The Prosthetics and Orthotics Podcast
The Prosthetics and Orthotics Podcast is a deep dive into what 3D printing and Additive Manufacturing mean for prosthetics and orthotics. We’re Brent and Joris both passionate about 3D printing and Additive Manufacturing. We’re on a journey together to explore the digitization of prostheses and orthoses together. Join us! Have a question, suggestion or guest for us? Reach out. Or have a listen to the podcast here. The Prosthetic and Orthotic field is experiencing a revolution where manufacturing is being digitized. 3D scanning, CAD software, machine learning, automation software, apps, the internet, new materials and Additive Manufacturing are all impactful in and of themselves. These developments are now, in concert, collectively reshaping orthotics and prosthetics right now. We want to be on the cutting edge of these developments and understand them as they happen. We’ve decided to do a podcast to learn, understand and explore the revolution in prosthetics and orthotics.
The Prosthetics and Orthotics Podcast
It's Personal: Socket Design and Product Development with Dale Perkins
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Join us as we celebrate 100 Episodes with Dale Perkins of Coyote Designs sharing his insights on how he has left a legacy through socket design and product development. His dual expertise as a prosthetist and an amputee brings a unique perspective to the conversation. We'll explore his personal story of overcoming his amputation through groundbreaking medical interventions and the life-changing impact of innovative prosthetic design.
Discover how prosthetic technology has transformed over the past five decades, from rudimentary wooden legs to today’s advanced 3D printed solutions. We'll discuss the resistance to change among seasoned practitioners, the importance of personalized patient care, and the essential role of new technologies in improving patient outcomes. Dale shares invaluable lessons from his career, emphasizing the need for continual learning and adaptation in this rapidly evolving field.
Looking to the future, we critique the current state of prosthetic education and industry practices, advocating for a more patient-centered approach. We explore the crucial influence of surgical outcomes on prosthetic success and call for younger orthopedic surgeons to engage more deeply in amputation surgeries. This episode is a celebration of our podcast’s global reach and the profound impact of shared knowledge and innovation in the prosthetics and orthotics community. Join us as we commemorate this milestone and envision the future!
This episode is brought to you by Comb and Advanced 3D.
Orthotics and Prosthetics Podcast Milestone
Speaker 1Welcome to Season 9 of the Prosthetics and Orthotics Podcast. This is where we chat with experts in the field, patients who use these devices, physical therapists and the vendors who make it all happen. Our goal To share stories, tips and insights that ultimately help our patients get the best possible outcomes. Tune in and join the conversation. We are thrilled you are here and hope it is the highlight of your day.
Speaker 2Hello everyone, my name is Joris Peebles and this is another episode of the Prosthetics and Orthotics Podcast with Brent Wright. How you doing, brent?
Speaker 1Hey, joris, I'm doing well. Man, do you know what today is? No, I think it's a milestone actually. Okay, and even our guest doesn't know that it's a milestone. Okay, and even our guest doesn't know that it's a milestone, but I'm super excited to get to him. But today marks the 100th episode of the Orthotics and Prosthetics Podcast.
Speaker 2Wow, I never thought we'd get here. So that means you can listen to yours and Brent for four days straight. That sounds like torture. Yeah, I know, I don't think, I don't think, I don't think anybody's out there doing hold up, but some of it, maybe some of it.
Speaker 1You know it was here's. Here's some crazy stuff. I don't know what's going on other than people are really looking for orthotics and prosthetic stuff. But we're starting to see a snowball in the statistics for the orthotic and prosthetic podcast. Um. So last week just alone, we had 400 downloads and we didn't even uh upload a podcast, uh, last week. Um. So that means that essentially for the orthotic and prosthetic industry, that's a very niche industry. We're literally talking to a room full of 400 people every single week and I think that's that's really neat that's cool dude, I think yeah, it's good.
Speaker 2There's not a lot of passengers. You know what I mean. If we're doing a podcast on baseball or whatever, we can have a lot of people who don't know what they're talking about or whatever, but there's not a lot of you know tire kicking people listening to orthotics and part of the percentage podcast. You know pretty much. Pretty much. You got a pretty pretty solid kind of understanding of what you're doing and you're probably involved in this industry, right.
Speaker 1Yeah Well, the other thing that was just interesting to me is that 40% of our listeners come from outside of the United States.
Speaker 2That's crazy. I thought it would be more American, frankly as well, all the time, yeah. So I thought that that also surprised me, that that so many people are like listening to us for so many different places all over the place. Where in america you really see this, this 3d printing, specifically in prosthetics? There's a lot of we talk about that a lot here. That's growing, you know, yeah, and and in a lot of other places, yeah, there's not a lot of people pushing it like there's some places in europe and stuff, but there's a lot of other international places where people are kind of wanting to pioneer, this being the first in columbia or new zealand or whatever, to really kind of lead the charge in their country, right right, and we uh, here's another crazy statistic we added another three countries, so 102 countries.
Speaker 1People, 102 countries have listened to the orthotics press like podcast. That it's just um crazy. And who who would have thought that, you know, two years ago, that that would have started that? And um, yeah, so I, I think it's, I think it's neat what a milestone. And today is I, you know, there's a reason why this guest is on the podcast. Uh, today as well, and and I know that he doesn't really care to think about that like that, but you'll, you'll see I mean, it literally changed the trajectory of my career when I started interacting with him.
Speaker 1But before we get to that, we do have a sponsor for your orthotics and prosthetics podcast, okay's that you would never guess it but it is advanced, advanced 3d right, so advanced 3d is uh the sponsor of uh really this season, and um advanced 3d is contract manufacturer. We want to meet you where you are, wherever your journey is, whether you're just scanning, whether you're wanting wherever your journey is, whether you're just scanning, whether you're wanting to get into 3D printing, whether you're wanting to do definitive sockets, if you have a product that you want to bring to market. Those are all things that we are good at doing, and so definitely check us out there.
Speaker 2We also do design work for people, right? You can help me literally if I have an idea, if I need some part made, that's like a some assembly part or something that you guys can help me design, do the defam design for additive manufacturing, get that thing made right, get it made and get it ready for 3d printing.
Speaker 1I mean, I think that's the biggest thing that I I think that is plays to our strength is that we can take a part and get it ready for 3d printing. There's a lot of parts that are not ready for 3d printing because they're made for traditional CNC or injection molding and make it either difficult or not the right application for 3d printing. And that's where we can come in and help and get you to, say, a production level before you cut a mold or or something like that.
Speaker 2Okay, Super cool and now. So I'm super intrigued about our guest Brent. So we were talking to yeah.
