A strong relationship between amputees and their prosthetists is crucial in the creation of a device that will improve the patient's quality of life. After my last prosthetist, Travis, got transferred to a different office, I doubted anyone could measure up or understand my needs and desires as much as he had. When Derick Schmidt took over, it took us awhile to figure each other out, but after a year or so, a solid partnership started to form. And now that three years have past, I can honestly say that I wouldn't trust anyone as much in providing my prosthetic care.
As I got to know Derick better, I realized that he was different... in a good way of course. When problems arose with the fit of my prosthesis, he sought out solutions that were outside of the box. He prides himself on being up to date on the latest research and happenings in the prosthetic field instead of relying on outdated practices. Because my limb is so difficult to work with because of its skinny, boney nature, Derick was met with even more challenges than normal. However, he didn't let that get in the way of making me a prosthesis that now feels like it's part of me. He turned his frustration into innovation and creativity, which I find to be a breath of fresh air.
Through reading the below interview with Derick, I hope it'll provide you with some insight into prosthetics from a different perspective- the prosthetist's side of things. You'll get information about the exciting direction prosthetics are going and what it takes to make good products.
Interview:
When did you first become interested in prosthetics and orthotics?
I first learned about this field from my undergrad advisor while I was at Penn State, that was near the end of my junior year in 2008. I had no idea O&P was even a thing, but it immediately appealed to me after a few years of bouncing around between engineering and kinesiology/biomechanics classes.
For those who don’t have much background in the field, take us through the process of getting a new device/prosthesis made and the time frame for each step in the process.
For a new amputee, the process really gets going after they are well healed and cleared by their surgeon. For an existing amputee, we get started on making something new once we determine the old device no longer fits and/or functions correctly and there are no reasonable options remaining for us to make it work appropriately.
The first step is an evaluation appointment to assess the patient’s needs and wants with their device. We lay out the blueprint for what we will make and order during that appointment and begin the documentation process. From there, a detailed prescription and notes are needed from a physician to be able to submit for insurance authorization, so an appointment to see the doctor is typically required.
Once we start working on the prosthesis, there will be a limb casting or scanning appointment and a series of fitting appointments which typically are scheduled about once a week. When the fit and function are dialed in during the fitting stage, we proceed to fabrication of the final device that you will take home and then schedule that final fitting and delivery appointment. The whole process usually takes about 6 to 8 weeks but may be faster or slower situationally.
What do you like most about being a prosthetist?
I really enjoy solving problems, and there are no shortage of those in prosthetics. In fact, we always start the process with a fundamental problem, which is that there is a missing body part we need to replace. Sometimes the process of replacing that body part is relatively straightforward, but quite often it is not because every limb is different, every person is different, and we are in the business of providing custom solutions. What I like most though is when I have to get creative and manufacture a solution for a problem that there is not an easy or obvious answer for.
Discuss some of the challenges that you face with providing patient care.
As I mentioned, there are plenty of problems and challenges in this field. The largest one for me is that we have to operate within the guidelines and restrictions of each person’s health insurance coverage. Sometimes that means one person has access to solutions that another person does not, which is a situation I really do not like and wish there was a better way around it. It can also mean that although I might be able create a solution if I were to dedicate enough time, effort, and resources to it, that sometimes as a matter of running a business and treating many patients concurrently, I just can’t pursue those things.
Another challenge that frequently comes up is that we are always chasing moving targets in prosthetics. A limb changes size and shape constantly throughout the day, and we need to do our best to work with and around that issue. Sometimes we make a device, and two weeks later it is nearly useless because of anatomical changes that occur outside of our control.
In your opinion, are there any changes that could be made with traditional practices that could provide better products and/or care for the consumers now that technology is changing so rapidly?
For sure! Additive manufacturing, more commonly called 3D printing, has opened up a whole new world of opportunities for us. We can now design O&P devices with computer softwares and manufacture them with 3D printers, and these devices can have features and benefits built in which we would not be able to create with traditional manufacturing methods. The additive manufacturing field is growing and evolving at an incredibly fast pace, and we are now beginning to see these technologies become cheap enough, reliable enough, and accessible enough that we can start integrating them into our clinical care models.
How do all the prosthetic companies compare? Do you like using one company’s products over another?
I try to stay up to date on manufacturers and their product lines as much as I can, and I like to try new things when they come out. It is a lot like other industries in that there is a mix of big international manufacturers who we use lots of products from, names like Ossur and Ottobock, but there are also great smaller manufacturers we may order from less frequently, such as Ascent Fabrication. The smaller names may have great products, but just not as many of them. Do you want a Toyota or a Ford, or does a Rivian fit your daily needs better? I don’t limit myself to using products from any single manufacturer because they all have unique products that provide the best solution for different people at different times.
How much choice do consumers have when choosing materials, products, etc… How much of a say do they have in their care?
Ultimately it is the consumer’s device and theirs to wear and use every day, so it needs to work well for them. This can be a tricky situation though. There are some products on the market that we would actually lose money as a business if we were to provide it because of insurance reimbursement rates and the cost for us to purchase that product along with our time and expertise needed to provide and maintain it. So from that standpoint we have to make some hard choices sometimes and not provide certain items.
