A career in rehabilitation medicineBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8554 (Published 04 January 2013) Cite this as: BMJ 2013;346:e8554
- Kanchana Devinuwara, specialty trainee year 51,
- Dan Burden, head of public affairs2,
- Rory J O’Connor, chair of the specialty advisory committee on rehabilitation medicine and senior lecturer in rehabilitation medicine34
- 1Yorkshire Spinal Cord Injury Centre, Pinderfields General Hospital, Wakefield, UK
- 2Spinal Injuries Association, Berkshire, UK
- 3Joint Royal Colleges of Physicians Training Board, London, UK
- 4University of Leeds, Leeds, UK
Rory J O’Connor and colleagues outline the purpose and the pathway of a career in rehabilitation medicine
Rehabilitation medicine entails the treatment of disabling conditions, active management of disability, and prevention of secondary complications. Doctors in rehabilitation medicine deliver the medical management of people with complex disabilities. Although the patients are predominately adults of working age, doctors in rehabilitation medicine may also work with children and older adults.
What is rehabilitation medicine?
Rehabilitation medicine consists of four main clinical areas: neurological, musculoskeletal, amputee, and rehabilitation following spinal cord injury.
Neurological rehabilitation entails working with people who are recovering from acute brain injury, including stroke. Services are also provided to people with long term neurological conditions such as multiple sclerosis and cerebral palsy, generally as outpatients within community settings.
Musculoskeletal rehabilitation is closest to rehabilitation medicine’s origins in physical medicine. This area covers the medical management and rehabilitation of disabling rheumatological conditions such as the arthritides, chronic soft tissue injuries, and back pain.
Amputee rehabilitation is focused mainly on outpatient care, although an important role is pre-amputation counselling, which includes inpatient assessment. Many doctors working in this branch of the specialty also provide medical input to orthotics clinics, wheelchair centres, and other services providing technological solutions.
In recent years much has changed in the management of spinal cord injury, with developments in spinal cord regeneration, advances in helping patients to walk again, and the key part that spinal cord injury centres play in bringing expertise and specialist management to patients coming to the major trauma centres. Doctors who work in one of the 12 spinal cord injury centres in the United Kingdom and Ireland are involved in the acute management, rehabilitation, and lifelong care of people affected by spinal cord injury.
Why choose a career in rehabilitation medicine?
Rehabilitation medicine is a bright, exciting specialty especially suited to doctors who want to work with a team to develop creative and innovative solutions to their patients’ problems. Doctors working in rehabilitation medicine need a wide range of competencies to provide holistic and lifelong care to their patients.
The core clinical skills of making a diagnosis, formulating a prognosis, and providing expert medical care—common to all specialties—are important in rehabilitation medicine. However, the diagnosis of a spinal cord injury, for example, may be made in the context of multiple traumatic injuries, and in an older person after a fall, as part of a complicated presentation. Furthermore, the prognosis is given to a frightened patient at a time that their life is changing, sometimes irreversibly.
Doctors in rehabilitation medicine also provide information, support, and counselling for patients and their families and carers. This service will include functional and prognostic information as well as information about vocational rehabilitation or return to work. Combining these skills with the specialised medical interventions that you can provide, and an ability to lead the multidisciplinary team in challenging situations, make rehabilitation medicine a tremendously satisfying career.
Box 1 Advantages and disadvantages
Knowing you can make a real and practical difference to the quality of life of your patients
Working with active and knowledgeable patients and their families
Wide range of clinical work, from acute rehabilitation to elective and outpatient rehabilitation
Patients and their families come with high, sometimes unrealistic, expectations
In some areas, rehabilitation medicine has a low profile
Advanced training in certain competencies is not available in all deaneries
Training in rehabilitation medicine takes four years and starts at specialty training year 3 (ST3) after core training in medicine, acute care, surgery, psychiatry, or general practice. Specialty trainees work in each of the four main clinical areas in rehabilitation medicine before developing advanced competencies in one, leading to a certificate of completion of training in the specialty. Academic clinical fellow and clinical lecturer posts are available in programmes with links to academic rehabilitation medicine.
Rehabilitation medicine has difficulty recruiting suitable trainees at ST3 level: in 2011 the fill rate was only 55%.1 As a result the Royal College of Physicians describes the competition ratio for ST3 posts as “particularly favourable.”2 Roughly 20 training places will be available in the next round of national recruitment, which is coordinated centrally by the Royal College of Physicians. Applicants must have the same experience and qualifications as any other applicant for an ST3 post; however, the advantage for applicants to training posts in rehabilitation medicine is that membership of the Royal College of Physicians, Royal College of Surgeons, Royal College of Psychiatrists, and Royal College of General Practitioners are all acceptable entry qualifications.
