Models of Prosthetics Clinic Team Management

OTTO GERENDAS


Concept of Prosthetics Management

For the purpose of this paper, prosthetics management is defined in its broadest possible sense as involving all activities, processes and procedures related to the provision of an artificial limb.

It is suggested that if an amputee is to be successfully provided with a prosthesis the conditions to be met are:

  • He should be medically evaluated;
  • His stump should be ready for fitting;
  • The appropriate fitting method should be chosen: Immediate Postoperative; with a temporary adjustable limb; or with a permanent limb;
  • The optimal time for fitting should be decided;
  • The limb should be specifically selected to meet the patient's particular requirements;
  • The limb should be manufactured according to the prescription. It should be fitted and aligned properly;
  • The necessary therapies and training in the use of the limb are to be provided;
  • Any psychological problems are to be resolved and necessary counselling is to be provided;
  • Socioeconomic problems are to be resolved including the question of financing the limb and the provision of vocational rehabilitation if necessary;
  • Appropriate controls and continuous feedback are to be assured, ideally from the time the decision to amputate was reached;
  • The limb(s) should be checked out for function, fitting and craftsmanship;
  • A system of long-term follow-up is to be instituted.

Early Models of Prosthetics Management

The very earliest artificial limbs were made by the amputee himself, later by his surgeon or other craftsmen. The specialist trained and engaged full time in manufacturing prosthetic appliances appeared on the scene relatively late. Until recently, and in some instances even now, the amputee dealt directly with the prosthetist and the recognition that timing, choice of limb and fitting can have important medical implications is a relatively recent development. The acceptance of this principle and a general agreement that none of the disciplines involved possesses complete, overall competence eventually led to the appearance of the multidisciplinarian team approach, embodied in the amputation or prosthetics clinic. In this report the term "amputee clinic" is used deliberately as a synonym for "multidisciplinarian team in charge of prosthetics management."

Composition and Purpose of Amputee Clinics

As the fitting is neither the beginning nor the end of the many procedures involved, an amputee clinic becomes the meeting point of all the medical, paramedical and vocational sub-systems at a time when psychosocial considerations may be of greatest significance.

The purpose of an amputee clinic is to serve:

  • as a structure for communication and exchange of information among the different specialists;
  • as a medium for the coordination of all treatment activities;
  • for decision-making in regard to all aspects of prosthetics management; and,
  • as a means of checking out appliances and following up patients.

Professions comprising an amputee clinic are:

Activity Patterns

Clinics follow different activity, levels of patient participation and movement patterns, and the time spent with one patient can vary greatly depending on the activity pattern followed. Regardless of the activity pattern involved, the clinic approach may, over the long term, save time for all concerned. The time the patient spends with the clinic is governed by the number of scenes used.

The extremes in terms of activity patterns are referred to here as the One-Scene and the Five-Scene amputee clinics.

The One-Scene Clinic

All clinic activities related to the patient take place while the patient is with the team.

The Five-Scene Clinic

Scene 1 : The clinic meets without the patient. His case is presented with the use of slides and movies if appropriate, the last clinical note is read or new developments reported, and particular questions and problems to be resolved are identified.

Scene 2 : The patient is in the clinic. He is examined by the clinic team; he demonstrates abilities to use the prosthesis; he conveys and communicates concerns and asks and answers questions.

Scene 3 : Clinic meets again without the patient. His problems are discussed and the best possible solution or alternative solutions for his problems are identified.

Scene 4 : The patient rejoins the clinic. The proposed solution is discussed with the patient and a final decision is made by all concerned.

Scene 5 : Clinic meets alone. A detailed plan is worked out, control is established and a prescription and appropriate recording are made.

Some clinics are mobile, moving from one patient to the other, while others are immobile and the patient is moving. The peripatetic approach lends itself more readily to the one-scene clinic while the multi-scene clinics are more likely to be immobile.

In the one-scene clinic, most of the communication and decision-making takes place within the clinic and in the amputee's presence while in the five-scene clinic this is done in his absence.

There are a number of alternatives between the extremes of one and five-scene clinics, and clinics should select the procedure most appropriate to their needs.

Qualitative Considerations

Amputee clinics can be compared, from a technical point of view, by organizational efficiency, validity and reliability of decisions, success in fitting; or from psychological points of view expressed in more subjective terms such as the patient's satisfaction, his cooperation, motivation and willingness to make maximum use of the available assistance.

To assume that the clinic, by virtue of its existence, is necessarily an effective device of prosthetics management is naive at best. Technically a clinic can be highly effective and ensure complete patient satisfaction; or, at the other extreme, it can be ineffective and the cause for complete dissatisfaction on the patient's part. Obviously, there are other possibilities between these extremes. Blake's Managerial Grid concept very appropriately applies to a clinic's activities and efficiency.

Variables Affecting a Clinic's Usefulness

Variables which seem to influence the effectiveness of an amputee clinic are:

Educational and Training Qualifications of Clinic Members and Significant Experience

Besides the usual professional qualifications, members of an amputee clinic require the specific training offered by specialized education centers such as New York University, Northwestern University, or the University of California at Los Angeles, et al. Experience gained in having handled a significant number of fittings at the typical levels of amputation is another consideration contributing to the efficiency of the clinic. This factor of experience tends to operate in favour of clinics handling larger case loads.

