Doctors in rehabilitation – 1
“But what do doctors do in rehabilitation? “I have been asked this question since I became interested in rehabilitation. Many healthcare professionals, including managers, worryingly state, “We don’t need doctors in our rehabilitation service.” When asked to justify this, the usual reply is, “Well, we can always ask their GP or consultant if we need to know anything.” Surprisingly, quite a few doctors in rehabilitation find it difficult to explain or articulate their specific role. This blog post will justify why a doctor is as essential as any other member of the multi-professional team, no more necessary and no less necessary. I explain the crucial expertise that a doctor trained in rehabilitation brings to the team. I will not be advocating the position advocated by the White Book on Physical Medicine and Rehabilitation (chapter three) that doctors “… work leading the multi-professional rehabilitation team …” because leadership is not exclusively a medical skill, and team leadership must be earned and agreed upon, not an expectation or right for any person or profession. There will, I hope, be similar posts from other occupations and even other doctors with different points of view. You should contact me if you want to put forward your ideas for your profession.
Table of Contents
The pre-eminent key feature needed for success in rehabilitation is a multi-professional team. The membership of the team depends on the expected caseload. The available expertise should be able to manage about 80% of a patient’s needs from within the group; every team will inevitably work with others within a rehabilitation network. Given the holistic nature of rehabilitation, encompassing all aspects of a person, most units will require a wide range of experts.
Identifying the specific contribution of individual professions is challenging because team members acquire expertise from other members; there is a shared body of knowledge and skills. As an example, consider a large hospital. The chief executive or finance director may be on holiday or sick for several weeks without the organisation failing. Yet, no one would suggest that a chief executive or finance director is unnecessary.
People question the requirement for medical expertise for several reasons. Many doctors do not understand or value rehabilitation, and when discussing services, for example, a medical director within an organisation will not support the need for medical input.
Conversely, many therapists experience a lack of respect by doctors or doctors feeling that they should prescribe (control) what other professions do. For example, the White Book on Physical Medicine and Rehabilitation (chapter six) says, “Thus, PRM physicians prescribe and propose different practice treatment schedules to get around the inadequacies of simple repetition of movement. “[PRM = Physical Medicine and Rehabilitation; one of many names given to doctors specialised in rehabilitation.]
I will discuss a doctor’s possible roles within a rehabilitation team. Some will depend entirely on their medical knowledge and skills, but other factors will determine many. On other pages, I have discussed some aspects of this topic, such as:
Doctors working in rehabilitation.
Many doctors are involved in rehabilitation to a greater or lesser extent.
Many hospital doctors have patients who are disabled, and they support the ward therapy team by giving medical advice to the team, attending team meetings, and, occasionally, case conferences. Many general practitioners will support the therapists by seeing their patients similarly. These doctors are supportive but not committed: the doctor provides information and advice but has no fixed role within a rehabilitation team and has limited rehabilitation expertise.
Some doctors are not necessarily trained in rehabilitation but take a much more significant and committed role. For example, many geriatricians will inevitably have a continuing close involvement with a therapy rehabilitation team; some stroke physicians will; a few psychiatrists specialise in psychiatric rehabilitation; paediatricians, especially those in the community, will often be committed to rehabilitation; and in other specialities (e.g. neurology) some doctors provide consistent, dedicated expert support to their team.
Doctors in several specialities are required to gain experience and expertise in rehabilitation, for example, elderly care medicine, paediatrics, psychiatry, and stroke medicine. The total numbers are unknown, but they are probably relatively high, especially in the UK, where they likely outnumber accredited rehabilitation doctors.
On the other hand, there are also doctors whose interest and support are small. They provide information on request but do not become proactively involved and rarely participate in discussions and meetings about a patient’s rehabilitation.
Last, some doctors are trained in rehabilitation formally (I never had any training, as it did not exist), and others are heavily involved in rehabilitation and have just as much expertise and experience in rehabilitation but whose title does not include the word rehabilitation.
Therefore, in their relationship to rehabilitation, doctors, in general, fall into one of four classes: those
- with expertise and who are engaged with a rehabilitation team actively
- who provide positive support but have no strong relationship with the team
- who provide information on request but are not positively supportive,
- who do not engage at all, even if approached.
The rest of this post concerns what doctors with expertise in rehabilitation contribute to a team that other team members could not or would be unlikely to contribute. To set this in context, I have shown the general roles of doctors within rehabilitation teams and services in this graphic. [A pdf version can be downloaded here.] The MindMap includes many functions that doctors generally take on or perform. It does not emphasise the unique aspects of a doctor’s input to a team; I will now consider some.
Doctors have a substantial body of specialist medical knowledge that other team members are unlikely to have. Possessing special knowledge is one of the defining characteristics of a profession. It is, of course, entirely possible for someone from another discipline (or from no profession) to have some of the knowledge. For example, a patient with a rare disorder will often know more about the condition than the doctor. The range and extent of a doctor’s medical knowledge will be much greater than that of other team members.
The most critical areas of knowledge within the context of a rehabilitation team are:
- disease – diagnosis, treatment, prognosis, likely impairments etc
- drugs – uses, side-effects, doses, alternatives etc
A person with this knowledge must be integral to the team, well-known and easily accessible to team members. It is unsatisfactory to rely on “asking the GP” (or the consultant). There may be delays or difficulties in making contact and getting help. Doctors not part of the team may not understand or know what the team needs to know. Referral diagnoses are sometimes incorrect, and suggesting to the same doctor that a review of the diagnosis is necessary, coming from a non-doctor, may not be appreciated!
