Medical Specialties - Rehabilitation Medicine (29 Mar 2023)

SPEAKER_03 0:00

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SPEAKER_00 0:31

Hello, my name is Carrie Baker, and I'm an acute physician in NHS Fife and Director of Education at the Royal College of Physicians of Edinburgh. Did you know that according to the King's Fund, 44% of doctors in the UK are female? That's over one quarter of a million of us. That includes 55% of medical students and 54% of postgraduate trainees. If this trend continues, women will make up the majority of the medical workforce within the next decade. However, only 32% of consultants and 24% of the medical directors are women. And women are underrepresented in leadership and academic roles. Together, the Royal Colleges of Physicians and Surgeons of Edinburgh, on behalf of the Academy of Medical Royal Colleges, are hosting an exciting two-day women in leadership event on the 27th and 28th of April. The first day will be a hybrid conference at the Royal College of Physicians of Edinburgh in our city centre-based conference centre, and also available online via live web streaming for those who cannot attend in person. The second day will be an interactive in-person event at the Royal College of Persians of Edinburgh, with workshops, parallel sessions, and the opportunity to interact with a range of inspirational speakers and hosts. This event is about helping build the workplace that we and our future colleagues and public deserve. It's about celebrating and inspiring women in leadership to serve as role models. We have an incredible range of speakers lined up for you, including Professor Dame Sally Davis, the previous CMO for England, and Professor Dame Carrie McEwen, the chair of the GMC. We hope to see you there.

SPEAKER_03 2:14

Today I'm delighted to be joined by Dr. Ollie Isaac, who's a specialist registrar in rehabilitation medicine within the West Yorkshire Deanery. So, Ollie, welcome.

SPEAKER_01 2:24

Thank you, Marilena. And thanks everyone for taking the time to listening. I hope that this can be enlightening.

SPEAKER_03 2:29

I'm sure it will be. So I guess we should start by you explaining to us if it's okay what rehabilitation medicine actually is. I know certainly before I'm at you, I hadn't even considered it as a potential option after IMT.

SPEAKER_01 2:45

One of the things that's the challenge of the specialty is actually in the UK it's a very small specialty. I can always talk about that a little bit more detail. And so I suppose because it's a small specialty, the question about what do we actually do gets asked quite a lot. There's a few ways to sort of answer that question. Maybe possibly the less abstract of those is to talk about the patient groups that we typically look after in the UK. It's a split into four broad areas. So there's the neurological rehabilitation side of things. So people with strokes, traumatic brain injuries, metabolic brain injuries, all those kinds of things. And then there's sort of more chronic neurological conditions, such as multiple sclerosis or cerebral palsy. So that's neurological rehabilitation. And then there's spinal injuries, rehabilitation. So that again can be traumatic spinal injuries or sort of other medical causes of spinal injuries. And then MPT medicine, so limb loss, both upper limb and lower limb, and that also extends into pediatrics, people born with limb difference. And then musculosquetal rehabilitation is another area that we can be involved with, many non-inflammatory conditions leading to that. So those are the kind of the patient groups. And then I suppose another way of looking about it is the question of what is rehabilitation. So rehabilitation is a set of measures that can be done to minimize the impact of the condition on the person. So looking at the disabling factors. And we do that as part of a multidisciplinary routine, and we're doctors within that team. So as doctors, we have diagnostic skills. The bulk of our training is how to assess a patient, so history, examination, investigations, all that kind of thing. And I suppose that puts us in a unique position in terms of problem solving. We can help guide people. Then there's a patient interaction as well. So problem solving with patients and then diagnostically, so investigations, we have a role in that as well. So working out, you know, an important part of any rehabilitation initially is thinking about is the condition being optimally treated and investigations can form part of that. And then there's the therapeutic side of things. So we're prescribers, we can do interventions, all those kind of things are part of rehabilitation method.

SPEAKER_03 4:38

Okay, wow. So you mentioned that you work alongside a multidisciplinary team. In my head, when I think about rehabilitation, the main other healthcare professionals that I would think about are the physiotherapists. And I suppose alongside that, it would be the occupational therapists. So is it something that would be typical in that you would still go do your wardround, and then the patients would go off, have, I don't know, their physio, and you would, you know, assess them from a medical point of view, and then they would see the occupational therapist, or what is your day-to-day like basically?

SPEAKER_01 5:08

That's another really interesting question. So I suppose it really depends on where I would be working or where my colleagues would be working. So I think rehabilitation, like any medical specialty, can be split into inpatient rehabilitation and outpatient rehabilitation. That really determines the course of the day. So maybe inpatient rehabilitation, maybe more people would have heard of that. So the doctor's role is kind of split between doing ward rounds, sometimes being part of MDTs, assessing new patients, or and I suppose the other thing is the acute side of patients as well, if their patients are deteriorating for whatever reason. That's what a doctor might do on a sort of a typical day-to-day basis. I think you asked about a multidisciplinary team as well. So the involvement of different professionals really depends on the patient's needs. So, you know, one patient might need more input from one professional than others. It would be the answer to that. So, yes, as you mentioned, physiotherapists and occupational therapists are an important part of that. And we also work with psychologists, dietitians, speech and language therapists. Those are the broad categories that you know there's orthodists within that. There's a load of different specialties for diatrixs as well. All these, ideally, if we can all be seeing from the same hinge sheets probably the best possible rehabilitation for the patients, that would be the best thing. I guess in our patients, it's slightly different because unless they're joint clinics, we tend to see patients on our own. They might have involvement from other professionals in the community or they may not. They may just be seeing us.

