“I am a doctor. Why should I specialise in rehabilitation medicine?”
In the UK, medical students and doctors in their first two foundation years are rarely involved in or taught about rehabilitation, even though it is occurring around them. They will know about the multi-disciplinary team and may attend a ward team meeting. However, many ward team meetings are managing short-term coordination issues. They are rarely patient-centred rehabilitation meetings, and discharge from the hospital is the most pressing issue, asking if the patient is “ready for discharge”? Consequently, many doctors have no idea about rehabilitation, no understanding of the vital role doctors play, and no appreciation of the life-long satisfaction and interest that working in rehabilitation offers doctors.
Table of Contents
Background
This page is entirely personal, based on my own experiences and perspectives. I want to convince you that it offers endless possibilities and that you will never feel bored. There are new daily challenges, and it is rare to be faced with the same problem twice. After 41 years, I am still learning, and I am only too aware that there is more about rehabilitation that I do not know than I do know. Rehabilitation has taken over my life! (Why else would I start this website at the age of 72 years?)
Like most doctors, I entered medicine with a commitment to helping patients. Once I was interviewed for a job in Boston (US) by a famous American neurologist, who asked, “And what are your research interests?“. Rather primly and embarrassingly, I said, “Oh, I am only interested in helping patients, not doing research.” To which he replied kindly, “Yes, that is an excellent ambition, but I think you’ll find that you will get bored of it after a while!” I did not get the job, I did do research, but I have never become bored by clinical work.
Once you have started, rehabilitation will likely remain an exciting area of work for your professional life. Why does it stay interesting?
Why choose Rehabilitation Medicine?
One could argue that rehabilitation is ‘hidden in plain sight’; weak and incomplete rehabilitation occurs throughout healthcare. Patients are mobilised after operations, go home to convalesce, attend therapy sessions, are seen at home by specialist nurses, and have many other services to support their recovery from or adaptation to an illness. Many small specialist services exist in any health district providing some aspect of rehabilitation but not as part of an overall rehabilitation team; the problem is the lack of coherent rehabilitation services.
Many doctors support individual therapists or services when asked, giving information about the diagnosis and medical treatments. They will discuss and initiate symptomatic treatments such as drugs to control bladder urgency or spasms. This contact does not give the doctor any insight into the proper role of a rehabilitation medicine specialist.
Many myths about rehabilitation and the role of doctors circulate, most being unflattering. For example, people assume there is no evidence for the effectiveness of rehabilitation, that rehabilitation is run by therapists alone, that the doctor coordinates and leads the team, or that organising team meetings is the only role of doctors. Another common assumption is that there is no opportunity for exciting research or academic activity.
Patient-centred, holistic medicine
Many doctors choose medicine wanting and expecting their practice to be patient-centred and holistic. They were interested in the patient with their fears, hopes, interests and ambitions and as a person with their family, friends, and roles in life. Their first ten years in education and training primarily concern parts of the person, their anatomy, physiology, disease, etc., so the person is lost.
Rehabilitation is perhaps the speciality that takes a holistic view of the patient. Of course, many individual doctors take a holistic perspective, and in some specialities, such as psychiatry and palliative medicine, a holistic approach is expected. Nevertheless, doctors practising rehabilitation must be holistic because it is based on the biopsychosocial theory of illness. This requires the doctor (and all other team members) to consider every aspect of a patient’s situation. It is person-centred.
Rehabilitation allows doctors to regain their interest in patients as people living in a complex society with many interests and aspirations. This facet of rehabilitation is discussed extensively on this site, for example, here.
Rehabilitation focuses on disability, and disability refers to (functional) activities that are altered or limited or even no longer possible as part of a patient’s illness. Activities are goal-directed behaviours which immediately require you to consider and explore a patient’s goals. It also requires you to view a patient’s context – what is happening in their life, physical environment, and so on?
Medical Expertise
Many doctors fear not using or developing their clinical skills. Your medical knowledge and skills are used extensively. Your diagnostic skills are vital for three reasons.
Patients arrive with a diagnosis, but this is often incorrect, and you need to be alert to this. Sometimes it is a relatively minor detail that is incorrect, which may still be significant. Not infrequently, either the presented diagnosis is wrong, or another additional diagnosis has been overlooked, but it is a major contributing factor.
Patients also develop new symptoms, and you need to be alert to the development of new diseases or complications of a known condition. The challenge arises because the patient will already have many symptoms and signs. Many patients may have difficulty communicating. You need to know how to make a diagnosis in a person who already has one or more significant conditions and who often have difficulty communicating. You must judge when to reassure and when to investigate.
Third, other team members bring up or mention in passing clinical observations they have made or report what a patient has said. You need to be alert to these comments, knowing when you should look further and when you can re-assure. For example, in a meeting to discuss all outpatients being seen, someone may say that a patient had “a funny turn”; you must decide whether you need to see the patient or whether this is likely to be innocent.
You will see many rare diseases or unusual signs often not seen by others. This is because rare diseases are often disabling, and patients are referred for rehabilitation – and continue to be seen in rehabilitation services for many years. Doctors coming up for examinations, such as the PACES examination, find neurological rehabilitation clinics and wards invaluable as a source of unusual clinical signs or diseases.
You will use other aspects of your knowledge and skills to support the team. You are the only person in the team with in-depth knowledge about drugs and diseases and need to educate team members about the patient’s condition. You will always need to review drugs taken critically; you will be able to give a prognosis; you will know what problems are likely, advising the team what to look for; you will know when an observation made by a team member raises concerns.
