Rehabilitation is unusual. Most areas of specialist practice in healthcare are based on disease and organ systems, physiological functions such as speech and language, cognitive function, or motor control, or specific interventions such as imaging or operating or providing equipment. The critical feature of specialisation in all these areas is that the person has focussed on a small part of a greater whole. This leads to more significant expertise in one matter but at the cost of losing contact with the whole person or process.
Rehabilitation, in contrast, is primarily concerned with considering the patient as a person with a unique background and context and seeing the process of rehabilitation as encompassing care from the outset to the long term, across all boundaries and involving all services. Above all others, the skill needed in rehabilitation is to be able “to see the whole picture”. This includes recognising that, for the person, the time in rehabilitation is a minor blip in their life and always considering many years ahead.
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Context – specialisation.
Education and training (education after graduation, as part of work) generally consist of learning more and more about less and less. The process of specialisation has occurred throughout human history. Soldiers fight on land, sailors fight at sea, potters make pottery, and storytellers tell stories. Most early specialisation was in developing a skill, but gradually, specialisation in areas of academic knowledge emerged, such as anatomy or mechanics.
Specialisation spread to processes, and Henry Ford’s production line is a good example where a worker or a machine undertook only a tiny part of the process. This spread to healthcare, too, with, for example, departments undertaking haematological investigations and departments taking X-rays that doctors would interpret. This specialisation reached its peak towards the end of the twentieth century.
In the 1950s, two healthcare specialities began to emerge that did not focus on disease. Geriatrics emerged as a speciality that managed people with multimorbidity associated with age – patients with several or many diseases and often on many drugs. Rehabilitation emerged as a speciality that managed the consequences of the disease, initially focused on the effects of single conditions such as stroke, phocomelia after thalidomide, polio, or rheumatoid arthritis.
Nevertheless, hyper-specialisation continued despite increasing awareness that most admitted patients needed input from several specialist teams and often had poor-quality care. As geriatricians took on more acute care, only general practitioners (family doctors) remained to consider the patient as a person. And in this century, the demands on general practitioners have led to some loss of the long-term relationship between a doctor and a patient.
Context – culture.
Culture refers to “the ideas, customs, and social behaviour of a particular people or society” and is a concept appropriately applied to healthcare. Anyone working in healthcare will rapidly learn that it has a different view of the world from people working in almost any other job. One specific part of that culture is the understanding of illness.
The biomedical model of illness is the culturally dominant model of illness in most developed countries and especially in most healthcare settings. Specialisation based on disease within healthcare is, therefore, unsurprising. The model also supports the idea of specialisation because it is based on a reasonably mechanistic view of illness; the person has a disease that causes symptoms that cause disability, so focusing on the condition seems correct. The model also engenders certainty.
Rehabilitation is not a sufficiently large area of practice to have developed a separate culture, and most practitioners were brought up and educated in a biomedical culture. Though much of the rehabilitation philosophy will coincide with the healthcare culture, such as concern about the patient’s well-being, there are some crucial differences.
Rehabilitation accepts uncertainty. The biopsychosocial model is inherently complex, with many non-linear relationships between different factors, and every element will be affected by and will, in turn, affect many other factors. This complexity enables rehabilitation to succeed because if one aspect cannot be altered, it is pretty likely that something else can be changed to benefit the person.
Rehabilitation recognises that the manifestation of an illness and its course will be influenced by many things, with the disease often playing only a tiny part. As with uncertainty, rehabilitation offers hope, whereas the biomedical model often does not.
Third, rehabilitation acknowledges that the patient has a significant past and a long future and that the healthcare episode must be placed in that context. In particular, the outcome may only arise after a few years.
These three features lead to a significant culture clash between rehabilitation and most acute medical care. Medical care aims for certainty, is focused on a single factor (disease) and is short-term. In contrast, rehabilitation expects uncertainty, expects multifactorial complexity and considers the long-term.
The significant consequence of this cultural difference is that rehabilitation professionals must reverse their cultural perspective as they move from their initial biomedical training into a rehabilitation context. They must embrace the need to have a broad and long view of the patient’s problems, adapt to the uncertainty associated with their work, and lose their attachment to disease.
Although they did not phrase it as I have, the General Medical Council’s review of medical specialisation and training in 2013 – the Shape of Training – came to a similar conclusion.
The General Medical Council also recognised that doctors need far more than simple competence in various medical activities; with others, they developed a Generic Professional Capabilities Framework. They noted that there were 66 medical specialities and 32 sub-specialities with “significant variability of core professional content across many of these postgraduate curricula.” The following paragraph states:
“Our fitness to practise data shows that most concerns about doctors’ performance fall into one or more of the nine domains identified in this Generic professional capabilities framework. And several high-profile patient safety inquiries have identified major deficits in these basic areas of professional practice. Reports from these inquiries recommend the importance of and need for specific training to address individual, team and organisational deficiencies, as well as addressing wider systemic failures.”