Speaker 1So, um, we are talking to dale perkins, um, from coyote design and coyote prosthetics, and dale and matt we've had matt on the podcast before are the founders of coyote design, and then they also have a clinical arm as well, and and this is a story whether Dale remembers it or not, but it was a tipping point in my life as a clinician is in 2000,. I believe it was 2005,. Aoppa would do these things called short courses, and so you would fly in and you would go in for two days and there was a specific technique that you would learn. And so you would like fly in and you would go in for two days and there was a specific technique that you would learn. And I saw this on the internet and I had I was a newly certified clinician or I was still in residency, I don't remember which one and I saw this thing called the RCR socket from Coyote and it was the goofiest thing I'd ever seen. It had some trim lines that I had never seen, some like little dimple things around the kneecap, and I, to be frank, I thought it was a little crazy, but I was curious. So I signed up for that course and literally the day before that course happened.
Speaker 1I get a call from the organizer and said, hey, the hands-on person that was supposed to be doing the casting and the modification for your patient model canceled. Do you want to do that? And I'm like I don't want to say no, but I'm very new in my career, but I was like what's the worst that could happen? I fail, okay, who cares? And so I took that course and I followed literally everything that Dale told me to do.
Speaker 1And this patient that was seen at a very prominent facility starts crying when she puts on my socket. And I was like, oh no, this is not a good thing, this is not good. What is wrong? And she says this is the first time that I'm comfortable in my prosthesis, that I've never had pain, and she had been trying to be fit by this group for about a year and had never been comfortable.
Speaker 1And literally all I did was follow the recipe. Okay, so there was nothing magical about it other than I followed the recipe. Prosthetists are notorious for not following recipes, and from that time on I started to become friends with Dale and Matt. I had already used their products as a technician, but then I became friends with them and I also had the opportunity to teach with them going to show other people the socket design and it's changed literally thousands of people's lives here in the US as far as patients go and changed a lot of clinicians and the way they treat patients and then ultimately affect patient outcomes. So I thought it would be very cool to have Dale on and share and hear his story and I mean it means that much to me, dale, for you to be on for the 100th episode and now really almost 20 years since I met you the first time and made such a difference in my career and trajectory.
Speaker 3Well, I appreciate that and I'm very proud of what you've accomplished. Like you say, a lot of clinicians don't really like to follow the recipe. They have a change before they get back home after a clinical meeting, and it really is an interesting profession at this point.
Speaker 2Okay. So, dale, I remember a little bit because we've had like I think Brenda's just like the biggest fan of Coyote ever we're having, like everybody, we'll interview everybody ever that works with you or for you guys. So I know a bit about you guys. So I know that you got involved with OMP as a patient first right Correct and so could you tell us a little bit about that personal bit of your history?
Speaker 3I was born with fibromyalgia and had partial foot congenital on both limbs, and the left side was way worse. And as I grew taller they stopped the growth in my right leg when I was 12 to equalize that. There wasn't a lot of prosthetics in that era, 1958, 59. It was pretty grim. So they opted to stop the growth in my leg to equalize my leg length and that really set a chain of events in motion that was not very good. I mean, I functioned pretty well till I was 40 years old, but then that ankle on that left foot wore out and I was faced with either fusing the ankle or amputating. And then I looked at, you know, amputating below the knee, which is real dicey when you don't have a fibula. So I ought to do a signs.
Speaker 3And I traveled to Seattle and met with with the group at Harborview Medical Center. Dr Doug Smith, and dr Hanson as well, was the ankle fusion guy and I was trying to decide whether to fuse or whether to amputate. So we talked about the signs and Doug was very comfortable doing a signs amputation. And then he happened to mention that you know, by the way, we could shorten your left femur as well to bring your knee centers back to my knee centers were two inches off so we could bring your knee centers back to level. So at that point I was all in. So this was in the spring of 93. I had the Simes amputation. Nine months later I went back to Harborview and had a closed terminal shortening, which they were really excited to do Because Boeing engineers had figured out for them how to shorten a femur internally, which I had no idea. But when you're having surgeries like that, sometimes you don't want to know the details and I wouldn't have done that today.
Speaker 2I wouldn't you don't want the doctor to be excited and to bring. It's bad when they bring all their friends and stuff and they're excited and wherever like oh is this, mr Johnson? Oh, you know you don't want to like, that's what I've learned, exactly. You don't want to twinkle in his eye a big day at the office. No, no, you don't. You want him bored. When I'm looking at his watch saying, oh, golf is free.
Speaker 2You know that's what you want you've got to figure it out yeah, so and and, um, and, after that, did it stabilize for you? Did it get the situation a lot better, a lot less painful? Were you able to, like you know, do a lot more or not, really?
Speaker 3oh, pain, pain was gone pain was gone.
Speaker 3So the other thing that occurred by when I went back and had the uh, I fit a typical socket um, I thought it was as my quad string came back rather quickly, the pain around that patellar bar was obvious and I realized what good salesman we were in prosthetics. And then when I went back and had the closed shortening that made my quad and hamstrings very weak, I had to walk with a cane for about well crutches first and a cane for about six months to get that strength back in the quad. But the amazing thing in that is that patellar pain, that patellar tendon pain, vanished. So I realized that if you have a really weak quad, patellar pain is no issue, patellar bar is no issue. And that really planted the seed for this socket design.
Speaker 3So the Coyote socket design and, like I was telling Brent earlier, the socket I'm in now is I've been in for 10 years, which in prosthetic terms that's almost unheard of, but it doesn't hurt. I do whatever I want. I honestly think if I hadn't had the surgery and the shortening, both together, I'd be dead now. I would have extended inflammation until I would have died, probably 10 years ago. So this is all a bonus to me.
Speaker 2And do you have that still? Do you have that still like every day? It's like well, another one that's cool, Like extra.
Speaker 3Oh yeah, I'm in the bonus round. So, yeah, okay, I just certainly enjoy waking up and I, you know, one thing I do is one thing. Another thing I did was in this process, I built a shower process. It's real simple to do for signs and without that, my right knee and hip would have worn out sooner. I've had a hip replacement and a knee replacement on the right side, but I've avoided that all on the left. So I haven't had a major surgery since 2020. I had a C1-C2 fusion in my neck, but I haven't had a major surgery since 2020. I had a C1, c2 fusion in my neck, but I haven't messed with anything in my lower.
Speaker 2Okay, and then you know, before those first years of your life, like those were actually kind of really low mobility, very painful and also like, yeah, children can be very harsh with that Did you feel that that was kind of especially difficult for you, or have you never really worried as much about that, or no, the kid.