There is also so much that goes into the device behind the scenes that there are many things we cannot leave to the patient to choose. Things like how the device is technically fabricated to make sure it is strong enough for them to safely use everyday. What we always try to do though is offer the ability to add customization such as fabric layers built into the prosthetic socket with a sports team, meaningful pictures, or just something else that the patient likes and it looks cool.
When it comes to what parts and pieces are used, we also want to work closely with the patient to choose the ones that are best for them. If I recall correctly, there are hundreds or different prosthetic feet on the market. We have to listen to the patient and use our experience to narrow that number down and provide a much smaller list of choices to them. Some products we know from experience aren’t durable or don’t function well, and we may need to have that discussion with the patient if they come to us wanting something specific which we don’t think is a good choice for them. Ideally they will always have some sort of a say in their care though.
What advice do you have to pass on to newer residents or clinicians?
School provides a good starting point to your education, but it is just that - the start of your journey. And the schools are all fundamentally the same because they are focused on teaching you how to pass your certification exams, although that generally means learning outdated techniques and methods that you often won’t ever use during your career.
Residency is the most important thing in defining how your career will play out. What you learn, or what you don’t learn, during that time will largely dictate what you do the rest of your career. Sure you will continue to learn and grow with continuing education, but you can’t know what you haven’t been taught or exposed to, so prioritize the quality of your residency over everything else. Find a residency site that is willing and able to teach you many ways to do things so that you can know your options and then make an educated choice about what you feel is the best way to provide care to your patients. Smart and talented people who aren’t taught well are very likely to just be average clinicians who don’t reach their true potential, and it is no fault of their own.
What advice do you have for amputees, both new and existing?
Be open minded and patient because being an amputee and getting a prosthesis is likely to have a lot of ups and downs. Stick with it and push through the challenges, because it is a process by necessity and taking shortcuts will probably lead to worse outcomes for you.
But also educate yourself. You always have a choice and you don’t have to accept care that doesn’t meet your standards or provide you with what you need. Just because your doctor recommended a certain prosthetic provider does not mean they are the best available to you. I would recommend you set up a free consultation with multiple prosthetists and then choose the one you like the best if you are ever not satisfied with your care.
Your passion has evolved to the world of 3D printing. What do you aspire to do with this new venture?
I have been using CAD for nearly 20 years now in various forms, and it has always been my goal to use the skills I have built over that time to make new and better prosthetic devices. The evolution of 3D printing has given me an outlet to finally do that in a meaningful way.
Over the past decade or so in O&P I have also developed an understanding of how the economics of the field work and how new technologies are often not usable or accessible because they have high price tags and unreliable reimbursements. I have also seen first hand how difficult it can be for clinicians and companies to adopt and adapt to using new technologies as part of their clinical care model. The world of digital design and fabrication is very different from the traditional hands-on approach to prosthetics and orthotics, and it can be a daunting and overwhelming transition to make for many clinicians.
So my main goal now is to bring all of those experiences together and create easier pathways for others to begin utilizing more digital technologies. I want to create affordable and accessible products that improve the lives of those who use prosthetic and orthotics devices. I also want to break down barriers and flatten the curve, the learning curve in this case, so that other clinicians can join me as I work to create a paradigm shift in the way in which we think about and interact with our work.
I know you have some exciting new things in the works. Tell us what’s next for you as you phase out of the clinical world.
Yeah, I’m taking the plunge and starting a 3D designing and fabrication company with a partner in New York, Joe Fairley. Our company is called Ascent Fabrication. Have I already mentioned that name? We will be functioning as an all-digital central fabrication facility. We are both clinicians ourselves, so it’s work done by clinicians, for clinicians, to create better outcomes for patients. We will basically handle whatever tasks our clients can’t or don’t want to do to allow them to begin using and realizing the benefits of additive manufacturing.
I’m also involved in the larger worldwide community around O&P and additive manufacturing and I will be working with a number of other people and groups to try and create the future infrastructure to make these technologies more available and easier to use and navigate.
12. I have to know- what was both your biggest joy AND frustration with having me as a patient for the last 3-4 years?
Well, I think it’s actually the same thing that has been both. You’ve pushed me to find solutions - a lot of them. It’s been great watching you evolve and learn how much more you are capable of, and to be able to contribute in some way to your success. But you also managed to hit on pretty much all of the biggest challenges at the same time.
Things like how after I finally convinced you to give up your daily use of a cosmetic leg with limited functionality, we then had to fight insurance denials for about a year to be able to get you a new leg with hybrid suspension and a hybrid walking/running foot. Then we spent a couple months trying to get the perfect fit because you have a very unique limb and unique needs. And finally we did it! But then a month after delivery your limb changed and shrunk a whole lot, even after 30 years as an amputee, so that nothing was quite right anymore and we had to try and adjust and make the whole thing fit comfortably and function correctly all over again. But now you also have a running leg and you’re training for a triathlon!
