Consultant physicians working with patients - Royal College of ...

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2 Specialties Rehabilitation medicineRehabilitation medicineDr John P McCann MD FRCP FRCPI Consultant in rehabilitation medicineDr Christopher W Roy MBChB FRCP(Glasg) Retired consultant rehabilitation medicineProfessor Christopher D Ward MD FRCP Retired professor of rehabilitation medicine1 Description of the specialtyConsultants in rehabilitation medicine (RM) servepeople with complex disabilities arising from conditionssuch as spinal and head injuries, stroke, multiplesclerosis (MS), musculoskeletal disorders, congenital oracquired limb loss, muscle disorders, cerebral palsy andspina bifida. Roles include: confirming diagnoses and prognoses preventing and treating symptoms andcomplications contributing to life decisions providing information, support and counselling forpatients, families and carers.Most RM consultants lead and coordinate amultidisciplinary team (MDT). Although the specialtywas originally developed for disabled people of workingage, 1,2 RM is now relevant to people of all ages.The World Health Organization’s (WHO) Internationalclassification of functioning, disability and health 3provides a conceptual framework. This recognises thesocial and physical environment as a target forinterventions: for example, someone complaining ofspinal pain may benefit from different seatingarrangements, drugs or medical treatments. The clinicalskills of RM specialists are essential for the effective useof many assistive technologies.Rehabilitation programmes are important in acute andnon-acute conditions. For example, RM consultantshelp individuals with MS to manage their own disabilityand prevent secondary complications, while providingtreatment as required.The British Society of Rehabilitation Medicine (BSRM)(www.bsrm.co.uk) provides further information on thespecialty.2 Organisation of the service and patternsof referralRehabilitation medicine is a consultant-led service thatworks closely with MDTs. Consultants haveresponsibility for inpatients in neurologicalrehabilitation units but also consult in stroke units,other wards (including pre-amputation) andmultidisciplinary outpatient services. Rehabilitation ofpeople with spinal cord injuries occurs throughsupra-regional centres. Specialist neurologicalrehabilitation centres accept the most complex patients.Rehabilitation medicine has important relationshipswith trauma, orthopaedics, neurology, neurosurgery,vascular surgery, acute medicine and palliativemedicine. 4 RM has a central role in the early andongoing management of patients within the majortrauma networks.Many consultants work in the community. In England,recent drivers for such services include the Nationalservice framework (NSF) for long-term conditions 5 andthe Department of Health’s Transforming communityservices programme 6 and Liberating the NHS whitepaper. 7 Community work entails frequent interactionswith primary care, psychiatry, urology, palliativemedicine and many other services. Most RMconsultants carry out home visits or review people innursing homes.Referrals come from GPs or consultant colleagues.In addition, professions allied to medicine triggerreferrals.3 Working with patients: patient-centredcarePatient-centred care is central to RM, which involvesmeetings with disabled individuals, family membersC○ Royal College of Physicians 2013 205
Consultant physicians working with patientsand others. The ability to facilitate these meetings is animportant consultant skill. Communications betweenprofessionals and patients are highly developed andinclude evaluations of rehabilitation goals. Consultantsin RM use educational approaches to help patients andfamilies, often raising their expectations of potentialachievement, and to support self-management. Patientsupport groups can be a major help in rehabilitation.Consultants in RM typically have close relationshipswith local groups, and many work with national patientor carer-led organisations.Rehabilitation must always consider other peopleimportant to the patient. The separate needs of carersmust be appreciated, but balancing the interests of theindividual patient with those of others can pose ethicalchallenges when the disabled individual has reducedcapacity. An important challenge for RM consultants isto understand the needs of people from differentreligious, cultural and ethnic backgrounds. RMfacilitates innovative approaches, with a great deal ofexpertise on cultural differences within the specialty;however, the cultural responsiveness of rehabilitationservices needs further development.4 Interspecialty and interdisciplinaryliaisonMost aspects of RM require an MDT. Evidence for ateam approach comes from research on acquired braininjury and MS. 8,9 The key to MDT working is thatprofessional roles are flexible, with the needs of adisabled individual superseding disciplinaryboundaries. Interspecialty links are strong throughoutrehabilitation, and links with primary care andcommunity services are particularly important duringcommunity reintegration. Social services work closelywith RM teams, alongside education, employment,housing and legal services, and voluntary agencies.Neurology and neurosurgery interact closely with RM inmanaging long-term neurological conditions. Vascularsurgery interacts specifically with RM for amputations.RM works closely with orthopaedics and neurosurgeryin the management of patients following severe trauma.Other joint work with RM consultants includes: managing handover of young disabled people frompaediatrics to RM managing spasticity in collaboration withgeriatricians working with surgeons to plan procedures andpostoperative rehabilitation following spinal or jointsurgery and tenotomies sharing care with gastroenterologists duringinsertion of feeding tubes obtaining support from otorhinolaryngologists inthe management of tracheotomy working with anaesthetists in the management ofcomplex pain collaborating with psychiatrists for patients withneurological conditions, including traumatic braininjury, functional disorders and Huntington’sdisease working with urologists in the management ofcontinence working with palliative medicine consultants in themanagement of people with rapidly progressiveneurological conditions (eg motor neurondisease).In the community, RM makes rehabilitation expertiseaccessible to disabled people and provides an interfacefor specialist community professionals, as advocated inSupporting people with long-term conditions. 10 Ways ofworking with GPs are constantly evolving, asrecommended in a joint statement by the Royal Collegeof Physicians (RCP) and the Royal College of GeneralPractitioners. 11 General practitioners with a specialinterest (GPwSIs) in RM participate in many stages ofrehabilitation.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality RM service provides equitable access tospecialist services for all, including those with the mostsevere disabilities. The services described here must beavailable within reasonable distance of a patient’s homerather than exclusively in specialist centres.Home-based intervention is therefore essential.Inpatient and outpatient services must be available forthose with brain or spinal cord injury, other acute orprogressive neurological conditions, limb deficienciesand rarer disabilities. Stroke rehabilitation should beprovided either by the RM service or with RMconsultant input. A consultant in RM must be involvedin providing complex assistive technologies, includingenvironmental controls and special seating.RM services must be based within a well-managed,adequately resourced MDT. Factors that determine206 C○ Royal College of Physicians 2013
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