SPEAKER_03 6:24

And Ollie, who determines if a patient has rehabilitation potential? I know that at the start you gave us those broad patient groups that you tend to be involved in from a medical aspect, but who ultimately decides whether there is potential for those patients to be rehabbed or not?

SPEAKER_01 6:41

So that's a really interesting question. I think it does depend. I think sometimes it's a really difficult question to be able to answer. And certainly, as rehabilitation medicine doctors, we can certainly be part of that decision. You know, if it's within our unique skill set of these patients that we see all the time, sometimes we can provide that advice. But quite often it's be a sort of team decision. It depends on an awful lot of factors. So I suppose there's the underlying problem, so the severity of that, the progress of that in itself, and then looking back, looking at what the patient cohombites are, what their functioning was like pre-injury, if that's a case, that'll determine that. But also, I suppose the ability to engage in therapeutic activities that will maximize their rehabilitation, that's also an important consideration. And I suppose if there's anything limiting that, looking at the potential of those to be managed as well. So for instance, if pain's an issue, but it's clear that that hasn't been addressed, that potentially would be a reason why there could be a good prognosis with that. So yeah, it really, really depends on a whole load of different factors. But as rehabilitation medics, we can certainly help advise that. But I wouldn't go as far as saying that we always decide that because I think it really depends on the patient.

SPEAKER_03 7:45

Okay. And I'm not aware, and please correct me if I'm wrong, of a deanery that offers rehabilitation medicine as part of the more junior training programmes, such as foundational IMT, or certainly if there are, there will be very, very few. How did you become involved in rehabilitation medicine? What made you think that actually this could be the career for me?

SPEAKER_01 8:10

So when I did my core medical training, one of my jobs was in the complex rehab units in Chapel Allison Hospital. So that is something that can be offered. I suppose it's like inpatient rehabilitation is only one side of rehabilitation. There's outpatient rehabilitation, there's community as well, which doesn't tend to be offered, I suppose, in foundation or sort of core training years. But I suppose me personally, I was always kind of interested in a holistic kind of medicine. So I did consider careers such as oncology or palliative care before general practice as well, but I hadn't really been exposed to it, I suppose, before doing that job, but I actually found that I really enjoyed the sort of work that I was doing, the people I was working with, both patients and staff. So that for me was a big drive to go into that area. It does highlight that there are overlaps with different specialties in so I suppose the holistic nature, which yeah, I find attractive.

SPEAKER_03 8:56

And if a trainee hasn't had the inpatient exposure that you had, is there anywhere that you could signpost them to to say this is what you could do or listen or see that could get you more involved or so that you could get a better idea of what the specialty entails?

SPEAKER_01 9:16

Yeah, absolutely. So I suppose an important part of considering specialties is doing things like taste today. So I actually did a few taste today in other areas just because I wanted to see what rehabilitation services look like outside of West Yorkshire. But that's certainly an opportunity to experience what rehabilitation medicine can offer or what career in this can offer. So I'd certainly recommend that, I think, to anybody who's interested. I think the other things are just networking. So to talking to people who train in rehabilitation medicine. There's the British Society of Physical and Rehabilitation Medicine, so BSPRM websites that can certainly provide some hopefully helpful information. So yeah, just there's various ways of increasing exposure, and I'm very happy to be contested if I can help at all.

SPEAKER_03 9:54

Perfect. And what I'll do is I'll make sure that we link the website to the show notes. So if anybody is interested, then you can easily access it. And following on from there, what skills do you think a doctor needs to have in order to go into this career?

SPEAKER_01 10:11

I think we need to be really good doctors. And I think all the skills that we develop through our medical school and through a core training, I think are relevant to rehab medicine. So good assessment of patients. I think, you know, honing in on diagnostic skills, I think is really important. Teamworking is really important as well, listening to people, the ability to manage different points of view because sometimes sometimes they're not clear-cut decisions, there will be different points of view and try and sort of work out what is best for the patient. I think that's really important. There are procedural things as well that we do. So we do a lot of injections. So procedural skills is something that is useful as well.

SPEAKER_03 10:43

And I've started asking other speakers to maybe discuss a case that's either stuck with them or that they found particularly interesting during their time in training. Do you have something that you could possibly share with us to give us a bit more of a flavor of your day-to-day job, really?

