The rehabilitation syllabus
In 2021, the Rehabilitation Medicine curriculum was published. Many doctors were concerned at the absence of any guidance on or requirement for more specific knowledge or clinical skills, such as how and when to inject a painful shoulder or being able to prescribe a leg prosthesis. I convened a working group to set out a non-mandatory syllabus, and after some discussion, a syllabus was written and published. I added 2-3 references for each competency, which needed to be improved. As I had recently started my website, I started writing about each syllabus item. This took some time and much work, but it is now complete. This page outlines my reflection on the syllabus and what I have learned from the effort; it also explains my goal for the syllabus items I have written.
Table of Contents
Introduction
Education traditionally specifies what a student should learn, and the student is examined on how much they have learned. The exams increasingly use items with a correct answer, with all other answers being incorrect; this simplifies marking and reduces bias.
Education’s goal is to give the pupil the knowledge and skills required to succeed in the world, whether generally, such as running a home or, more specifically, working as a self-employed plumber (for example). Unfortunately, almost every aspect of a person’s life comprises complex situations with no single, unequivocal correct answer. This is especially true in healthcare.
The expertise of healthcare professionals is generally assessed using competencies. Regulators or professional bodies identify tasks or activities a person should be able to perform safely without supervision and then confirm this from evidence provided by the professional. The competency usually has associated knowledge and skills, which may also be examined.
Doctors are regulated by the General Medical Council, which decided to change from requiring evidence on many competencies to evidence on a few higher-level outcomes. The curriculum outlines these outcomes and how they should be assessed. No lower-level competencies and no knowledge of specific skills are mentioned; they are assumed because otherwise the doctor would not achieve the high-level outcomes.
Nevertheless, students and some of their teachers like the structure of a fixed syllabus outlining knowledge and skills they may need; to meet this requirement, I, with others, developed a list of 39 competencies, which has now increased to 40. The original rehabilitation syllabus can be downloaded.
The group that developed this rehabilitation syllabus also suggested giving texts, but the effort required to achieve that consistently was too great; it would have implied official recognition and needed regular review and updating. Instead, I have provided a ‘Rough Guide’ to allow anyone interested to enter a topic and challenge them to think.
The work has been considerable; it also made me think. I will now record my thoughts.
The rehabilitation syllabus: my goal.
This site aims to improve rehabilitation for everyone (a bit ambitious!), and the syllabus suggests areas of knowledge and skills related to 40 different rehabilitation aspects. However, rehabilitation textbooks can be well over one thousand pages of close type, and this website cannot compete on specific knowledge; skills need to be learned while working, not from text. In any case, the internet can give exact information that is often more up-to-date than a textbook.
My aim is for each page to spark interest in its topic. I have usually concentrated on one or two matters that interest me. I have then given a particular perspective; it is usually my opinion, but not always. I intend you to disagree or question what I write because, as I conclude at the end of this post, what you know is relatively unimportant. The three crucial steps for good professional practice are to know when there is information, to appreciate that you do not know it, and to have the skill to discover what you need quickly and dependably. I intend to stimulate these three steps.
I have also provided some references to help the novice enter the field. Everything I have written is correct (I hope!), but it inevitably has a bias, and every reader should question what I write.
When developing the original rehabilitation syllabus, we debated its structure and level of detail extensively, and some people then completed some items. I divided the items into groups, including one on the rehabilitation process. I then wrote five competencies to encompass this process. As I started expanding on each competency for this website, I realised I had overlooked a crucial skill: evaluating the effects of an intervention.
I wrote a blog post at the time on assessment competency, which emphasised the difference between the initial assessment that helped in formulation and a later assessment that detected changes after an intervention. This evaluation should cover both beneficial and harmful consequences. Thus, the original clinical assessment competency (B3) was divided, with the second part being the ability to evaluate the effects of an intervention; the evaluation competency (B6).
As I continued, I considered other items and wondered about some distinctions. For example, cardiac and pulmonary rehabilitation concern a single cardiopulmonary system, and the specific rehabilitation interventions are similar. On the other hand, one might consider visual and auditory rehabilitation as separate.
The debate on how to break expertise into manageable chunks has no solution, and this syllabus is a compromise. The problem of taxonomy is universal, and I have illustrated it in a post on diagnosis. I discuss what I have learned about rehabilitation expertise at the end.
Items and categories.
My ignorance
I have realised how little I knew about vast tracts of rehabilitation practice. I trained broadly when one could work in a variety of specialities, but, nevertheless, I knew little about cardiorespiratory, paediatric, or burn rehabilitation. I learned much about each of the 40 competencies, including those I specialised in, such as neurological rehabilitation.