Similarly, other doctors may not understand that drugs can have serious adverse effects on people with disabling conditions, especially neurological diseases. If a drug is being altered, for example, to control spasticity, it may be challenging to have a close liaison between the team and the doctor so that the dose can be quickly adjusted if needed.
In rehabilitation, patients and their families are encouraged to manage their condition actively. Within this, doctors should teach patients how to control their drug regime. Doctors outside rehabilitation are not used to allowing patients to have control over medication. They may resist it or not feel able to teach the patient how to do it. These attitudes reduce rehabilitation’s effectiveness.
Third, the team may discover that the patient has many worries about their illness requiring expert medical knowledge, and other doctors outside the team may not have the time to answer these worries. Indeed, team members will often have limited knowledge about a disease, such as its cause, its treatment, its prognosis, or what complications may arise.
One skill unique to doctors is evaluating new or altered symptoms or other patient features, causing concern to determine whether they indicate a new disease or a change in the known condition. Doctors working in rehabilitation become skilled at recognising which symptoms a patient will often mention need attention and which do not. Moreover, the doctor is adept at picking up events or changes from information given by other team members, for example, when a team is reviewing patients.
A second skill that doctors have, related to their knowledge, is educating team members about their patients’ diseases and what to be alert for regarding complications or progression.
Third, some doctors will have treatment skills relevant to areas of practice, such as giving botulinum toxin injections or injecting joints.
Many of the other clinical skills are or should be shared across the team, particularly those skills relating to communication. Nevertheless, a doctor familiar with rehabilitation will be able, automatically, to communicate to the group the input they need quickly and effectively because the doctor knows what team members need to know. Other doctors will not have this skill.
There are also areas where doctors, especially those who have undergone specialist training, will be more likely than other team members to have the necessary skills.
A doctor working within a rehabilitation team should also have the skill of relating the disease to the disability and other problems and have the knack of setting the patient’s issues into a broader context. Further, a doctor usually has the skill of identifying and articulating priorities. These skills are not unique to doctors or to rehabilitation-trained doctors, but they are more likely in trained rehabilitation doctors.
A doctor's other assets
There are many other things that a doctor may add to the team. These are determined by and related to the following:
Status as a doctor
Some matters require a registered doctor’s input, such as signing documents. Many other actions are more influential if a doctor undertakes them. Patients will also be more likely to agree with advice if it comes from or is supported by a doctor.
This asset must be used carefully, weighing the advantages against the risks. If used too often, it loses its power. If used to achieve a doubtful end, the respect will be lost. On the other hand, their status can have a huge beneficial impact. The doctor must be wary of becoming over-enamoured with their status.
Experience and longevity
Though less so than before, a consultant will likely be in a post for many years. Longevity gives the consultant a wealth of experience and local knowledge to draw on. The doctor will know who to contact, where something is, how they managed a similar issue last time it occurred ten years ago, etc. This can be summarised as bringing wisdom to the team, not unique to doctors, but as wisdom is the judicious use of experience, and as doctors often have the most experience, they are more likely to possess it.
Familiarity with healthcare management
Most doctors are necessarily and, I would argue appropriately, involved in NHS management locally, regionally and often nationally. This experience gives them greater familiarity with national policies, the law, financing, etc.; especially in rehabilitation, such knowledge is often crucial. In management terms, it is awareness of the broader healthcare, legal, and political context – what is happening in other related places and organisations.
Given the relatively small number of consultants (200 in the UK), consultants inevitably get to meet and know colleagues in other areas and services, which brings much helpful information to the team.
More generally, doctors will usually have more contact with services over a region or nationally because they are more often involved in working parties, committees, conferences, lecturing, etc. All these activities generate contacts with services well outside the area of the rehabilitation team’s locality.
I have not yet mentioned leadership. The White Book on Physical Medicine and Rehabilitation is a document that discusses and specifies the medical role in rehabilitation services as agreed by consensus among national rehabilitation organisations in Europe. Chapter three recommends that doctors should lead the rehabilitation team. I disagree that doctors should lead; I accept that they often do.
Though often doctors and others assume that doctors will be or should be leaders, this is unwise and inappropriate. Leaders should earn their role in any team or organisation through actual performance. Doctors can and do learn about leadership, and their s status and familiarity with management and other matters listed above may well equip them to be leaders. Still, it is not a unique skill relating to being a doctor.
Of course, many doctors are excellent leaders and capitalise on their status, experience and training to benefit the team. Some doctors believe they are suitable or should lead by right but are not good leaders. Other doctors do not want to be leaders, though they may be given leadership roles. Members of any other profession are just as capable of being excellent leaders. I do not count leadership as something a doctor brings to the team.
I conclude that a doctor is or should be a member of every rehabilitation team because they bring:
- medical knowledge and skills relating to disease and drugs, and these ensure a better understanding of the situation and improve effectiveness and efficiency;
- experience of and familiarity with relatively more complex or rare problems, reducing the stress on team members and helping them to learn;
- understanding of and familiarity with NHS and other managerial and financial matters, both representing the rehabilitation service and improving access to resources for individual patients;
- an ability to take a broader view of the patient’s situation and to negotiate and set priorities.
- Last, if the team is lucky, their doctor may contribute wisdom, “the quality of having experience, knowledge, and good judgement; the quality of being wise”. [OED].