores all other types such as MASS casting, foam box, shank dependant...

    The obvious problem will be time and resources.

    ... and 100% of practitioners who do or have made their own devices beleive they have gained knowledge they could not have got any other way.
    It is simple- those that are in this 1% will always support teaching manufacturing, those that think it is a waste of time have never done any manufacturing of any volume.
    (nb: by manufacturing I mean for your own patients- if you are made into a lab rat doing the work of others without seeing the results first hand, you do not have the same benefit)
  25. :good:

    Hey Nick

    Thanks for the reply. And Kudos again for having the guts to post. With that attitude whatever you don't yet know, you'll soon learn.

    Interesting that you define a flat base with a D Pad (arch cookie is the name most of our colonial friends use btw) as a functional insole. I've long held the view that any device which changes the function of the foot is a functional device, however most would define a functional foot orthotic as a standard Root device.


    OK i'm going to P*** some people off here. I think a lot of people who "DIY" their own casts make, frankly, a dogs breakfast of it. I base this observation on the early work of many a student and new graduate and without a doubt some of my own early stuff. I'm presently reviewing the caseload of a podiatrist who has just left and I'm frankly horrified at some of the things I'm seeing! Chairsides and "simples" are easier to make but I think that that should not be used as a cop out. So don't be on too much of a downer on casted insoles based on that!

    Also SCF is damned expensive and does not last very long! Not cost effective in the long term, or even the medium term. Cost wise there was not a lot to choose between the SCF device you used to see if the device was working and the "perminant" device you issued afterwards!

    When I was a student we used to make the "simples" while the patient waited. With 2 or more of us working on a pair we could do it in an hour or so and it meant the patients details were fresh in our mind when we made the device. I think having one lab day a month is nowhere near enough! Do students still have "self guided learning" slots? Thats when we did most of our lab work.

    This is one of the reasons I've seen for the idea of stopping lab training but I think that is looking at it the wrong way. If something is hard we should surely not just drop it and take the path of least resistance!

    As an additional point, one of the things I do when training people in chairsides is to stick a synthetic "corn" to their foot and have them make devices for themselves. Its amazing how the devices change when they feel what its like to wear them! Somebody else picked up that one of the most valuable lessons is in what not to do, feeling what its like to wear an insole with a ragged edge, a ridge, or too much bulk is a memorable way to learn. So I'd have them making insoles for themselves as well.

  26. Craig Payne

    Craig Payne Moderator

    Exactly. We constantly being told that we are not teaching enough of {insert pet topic} or devoting enough time to {insert pet topic}. We can't teach more of everything. To devote more time to something, we have to take time away from something else. Some areas (esp orthotic manufacture) cost a lot more money than others to teach, so will always be under pressure for better ways to deliver it and still achieve the outcomes that are imposed on us by external bodies. The primary aim of those externally imposed outcomes are to graduate safe entry level practitioners.
  27. N.Knight

    N.Knight Active Member

    Sorry if I mislead you here. I ment that a new device was made not added to the casted device.

    God this can all get confusing. I believe it was Craig who said that if you confuse the student you have done your job.

    I have no problems posting, even if some times I sound so wrong, all good learning


  28. Nat Smith

    Nat Smith Active Member

    To make or not to make orthoses? Let's look at some of the issues that have come up when making that choice:
    1) Have you got the skills to manufacture a professional enough looking device that you can charge people money for? Unlike Nanna's knitted beanie that's made with love...your home-made orthoses should look like a professional medical appliance. Most don't. I've seen some new patients who have pulled out the most shocking examples they've been walking around in and the pod's who have made them should be ashamed of themselves.
    2) Who the hell has the time? Phil mentioned that he spent all weekend making 9 pairs. That's his personal choice and all power to him for loving the process. Personally, I'd rather spend the time with my family and friends or my favourite hobbies. Maybe making orthoses is your hobby? That's cool..as long as you feel that making them is worth your time and whatever else you're sacrificing.
    3) Do you need to manufacture orthoses to truly understand the process? Using the analogy of the motor mechanic...whilst he can do repairs and modifications on a vehicle, he doesn't actually build it. You can study and observe professional manufacture and then have your hands-on practice with modifications and additions.
    4) Costs of home-made vs. lab. On average a lab fee is about $100 a pair (here in Victoria). I would be speculating that the cost of home-made would be about $30-$50 a pair once you bought all the materials? (Agree or disagree? I'm not entirely sure how much it costs to make your own, but materials aren't cheap). Let's just say that home-made would possibly be cheaper without adding in the labour cost. So, how much is your labour worth to you? How long does it take you to make a pair? How many do you need to turn out every week? If you're having to work nights and weekends just to get them all done, is it worth it for the small saving of lab labour costs?
    5) Profit margins. I have heard of pods charging anywhere from as low as $250 to as high as $650 around Melbourne. With a $100 lab fee, even the lowest end of the scale is still making more than 100% profit. We overcharge for what is essentially a couple of bits of plastic, rubber and glue. How much profit do you need to make? Paying the lab fees are inconsequential.

