2021 Rehabilitation Curriculum
The new, significantly changed, and improved 2021 Rehabilitation Curriculum for training doctors in rehabilitation became active on August 1st 2021. This page introduces the new curriculum and its associated documents. In the UK, Rehabilitation Medicine (but not the practice of rehabilitation generally) has previously had a limited scope, reflecting its history. The 2021 curriculum is the fifth since 1997 and a dramatic and radical break from the past. It recognises and emphasises that rehabilitation expertise can and should be applied throughout all health conditions. The need for this much broader scope has been highlighted by the longer-term problems arising from Covid-19; it was also highlighted with trauma in 2010, but the change was slow. We can thank the General Medical Council for precipitating the change because they required completely new curricula for all medical (including surgical) curricula.
Table of Contents
A brief history
History is important. Rehabilitation has been practised since Roman times, returning wounded men to fighting. It entered civilian practice in the 1800s and became more prominent during and after the First World War. Its initial focus was on men with acute injuries needing to return to employment, and its initial approach was through exercise and technology, especially electricity. The success of rehabilitation transformed the lives of people with spinal cord injuries in the 1940s-1950s and those left with the effects of polio and thalidomide. Technology advancements also increased rehabilitation awareness as better prostheses, wheelchairs, and environmental control systems evolved.
In the UK, rehabilitation was first a speciality in the 1930s, termed physical medicine, but disappeared from about 1970 to 1984. At the same time, in the 1970s, the speciality of geriatrics was growing fast and took on rehabilitation for stroke and all problems associated with older people. In 1984 a new specialist society was founded (Medical Disability Society).
The General Medical Council only recognised the speciality in 1997, when the speciality of Rehabilitation Medicine was founded in the UK. It involved the amalgamation of several quite disparate groups of doctors:
- Doctors who worked in the Civil Service, not the NHS, and they were responsible for prosthetics and wheelchairs;
- consultants in spinal injury rehabilitation whom almost all worked in geographically and managerially discreet units;
- some rheumatologists who remained interested in rehabilitation, working within the acute sector of the NHS; and
- some neurologists working in the NHS who had become interested in rehabilitation.
The first curriculum was published in 1997, and a second curriculum followed in 2001. I have yet to find any copies of these first two curricula. The third curriculum was published in 2007; anyone interested can download it here. The fourth version was published in 2010, available for download here.
These curricula all reflected the historical development of rehabilitation in the UK, and the training fell into four subspecialties:
- Neurological rehabilitation
- Spinal cord injury rehabilitation
- Musculoskeletal rehabilitation
- Amputee rehabilitation
The 2010 curriculum fell into two two-year halves. The curriculum stated,
“Basic requirements include at least 12 months in Neurorehabilitation, six months in musculoskeletal medicine, three months in spinal injuries, three months in prosthetics, orthotics, special seating. The remaining 24 months are spent in a range of rehabilitation environments addressing both generic and specialist training requirements across the curriculum.“
In 2013, the recognition that rehabilitation was not available for people with problems after trauma precipitated a change in rehabilitation training. Major Trauma Centres were all required to have input from consultants in Rehabilitation Medicine with expertise in rehabilitation after trauma.
Dr John Burn and colleagues developed additional competencies for trauma rehabilitation, but the final changes to the curriculum had not reached fruition by the end of 2016. In January 2017, the General Medical Council required all curricula to change, moving from achieving multiple competencies to focusing on a few higher-level outcomes. The next four years were devoted to writing an entirely new curriculum and, more importantly, gaining agreement from the General Medical Council that it was an appropriate curriculum.
The 2021 Rehabilitation Curriculum
This requirement by the General Medical Council for a revised style of curriculum allowed the general dissatisfaction with the continued restricted scope of Rehabilitation Medicine to be resolved when designing the new curriculum.
The significant changes were:
- allowing entry into the specialist training programme of any doctor with post-graduate accredited core training in almost all clinical specialities.
- broadening the scope of training to cover all ages, all settings, all conditions (including mental health), all interventions, and all stages of an illness from onset to end-of-life care.
- Abandoning the use of competencies to measure training achievement and moving to fewer, high-level training outcomes termed capabilities.
- This was associated with the use of entrustability as the criterion for success
The training is described in three primary documents, all available on the Joint Royal Colleges Physician Training Board (JRCPTB) website here (expand ‘curriculum’ at the bottom):
- the curriculum, the definitive document
- the Rough Guide to the curriculum, which adds explanation to and clarification of the curriculum, and its implementation
- the syllabus, which guides the clinical areas that will need to be covered.
Three MindMaps summarise the training. The first shows the 14 Capabilities in Practice (high-level training outcomes) given in the curriculum that trainees will acquire. (here) The second shows the 39 competencies that are outlined in the syllabus. (here) The third, derived from the curriculum, summarises the training programme. (here)
The primary purpose of the Rough Guide is to help trainers and trainees implement the curriculum. It clarifies, where necessary, what the curriculum means. It suggests ways that the goals can be achieved. It is supposed to answer questions that arise from the curriculum. If you, as a reader, trainee, or trainer, have a question about the curriculum that the Rough Guide does not help, please email the chair of the Rehabilitation Medicine Specialist Advisory Committee at the JRCPTB.
The primary purpose of the syllabus is to illustrate the areas of clinical expertise that are likely to be needed to achieve the capabilities, especially the eight specialist Capabilities in Practice. Each area outlines the expected observable behaviours, knowledge, and skills a trainee will need to acquire. There is also a system for grading expertise.
The document stresses that the syllabus is guidance only. It was written before the new training started, so it will likely need improvement. If anyone has any questions, comments, or suggestions for improvement (adding, subtracting, changing), please email the chair of the Rehabilitation Medicine Specialist Advisory Committee at the JRCPTB.
The training programmes also needed adjustment to increase the range of experience for each trainee. This has been achieved. Over time, as the work’s nature evolves and needs become more apparent, there will no doubt be changes in training programmes – but that happens anyway.
The new curriculum came into force at an exciting and challenging time for rehabilitation. The need for expert rehabilitation services to cover an extensive range of problems has been brought into sharp focus by Covid-19. The curriculum is designed precisely to train consultants who can meet those needs. There are several challenges. The resources devoted to rehabilitation need rationalisation and need to be increased. (here) Existing consultants will need to learn how to assess and manage the new problems arising from Covid-19. Trainees will often need to help improve services and to learn with their consultant trainers. In ten years, we could have excellent and better-resourced expert rehabilitation services.