The Rehabilitation Medicine (RM) rotation is 4 years long and can focus on sub-specialty areas for the last 2 years once the essential components are complete. Areas are neurological rehabilitation, spinal injuries, amputee and prosthetics and musculo-skeletal rehabilitation, which includes the new area of trauma rehabilitation. Most of these areas are new to trainees, as specialist rehabilitation units are few and RM is not often taught at undergraduate level. Trainees may enter from a medical, surgical or general practice background.
When I am doing my neurological rehabilitation attachment (initially 1 year in length), my day usually starts at 9am and I could have a range of duties to do, starting with a ward round in the specialist level 1 rehabilitation neurological inpatient unit with my F2 and consultant, or in outpatients, or seeing external consults or doing a specialist MDT ward round on the neurosciences unit at the Major Trauma Centre. There is great variety in this job and I have been able to look after patients with many of the rare conditions described in a few lines in a textbook, or one question in my MRCP examination. We teach for PACES and many of the patients who are with us for 3-6 months enjoy this as it passes time for them. We have many interesting “cold” neurology signs and also other areas as sometimes multi-system diseases or cardiology problems are the cause of the illness or injury. The patients often have cognitive and psychological problems as well as physical ones, which makes their presentations more interesting and more of a challenge. The inpatient unit has approximately 30 patients and they are all working towards their own individual goals which are negotiated with the clinical team following an initial assessment period. Our job as doctors is to manage the medical conditions to keep the patients well enough to do their best in therapies and also to anticipate and prevent complications of their illness and underlying conditions. We also have an important role in maintaining the focus of the team on the patients’ goals and also helping the patient and families or carers to come to terms with new disabilities and life moving on in a different way .Good communication skills and the ability to be patient for outcomes in the longer term are crucial in this job.
If I am in outpatients, I would usually see 5-8 patients in a clinic, with my consultant working with their own list alongside me. The appointments are long as we are a holistic specialty, usually with a long complex list of patient’s problems to work through and decide how the clinical team might be able to help. How the patient is functioning in different domains of their life, what their goals are and their barriers to successful rehab are all part of the clinical assessment. Team-work is the basis of rehab practice and often there are 4-8 specialist therapists working with each patient. My role includes pulling all the information together and I need to liaise with the patient’s GP and other medical specialists to ensure accurate information exchange. In clinic I also do botulinum toxin injections for muscle spasticity in the clinic and sometimes do specialist clinics for transition patients from paediatrics to adult services, Multiple Sclerosis, traumatic brain injury and specialist sex and relationships clinic.
Seeing external consultations for RM allows me to do assessments of patients in the early stages of their illness and I often visit patients on critical care units, neurosciences wards, general medical wards and all the local district general hospitals. There are a range of illnesses we see including traumatic brain injury, stroke in young people, MS, peripheral neuropathies such as Guillain Barre Syndrome. We have experience of looking after patients with tracheostomies and a high level of dependency, including assessments for patients with prolonged disorders of consciousness. At the other end of the spectrum we also look after patients with memory and cognitive problems who are physically fit but not able to return to usual activities due to cognitive issues. There is sometimes overlap with psychiatric conditions.
I usually have time for lunch and sometimes there is teaching for the team. In the afternoon I might chair a family meeting for a patient when the team can provide feedback and we can review their goals together. One benefit of the job is getting to know patients and their families well over a number of weeks, which doesn’t happen in other medical specialties. It is really rewarding when the patients get home, which happens in the majority of cases.
If I am doing my spinal injuries attachment (3months), I would spend the day seeing patients at the regional spinal injuries unit which has specialist inpatient beds, including for ventilated patients. The unit also has a specialist outpatient service and care for the patients is lifelong. There is a specialist urological service as well as the patients have to have upper tract monitoring and ongoing bladder (and bowel) care. My other curriculum components are prosthetic and amputee rehabilitation (3 months) and musculo-skeletal rehabilitation (6 months) which includes the rehab of trauma patients.
My clinic is usually finished by 5pm at the latest. My on call is for the level 1 specialist unit which is off the acute site so usually the patients are medically stable, or we transfer them for ongoing care. As a rule it is quiet and I am on a 1 in 8 rota with no difficulty getting compensatory rest. As a rule it is straightforward to get study leave as well. We can access the national training programme and junior medical group, as well as having weekly postgraduate teaching. We also teach 3rd and 4th year students. There is time for audit and we are encouraged to submit work for the British Society for Rehabilitation Medicine Annual Meeting. Overall I find my job interesting and rewarding and at times challenging. I would recommend it to anyone who enjoys having a holistic approach to their work and tackling complex problems whilst working as part of a specialist team.