Evolution of rehabilitation expertise
What is rehabilitation expertise, and how can you know if someone has it? Indeed, how do you know that a service purporting to offer rehabilitation is specialised and capable of delivering an expert service? These are difficult questions that this page will consider, starting with the nature of expertise. The Oxford English Dictionary describes an expert as “a person who is very knowledgeable about or skilful in a particular area.” and a specialist as “a person who concentrates primarily on a particular subject or activity; a person highly skilled in a specific and restricted field”. These words are similar, though not synonymous. Clinical expertise includes knowledge, skills, experience, and wisdom.
Rehabilitation was first promoted for civilian populations in 1918. It was called physical medicine for a while, but this is only a minor part of rehabilitation. Over the last century, rehabilitation practice has evolved, especially following the development of the biopsychosocial model of illness and the output of much high-quality research over the last 50 years. The general theory of rehabilitation I recently published may lead to further developments.
Table of Contents
Introduction.
Rehabilitation emerged from the Great War, and many of its essential characteristics were immediately present, if not explicitly recognised: a multidisciplinary group of people covering different aspects of the person’s needs, the value of exercise, the need to practice functional tasks, and the crucial influence of contextual socio-economic factors.
Before 1914, some ideas and techniques, such as electrotherapy, had been used without direct evidence or justification. Immediately after the war, the focus was mainly on previously fit men of working age. Most available work required physical labour. Unsurprisingly, the emphasis was on rehabilitation’s physical (i.e., motor functional) aspects.
Doctors wanted to stress their separation from physical therapists, and the term Physical Medicine became attached to Rehabilitation. Physical Medicine is defined thus “the branch of medicine dealing with the diagnosis and treatment of disease and injury by means of physical agents, as manipulation, massage, exercise, heat, or water.” It is only a minor part of rehabilitation; doctors trained in rehabilitation have a vastly broader scope, as exemplified by the UK training curriculum. The vital roles of clinical psychology, social work, education, and vocational training were all known by 1920.
The medical speciality of Physical Medicine and Rehabilitation grew. As training developed, the medical curriculum content implicitly defined the expertise needed. Initially, no framework or theory existed to guide educators on the required expertise. Additionally, other professions increasingly participated in the rehabilitation process but did not explicitly train people in rehabilitation; the professional training gave trainees expertise unique to their profession but no training in rehabilitation.
Consequently, rehabilitation does not have any generally agreed core expertise. This page explores the development of medical rehabilitation expertise, including some key concepts that have influenced it. It then explores how this may be used to define rehabilitation expertise for team members and services.
Brief history of medical rehabilitation training.
One defining characteristic of a profession is that any member is expected to train new entrants to become accepted members. Acceptance may have been informal originally, but it became subject to formal examination in most professions. Now, validation of professional standards is often the responsibility of an external body such as the General Medical Council for doctors.
For many years, training in a profession was based entirely on apprenticeship. The trainee worked with or for qualified people. Qualification depended on the person or people agreeing that the person could become a member. Sometimes, a defined time or range of experiences was given. For example, I became an accepted rehabilitation specialist after working in many specialities at various levels of responsibility, including research; there was no curriculum, no examination, and no formal exposure to rehabilitation!
As healthcare improved, patients, employers, and professional regulators required evidence that a professional was qualified to perform their duties, and this extended to evidence of professional performance. This drive translated into formal curricula setting out the scope of a professional’s knowledge and skills, usually focusing on competence and the ability to undertake tasks.
The only profession to specify qualification in rehabilitation was medicine; physicians with a professional qualification in medicine could acquire a further qualification in rehabilitation. Starting in 1997, the UK curriculum included some generic rehabilitation competencies but was mainly concerned with definable medical tasks in a rehabilitation context.
Judging from the American Board of Physical Medicine and Rehabilitation’s examinations, Part I Certification Examination and Part II Examination Outline, the US system is based on a task or topic competency model. Each training centre has its curriculum, but certification is by these exams.