Speaker 3I mean growing up with an amputation is way different than having an amputation when you're 60 years old. Uh, it's a shock. At 60 or 50 or whenever, uh, when you've had really good original equipment and then you lose some of it, that's a much bigger deal than a congenital like I was and I didn't really know the difference. So I played basketball, I did all sorts of things, but later, when I got a little older, I started to have real issues with pain.
Speaker 2Okay, okay.
Speaker 1So I want to explore a little bit on the socket design and I think this is yours, I think this is where our listeners will find a lot of benefit and there's some key points that that Dale kind of glossed over quickly, because this is his life every day, but so typically when we're making a prosthesis, or in the school like the school answer for a prosthesis they're under your kneecap there's what's called a patellar bar, so it's like a depression that goes under the kneecap and pushes in to a tendon ligament that goes to the top of your tibia, and so that was the typical way that things have been done forever. And one of the interesting things is Dale was his own guinea pig, essentially. So Dale at the time was a prosthetist and he made his own prosthesis and found that it was as he gained strength, he was uncomfortable under the kneecap so he ended up just cutting that away and saying, oh, that's more comfortable. And that is when the socket design of the RCR but the Coyote socket design was born. So it was really born out of his experience, like he had learned and this is the way that he was fitting patients and fitting even himself, and then he learned that, hey, maybe this isn't the right way to do things, and so one of the other interesting things that Dale glossed over a little bit was that he's been in a socket for 10 years.
Speaker 1It's very common for patients to go through multiple replacement sockets over the course of 10 years because they have what's called atrophy, or you get smaller and smaller and smaller. One thing that I found interesting in our practice and I know Dale sees it in their practice when you follow the recipe of the coyote socket, you're going to see it's not necessarily good for business, so you're going to see less replacement sockets because you're actually letting the muscles fire and the blood flow go from the extremity from the leg all the way through the extremity from the leg all the way through, so typically under the knee and then behind the knee was pushed together and that's what we call the AP or the anterior posterior dimension. But what people don't realize is behind the knee there is a vascular bundle and that's where all your circulation happens, is behind your knee, and when you push in on that area you limit the circulation, which then makes the leg get smaller, makes the muscles fire less, and then you end up getting another socket. When you do not do that. The opposite happens. So you potentially could have hypertrophy, where the muscles start working again and you don't end up doing replacement sockets.
Speaker 1So is that a fair? What did I miss there, dale?
Speaker 3Well, you do some. I mean, like, if we fit many, many PTB socket wearers and as soon as we did that, they had that hypertrophy. As soon as we fit them in the coyote socket we had that hypertrophy which created too tight of a socket and we had to do a socket replacement. It's not like we don't do socket replacements. I meant signs, congenital signs, which is a different cat below the knee amputation. So we still do replacement sockets on a fairly regular basis for multiple reasons. With the trans-tibial amputee there's all sorts of issues that have to be dealt with, but we had the opposite effect. We had the limb getting that palpatine area hypertrophying and made the socket way too tight, and so we had to make them a bigger socket, which is kind of just not intuitive in prosthetics.
Speaker 2And so did you officially. Well, did you first get involved in prosthetics because you're a patient yourself, or did you want to solve your own problems, everyone's problems? Why'd you get in this business?
Speaker 3that's really the reason I did it, and and I certainly wasn't alone when you went to the first national meetings I went to, you could tell it was a prosthetic meeting because there were just some horrible walkers. They were, uh, you know, just uh, almost all all the folks in the field were amputees. There weren't a lot of people that weren't amputees doing prosthetics and so, yeah, it was a kind of a normal progression. I grew up. My dad was a contractor. We did building. I realized fairly early on that I was never going to be able to do that long term, but it gave me a lot of insight into design and what you had to do to solve a problem. We did a lot of remodeling of poems and that's all about problem solving. So that certainly helped me in my quest to become a prosthetist.
Speaker 2And then do you think well, what unique insight, as both a prosthetist and also a patient, like, is there something you'd like to tell people who maybe because now, like a lot of people aren't patients? Is there something you would like to tell people that they should pay more attention to prosthetists? Like, hey, you should really be asking more about this, or equalizing more about what you understand to be pain, or is there certain things you think that people should be better at?
Speaker 3Well, I've heard lots of stories from amputees about being told they would get used to it. When the socket was not comfortable, you'll get used to it. Well, that's bullshit. Used to it? Well, that's bullshit. You really need to listen to your patients and really question the principles and theories that you were taught and got your A in school. But it doesn't help you fit a prosthesis. It's a really interesting process fitting someone in a prosthesis if you take the time to listen to them, and I realize that's getting harder and harder with how we are viewed in the market as a medical professional. But that's the bottom line. It's just don't ignore a complaint and then really try to examine why. Why are they having this problem? You built this socket. I would have got an A for it in school. Why are they having problems? Are they just not very tough? What's going on? But no, listen to them, Just listen to them, that's all.
Speaker 2Okay, and then for you guys at one point transitioned to becoming well, you're still a practice rep. You also make kind of tools and products for the industry as well. So as a product fabricator or whatever, or somebody making devices, do you have any advice as well what these people should do more often?
Speaker 3Well, same process. You just question what's there? There were some big. During my time in prosthetics there were some huge innovations. There were some huge innovations the gel liner, roll-on gel liner, the endoskeleton components and the pinlock locking system and then later vacuum and some other things. But those three the pinlock system, the roll-on gel liner were really two of the major things that occurred. But we would talk with lots of practitioners and they would be well, I only felt pinlocks. All my patients had pinlocks, or the next guy was all his patients they get suction. Well, that's not good. You can't all have the same thing. There are reasons for every type of prosthetic system suspension system. So you really need to evaluate the patient and see what will work best for him, not you, and see what will work best for him, not you. And that's probably my nutshell device on prosthetic suspension systems.
Speaker 2If you look at these big improvements, let's say, and you look at stuff we're really excited about 3D printing, how about yourself? Are you seeing, oh, is it going to be a really huge thing for the market, or are you considering it relatively minor? If we look at certain inventions, such as this gel liner, which course, like it was huge, um, you know what would you think? The impact?
Evolution of Prosthetic Technology
Speaker 3of the additive or 3d pruners. No, it'll, it'll, it will be huge. I've I've been around long enough. I've been in the practice over 50 years, uh.
Speaker 3So when I got out of school in 1974, it was pretty grim. There really weren't a lot of them. There were only three prosthetic feet. There really was not very many. A big innovation was getting rid of the side joint and laser and having a PTP strap to hold your leg up. Those were the big innovations and it was really pretty grim and it was really pretty grim.