The Generic Professional Capabilities framework covers:
three areas concerned with professional matters:
- values and behaviours
- communication and interpersonal
- dealing with complexity and uncertainty
- professional requirements
- national legislative requirements
- the health service
six areas labelled capabilities that cover:
- Health promotion and illness prevention
- Leadership and team working
- Patient safety and quality improvement
- Patient safety
- Quality improvement
- Safeguarding vulnerable adults
- Education and training
- Research and scholarship
In other words, in medical training, at least, there is as much attention paid to general professional and personal skills that are crucial for effective teamwork, supporting and training colleagues, and functioning within a complex healthcare system as there is to purely professional clinical skills.
This focus is of greater importance in rehabilitation, which depends on teamwork among many different professions and organisations; many medical interdisciplinary teams involve doctors and nurses from other specialities but rarely depend upon a team with perhaps five completely different professions.
Consequently, training in rehabilitation needs to recognise the central importance of general professional capabilities.
Some years back, a doctor coming to the end of their training in rehabilitation said to me that they wanted to go on a course to learn some specific skill, such as injecting using ultrasound guidance and when I asked why they said: “But when I go to a multidisciplinary team meeting, I need something special I can contribute”.
I was shocked that he had not been given any idea about the special skills needed by anyone specialising in rehabilitation. I was sad that he thought the only way to demonstrate this was to acquire competency in a procedure.
As they specialise, most professionals learn more within the same framework they are trained in. Almost all professions train within the biomedical framework (described here), the culturally dominant model of illness used by nearly everyone in most economically advanced countries. The model is based on a scientific, reductionist approach to illness, which focuses on identifying a single specific cause for the illness and giving a specific curative treatment.
Rehabilitation is set in a different framework, the biopsychosocial model of illness. This model is not widely known and is quite different from the biomedical model, which almost everyone always uses. Consequently, rehabilitation training must start by inculcating a different analytic approach. There are no single causes or treatments but many relevant influencing factors with non-linear relationships and many possible actions. Some other medical specialities also need to install a different view of illness. Psychiatry and general practice are two prominent examples.
Only doctors have a specific curriculum for training in rehabilitation as an area of specialist knowledge and skills. Completing training over four years allows them to be on the General Medical Council (GMC) specialist medical register. The GMC determines the structure and the standard of all medical curricula. It has recently moved to require “higher level outcomes” from training, in contrast to previous medical curricula and most other curricula, which focus on acquiring many competencies. The curriculum focuses on training rehabilitation knowledge and skills, which can be applied to any patient with any condition at any stage of their illness or life, wherever the patient is.
Focusing on rehabilitation training causes some doctors to be concerned until they understand the nature of their expertise. There should be a distinction between a person’s professional knowledge and skills and their team or service knowledge and skills. In this analysis, one would expect the doctor to develop and maintain their professional aspects to meet the requirements imposed by the medical aspects of their clinical work. This would apply to any other profession. They need to build expertise in team activity and rehabilitation and use their specialist medical knowledge and skills within the rehabilitation context.
For example, a nurse specialised in oncology would be expected to have (a) good professional knowledge and skills relevant to oncology and (b) specialist knowledge about oncology over and above and outside the scope of any professional nursing expertise. At present only doctors are expected to have universal professional knowledge and skills with demonstrable additional expertise in a speciality.
Given the importance of rehabilitation teamwork, it seems essential for all professions involved in rehabilitation teams to acquire special knowledge and skills about rehabilitation to complement and extend their professional knowledge and skills. Some core capabilities (high-level outcomes) that could characterise someone specialised in rehabilitation from any profession (including managers) have been published.
The detailed pages in this section of the website cover a variety of training and educational matters relevant to any profession (and even patients and their families?). Because doctors are the only professionals who must undertake specialist training in rehabilitation to be recognised as specialists, it will have more about medical training. Nevertheless, I hope an increasing amount of its content will be relevant to all professions.
On this page, I have given an academic presentation about training in rehabilitation with a significant focus on medical training. I hope it will provide doctors considering rehabilitation training insight into the nature of the training programme. In contrast to most specialist medical training, which extends one area of medical expertise the doctor already has, training in rehabilitation gives a doctor an entirely new way of looking at health and illness. You will also learn how to use all your medical diagnostic and treatment expertise in a patient-centred manner. You have expertise greatly appreciated by patients, doctors, and other health and social care professionals.