Rehabilitation Medicine Gold

Why your job in subacute medicine is more than what you think it is

An introduction to the rehabilitation medicine ward for new doctors

The transition from acute hospital medicine to the rehabilitation wards can feel disorienting. The pace is different. The priorities are different. And often, the purpose feels less obvious. The subacute wards don’t only focus on medicine, but also on function, participation and recovery. Finding your place can be challenging – I know that I found this difficult, moving from the emergency department into an acute spinal service. 
 
In this email, I aim to not only help orient you to the role of the rehabilitation doctor, but to help you become a high-performing one.
 
In rehabilitation, and especially as a junior doctor, you are working as a team – you are part of the medical team, but greater than this, you are part of the rehabilitation team. 
 
For all doctors-in-training (interns, residents, registrars) working in a hospital, I conceptually split the role into a clinical role and an educational role.
 
Let’s start with the clinical role:
 
To understand this, we need to understand what is rehabilitation medicine and what do rehabilitation physicians do?
 
The Australasian Faculty of Rehabilitation Medicine states that “Rehabilitation Medicine is the diagnosis, assessment and management of an individual with a disability due to illness or injury and that rehabilitation physicians work with people with a disability to help them achieve an optimal level of performance and improve their quality of life”. 
 
Let’s align that statement to your role using a clinical scenario.
 
You are admitting Mr Smith, a 55 year old man to your rehabilitation ward. He has had an ischaemic stroke and has no significant comorbidities.
 
Why is he there?
He has a new impairment and a new disability – a loss of function due to his stroke – and part of your role is to diagnose, assess and manage this.
 
Diagnosis – this has usually been done in the emergency department or by neurologists – here your medical role is to confirm the diagnosis and ensure that the medical plan for treatment and secondary prevention.
The rehab medical team also needs to prognosticate for “rehab potential” – the likelihood of improvement with treatment and how long that will take.
 
Assessment – The rehabilitation assessment uses a biopsychosocial framework (a template for this will be in next week’s email)
 
Management – The overall aim of your management is to keep Mr Smith well to maximise his ability to participate in his rehabilitation therapy program in order to achieve his goals, improve his independence, maximise the likelihood of discharge home and maximise his quality of life.
 
How to keep Mr Smith well? You need a clear plan to:

• Optimise his medical treatment (e.g. The Holy Triad: Antiplatelet agent, antihypertensive, anti-cholesterol)
• Prevent complications by predicting them (e.g. DVT, pressure injuries, falls, shoulder injury, pneumonia, UTI)
• Monitor for potential complications (e.g. Check medication chart, obs chart, see and talk to Mr Smith frequently)
• Communicate with Mr Smith, his family and his team (they will often notice first if there is a problem)
• Prevent events from occurring that reduce participation in his program (e.g. losing motivation, difficulty adjusting, anger, grief, sending Mr Smith for multiple appointments or investigations that interrupt therapy)
• Take action quickly if events or complications occur so that he can once again participate
• Support nursing staff and the therapy team looking after Mr Smith by having a patient-centred and team-agreed plan
• Try not to disrupt the plan by over complicating the issues, over investigating them or trying to do everything at once.

Rehabilitation wards function best when the medical team creates a clear plan of direction.
Unclear plans create tension and chaos – clear plans create confidence. Once you understand your clinical role, learning how to execute it well through practice is the next step. 
 
The educational role
 
You are also there to learn!
To learn medicine. To learn rehabilitation medicine.
 
But also – 
To learn about quality and safety – how the hospital system functions to keep patients safe and improve outcomes.
To learn from your specialists – this is twofold – learn what works and learn what doesn’t work (nobody is perfect!).
To learn from the team (nursing and therapists)
To learn from your patients
To learn how to lead a team (negotiate & collaborate)
To learn professional behaviours.