From the moment I became interested in rehabilitation (1980), I have been asked “But what do doctors do in rehabilitation?“. The implied, and often stated corollary is, “Isn’t rehabilitation what therapists do?” So I have had forty years to think about and practice my answer. This post puts my answer down on paper. It is, self-evidently, a personal view but I hope it is also a reasonably objective view of the roles doctors can, and should play within a rehabilitation team and service.
One of a series (I hope)
Before I start, I will state my hope that other people from the very many other professions involved will contact me with material to post (with their name, provided they agree), giving their opinion on what their profession contributes. And, if this happens, then I hope to have a section within the website synthesising what each profession’s unique and substantial contribution is. More details on this project are in this accompanying post here.
Doctors in rehabilitation.
Doctors may be involved in rehabilitation in several ways. Many hospital doctors have patients who are disabled, and support the ward therapy team by giving medical advice to the team, and attending team meetings and. occasionally, case conferences. Many general practitioners similarly will support the therapists seeing their patients in much the same way. This is a supportive but not a committed role: the doctor provides information and advice, but has no fixed role within the team, and has limited rehabilitation expertise.
There are also doctors, who are not necessarily trained in rehabilitation, that take a much greater 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) there are doctors who provide consistent dedicated expert support to their team. The numbers in total are not known, but they are probably quite high – more than the total number of rehabilitation doctors!.
On the other hand, there are also doctors whose interest and support is small. They provide information on request, but do not become proactively involved and rarely if ever participate in discussions and meetings about a patient’s rehabilitation.
Last there are doctors who are trained in rehabilitation formally (I never had any training, as it did to exist), and others who 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 one can distinguish three classes on doctor:
- those with expertise and who are engaged with a rehabilitation team actively
- those who provide positive support, but have no strong relationship with the team
- those who provide information on request, but are not positively supportive.
The general roles of doctors within rehabilitation teams and services is shown in this graphic here. This includes many roles that doctors generally take on or perform. However it is not showing the unique aspects of a doctor.
This post concerns what it is that doctors who have a specific relationship with a rehabilitation team contribute to a team, that other team members could not or would be unlikely to contribute.
Doctors have a substantial body of specialist medical knowledge that other team members are unlikely to have. This is one of the defining characteristics of a profession. It is, of course, quite possible for someone from another profession (or from no profession) to have some of the particular knowledge. For example, patient with a rare disorder will often know more about the disorder than the doctor. The body of medical knowledge held by a doctor, its range and extent, will be much greater than that held by other team members.
The areas of importance, within the context of a rehabilitation team, are knowledge about:
- disease – diagnosis, treatment, prognosis, likely impairments etc
- drugs – uses, side-effects, doses, alternatives etc
These two sets of knowledge are needed within the team. It is not satisfactory to rely on “asking the GP” (or the consultant). There may be delays, or difficulties in making contact and getting help. Doctors who are not part of the team may not understand or know what the team need to know. Referral diagnoses are sometimes incorrect and suggesting to the same doctor that a review of the diagnosis is needed, 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 disease, especially neurological disease. If a drug is being altered, for example to control spasticity, it may be difficult to have close liaison between the team and the doctor. Doctors outside rehabilitation are not used to allowing patients to have control over medication, again reducing the ease of rehabilitation.
Third, the team may discover that the patient has many worries about their illness that require expert medical knowledge, and other doctors may not have the time needed to answer these worries.
The one skill unique to doctors is evaluating new or altered symptoms, or any other patient features causing concern, to determine whether or not they indicate disease, either new disease or a change in the known disease. Doctors working in rehabilitation become skilled at recognising which of the many symptoms a patient will often have needs attention, and which do not. Moreover the doctor is skilled at picking up events or changes from information given by other team members.
A second skill that doctors have, related to their knowledge, is educating team members about the diseases their patients have and about what to be alert for in terms of complications or progression.
Third, some doctors will have particular treatment skills relevant to particular 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 team 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 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 they should have the skill of seeing the patient’s problems as a whole. 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 doctors.
Other team 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 actually require a registered doctor’s input, for example signing a document. Many others 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
- experience and longevity. Though less so than in the past, a consultant is likely to be in a post for many years. This gives the consultant a wealth of experience and local knowledge to draw on. The doctor will know who to contact, where something is, how this was managed last time, ten years ago etc.
- familiarity with management. Most doctors are necessarily, and I would argue appropriately, involved in NHS management locally, regionally and often nationally. This gives them greater familiarity with national policies, the law, financing etc and, especially in rehabilitation, such knowledge is often crucial. In management terms, it is being aware of context – what is happening in other related places and organisations.
- networks. Given the relatively small number of consultants (200 in the UK), consultants inevitably get to meet and know colleagues in other areas and other services. This again bring much useful information into the team.
I have not yet mentioned leadership, for a good reason. Though often doctors and others assume that doctors will be or should be leaders, I think that this is unwise and inappropriate. Leadership of any team or organisation should be earned through actual performance. Doctors can and do learn about leadership, and their s status and familiarity with management and and other matters, listed above, may well equip them to be leaders, but it is not a unique skill relating to being a doctor.
Od course, many doctors are excellent leaders, and capitalise on their status, experience and training to the benefit of the team. Some doctors believe they are good or that they should lead by right, but are no good leaders. Other doctors simply do not want to lead, though they may be given leadership roles. And members of any other profession are just as capable of being excellent leaders. So I do not count leadership as being something that a doctor brings to the team.
I conclude that a doctor is or should be a member of every rehabilitation team because she or he brings:
- 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;
- experience 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.
In a word, the asset that a doctor brings, if the team is lucky, might best be described as wisdom, “the quality of having experience, knowledge, and good judgement; the quality of being wise”. [OED].