Speaker 3But as things changed and that technology came along, I was fortunate to be able to witness the end of the wood leg era. So I had lots of patients that were in wooden legs and most of them loved them because they had a thigh joint laser that took all the weight, or a lot of the weight, off the end of their limb and they excuse me, they were really reluctant to try this great new technology that was a plaster cast and then we make this cast and we make this perfect device to fit your limb in. And this evolved fairly quickly to having clear test sockets as plastic technology came along. But a laminated socket was not a wood socket, and especially in the south where the humidity was so high they they just loved them. And in the north, wood was a better insulator than plastic. So the the socket was cooler and warmer both compared to a laminate socket. So I see the same thing happening in 3d printing. It's just it's going to change. But it was very slow changing wood sockets over because people loved the wood socket but they just ended up. That was technology. We're moving forward. This is what we're going to do. This is all really technical. Now You're taking a cast, you're modifying that flasher model and that's just really difficult with uh way to manufacture. It just has a lot more hurdles to go over and a lot more guesswork.
Speaker 3The 3D printing, especially the way the scanners work I made it. I have a socket that we made and scanned the totally eliminated the plaster process. As far as taking a plaster cast, or fiberglass cast in my case, and then going right to a test socket, that's kind of unheard of the way I make my socket. We had to go back to old school to finish this processes, but it it was much simpler than trying to take a mold. The scanning has gotten so good and and 3D printing is getting what it is now, it won't be. Next year, it's going to be way different. So, as materials come along, technology comes along, it's yeah, it will change everything and it's really hard when you are really good at one thing, like the old guys. There were old guys when I was in the field that were making wooden sockets. They struggled to make a plastic, a plaster model socket.
Speaker 2So it's the same thing now and do you yourself use your brain at all? Or you're like, yeah, let's leave it to the young kids and like that's not for me I don't know, I'm pretty much done.
Speaker 3Uh, you know, you, when you own a business, you lead, follower, get out of the way. Uh, and it's my my time in life to get out of the way, so that's uh, I don't really interact with them much unless they have a question about some, some older technique they need me to chime in on no, but this is the get out of the way is, I think, a really good point.
Speaker 2And we're um, I was talking about a business today that is actually doing really badly because there's a founder that is not getting out of the way. It's just like like looking over everybody's shoulder every 10 minutes and that at one point, yeah, you do kind of have to have to let other people run. Uh, what you helped build for so many years, I think.
Speaker 3I think it'd be difficult to oh, absolutely, and that is hard, it's um, but it's necessary. Yeah, you can see it. You see it a lot. Uh, this is your baby. I've always told people I looked at it differently. I mean the first two years I owned the business, I felt like I owned the business. After that first two years, it owned me. I worked too much, spent too much time there and really had a hard time trusting people to come in and do the work I was doing. So I wasn't a great employer at times. So getting out of the way was one of the easiest things I did, but I still miss it, the challenge of it. It would be fun to you know. It's fun to see how it's going to evolve and change as 3D printing becomes the benchmark. I mean it's going to be and change as 3d printing becomes the benchmark. I mean it's going to be the way things are done.
Speaker 1Hey, we're going to take a break right there and I promise we'll be right back with Dale. I wanted to introduce another sponsor specifically for the hundredth episode, and that is comb scan. Comb scan is affordable and accurate and fits in your pocket, on your iOS device. It is designed for the practitioner, by practitioners, and it allows you to capture precise 3D scans of your patients From there. You download your scans from the Comb portal to prepare for catar rectification and fabrication. And one of the greatest things is ComScan is approved for many central fabricators, such as Cascade, dafo, persco, ortholabs, hitech, custom Composites, o&p Solutions and Limboss, along with many more. Check them out and hit them up for your 10-day free trial.
Speaker 1So, on that, though, like. So, yes, you have moved out of the way, retired, what have you? But I mean, I still think that there's some foundational concepts right in the prosthetic. So 3D printing is not going to save the world. It's going to be very cool. It's probably going to be introduced. Some things like gel liners has that allows people that aren't as skilled to make something that somebody can walk on. But, like, clinically, you still have to fit the patient, and I think that's what people miss a lot of times, regardless of the technology. Can you share some of your insight into that?
Speaker 3Well, one thing that is interesting, I think, is the scan. So you take a scan and when you took a plaster or fiberglass mold plaster or fiberglass mold you had something to work with. In a scan it's just all an image and if you're trying to carve a patellar bar in there and make a tight AP PTV socket, you're in big trouble and your patient's in bigger trouble. So the thing that I'm proud of with our socket is it fits right in with 3D printing. It's an easy I guess it's a hard concept, but it's an easy thing to transition to 3D printing. That technique it's because you're really not trying to do anything goofy.
Speaker 3One of the really goofy things in prosthetic sockets for bologna amputees was the 5 to 10 degrees of flexion that the socket was put in, and this was to open up that gap for the patellar tendon bar to go in, because if they're in full extension you can't put a bar in there. So I don't know how we could fool ourselves into believing that you could put a socket in flexion and not be dorsiflexing the foot. And so patients walk amputees walk like amputees. They didn't walk normal gait because they couldn't. So that's another thing I'm really proud that we introduced, but it's not widely received. I can say that it's kind of funny.
Speaker 2And if you look at like well, how is like so 50 years has been a long time and we talked a little bit about like gel liners are big things that have changed. But you guys also have a CFAB right and so, from the manufacturing viewpoint, what has changed for them From this wood era to going to carbon fiber and now 3D printing? What has changed on the CFAB business over that period?
Future of Prosthetic Education and Industry
Speaker 3business over that period. Well, it, uh, it certainly uh. Cfab is in old school techniques I'm talking old school like it was five years ago uh, taking a wrapped cast, uh, and a plaster model and moving forward, sipping that off to somebody, uh, and so they, what we receive are just negative model casts and then we fill it, modify it and do all that and if that cast is wrong, you're swimming upstream. I mean, it's really hard In 3D printing if somebody can take a good scan and move forward. It's pretty simple and much more accurate. So it and it's. The current practitioners really aren't wanting to fabricate it's. You know, they want to put it in the mail like a pair of arch supports and get it back in the mail and fit it, and that's really really difficult for the patient anyway to come up with a really good product.
Speaker 1So if you had your, let's just say you know, let's take the coyote hat off, the business owner hat off and you, dale the patient, the business owner had off and you, dale the patient, and you had an opportunity to talk to the incoming education of some magic wand stuff that you'd love to see about our industry moving forward. What would be some advice that you give them?
Speaker 3Well, it probably wouldn't be well received. I think we should close all prosthetic schools. The Academy of Orthodontics and Prosthetics should be a building, not an organization. We should be training practitioners ourselves, not turning it over to a really expensive operation for a university to set up a prosthetic prosthetic school, and it's way too slow. You know, you could have an academy in three cities in the US and they would train patients via what we're doing today a computerized system to educate folks and then have hands-on sessions for certain things and certain devices. And you could get to me.