Further, even in a clinic with everyone having the same disease, the actual problems you need to consider differ from patient to patient, which is very different from clinics in most specialities.
You gain an insight into how a health condition impacts everything about a person and how the person and their circumstances influence the consequences of the health conditions. You will soon realise that the medical diagnosis is only a tiny part of a person’s malady and how and why patients with a similar disorder vary so much in how they are affected. You also become familiar with the patient’s journey through their illness, recognising that what you see is only a part of their whole life and understanding how people weave disease and illness into the narrative of their life.
This engagement with the patient also reminds you of the consequences of medical decisions, actions, and diagnoses and how extensive your responsibility is. You inevitably face complex legal and ethical issues where you must use your medical knowledge and analytic skills to make sound decisions.
There are many other fascinating and challenging aspects:
- the opportunities for research are endless and range from fundamental neuroscience to epidemiology and health services research;
- legal and ethical problems are common, and involvement in practical discussions about law and ethics concerning your patient makes you think – and learn;
- if you are or become interested in NHS management, developing services etc., your skills give you a head-start over others;
- and, if money interests you, offering opinions on ‘condition and prognosis’ in personal injury claims provides an income combined with fascinating ethical, legal, and clinical questions.
I have summarised the many roles of a doctor in the rehabilitation team. I have also discussed what a doctor adds to the rehabilitation team.
The speciality
In the UK, the official General Medical Council name for the speciality of doctors in rehabilitation is, unsurprisingly, Rehabilitation Medicine. The name indicates that the doctor has two areas of expertise:
- professionally in medicine, and
- clinically in rehabilitation.
Similar titles are used in other specialities: Palliative Medicine, Respiratory Medicine, Medical Ophthalmology etc.
Internationally the commonest name for the speciality is “Physical Medicine and Rehabilitation”, with Rehabilitation Medicine being the second most common name, followed by “Physical and Rehabilitation Medicine”. The term, physical, reflects the historical development of the speciality, which started with electrical treatments and exercise. Exercise is still a key component of almost all rehabilitation, but electricity is not.
You can discover more about the speciality from other online resources, some of which were outdated when I published this in November 2022. They are:
- Rehab Roundup, a series of podcasts discussing aspects of rehabilitation with experienced consultants;
- The British Society of Physical and Rehabilitation Medicine website has a large section on training.
- The Joint Royal Colleges of Physicians Training Board (JRCPTB) page for Rehabilitation Medicine gives access to all official documents.
- The NHS careers website has a page covering Rehabilitation Medicine.
- The Royal College of Physicians website has a speciality spotlight that includes a video discussion by two doctors.
Who can enter training?
Rehabilitation covers all illnesses. There is no part of healthcare where patients will not need rehabilitation. Therefore, rehabilitation moved (in 2021) to welcome any doctor who has completed the basic core training in any clinical, patient-facing speciality.
Doctors who have achieved any of the following UK post-graduate qualifications may apply:
- Internal Medicine Training stage one (two years),
- ACCS-Acute/Internal Medicine (three years),
- Level 1 Paediatrics training (three years),
- Core Surgical Training (two years),
- Core Level Training in Anaesthetics (two years),
- Core Psychiatry Training (three years),
- Basic (ST1 and ST2) Obstetrics and Gynaecology training (two years),
- ST1 and ST2 of Ophthalmic Specialist Training (two years), or
- completion of a General Practice speciality training programme (three years)
Almost any doctor with core training in a patient-facing speciality is accepted into rehabilitation training. This broad range of entry routes reflects that rehabilitation is appropriate for nearly every patient with a continuing disability. Each trainee will bring essential knowledge and skills into the speciality they can continue using. This broad entry benefits the speciality by giving the speciality an extensive range of specialist knowledge. It helps patients who will benefit from the accumulated expertise within the speciality. It benefits the doctor because they will continue to use and benefit from their initial core training.
The training programme
The programme’s indicative length is four years; in principle, leaving the programme is determined by achieving the necessary outcome. In practice, some people may achieve entrustability in all 14 capabilities in less time, especially if they enter with significant relevant experience. This is usually identified at the first annual review.
Four Mind Maps 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 last one gives an overview, relating the curriculum to the syllabus.
Anyone reading this who wishes to know more should:
- look at the page discussing the 2021 curriculum, its associated guidance, the syllabus, and the training programme. (here)
- read the education and training blog (here).
- visit the website of the Specialist Society, the British Society of Physical and Rehabilitation Medicine (BSPRM); there is a section on training
- find a local rehabilitation service and contact one of the consultants to talk about the speciality and, if possible, spend a day or two with a doctor in training or a consultant.
- look at a textbook, a recent UK one being the Oxford Handbook of Rehabilitation Medicine.
- look at a journal; there are two UK-based international journals, Disability and Rehabilitation and Clinical Rehabilitation.
Conclusion
A career in rehabilitation medicine will offer you endless and varying challenges in your professional life. It is never dull or routine. The vital role of rehabilitation services has been highlighted by Long-Covid, which may if we are lucky, facilitate changes and developments in rehabilitation. Doctors are essential team members in an expert rehabilitation service and work with many other equally knowledgeable clinicians who ask challenging questions that make you think. They also give you further knowledge and skills.