I then realised how unrealistic it is to expect any trainee to acquire detailed knowledge about every aspect of rehabilitation. Although I learned many new things, I suspect I have forgotten half of them already because I did not need to know the information, and I do not use it in my clinical work. Over four years of medical training in rehabilitation, the trainee will acquire knowledge she may never need.
On the other hand, I also realised how each area of practice had something to contribute to the overall rehabilitation practice. For example, rehabilitation services for people with spinal cord injury highlight the value of obsessive attention to the prevention of avoidable complications through a combination of suitable equipment and the behaviour of patients and their carers.
Skill acquisition is essential for all trainees in all professions, primarily skills concerned with the rehabilitation process and optimising it in different situations. Skills can be improved throughout a professional lifetime, but training offers the opportunity to experience many situations. Trainees and their trainers should worry less about knowledge because that can always be learned when needed.
Parallel evolution.
Most rehabilitation has developed initially within a speciality, which the founders of the NHS thought was the appropriate way to deliver rehabilitation. Unfortunately, integrating rehabilitation with a speciality has prevented rehabilitation from emerging as a speciality.
It is striking how rehabilitation emerged and evolved similarly in all specialities. Initially, the services focused on impairment and disease. Multi-professional teams and the biopsychosocial model increased in importance at different rates in different specialities, but all specialities took the same road. Then, services recognised the importance of social participation and personalised interventions.
All rehabilitation specialities recognise the crucial roles of cardiovascular exercise, practice, psychosocial interventions, education, and self-management, which underlie all effective rehabilitation. The processes were also similar, though only sometimes made explicit.
This parallel evolution reaching a similar end state is strong evidence that rehabilitation is vital and that the components identified are central to its success. My review of rehabilitation in different specialist fields has supported the empirical approach I used initially to identify its critical features.
Being holistic and person-centred
When writing the competencies, I noted my tendency to concentrate on the detailed, specific knowledge and skills needed, such as understanding exercise physiology or the ability to adjust a baclofen pump. Other people or professions have more equal or better expertise in many of these skills. Developing specialised knowledge and skills in specific treatments carries risks, particularly not attending to the patient.
For example, anyone working in a spasticity clinic which primarily uses botulinum toxin may become too focused on identifying specific muscles using electromyography or ultrasound to stop and consider whether the injection is needed or, more likely, whether the patient has any other needs. Someone in the clinic must ask about everything else: loneliness, equipment, pain, housing, relationships, work, etc.
Another example is pain management. All rehabilitation experts must be familiar with chronic pain and its management. The General Medical Council has a credential in Specialist Pain Medicine to cover all pain, including chronic pain. Despite the central importance of the biopsychosocial model in understanding chronic pain and the crucial role of rehabilitation, neither is discussed. Rehabilitation only refers to doctors trained in rehabilitation and, apart from saying the credential requires a biopsychosocial model, it is never mentioned again.
In other words, someone acquiring rehabilitation expertise must balance their rehabilitation, professional, and condition- or treatment-specific expertise. They must always retain their person-centred, holistic approach, however exciting and satisfying the other constrained areas of specialism are.
The General Theory of Rehabilitation.
Shortly after starting my rehabilitation syllabus pages, I had an insight that developed into my General Theory of Rehabilitation, published on 27 October 2023 and described on this website. I had already established that spinal cord injury rehabilitation was a great success despite no change in impairment. As I worked through different conditions, other examples arose, primarily visual and auditory rehabilitation and rehabilitation for people with structural limb losses.
Then I realised that many people with congenital or progressive conditions adapted successfully, often without much help. For example, people with muscular dystrophies, relatively mild cerebral palsy, spinal muscular atrophy, etc, all often retain function by discovering how they can alter how they undertake activities without specialist help.
Finally, it became clear that the specialist rehabilitation help needed by most people revolves around adaptation, altering the environment, explaining what can be achieved and how to achieve it, and helping people accept any limitations involved.
The traditional and implicit paradigm of assisting expected natural recovery only applies to a minority of patients needing rehabilitation; even in this small group, recovery is usually limited.
Care home rehabilitation.
In 2019, I joined Dr John Burn’s working party to revise the 2013 British Society of Rehabilitation Medicine’s guidelines on specialist nursing homes. We aimed to write a document to assist any care home providing rehabilitation to their residents and to enable commissioners to judge whether the care offered safe and effective rehabilitation. As we debated the issues, which we did frequently, I realised that my work on the Rehabilitation Medicine curriculum and the rehabilitation syllabus could be adapted to achieve our goal.