Speaker 3I would like to see practitioners certified really quickly, but more like a physician. So they're at the low end. They're not an orthopedic surgeon yet they have to do a fellowship to do that. That's what I would rather see in the market instead of getting patted on the head and kept requiring a physician to write notes for us and make that prescription before we can move forward. I think we should be able to evaluate patients and make a reverse referral, not have the physician refer to us, but we refer to them. I think they need to oversee that. But most physicians that do an amputation don't want to see the patient again. That's unusual, especially in rural areas. So that's not going to happen in my lifetime for sure. But theoretically you want me to tell you what I think I should should be. That's what I think it should be so, so it sounds like uh, more.
Speaker 1So essentially taking the education into our own hands, almost like what, um, like, chiropractors have done yeah, I would much rather we follow chiropractic and podiatry models than orthopedic surgeon model.
Speaker 3We're not an orthopedic surgeon, Never will be, so we need to understand what they do. But it's the. Chiropractic and podiatry legislated their own position in the market. So did physical therapy. They legislated their position in the market. So did physical therapy. They legislated their position in the market and they went to insurance companies, showed them that you know, these patients get physical therapy. It's going to save you money. I don't think that's really occurred, but they believed it. And you can't hardly go to a doctor with like I have my neck fused, so I had to go to therapy first. You know that's just a knee-jerk reaction. When you get diagnosed with something, you're going to go to therapy before they're going to invest any time in doing any surgery on you. So that's just, and that's just legislation, legislation. That isn't something that somebody went oh, this would be a better way to do it and then and I'm also really interested to to look at this the industry, right.
Speaker 2So when you joined, was everybody just a separate little mom and pop store, I'll tell you. And now you see all these hanger, all these giant companies. What do you feel like how the industry is changing?
Speaker 3well, that's the corporate world. That's. That's crippled america. Uh you. You know a little town I grew up in. Five thousand people had three car dealerships, six uh six uh restaurants, uh, four small grocery stores and all that's gone. Now they have corporate, just corporate. This. Everybody gets their McDonald's and then all these little mom-and-pops close and that's where they lost that. What's happened in prosthetics? We're no different than anybody else as far as corporate efficiency and taking the money out of a local community. It hurts this country, but we're not going to go back to that ever. So I don't know how we deal with it, but yeah, it's not good. It was much. I think the patients had a much better relationship with the customer. We only go to hamburger places that are family-owned, small hamburger places. We don't go to corporate places. But can't do that in prosthetics or orthotics that easily. So it's just the way of the world.
Speaker 1I think that's a pretty interesting point, though, is that you never like, when you talk to somebody uh, specifically patients that uh use a prosthesis it's always the clinician that they refer to. It's never the company, like the. The relationship is always with the clinician and so, like as much as what I would love to say you know, we've done such a good job at East Point that people you know say I'll see anybody at East Point to make my prosthesis or orthosis. But the reality is is that people want to see a Brent or Paul or or Audrey or Sophie, like those people have the relationship and have the trust and the idea of brand recognition for prosthetics and orthotics. Other than it's becoming big in corporate, it's still going to be I want to see. You know somebody at that office. It just happens to be named East Point or Hanger or whatever it is, but it still is super personal and I think that's the part that's that's hard to see.
Speaker 3No, I agree completely. It is a one-on-one relationship and when you find somebody that will do a good job and listen to you, you're going to be loyal to that person, not necessarily the company. So that's a great point.
Speaker 1We just had a situation actually with a patient who has Charcot-Marie-Tooth and they were looking around their house and I guess they were engaging in a discussion with their family members for, let's say, a birthday or something like that, and they were kind of going around like what is the most important thing to you? And he was sitting down, didn't have his braces on and he said those two things, sitting right there, are the most important things in my life. They allow me to go to work, they allow me to go to the grocery store, have a life, all that. You can take everything except those two things. And I mean it just goes to show how important that is and you can't put a big banner over that other than it's a personal relationship for these devices oh, you're absolutely right, and that's um, I don't feel like a, like I have a disability, until I take my prosthesis off.
Speaker 3then that's a different deal and it's just a science. I can stand on my amputation. I don't walk very well but I can. But I use the shower prosthesis to walk around and take a shower. But for an above-the-amputee or arm amputee or whatever, you're really limited. Once you take the device off, or Charcot-Marie-Tooth, you get up on mobile and you have freedom to move around. That's a big deal and it's not something people want to give up. So there's, people walk on a really uncomfortable prosthesis because it's better than not having one. It's a low bar to fit a good prosthesis, an acceptable prosthesis. It's a really low bar. People just want to move. And the 2% or 3% that are runners or high-end athletes, that's the small part of the market, it's the fun part. But athletes that the small part of the market, it's the fun part, but it's a small part, the really one. The ones that are really important are the 80 or 90 percent that are, you know, can't hardly function without the prosthesis okay.
Speaker 1So, dale, I find that very interesting that you talk about. You know, the bar is very low to fit a prosthesis and, whether it should or not, my mind goes to some of the research that's been done in orthotics, prosthetics, specifically some that has been done back in the probably the 70s, when there was a lot of research done on amputees that were coming back from the war, right, so very healthy people, but otherwise had an amputation, and a lot of decisions were made regarding socket design from these healthy people that are taught in school. Whether that's right or wrong, I don't know, but that's not the population that we see. And so my thought when I see that and I hear the low bar yes, it's a very low bar to fit somebody that's athletic, that tolerates a lot of pain and that wants to get up and walk and wants to live their life. But it's a lot more difficult to fit somebody that, say, has an aroma, sensitive skin, maybe a little bit of diabetes, and you cannot have skin breakdown. Can you just share some thoughts around that?
Speaker 3Well, I say it's a low bar because Well, I say it's a low bar because I mean just get up and hop around for a little bit on one leg and then think, well, what if I had to hop? And I couldn't hop, I had both legs amputated. Just to get up and walk it can feel pretty bad and you're going to soldier on and that kind of looking at those healthy patients that started before Vietnam. That started World War I and II. World War I we didn't do much. They got two prostheses from the VA. That was automatic. They get two processes and then World War two, they did some of that for a while and it depends.
Speaker 3It got really complicated as far as where you serve and all that. But that's where really all of the all of the real engineering thought and prosthetics came in. World War II, after World War II, that's when we had engineers at Berkeley tell us how we should fit a prosthesis. Really they had no idea in the world. They were just looking at a skeletal model and above the knee. They really weren't looking at wounds and scars and burns and all kinds of issues that we have to deal with. They were just looking at healthy tissue and how to build a socket around that.