Focusing on small topics or tasks poses a vast and increasing challenge: how does one formally test and certify potentially several hundred items while allowing the trainee and trainer to deliver healthcare? In addition, many competencies learned will not be needed by the trainee in their job, and the trainee may lose competency gained early in training through lack of practice by the time of qualification.
Two further flaws with competencies are that they concern the past – the trainee was competent at the time – and they do not assess whether the trainee knows when to perform the task.
From about 2000, educationalists developed the concept of entrustability, a forward-looking approach that says someone can be entrusted to perform the task correctly, safely, and only when appropriate. This development coincided with a change to assessing high-level training outcomes, specifically the ability to perform complex activities over a longer timeframe. Third, at the same time, service commissioners and regulators recognised that specialisation was progressing too far, leading to increasing fragmentation of care; this has been explained in the Shape of Training report.
In the UK, the upshot was that medical specialist training required evidence of a small number (6-8) of high-level specialist abilities added to six generic abilities applicable to all doctors. One term used for these outcomes is Capabilities in Practice.
One incidental but crucial consequence of this revolutionary approach to training is that the specialist Capabilities in Practice define the specialist expertise associated with the speciality.
The evolution of rehabilitation expertise.
The biomedical model of illness and healthcare was the only framework when rehabilitation started. This, coupled with an emphasis on physical medicine, meant that rehabilitation was conceived of as a treatment to be prescribed. This was a long-lasting belief; rehabilitation prescription still occurred in some Swiss rehabilitation units in the 1990s, and the view that it is a treatment persists today. For example, though the UK has not prescribed rehabilitation for decades, the phrase, Rehabilitation Prescription, is still used.
The value of a group of professionals was accepted in 1920, but the concept of a multidisciplinary team only emerged in the 1950s; the earliest reference I found was in 1952, with another in 1959 and another in 1961. The term was used for primary healthcare services in 1927. The concept of a multi-professional team is now central to rehabilitation.
Goal setting was the second conceptual advance. Edwin Locke and Gary Latham summarised the history of goal setting in general. Goal setting was part of typical rehabilitation practice in some centres by 1968; it was mentioned in the description of a cohort study. It was probably being used in 1955 – see here.
The need for a holistic approach was recognised in 1920, though the concept of holism only arrived in 1927. A sound conceptual framework only came in 1977 when George Engel published The need for a new medical model: a challenge for biomedicine, introducing the biopsychosocial model of illness building on work by others, including Saad Nagi.
This model was adopted immediately, for example, by the World Health Organisation in its International Classification of Impairments, Disabilities, and Handicaps in 1980. The biopsychosocial model has been extended and is now the only framework used in rehabilitation.
During the 1990s, people started to recognise the need to analyse and understand systems and complexity in healthcare, both when considering patients due to the frequency of multimorbidity and when considering service. Trishia Greenhalgh and Chrysanthi Papoutsi consider the impact on healthcare research to be limited. Still, complexity measures in rehabilitation have been developed: the Oxford Case Complexity Assessment Measure and the Rehabilitation Complexity Scale.
The most recent conceptual advance is the General Theory of Rehabilitation, which I published in October 2023. Time alone will tell whether it is an advance or a dead-end! This is an overarching theory or rehabilitation based on the following:
- The biopsychosocial model of illness (1977)
- The process of adaptation
- Homeostasis (1926) and an assumed General Homeostatic Network (2016)
- Maslow’s five domains of human motivational need (1942)
Evidence of expertise.
The UK medical training curriculum identified eight high-level capabilities associated with rehabilitation. There were six associated generic capabilities that all independent medical practitioners were expected to have. I have revised these slightly to give seven specialist and seven generic capabilities. These capabilities can apply to all professions because the practice of rehabilitation is added to an existing professional expert practice, and the capabilities are written to reflect different areas of professional expertise.
