B-0 The rehabilitation process
The process of rehabilitation is covered in detail on this site. The original syllabus for the Rehabilitation Medicine curriculum had four competencies, but as I wrote this section, I realised that the original “assessment competency” was faulty; it had to be split into two, and I have reported my epiphany. Thus, five competencies relating to this process are included in this section (B) syllabus, and this page explains why and how they were chosen. The competencies highlight some vital differences between the traditional biomedical approach to diagnosis and treatment and the rehabilitation approach. They make the differences explicit through the recommended behaviours, knowledge, and skills, which are given in detail within the syllabus.
Table of Contents
Rehabilitation process analogies.
All healthcare can be considered a problem-solving process, which will have similar steps or stages, whether the focus is on a genetic alteration affecting movement control, management of persistent distressing anxiety, or helping someone whose leg has been amputated return to employment. The differences arise from the service’s focus of attention. Some specialise in diagnostic imaging of the body, some in diagnosing structural or physiological abnormalities, some in treatments, etc. Rehabilitation focuses on disability.
I have discussed the healthcare problem-solving process in detail before. Below I summarise the contrast between rehabilitation and acute biomedical services. Of course, professionals in most healthcare services take a broader view, but the service may not.
Clinical clerking: taking a history, undertaking an examination.
Diagnosis: identifying the disease and possible alternatives.
Management plan. Setting out immediate care and treatment, and details of further data needed.
Assessment: taking a history including function and context, observing and examination.
Formulation. Identifying how the problem arises by reference to disease, impairment and context
Rehabilitation plan. Setting out long-term, social goals and intermediate steps.
Both involve collecting information to allow a sufficient formulation and initial plan.
Both are a summary of the situation, now focused on disease, the other disability.
Both set out what is needed next, with rehabilitation’s plan generally being much more focussed on the long-term and high-level goals.
Reasons for the differences.
The specific differences arise from four inter-related features of rehabilitation:
- Its use of the biopsychosocial model of illness, which leads to:
- Its holistic nature, taking all factors into account rather than only the disease and factors directly relating to the condition, which leads to:
- a need to use all evidence to create a formulation; and
- a much greater dependence on multidisciplinary teamwork, more accurately defined as multi-professional)
The syllabus’s process competencies reflect the use of the biopsychosocial model and the three phases of the process shown above.
These competencies are used in all rehabilitation, regardless of any specialisation in a particular group of disorders or type of treatment. Consequently, every rehabilitation expert should have good knowledge and skills, as demonstrated by their behaviours.
When writing the syllabus, we chose four competencies from the process. These do not cover the process comprehensively, and the knowledge and skills given as examples only cover some things that can be known. I have emphasised the importance of an interest in matters outside any formal syllabus, such as humanities and wisdom. These characteristics can be learned and improved and usually develop with experience.
The four competencies are shown below. There is a brief overview, and (over time) each will be linked to the appropriate page giving more information.
Using the biopsychosocial model.
A good understanding of the biopsychosocial model is essential. It underlies all effective rehabilitation. The competency includes using it in all clinical contexts and in other contexts such as service management, quality improvement and research. The model is discussed extensively on this site, and I have written a detailed article about it.
Clinical assessment of the patient.
This activity requires a systematic approach, just as traditional medical diagnostic training does; the difference is in the structure of the systematic approach, which is based on the biopsychosocial model’s domains. The rehabilitation doctor also needs to retain good biomedical diagnostic skills acquired during their earlier training. The competency page discusses using a narrative medicine approach to obtain the patient’s perspective and the Oxford Case Complexity Assessment Measure as an aide memoire.
Complete formulation of the patient’s situation.
I think this is, perhaps, the crucial competence, and it is a skill that distinguishes rehabilitation professionals from their colleagues who practice within a biomedical culture. It requires thinking about and analysing the whole range of matters influencing the patient’s management. Coupled with that skill, a suitable formulation requires the skill to summarise, communicate complex issues clearly, and document the reasoning.
Person-centred rehabilitation planning.
This, too, is an activity that has been discussed extensively on this site. It requires the professional to put their interests and areas of expertise into perspective, not assuming that what you or your service can do is necessarily the best or even the correct thing to offer. Nonetheless, you have a responsibility not only to identify what else is needed but to facilitate the person’s access to it.
Has our intervention helped you? This competency discusses judging whether therapy or other activities are beneficial and whether significant harm is occurring. It stresses the need to avoid measuring outcomes that can be measured, instead evaluating your effect on outcomes the person considers valuable. It also cautions against over-evaluating, suggesting you should target evaluation on interventions that carry greater risk or need significantly more resources than usual.