I seldom take the time to comment about the opinions of others, however the short essay regarding Orthotic Packaging by Mr. Rosler is one that I'm going to have to totally disagree with. The reasons for this disagreement have to do with my own experiences in treating patients with functional prescription orthotics. When we are concerned with packaging of the device, we relegate ourselves to being orthotic salesmen. [note that the use of the term is not gender specific]
The question is: What are we really selling? Hopefully all in the profession would say that we are selling service, not products. That service is specifically tied to our knowledge and technical expertise.
I have to lament the fact that the rise of professional orthotic manufacturers has hurt the knowledge and expertise of the profession more than we realize. Before the 1970s most custom made orthotics were made by the clinician who was making the diagnosis and also then taking the mold, and fabricating the device. Some clinicians had small labs in their offices, others in their basements or garages at home. The clinician had to then fit the device to the patient's shoe, dispense the device and follow up, often having to make adjustments in followup office visits. The simple fact is that in so doing, the clinician learned by experience of both succeeding and failing what worked and what didn't work. Conferences were held in which clinicians shared their experiences to learn from one another.
I have made myself several thousand pairs of orthotics for patients. All the time I was in private practice, I made my patients' orthotics. It took me, on average, about 1-1.5 hours to make a pair, depending on the complexity and materials I was using. Of course, in those early days, we spent far less time in writing notes and in coding and billing than practitioners have to today.
My usual experience was that I would fabricate the device and cut it to what would fit in a very roomy tennis shoe. The patient would come to the office for initial fitting of the device, and I would take the patient's shoes to my small orthotic adjusting space, and there fit the orthotic to the patient's shoes. This would often require a little bit of sanding in width. I never polished the devices when I sanded them. I would then put the orthotics in the shoes and take them to the patient waiting and physically put the shoes on the patient, without letting the patient physically examine them. The patient would then walk on them and I would observe them. They would tell me if the device was comfortable or not, and if not, I would then make adjustments back in my orthotic adjustment area. I would not allow the patient to leave the office with the device until they told me they thought they were comfortable.
My experience with practicing like this was that I never had a patient refuse to wear an orthotic or pay for it because it wasn't the prettiest device they had seen or didn't come in a pretty box. Yes, I had some experiences where patients didn't wear devices because they weren't comfortable or didn't fit in the shoes they wanted to wear. However, patients always knew that I stood behind the device, to make it right. Yes, all physicians will have some failures no matter what treatment is utilized, however those failures are greater teaching tools than all our successes.. It was when I failed the first time, and then found a solution the second or third time that I really started to learn biomechanics.
I could write much more, but in summary, I believe that we need to quit selling orthotics and we need to start selling service. If a practitioner is going to provide custom made orthotics, he/she needs to take ownership of the device and have a place to make adjustments. The practitioner should treat the commercial laboratory as they would any nurse or other allied health professional whom they supervise. The laboratory may do some of the work, but the practitioner has the final responsibility for the device, to prescribe it, to oversee what the laboratory does and to service the device to make it accomplish the goals of therapy. If we do so, few will ever question the cost of the device. If we have to put it in a fancy box to make it seem that the cost is justified, then we have failed.