Trainees are expected to develop advanced competencies in one of the four main clinical areas of rehabilitation medicine and will spend most of their training in one of these areas. There are ample opportunities to develop these competencies but not all deaneries offer advanced training in every clinical area, so talk to the director of the training programme in the deanery in which you would prefer to work.
There is an excellent balance between training posts and consultant posts in rehabilitation medicine, so career opportunities for dynamic, proactive doctors are good. As of April 2011, there were 159 (134 whole time equivalent) consultants in rehabilitation medicine employed in England.3 The consultant workforce in rehabilitation medicine has expanded by 4.2% in the past five years1 and is expected to increase by 4.6% a year to about 170 full time equivalent posts in 2020 (around 180 head count).
Consultants in rehabilitation medicine provide rehabilitation to critically ill and injured patients by working in general hospitals alongside the acute medical and surgical teams. They also work in post-acute rehabilitation units to facilitate patients’ recovery and safe discharge. These posts have on-call commitments, particularly those attached to major trauma centres, where there is an expectation that rehabilitation prescriptions are completed rapidly once a patient is stabilised. Often these roles include outpatient and community rehabilitation—managing people with long term conditions in their own environments.
Consultants in rehabilitation medicine have the knowledge and skills to confirm medical and functional diagnoses and prognoses, prevent and treat secondary and tertiary complications, manage symptoms, facilitate treatment, and contribute to life decisions. In addition, consultants lead and coordinate the activities of the multidisciplinary rehabilitation team.
Box 2 Day in the life of a specialty trainee in spinal cord injury rehabilitation
9 am—ward round
The day starts with a ward round and I see two new admissions from the day before. The first patient has T12 incomplete paraplegia after a fall and her family are understandably anxious about her prognosis and the length of the rehabilitation process. The second new patient is a middle aged man with central cord syndrome caused by a car crash. I continue with the ward round and arrange an x ray examination of a patient with suspected heterotopic ossification causing pain and reduced range of movement at her elbow.
12 noon—protected meal time for patients
I do some administrative work before going to the lunchtime radiology meeting.
1 30 pm—clinic
The first patient I see in clinic has cauda equina syndrome and was discharged two months ago from the regional neurosurgery unit. She was seen by me as a new patient when she was struggling with faecal incontinence. We initiated an anal irrigation system and clean intermittent self catheterisation. At follow-up today she tells me she has returned to work.
My last patient of the day has been paraplegic for nearly 30 years. It reminds me that before spinal cord injury units existed, people with spinal injuries had a life expectancy of less than a year.
I do my dictation and finish the clinic at 5 pm.
Patient’s view—why specialist doctors in spinal cord injury units are so important (Dan Burden)
For those people with spinal cord injuries who never make it to a spinal cord injury centre, the outlook can be bleak. While many patients with spinal cord injury will find themselves under the care of specialist doctors in the UK’s spinal cord injury centre service, a substantial minority will find themselves rehabilitating in a non-specialist district general hospital. The prospects for these patients are considerably worse than for those who have been under the care of a specialist in a spinal cord injury centre.
The contrast between the experiences of these patients and my own is considerable. I was one of the lucky ones. From the moment I was admitted to the spinal cord injury centre my consultant was the “conductor” of my care. As the head of a multidisciplinary team, he ensured that my fractured spine was stabilised, the most suitable regimen was found for my bowel and bladder management, my spasticity was controlled, and that I was sufficiently educated to understand the implications of my injury and how I could live independently despite my impairment.
Little over a year after being discharged I got myself a job. Ten years on, I have been employed continuously with no serious health complications. I am fully independent and mobile, and I have the positive outlook on life that is shared by many of the people I know with spinal cord injuries who were also rehabilitated under a specialist doctor. I still see my consultant every 18 months for what people with spinal cord injuries refer to as our “MOT.” He knows my name, my lifestyle, what problems I have faced since I fractured my spine, and what problems I may face in the future, and it is through this ongoing care that I can live an active, daily life with little thought to my spinal cord injury.
Rehabilitation medicine has a promising future. As a result of the national stroke strategy and the more recent trauma network initiative, clinical services in rehabilitation medicine are expanding across the United Kingdom. Advances in restorative rehabilitation technology are promoting research opportunities and shaping how rehabilitation is delivered.
If you want a career that is challenging and rewarding, arrange a taster day at one of the rehabilitation centres around the United Kingdom to experience the passion that doctors in this field have for the specialty.
Spinal Injuries Association—www.spinal.co.uk
British Association of Spinal Cord Injury Specialists—www.bascis.co.uk
Training in rehabilitation medicine—www.jrcptb.org.uk/trainingandcert/st3-spr/pages/rehabilitation-medicine.aspx
Competing interests: None declared.
Patient consent not required (patients anonymised, dead, or hypothetical).