SPEAKER_01 11:01

Yeah, absolutely. So in my current job, I'm working in the community neurological rehabilitation team, and we see people with long-term neurological conditions as part of that. A common problem with people with neurological conditions is spasticity, and sometimes that can affect on their day-to-day life. So I saw a patient yesterday, his lower limb spasticity was affecting his ability for his carers to maintain perineal hygiene. And he'd had previously had some botulimin injuries to his hip adductors, so the muscles that bring his knees together to try and manage the spasms that he was getting so that his legs could be a bit more loose and that could maintain perineal hygiene. The other thing of relevance to this chap is that he was also standing. So with the trouble with botulinum toxin injections, they can weaken muscles. And if someone has weaker muscles when standing, that increased their risk of falls or other problems to do with that. So really it's quite a tricky balance to maintain. Unfortunately, these injections hadn't particularly made much difference last time. So we looked at a range of different things. So the spasticity, there can be other things than just the underlying condition that may lead to a worsening of spasticity symptoms. So it's always important to think about other things like pain or blood or bowel management, things like that. Another thing with him was he's having swallowing difficulties and recurrent aspiration pneumonias. We discussed a few different options of things that we could do, and then we decided that actually probably starting a different medication called baccalophilic oxygen that has systemic effects rather than targeting specific muscle groups. We decided that that would be the most likely option to offer him some benefits. We obviously safety netted him because sometimes there can be complications with starting medications. So that forms a very important part of the management, like in any medical specialty. So that was our plan for him, really.

SPEAKER_03 12:33

Oh, excellent. And then how long will you give him to see if it's worked before you see him again?

SPEAKER_01 12:40

So it we depends on patient to patient how long we leave it before, you know, what was a reasonable trial. So I think him we felt at least a couple of weeks of having this medication regularly, and then we could always review to see whether the dose could be increased or whether, you know, obviously part of the safety net is if there's any serious effects initially, then it should be stopped straight away. That's clear. But obviously, there's other professionals who might be able to spot that as well.

SPEAKER_03 13:02

And if you could give one piece of advice to a trainee that's interested in doing rehabilitation medicine, other than do it, I love it. What advice would you give them?

SPEAKER_01 13:14

Yeah, I'd really just advise them to have a think about it, to consider it, to explore their options. For me, I really like my job. I enjoy it more than I did my foundation and my core medical training for various reasons. But yeah, I'd say explore it, ask questions, meet people, go on taste today's. Sorry, you ask for one piece of advice, I'll give you lots of different things. I think career decisions is complicated because it depends on a whole load of things and we change as we go through our careers, matching what we enjoy and what our skill sets are with a career is not an easy thing to do, really, but just increasing exposure, gaining awareness of what we're good at, all those kind of things, I think will certainly help to know if rehabilitation medicine is for you.

SPEAKER_03 13:55

And just one last question. Based on what you said about making our career choices and finding the right thing for us, I know that you mentioned a bit about what your day-to-day life is and the inpatient versus outpatient demands of the specialty, but how long is the training scheme?

SPEAKER_01 14:15

So the training is currently four years after core training. So there's a lot more information on the JRCB TV websites. On call requirements vary from region to region. So in Leeds, there is no current requirements due on calls. I think traditionally some of the registrars did neurology on calls, but that's not the case at the moment. In Sheffield, by comparison, the registrars cover the spinal injuries units and the neural rehab units house for hours. So that's an on-call requirement for that.

SPEAKER_03 14:42

And would they be resident or non-resident on calls?

SPEAKER_01 14:45

So in Sheffield, I think during the weekends that's resident till 9 pm and then not resident from 9 pm until the morning.

SPEAKER_03 14:52

Obviously, at this point to anyone listening, it would be good to check your local requirements because as you can see, in just a very small area, two hospitals quite close by have very different commitments and requirements. But certainly from what we can gather, it wouldn't be a training program where you would have your medreg on course.

SPEAKER_01 15:09

No, that's correct. Yeah. So it's a group two specialty.

SPEAKER_03 15:12

Right, Ollie, I think that's everything from my side, unless if there's anything else that you feel that we need to know about from your side.

SPEAKER_01 15:20

Well, there is one thing I should mention. I suppose, you know, the very start, I said it's a small specialty. And I was looking at this this morning. The workforce of rehabilitation medicine is roughly, I think it's 0.3 rehabilitation medicine doctors per 100,000 population in the UK versus three per 100,000s in the rest of Europe. And I suppose there's potential for the specialty to expand. And obviously, those numbers are just very broad. There's a lot of things that um underlying that. But one of the things that I really enjoy, and I haven't really mentioned that so far, is looking at different areas. And I started by talking about the traditional groups of patients that we look after, but there are emerging other areas. So, for instance, the long COVID work, a lot of work that's been done in Leeds. So I've worked for the long COVID service, and that's been really interesting. Then there's the chronic pain, so fibromyalgia clinic is another area that's expanding into. But I think within that as well, there's a load of different specialties that currently don't really have much rehabilitation medicine into, partly because our workforce is so small. So the message that I wanted to give is that rehabilitation medicine doesn't just need to be confined to the patients that we currently traditionally cater for. So that was one other thing I'd wanted to highlight.

SPEAKER_03 16:21

That's great. So please, if anyone is interested, feel free to follow us, read the show notes. As Ollie said, he's more than happy to be contacted. And we thank you all for listening. We hope you found it interesting and join us soon for another episode of Career Conversations. Thank you so much, Ollie. Thank you.

SPEAKER_01 16:39

Thank you very much, Maranina.