The three challenges were to identify that the care home:
- delivered effective rehabilitation
- provided safe care for the residents receiving rehabilitation
- could be trusted by commissioners and patients to carry out safe, effective rehabilitation
The solution had to be:
- applicable to a range of care homes
- delivering a range of different types of rehabilitation
- to residents with a range of varying care needs
- feasible and credible
We developed a systematic framework such that:
- effective rehabilitation was determined by demonstrating seven generic and seven rehabilitation capabilities
- safe rehabilitation by demonstrating competencies specific to the care needs and rehabilitation skills needed by the residents accepted
- the data required were indicative, a selection of a few items sufficient to allow users and payers to trust the provider.
- The provider is responsible for choosing:
- indicative competencies appropriate for their caseload
- indicative data items appropriate for each competency
The parallel with training in rehabilitation is that:
- the capabilities of the care home mirror the capabilities needed by a rehabilitation specialist
- the care home is responsible for ensuring they perform according to accepted standards, just as a professional must practice within their expertise
- the care home is responsible for providing appropriate information to engender trust, just as a professional must show continuing professional development
Therefore, reflecting on that framework, a rehabilitation specialist needs to show a good standard of practice in the generic items within the syllabus, especially those related to the process, but only requires a high level of specialist knowledge in the syllabus items they need for their caseload.
Expertise, capability, and the rehabilitation syllabus.
A rehabilitation trainee aims to become a trusted specialist with professional and rehabilitation expertise. They will acquire the seven rehabilitation capabilities I have written about and discussed on this website. [Rehabilitation Medicine trainee doctors have eight set out in the curriculum, but they are almost identical.]
How should the rehabilitation syllabus be used?
The syllabus should not be considered a compendium of all a specialist needs to know when becoming a specialist. Other knowledge and other skills not mentioned in the syllabus are also essential. Hyper-specialists will need some items in their field that no one else will ever need. Knowledge of peripheral disciplines such as sociology, organisational theory, finances, and health economics will significantly enhance a specialist’s success. Conditions such as functional disorders have not been covered, though they are common.
Thus, good knowledge and skills of all 40 items are neither sufficient nor necessary to be a specialist.
Fortunately, full knowledge of all 40 items is optional because acquiring that knowledge in the four years allocated to medical training would take superhuman effort. More importantly, it would be pointless because, by the time one completed the task, one would have forgotten most of the material learned initially.
Nonetheless, the syllabus has a crucial role. Specialists must know what knowledge they need to undertake an activity safely and effectively. If they lack the necessary knowledge and skills, they must be able to acquire them. This is meta-knowledge. One needs to know what needs to be known, what one knows, and how to fill any deficits.
Ensuring one has experience with as many syllabus competencies as possible is one effective way of realising what one needs to know before taking on that activity. One rapidly realises what one needs to know when learning a competency in daily clinical practice. Working in a stroke or paediatric service for a week will embed your ignorance. If you were going to work there for a year, you would learn the specific knowledge and skills needed over four to eight weeks. Otherwise, at the end of the week, you will understand what expertise you will need to acquire if you ever take on that activity.
Thus, the syllabus will guide a trainee in acquiring experience across the whole scope of rehabilitation; each trainee should have worked in services or settings to gain at least a little experience in most competencies. The specialist should then be safe and effective.
How does the syllabus relate to the higher-level outcomes on entrustable capabilities?
The move from using lower-order competencies to higher-order capabilities to assess educational outcomes has been accompanied by a move from scored examinations to trust in the individual. Onora O’Neil suggested this in her Reith Lectures in 2002 (see also a short essay), and trust has been developed in healthcare training by ten Cate, as I have discussed.
Trusting someone is a judgement that relies on a holistic consideration of many items. In professional activities, information from various sources covering various settings and activities is used. These are indicative data; they illustrate professional performance.
Using a medical example, running an acute hospital admissions service over eight hours, one cannot possibly check someone has every conceivable competency they might need, and even if one could, one would still need to find out if the doctor could manage the unpredictable caseload. A supervisor will consider whether the trainee has a few of the competencies and a range of other matters, such as feedback from other staff involved, to assess their overall capability.
In rehabilitation, indicative data relevant to capabilities could include experience in some of the competencies set out in the syllabus, but they would also include many other items.
Conclusion
The rehabilitation syllabus provides a framework of competencies to help the trainee identify the experience needed to become aware of the specific knowledge and skills required when undertaking an unsupervised activity. It also provides trainers a framework for assessing one aspect of the trainee’s performance. It is a tool, not a comprehensive or mandatory list to tick off.
The syllabus pages on this website each introduce a competency. The content is not comprehensive. Each page provides some information about the competency and should challenge the reader to be curious and sometimes to disagree so that they investigate further. The introductory page gives further information and includes a table showing all competencies, with a link to each competency’s page.
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