Speaker 3So it was really not reality, really a really not reality. But we clung to those concepts for 50, 60 years and it's 70 years and it's just bizarre to me, uh to uh that we haven't done our own research. And the research today, and prosthetic pinning today, is on L-codes. You're fitting by L-code. You're not fitting by what the patient needs, you're fitting by economically. How can I fit a for-profit socket on this guy or gal? And how many L codes can I add to this to make my car payment or building payment or whatever? Or get my salary in keys because my production is up? That's sad, that's just sad, and that's one reason it's really easy to walk away.
Speaker 1But I'm not young like you, so Well, one other question I had for you is the role of the surgeon in a good outcome.
Speaker 3That's a good point and that's why it should be kind of a reverse role. The big corporate companies have the money and the time to go after and get the ear of the surgeon. And then, like Doug Smith told me once, we were talking about amputation surgery and he said you know, if you go to an orthopedic meeting and you go to a talk on amputation, there is nobody in there that doesn't have gray hair. You go to a talk on amputation, there is nobody in there that doesn't have gray hair. There are no young guys. When hip joints and knee joints came along, they had no interest in doing amputations. They didn't give it up.
Speaker 3And it's unfortunate that there wasn't a subspecialty of orthopedics vascular that didn't do amputations and strictly amputations. But that's not practical in rural america or anywhere else. I guess you could do in a big city, but uh, you know, and it it doesn't mean anything. I mean there are techniques and surgery that come along, like the Erdl, that probably are almost unheard of now. It died in 1950 after he introduced it because it's so hard to do the way he did it. But later on, when he and his sons reintroduced it, it caught on really quickly. But just like prosthetists, orthopedic surgeons start finding shortcuts to cut down a two and a half hour surgery, like Ertl designed it, and they did all kinds of things that created real problems for patients. So it's unfortunate we don't have a better relationship with orthopedic surgeons or there isn't another surgical specialty introduced that specializes.
Speaker 3I mean, you know, like a PM&R doc would be a great guy to do an amputation, but they're not surgeons. Why not? Why not? You're dealing with the problems after somebody else does a surgery and I would guess even in today's world there are less than 50% good amputations. It's a real thoughtful, hard thing to do. I was fortunate to do a meeting with both Sig Hansen and Doug Smith, deciding whether to do a fusion or do an amputation, and so when Matt came along, I still had those guys to rely on, Didn't need Sig Hansen, Matt wouldn't be a fusion. But you know, being able to talk with Doug and really have a good relationship like that, that was huge. I would have been smart to move my practice to Seattle and saw a lot more of his patients.
Speaker 1But it is what it is we've got a episode coming up on just what the the role of the surgeon, as well as specifically for transfemoral gait and surgery, like how the the role of the IT band is is not talked about like it should be and is actually the cause of a lot of issues for transfemoral patients, and so I think that's what I wanted to get through to you. You've been very successful with your situation because you had a good relationship with the surgeon. They listened, you guys came up with a plan together, not only for the science amputation but for the closed femoral shortening. Those are all things that are. You know, those are discussions that should be had but that probably the majority of people are not having, and it does have a direct impact on what your outcome is going to be.
Speaker 3Yeah, if I were a surgeon, if I weren't a big surgeon and I had a patient that had a crush injury to his lower leg and I had to do an above knee amputation but he's he had good vascular supply to his knee I would do a knee disarctic every time, kind of a high level knee disarctic and be like a two-stage surgery and then a shortness femur four inches depending on the height of the patient, so they had a really good in bearing limb and wouldn't really need any kind of issue. Weight bearing it would be, it would be simple, and but that's not the case. But that's not the case. Nobody's even going to suggest that to somebody except me and I don't count. So that's.
Speaker 3I mean there are things that they do that really you know I don't know how many amputations I've seen that the fibula was longer than the tibia Really, I mean really. But when you see a surgery, when you see how surgery is done, they don't see the patient. They've got them covered up and so they open a little window and they measure down with their hand or some way and discern when they're going to do a BK. And they're all the same length. I mean they're all the same length from tibial plateau to the end of the amputation. Well, that's stupid, but that's the way it is. And, like I say, now there's nobody coming in that wants to do amputations. Do you see any hurdles anymore?
Speaker 1So there is a surgeon here locally that does them. I would say that really a lot of the talk is what opened up this whole surgery talk is that surgeons get under $ thousand dollars for an amputation. So they want, they want to be in and out very quickly. Um, how?
Speaker 3but they're not advocating for that. They're not advocating no.
Speaker 1So, but this is the interesting part that that's becoming part of the conversation is how can you do if you do an amputation? How do you do limb reconstruction? So, and that's where there is more money available to surgeons, and that's how you get some of the interest into. Hey, these patients that are diabetic, dysvascular, that, how do we get the most life out of them? Well, it's to get them up and going, those that want to. Well, how do we do that? Well, we've got to take away the issue of a poor surgery with them to ensure a better outcome.
Speaker 1So it is considered kind of osseointegration, but it's inside, so you don't have the stoma coming out, but you can have weight bearing on the end of like a femur, or they're doing some on the tibia as well, and it closes up the what is it? The intermedullary cavity. I'm not a surgeon or a doctor, but it's pretty amazing and it gives a place for the IT band to connect. So you continue with the adduction of the limb, and so I think some of that stuff is very interesting because Well, the adductor longus is really the thing they miss in transfemoral.
Speaker 3The adductor longus keeps that limb in abduction and as soon as you cut that limb off, I wouldn't worry about the IT band as much as I would the adductor longus. That's got to be osteointegrated. You have to really attach that, no matter what. You have to attach that thing somewhere to keep that limb muscularly balanced. To me that's the key. I mean, we do these really elaborate socket designs, really elaborate socket designs, cat Cam, savile Edge and all this bullshit, just to keep that adduction angle. Well, all you had to do was keep that adductor long, which is why those NIDISR ticks.
Speaker 1do so well, because you've got a place for it.
Speaker 3Exactly.
Speaker 1Long.
Speaker 3AKs are easy, because that's things still in fact.
Speaker 1Well, let's let's talk a little bit about your journey with matt. Uh, too, on kind of the evolution of the socket design and how we we have, believe it or not, a lot of, uh even, parents that have kids that are having an amputation or facing an amputation, and they sometimes will listen in to what is some of the latest or some of the things that parents can do to make sure their kiddos excel at life. So I'd love to hear you know a little bit of your journey with Matt, for sure, sure.