The evidence is mainly derived from observed behaviours in clinical practice; additionally, the knowledge and skills associated with the capability are given. This method enables a better assessment of a person’s ability when working. However, it depends upon an effective educational system with clinicians who can provide fair reports and constructive comments. In some medical specialities, there is also an examination which allows a more detailed assessment of knowledge. However, it also requires considerable resources and knowledge, which does not necessarily translate into effective clinical performance.
The seven specialist capabilities are given below; each has a link to a more detailed description on another page. The behaviours were developed for doctors training as UK consultants (senior doctors) in Rehabilitation Medicine.
Biopsychosocial model
Able to use the biopsychosocial model of illness in all areas of practice.
Understanding and using this model in all situations is crucial to effective rehabilitation. This means using the framework, terminology, and concepts. It means using it not only in every aspect of clinical work (e.g. letters, reports, forms, etc.) but also in research, service design and management, and when talking to any non-specialist. The behaviours will demonstrate its use and familiarity with it.
Multiprofessional team
Work as a complete and equal member of any multi-professional team.
This is also crucial; no member should believe they are more or less important than any other member, and all members must be able to contribute what they can to team activities. This also applies broadly to clinical work, team management, and education. Trainees and newly appointed people will have less to contribute initially, but their value as team members is equal.
Rehabilitation plan
Develop, with others, a rehabilitation plan.
Although the details of every plan can only be developed by all professions involved, every team member should be able to set out an outline demonstrating they appreciate and understand the need for long-term, person-centred goals and the need to take a holistic approach based on Maslow’s five areas of human motivating need or a similar framework. This requires some understanding of other professions.
Across boundaries
Work across organisational, geographic, and temporal boundaries, collaborating with other professionals and teams.
The general theory of rehabilitation shows that rehabilitation necessarily involves many teams from many organisations as part of a local rehabilitation network. The patient must have a seamless service with no break imposed by any boundary, including those based on time. Continuity of care over time is essential. This requires team members to work in different settings, with other professions, often based in non-healthcare organisations.
Complexity and uncertainty
Recognise, accept, and manage uncertainty and complexity, with a long-term commitment to the patient if needed.
Rehabilitation is a complex service working within a complex model of illness. Uncertainty is an inevitable feature of rehabilitation. Anyone working in rehabilitation must acknowledge and accept uncertainty, including sharing the knowledge with the patients and any professionals unused to doubt. Some patients are likely to need expert rehabilitation on and off over their lives, and it is most appropriate, when possible, for the same person to be involved with the patient if available.
Team approach
Support the team’s approach to a patient’s situation, including information, terminology, and rehabilitation interventions.
Consistency is vital; patients and relatives can be confused if they receive different information from various team members, and, at times, they may use the differences when talking to other team members.
Professional expertise
Use profession-specific expertise to help the patient and assist team processes.
This is the only capability that is directed at the profession. Each professional will have expertise associated with their profession, and they must use that expertise not only with individual patients but also in other team activities such as developing policies, education, and research.
Two adaptations of this scheme will be necessary. First, the behaviours, knowledge, and skills may need refining; they could be better for doctors. Second, the performance level required for different grades may need adjustment. In practice, many specialist practitioners in all professions are incapable of fully independent practice; they do not need to be in their jobs and may not wish to be.
Based on seven rehabilitation-specific high-level characteristics, this framework can be further adapted to apply to services. I hope this will be published in due course (by April 2024).
Conclusion.
High-level rehabilitation-specific abilities can be used to define rehabilitation expertise. They are only utilised formally for doctors (physicians) specialising in Rehabilitation Medicine in the UK. They encompass many lower-level competencies which do not need to be assessed individually; they can be evaluated from observation of behaviours seen during daily clinical practice; they can be used with all professions with only minor adaptations; and they can be graded to indicate different levels of expertise. Moreover, they could be adapted to define service expertise.