    Personally, I haven't made a pair since I left uni. I think I'm a bit of a perfectionist and quite frankly would take too long to make a pair I would be happy to issue and charge money for. (I also have no problem sending them back to the lab and demand they do them again if they aren't up to scratch). I remember quite enjoying making them at uni, but I also remember that none of us made any that actually looked any good. I think at the end of the day our clinical skills are vastly different from technical manufacturing skills and we aren't all great at both. We need to know what we're good at. We need to evaluate what we feel is worth our time & effort and we need to work out what is best for our patients. If you love making orthotics and can make a great looking pair keep on doing it. If you can't make a professional looking device or can't be bothered...then keep paying the lab fees.
  29. pgcarter

    pgcarter Well-Known Member

    A terrific illustration of my points, some one is not much good at it, never put much time effort or rescources into gaining professional level skills and uses all sorts of justifications for doing things the way they do.
    Workshop tools are cheap, I've spent about $5k over 12 years and have a well eqipped workshop.
    Materials are cheap, the typical plain device with no add ons costs about $5.50 for materials, the hamburger with the lot is about $15.50 for materials.
    If you do the maths for overheads of a small single person practice it is very cost effective to make your own devices if you can batch them and do them in about one man hour per pair, this is the speed you would get to with suitable teaching and practice. I can effectively earn $100 to $150 an hour with very low overheads in the workshop, it very hard to earn that well seeing patients at 3 per hour in a clinic by the time you take out all the overheads.
    Here are the numbers the way I see them.
    Initial assessment 45 min to 60 min $50
    Orthoses this includes making say 60 to70 min
    issue 20 min, reviews 2 by 20 min or less as average $475
    So for about 2 hrs of my time and expertise I get $475 less materials cost and power etc (minimal). It's not a mark up, it's me charging more than a plumber for my expertise and I can sleep at night.

    I actually have a better income and quality of life by only consulting 4 days a week and spending the 5 th day in the workshop.

    I used to be a retailer and in that game you make money by having a mark up on the products you sell, everybody knows that and the shop assisstant is paid very poorly and their time is not considered to be worth much. As a qualified and registered professional my fees are for expertise and it is my expertise and time that is supposed to be the valuable commodity that I am selling. If you use a factory and mark up your orthoses to the level that supposedly 99% of pods do then all I can say is I don't know how you can sleep at night......what a rip off, all that mark up? and consultation fees? no wonder plumbers and electricians earn more than podiatrists.......they clearly have more skills, for which they can justifiably charge a higher hourly rate. (there is a little bit of tongue stuck in my cheek here)
    regards Phill Carter
  30. Wise words, well said.
  31. pgcarter

    pgcarter Well-Known Member

    The other some what trite but relevant thing to say here is often said about my main hobby, which is hunting for ship wrecks. "IF IT WAS EASY EVERY ONE WOULD DO IT". Clearly it's not easy, but it is possible if the rescources and teaching skills are there. If the teaching of the skills goes, so do the skills from the profession( as has already happened apparently), and then we'll be paid for what is left and according to the governments view in Aus a pod is hardly worth any more than a nurse. And if any fool can prescribe a device......and they are allowed to, then chiros, physios, myotherpists, people with a 6 week massage ticket can all set up an account with an orthoses factory and away they go, just the same as you.
    regards Phill
  32. Go, Phil, go......I love it!!!:drinks
  33. Nat:

    You are missing the point. We don't need to train our podiatry students to be orthosis lab technicians or to even make their own foot orthoses when they open up their practices. What we need to do is to train our podiatry students in the process of making good custom foot orthosis and to give them the basic technical skills to be able to effectively modify foot orthoses in order to optimize foot orthoses for their own patients. What better way to learn to grind, cut, mold, glue foot orthoses than to make 5-10 pairs of devices while in podiatry school for their own patients??
  34. CraigT

    CraigT Well-Known Member

    As always I have a lot of difficulty disagreeing with anything you say...:drinks

    In nearly 15 years of practice I struggle to remember any patient complaining about the appearance of their orthoses. We did have an expat American here complain that the devices we made didn't look as good as her friends of the previous ones she had... she has since come back with the rest of here family for new orthoses (not my patient in this case, but I understand the other devices were 'semi-custom'... perhaps from TOG?)
    I actually had many athletes come to me because I did the work myself. One runner- who was an olympic and world championship medallist- thought it was great that her orthoses were made in my garage. She likened it to the original Nike Waffle running shoes... soles were made using a waffle iron in Bill Bowerman's kitchen (someone feel free to correct me if wrong).
    It is a great feeling seeing an athlete competing well due to you handywork. (not so great when you see them call for the trainer, remove their shoes and throw their orthoses out during a match- hasn't happened, but would not be good)

    Manufacturing your own device is something that I encourage, but is not 100%necessary. However my experience is that doing this has taught me aspects of orthotic design which you cannot easily learn otherwise. Practice does make perfect, and if you can put yourself in a position where you can take the time to practice- yes you may be worse of financially initially as you are not as efficient- you will be wiser for it.
    As for the appearance- you can get fantastic looking 'medical grade' off the shelf orthoses...
  35. cpoc103

    cpoc103 Active Member

    Posted by Kevin

    Kevin may I ask, what is the level of training/ teaching in the US how much time are students over there given to orthosis manufacture. Would be interesting to see what the difference between the UK and Aus and the US are??