Advancements in Prosthetic Innovations
Speaker 3Well, it was really not something I wanted to take my work home with me. So when Matt was born, it was a shocker. I actually dropped out of the field for two years and then I realized that I had to be involved, um with this. So I really waited too long. I um, you know, I met with uh Pellicor in Chicago and uh what's the guy in Wisconsin, critter? I met with those guys and then went to the University of Oregon and met with the docs there and they wanted to fuse his hip. And then I had to start doing research and really understand PFFD and how I wanted it.
Speaker 3The only real biggest mistake I made was waiting too long. We didn't amputate the foot. It was 10 and he didn't grow as tall as my other son. So he he ended up almost a knee disarctic with very little you know, very little clearance, with very little, you know, very little clearance. But that talked to those guys.
Speaker 3Well, like Pellicor, he was doing Van Ness procedures. So I said, no, I've been reading some. I said you know, there's no Internet, so some of these turn back. I said how do you keep it from doing that? I said, oh, you don't, you just redo it, cut them again, turn it, and then some guys that could wedge cuts and lock it in a mortise, yeah. So I said, okay, I'm not doing a bad thing. You know, you look at everything. When you're faced with it, you can do anything. Theoretical, that's fun. When it's staring you right in the face you've got to make those decisions.
Speaker 3That was the biggest mistake was not doing it quickly enough. And then he had a real angulated limb. It was really and talking to Doug Smith after my amputation, it was easy to discuss with him how to change that. So he had this flexible rods. Well, I have no idea what a flexible rod was, but that's what Matt has. They did flexible rods and straightened his limb out.
Speaker 3So, like when in his first sockets he had, you couldn't see the bottom of the socket. You looked down his socket, you couldn't see the end, it was around the corner. Down his socket, you couldn't see the end, it was around the corner. And so that would be was the one surgery that really helped get him the gate that he's got now and they or he can function, and how he can function and any and anything you can do. Convince the surgeon to do that will help. Fitting, make fitting easier is good for me or you, but it's a dicey thing to start talking to surgeons about how they could maybe improve this amputation. That's really not something they want to touch. Way too much litigation in that bullshit and that's just the reality of life. But there is so much that can be done surgically pre-op, post-op and then revision surgery. Those are all things that I would think half of all amputations should have a revision.
Speaker 1So yeah, and then Matt I mean went on high level competition stuff and I mean I think you guys kind of pioneered the way for a lot of the current, even triathletes, in the way they think about sockets, components and all that stuff that you guys had to hand make for Matt to be successful on his journey.
Speaker 3Oh, yeah, yeah, I mean, matt won five world championships in a row and he did that because he didn't have a knee joint in his prosthesis. His running prosthesis weighed like uh, two and three quarter pounds, uh, and and it was just a pylon, just a pylon uh, and had to get it at the right angle. He had to have a foot that would have some energy return, but he ran with a whip gate, an adduct and bring it back in, but he just smoked people that were trying to run with a knee, and now they've made some knees and they do all kinds of stuff. One real issue in prosthetics is all the research is done on components. This new computerized foot what a waste of money. I would love to see all that money go to prevent diabetes, because the people that money go to prevent diabetes, because the people that are going to use a million dollar foot are very few and far between. That's the frustrating part with reimbursement.
Speaker 1And it's interesting, we have this discussion a lot, especially with our young athletic patients and such.
Speaker 1They see the Instagram and TikTok and all that stuff and they say I want this computerized knee computer, this and that. And luckily we have some patients that are very active and we say, hey, we've had some patients that have tried all this stuff and they always go back to a total knee and some sort of dynamic foot right If you're a transfebrile patient. But the cool thing is is that having the opportunity to demo some of that stuff, especially now, so they can make their own decisions. But like I just had a situation with a insurance company that wouldn't cover a patient for a second prosthesis for sports, but they would cover, you know, a $50,000 microprocessor knee for his everyday leg instead of you know we were looking for something with a total knee. So you know, definitely way less than that. And trying to have that discussion of like, hey, you're actually going to pay more for one prosthesis and have somebody that's still not able to exercise or what have you, than for this, it's just that conversation is. It is maddening for sure.
Speaker 3Well, we've got nobody in our corner. You know, historically orthopedic surgeons became orthopedic surgeons with the were anointed. They didn't have to do anything, they just had to have somebody that had gone through the process paperwork-wise, and become an orthopedic surgeon to anoint them as an orthopedic surgeon. There was no real formal education and that certainly was the same way prosthetics was. You had an orthopedic surgeon or even a surgeon make you a CPO, or even a surgeon make you a CPO, and it wasn't, but it created such a synergy between the surgeon and the practitioner because we were important to them at that time.
Speaker 3All sorts of back braces, I mean, we had to. It was nothing prefab, you had to fabricate everything, so they really relied on us. They don't even know who the hell we are now. They just have no concept. You want to get some cute gal to come in and show me about the Nolita's total knee? I'm all in. I got tons of time to go over this and you can fly me somewhere and do the seminar and make an extra 20 grand to do a seminar, and you know, it's just a different world, but that's.
Education and Innovation in Prosthetics
Speaker 1Yeah. So, just like knowing, knowing, looking at history right and as we're, as we're moving forward. What are some other than 3d printing? What are some exciting things that you see moving into the field, and where do you find that there might be some? For those that are listening, some white space of hey, people are not doing this. It may be something that you want to look at.
Speaker 3Well, I've tried to convince Matt that we do some central fab, but most of it's in our AFO stuff. He could be crazy busy just doing our sockets. Teach somebody how to do the scan, set them up with a scanner and then build sockets for them all day and it would be easy. I mean it's To take a scan of a limb and do it properly, I think entry-level-wise. If you're going to get into 3D printing, learn how to scan and get that image and have somebody else print it for you. Then and you guys can do that, I mean you could be crazy busy doing just that. But that's when they try to do everything. You know how much there is involved in 3D printing. I mean there's a lot involved and a learning curve like everything else in the world. But to be able to scan and take a decent scan.
Speaker 3And then the other thing I disagree with what we're doing now I wouldn't do a clear test cycle except my AKs, and I'm not sure I'd do it. Then there's not much you can learn and there's other materials that you don't have to worry about snapping in half. So I wouldn't. I'd go like Belgium does they don't get paid for test sockets, you just have to make a socket like we used to. And that's way more important to me and that's what I would do is just learn to scan, have somebody else make your sockets for you for a while before you make that investment, because it gets really complicated and you can buy a junk machine for very not much money or you can spend thousands of dollars.
Speaker 3So it's really not. I don't know how. I mean there's not a good way to do. If you try to it looks like to me if you try to bite it all off and do your own fabrication, you're just setting yourself up for failure. If you learn how to scan, get somebody to somebody building sockets for you, like Brent Wright, then you can move quickly. And if you want to get your own stuff, then you have an investment. You know it's just not going to sit there and draw dust or break down. You don't know what to do with it. You know it'd be just frustrating.
