Rehabilitation Medicine Gold
Issue #2: A Framework for Thinking in Rehabilitation Medicine
How structure frees cognitive space to improve clinical judgement
When you first rotate into rehabilitation medicine, it can feel cognitively overwhelming.
The problems are broader. The ward rounds are longer. The conversations extend beyond diagnosis, investigations and medication charts. You are expected to think about housing, mobility, mood, supports, equipment and discharge planning – often all at once.
It can feel as though the role of the rehabilitation doctor is simply to keep track of an ever-growing list of problems.
But rehabilitation medicine is not about holding a long list of problems.
It is about structuring those problems into a recovery plan.
In this issue we will discuss:
• Why rehabilitation medicine requires structured thinking
• The difference between listing problems and designing rehabilitation
• A simple framework that helps organise complex patient care
It is about structuring those problems into a recovery plan.
Over time, I realised that the single most important tool in rehabilitation practice was not a particular investigation or medication. It was a reliable thinking framework.
A framework reduces the mental load of trying to remember “everything.” It frees cognitive space so you can focus on nuance, communication and judgement.
The framework is used not only for assessing each patient, but for guiding the interventions for recovery.
I use this framework:
- For hospital inpatients
- In public and private outpatient clinics
- In medicolegal reports
- In letters to other doctors
It structures information in the biopsychosocial model proposed by Engel and adopted by Rehabilitation Medicine.
It aligns with the WHO International Classification of Functioning, Disability and Health in considering body structure, activity and participation.
It must always be contextualised to the individual patient’s goals, environment and culture.
But the structure remains constant.
The Framework:
- Medical
- Physical
- Functional
- Psychological
- Social
- Recreational
- Vocational
At first glance, these headings seem simple – the power lies in using them consistently and applying the subheadings.
This framework can be applied to any of the 20+ impairment groups of patients in rehabilitation medicine, including the Big 6:
- Stroke
- Traumatic Brain Injury
- Spinal Cord Injury
- Amputee Medicine
- Pain Rehabilitation
Applying the Framework in Assessment
Each heading acts as a prompt for the subheadings of history to gather
Medical (and nursing)
- Medical management of the primary condition
- Medical management of comorbidities
- Wound management
- Medication management
- Primary prevention
- Deconditioning
- Related to current conditions
- Secondary prevention
- Nutrition
- Toxins (smoking, drugs, alcohol)
- Lifestyle (sleep, exercise)
Physical
- Targeted physical exam findings (specific to patient group)
- General strength and movement (hands on back of head, lower limb strength)
- Gait and balance
- Cardiovascular (pulse, blood pressure, oxygen saturation and presence of cardiac failure – all important for exercise)
Function
- Think functional independence measure (FIM), especially
- personal activities of daily living (pADLs)
- Cognition and capacity to engage and learn
- Stairs
- Bladders, bowels and sexuality (a good sequence so that you don’t forget sexuality)
Psychological
- Stress/ Anxiety/ Depression
- Insight/ understanding of condition
- Cognitive flexibility
Social
- Housing
- Relationships
- Finances – who pays the bills?
- Insurance
- Supports – emotional/ financial/ physical
- Transport
Recreational
- What do they like to do? What aren’t they able to do? What gives them meaning?
- Sports
- Community involvement
- Fitness (assessed by history)
Vocational
- Education
- Paid or volunteer work
- Caring for others
- Grandparenting
- Aspirations/ plans for retirement
Patient management uses the same structure
The elegance of this framework is that it applies equally to rehabilitation treatments.
Within each domain, you draw from the rehabilitation treatment “toolkit”. We will explore the toolkit in detail next week.
Rehabilitation medicine is not simply about identifying problems. It is about designing a multidimensional recovery plan.
Why This Framework Matters
In early training, the cognitive load of rehabilitation medicine can feel heavy.
But the goal is not to memorise more.
The goal is to structure your thinking so well that it becomes automatic.
Once the framework is internalised, you are freed to think at a higher level:
- What is realistically achievable?
- What is limiting improvement?
- Which intervention will have the greatest value?
- How do we align the team around a unified plan?
The Gold
Without a framework, you react.
With this framework, you can design.
Structured thinking produces focussed plans and clear communication.
Listing problems is only the beginning.
Rehabilitation physicians integrate them into a patient-centred plan.
This is the difference between completing tasks and practicing rehabilitation medicine.