  36. pgcarter

    pgcarter Well-Known Member

    In Aus at Latrobe the effective time per student has been fractionated over the past 5 years, so regardless of "outcomes" or educational techniques the plain truth is that practical clinical skills are lower....and I see that in students who come out on placements.
    regards Phill
  37. Nat Smith

    Nat Smith Active Member

    I'm not sure what point you think I'm missing exactly, because I don't actually disagree with what you're saying. I never said that pods don't need to have any technical skills with orthoses. I don't advocate abandoning all our skills to the labs. My previous post was only aiming to look at why it is that the so-called 99% of pods are choosing to not make their own orthoses.

    Whilst I advocate using a lab for manufacture, I still think it's essential for pods to be able to have the technical skills to do appropriate adjustments/modifications etc to give their patients the best treatment.

    I think we need to possibly look at orthotic therapy in 2 parts - the manufacture of the basic orthotic shell and the modifications/adjustments/repairs etc. that we do to them afterwards. Both you and CraigT talk about a greater development of technical skills by undertaking orthotic manufacture from scratch. Of course I can agree that this is the ideal; to learn something from scratch can make one proficient with practice - but we all seem to be acknowledging the fact that this isn't actually happening once pods are in the workforce. Whether it be through lack of time, opportunity, skills or desire, 99% of pods are not willing to dedicate themselves to what would really make them proficient orthotists.

    As I mentioned in my prev post 3rd point with the motor mechanic analogy - they don't build the cars, but they become proficient in learning the skills required to do repairs/modifications/customisation of a vehicle...Why can't pods be the same with orthoses? Do you think that technical skills and proficiency can be learnt by working on orthoses without having to create the orthotic from scratch?

    So, what are we to do as a profession? If 99% of pods are coming out of uni with a skill set that they are not going to use, it seems to be a huge waste of uni resources and time. Craig P talks about the problems with funding at uni - orthotic teaching costs more; they're trying to teach as much as possible, but are they spreading themselves too thin? Phil mentions that the students coming out on placements aren't up to par and would essentially require a lot more practice to achieve the skills necessary for manufacturing a professional quality device.

    I think the uni courses need to focus on accurate bio assessment and accurate orthotic prescription and teach the skills to "work on" the orthotics. Those that choose to make their own afterwards are obviously going to take the extra time required to practice until perfect. Those that are going to use labs still need to be proficient enough to do modifications as required.
  38. Nat:

    I understand you better now.

    However, I still believe that the skills and knowledge that a podiatry student can gain by building a relatively small number of custom foot orthoses for a few patients is the best method to give podiatry students a better knowledge of the orthosis fabrication process while also providing them with enough lab time to learn how to better grind, glue and mold foot orthoses in the process. There is nothing that gives a podiatry student greater confidence in their orthosis skills than being able to hand fabricate a foot orthosis from start to finish so that they can then dispense their orthoses to a patient to see if they can resolve thier patient's symptoms as a result of their labors.

    If you don't think this is a good idea, Nat, then how do you propose we give them the skills....hand them a few unfinished orthoses that someone else has pressed over a cast so that they can be shown how to grind it to fit into a shoe that in the lab?? Maybe I just don't understand the Australian way of teaching orthosis manufacture to podiatry students.....please explain.
  39. Nat Smith

    Nat Smith Active Member

    It's not that I don't think learning manufacture from scratch isn't beneficial, but when 99% of our qualified professionals are not utilising an aspect of their training, then perhaps the current mode of teaching needs to be amended? Our profession needs to continue to change and grow. We either need to make the current orthotic training better or totally different...
    I'm not actually quite sure what changes would need to be made to the uni course...perhaps Craig can weigh in here regarding the Australian way of teaching and what other ways we can get that knowledge and skills? Obviously as previously mentioned there are required outcomes and accreditation that schools need to satisfy to the relevant bodies. However, do we just continue with the same mode of training when we can see it's not really working? What factors do you think are causing pods to steer away from manufacturing and choosing to use labs?
  40. Here is the rub. I don't beleive that the benefit of learning to make orthotic is in making orthotics. I think knowing how orthotics are made makes one better at prescribing. So I would like to think that the 99% of the qualified Professional ARE using that aspect of their training.

    Rather than the analogy of a car I prefer the analogy of cooking. The prescriptions we make are unique for each patient with a blend of subtle flavours and textures. We could simple sample a dozen different dishes and serve to our patients the one we think they'd like. But to really give them what they want would it not be better to know HOW those dishes were made and what ingrediants went into them. That way when we have a fussy eater we can tell the chef "make it like the last soup but with a shade less garlic and caramelise the onions for a shade longer" rather than "make it taste more like dish B".

    In other words, it helps us to tell the chef what we want if we are coming from the same background as the chef, use the same terminology and understand how the chef works whether we still work in the kitchen or not.

    Damn, I've spilt allegory down my shirt again.


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