Speaker 1On the scanning side if you're able to share. So you know, I know that previously when we were scanning, we would do or when we were casting we do, a high tension fiberglass cast and I still do it that way and I scan the inside of that cast and I still do it that way and I scan the inside of that cast. When you're talking direct scanning, um are how like, where do you see that that going? Because I do think the high tension is important, but I know that there's probably ways to predict that right.
Speaker 3Well, I'll just use myself and Matt as an example. Congenital limbs are a different deal. It's way different than a normal human anatomy that's been amputated. There's two categories there. And those congenitals like with me, it was really simple. Like with me, it was really simple. And I just I bought some black socks, kind of lycra socks, and pulled that up over my limb.
Speaker 3We scanned it really in a signs, you don't have to modify it. There was really no modification. And then what we did? I didn't even try it on, I just filled it with plaster, got a plaster model, put a Kesey cone on it and laminated the socket and that was done. I didn't touch it. So that's just the difference. I mean, if I had taken a mold, like I normally do, that would have created. Now fill a mold with plaster and modify that. Now you're really into the guesswork area of prosthetics and to me, scanning takes the guesswork out, but you can screw yourself up. If you're trying to modify a socket like a PDD off of a scan, you are in big trouble, your patient's in big trouble.
Speaker 1I think that's interesting and going direct is definitely. I see that happening and I think it really just matters. And it goes back to the surgery. Right, if you have a poor surgery and say they have a lot of tissue at the end or something, and you've got them holding their leg out and you're scanning and that tissue is kind of falling, and then you're, then you're making guesswork digitally, so it's, it's how do you get that limb? And it's similar to what we've said all along with our CR method is, how do you get that limb into a position where you can cast it so it looks like it's supposed to when you're weight bearing? And I think that's going to be the trick as we go to direct scanning.
Speaker 3Yeah, I think your method and we don't do it, we're still trying to direct, scan and move forward, and that's really hard. I totally all in and have an internal scan and taking a fiberglass mold for a BK. It puts you hands-on to the patient, which in Europe and in Asia, hands-on is a big deal. I mean they really talk about when they see a patient in the hospital. They touch them. They're not just talking to them or looking at their computer while they talk to them, they actually touch the patient and that's a big connection. Touch the patient and that's a a big connection and that's um you, you can't do that with a scan because you can't touch them.
Speaker 3Yeah, so that, yeah, I mean I think the scan for a bk is is really important, um, and and then you, you're closer to what your shape wants to be. Then you can scan the inside of that mold and you're really close. You may not be perfect, but you're closer to what your shape wants to be. Then you can scan the inside of that mold and you're really close. You may not be perfect, but you're really close, without having to put a patellar bar in um, keeping that white AP, a natural shape and full extension. That's just simple. It's just simple.
Speaker 1You. You would appreciate this, dale. So a friend of mine, uh, I've known him for a long time. I said you really should just check out the the course online. And uh, and he's been in the field a little while and, um, it's probably a couple months after that he goes. Man, I watched that course and I did it with a patient. That's always been a very difficult patient for me and the patient got up and could not believe that he didn't have any pain and I was like isn't it great?
Speaker 1Like it's, just it's a recipe, like it's, and it just makes sense. And I'll never forget, like when I went to go modify the socket, when we were doing that short course, and you would always say do not touch it, you're going to screw it up. And so it's like you don't touch it and you're really, really close and I love that about it. Our listeners, just to give a little bit of description of what we're talking about, and you have the opportunity to go to Coyote Prosthetics and they have a continuing ed course. The socket is called the StableFlex course, but the overarching idea is you want to take a high tension fiber this for trans-tibial patients a high tension fiberglass cast.
Speaker 1And when I say high tension, it is. You go to, you hear the fiberglass ripping and you back off a little bit and then, uh, the, but you, what you do not want to do is wrap super tight around the cut end of the tibia and fibula. Uh, just so, most of your tension is just right above the cut end of the tibia and fibula and you get full contact on the distal end. But you've now created a relief and you've ensured contact on the tibia and I think the other part that I think is really important. That Dale has always said it's total contact on equal pressure. So it's okay to put pressure in the pressure tolerant areas, uh, but you want to continue with total contact, um, and you might have some small reliefs, but it's not a relief in the traditional sense where you're putting this massive relief for an area because you're controlling the whole volume, and so I really think that that's made a big difference for our practice for sure.
Speaker 3Yeah, it's really just simple. The more education you have and the older you are in prosthetics, the harder it is to shift to switch to do something. Shift to switch to do something. But I really think the education process in prosthetics is really pretty poor right now. When we had just three schools and they were dedicated to prosthetics, that was one thing and they had the short-term courses and then the long-term courses. But now to have a BA degree or BS degree, whatever you know, it's just taken too long to get to that end run. Now you've got a guy that's got debt and he needs a salary, and so it's really. It really didn't improve us as a profession. Let me put it that way. I don't think. But that's I mean.
Speaker 3And prosthetics is a minuscule expense in the world of third-party payers. Compared to everything else, it is peanuts. Not even a full bag, it's just peanuts. But what really makes it? It could be even less if you didn't have patients going from one practitioner to the next, to the next, to the next. Most revisions are done for that reason. They're unhappy with where they're at they have. And the trouble in prosthetics is we should have, we should legislate, that they are totally covered, so becoming an amputee doesn't make you wealthy, and that 20% is a big deal and then you can play the game and they don't have to pay, but then you have to write it off after they become a bad debt.
Speaker 1And then you've got to talk to your banker and the banker's like what's going on here, and then they get upset at the insurance companies. It's just like this annual event owning an O&P clinic.
Speaker 3It is. It owns you after a while.
Speaker 2So thank you so much for being on this episode. Dale, Thank you so much for your insight and everything. This was absolutely wonderful, Thank you.
Speaker 3You bet Nice meeting you.
Speaker 2All right, thank you so much, and, brent, I know you enjoyed this.
Speaker 1Oh, this was great and just hearing a little bit more of the history and the why behind it and I know our listeners are going to get a lot out of this.
Speaker 2Awesome and well. I hope you guys enjoyed listening to another episode of the Prosthetics and Orthotics Podcast with Brent Wright. Yours, peebles, and you have a great day.
Speaker 1Hey, and that wraps up the 100th episode of the Prosthetics and Orthotics Podcast. A big thank you to Dale Perkins for sharing his expertise and insights today. If you enjoyed today's episode, make sure you hit the subscribe button so you never miss out on future episodes. Thank you for listening and we'll catch you on the next time on the Prosthetics and Orthotics podcast.