Minimal expectations can be specified and one jurisdiction in New York City accepts prescriptions only from amputee clinics meeting high standards rigidly applied.

Internal Communication

Participation and free expression of views by all team members, regardless of status, are requisites of effective internal communication. This exchange may be informal. Visual devices (slides, movies, etc.) can be used effectively in the presentation of cases.

All pertinent medical records should be available to the clinic and recording of clinic notes should be compatible with existing charts and recording systems.

Amputee clinics meet the generally accepted definition of a "small group" hence appreciation and understanding of group processes and dynamics are of importance. A clinic chief who sees himself more as an enhancer is likely to elicit an internal communication pattern different from a chief who acts as the captain of the team.

External Communication

External communication will need to be written and formal; and include all other parties concerned with the patient. Itemized prescriptions using standard terminology and the sharing of clinic notes with all other agencies and persons involved are necessary conditions for effective communication.

Although an amputee clinic may be sponsored by, or care primarily for the clients of a particular agency, it should be available for consultation by other agencies or individual physicians.

Frequency and Regularity

For various reasons, once-a-month clinics may not meet all needs if case loads are large and twice-a-month clinics may be the minimum acceptable schedule. Clinics should be conducted at regular intervals and schedules established as far ahead as practical.

Decision-Making

In view of the interaction of medical, prosthetics, social, psychological, vocational and economic considerations, decisions can be made by a single person alone in only a very few cases. In most instances, the best decision will be the one which has the benefit of participation of several, if not all, team members. It is recognized that legally the physician, as the chief of the clinic, is responsible for the prescription.

Patient Participation

Although the responsibility for the decision reached is in the hands of professional and highly skilled team members, any decision that is made without the understanding and participation of the patient can only be of limited value. It will be desirable, therefore, to involve the patient by:

  • informing him, in language he can understand, as to the alternatives available to him and of advantages and disadvantages of the different alternatives;
  • letting him participate in the final decision to the extent that he is able to do so.

A social worker with a basic understanding of the fitting process can be of assistance in ensuring patient understanding of the procedures and in securing his participation.

Psychological Considerations

The patient's pre-traumatic psychopathology can be a factor contributing to the amputation itself and may affect the outcome of the fitting. Psychological over-reaction to physical trauma should also be recognized and treated if necessary.

Being regarded as a person and not just as an appendix to a stump, considerations as to his worth as a human being, the requirements of privacy, a total person-"Gestalt"-approach versus disability-focused rehabilitation, are some of the other issues here.

Maintenance of Standards of Competence

Keeping up-to-date with the most recent developments in the field is a legitimate concern of the clinic and its members. To ensure this, the clinic should receive all related publications and the team members should attend appropriate conferences and courses.

Evaluation

Evaluation of the effectiveness of devices and techniques is a prerequisite to a scientific approach in prosthetics management.

Periodic meetings are desirable to review the functioning of the team as such and the appropriateness of the activity pattern used.

Physical Arrangements

Physical arrangements should ensure the privacy and appropriate accommodation of all clinic members and patients in and/or waiting for the clinic.

Financing

The clinic should have a proper mandate and support from the medical community and be recognized by the jurisdiction paying for the appliances to be provided. The population to be serviced should be defined and the proper financing of employees' time should be assured.

An amputee clinic is a complex device consisting of a number of highly skilled persons and its existence cannot be justified from the cost-benefit point of view unless a sufficient number of patients benefit from its services.

Miscellaneous Items

This category includes concepts such as: team morale;

stability assured by permanence of the staff or at least of its nucleus; the quality of leadership, and democratic and participatory management >practice.

Quality of Appliance

The clinic should set standards for the prosthetics services to be provided through the clinic and, have discretionary power to invite or exclude prosthetists to be part of the clinic. When selecting the prosthetics supplier, the quality of the product and not the cost factor should be the overwhelming consideration.

Disadvantages of the Conventional Clinic Approach and Possible Alternatives

In spite of the obvious common-sense advantages in handling amputees by clinic teams, one must not ignore the negative, psychological reactions which may be involved. A situation in which one person, the amputee, faces a group of individuals who are more-or-less strangers, who talk about him, frequently as if he were not there, and use technical terms he does not understand can be a traumatic experience. The patient's subjective reaction to such an experience can, and in some instances does, offset all the advantages of the clinic team approach.

If a team of experts is required to handle the technical problems related to prosthetics management, what avenues are open to diminish the patient's negative reaction to the clinic experience?

One alternative is to give more consideration to the amputee's nontechnical needs through intensified social worker or psychologist activity within the framework of a conventional amputee clinic.

The other alternative is a more flexible, individualized and modified clinic approach which would rely more on a one-to-one relationship between the amputee and a team member, and a one-scene clinic, thereby reducing the patient's exposure to the total group. The team still will meet, but without the patient, to confer on the case-i.e., to communicate, to plan, to make decisions, etc. (see steps 1, 3 and 5 of the previously mentioned five-scene clinic).

In some inpatient settings it may not be necessary for the amputee to meet the clinic except at the critical points of the prosthetics management such as prescription and check-out. In an outpatient setting, a negative reaction can be diminished by the use of the multi-scene approach and/or by leaving most of the communication between the team and the amputee to one of the team members.

Vocational Rehabilitation Services Ontario Ministry of Community and Social Services Toronto, Ontario, Canada