Trainee Handbook
The Trainee members of the British Society of Rehabilitation Medicine meet regularly at BSRM events and are represented on all the Society's committees. They have good communication networks and have produced a handbook as a quick guide for all Rehabilitation Medicine Trainees.
Foreword
This handbook has been written by your BRSM National Trainee Representatives, we hope it will be particularly useful for prospective and trainees new to the speciality but it also provides information for current trainees wishing to refresh their existing knowledge, looking for tips or seeking information about trainee representative roles. It is not a single piece of work but a combination of all representatives’ work, past and present, along with a group of excellent trainees who have helped with the content. Without collaborative working this would not have been possible and I cannot thank those who have dedicated their own time enough. It is worth noting that the introduction and welcome is based on and reproduces some material from a lecture and material written by Prof. Tony Ward and presented at a collaborative conference between the BSRM and the Royal College of Physicians on 25 November 2010 ‘The National Service Framework for Long-Term Neurological Conditions – Five Years On.
Sarah Leeder
Welcome to a fantastic speciality!
Rehabilitation Medicine (RM) is an inspiring career choice, combining enormous variety with medical complexity and interdisciplinary working. The core role of a Rehabilitation Medicine physician is to provide expertise in the diagnosis, assessment and management of people with disabling disorders, supporting their right to lead fulfilling, normal lives.
Training in RM provides an excellent opportunity to combine the management of disability in secondary care and the community. It is an expanding, evolving branch of medicine, which covers a range of sub-specialty interests, pathologies and patient groups.
Background
Rehabilitation Medicine (RM) is a small and relatively new speciality in the UK, first established in 1991. Compared to the rest of Europe, only Ireland has a smaller number of specialists per capita. Due to it's expanding nature, the job prospects are excellent.
Rehabilitation Medicine is unique because the primary treatment strategy is rehabilitation and the specialist’s daily routine often involves writing a 'Rehabilitation Prescription'. As such, the doctor does not govern all aspects of treatment. Instead, the physician works simultaneously within a multi-professional team utilising their emotional intelligence, ability to assess risk and an array of clinical and leadership skills to effectively manage patients in a goal orientated approach.
This wide remit combines clinical skills and practice with the prospect of developing and implementing services, teaching and training members of the multi-professional team and promoting evidence-based rehabilitation through local and national policy. Training in RM complements other specialties and there may be opportunities to attain dual accreditation in neurology, rheumatology or stroke medicine. There are several areas to develop sub-specialty interests, which include neurorehabilitation, spinal cord medicine, limb loss medicine, assistive technology, musculoskeletal medicine and trauma rehabilitation. Physicians may work synchronously within two or three specialist fields or combine clinical work with academic medicine, research or education.
Overview of training
Training typically consists of a four-year programme, which encompasses learning in most sub-specialties area. Core skills and competencies are be gained in neurorehabilitation, spinal, limb loss and musculoskeletal medicine. Access to the programme being attainable after achieving MRCP, MRCS, MRCGP or MRCPsych qualifications. Rehabilitation is increasingly becoming the focus of effective patient management. Current patterns of training and working are likely to change, the most influential documents include the 'Shape of Training' and the 'Future Hospital Commission' reports. It is likely that our patterns of working and training will change in the near future. Both these reports highlight the need for acute medical input across all specialties.
In summary, RM is a bright, exciting specialty especially suited to doctors able to ‘think outside the box'.
Areas of specialist interest in RM
Area |
Examples of work |
Neurorehabilitation |
Traumatic brain injurySpasticity managementProgressive neurologic disabilityStrokeProlonged disorders of consciousnessCerebral palsy |
Spinal cord medicine |
High spinal cord injury (SCI)Prevention of complications of SCI |
Musculoskeletal |
Early referral clinicLocalised and complex painPolytraumaNon-inflammatory musculoskeletal conditions |
Amputee rehabilitation |
Upper and lower limb prosthesesDiagnoses and management of complications |
Specialist equipment |
Complex orthoticsWheelchairs and other specialist seatingAssistive communication technologiesEnvironmental controlBladder/bowel management with neuro-prostheses |
Key roles and skills of the doctor in RM
Role |
Tasks +Skills |
Examples |
Diagnosis and prognosis |
Diagnosing pathology and complicationsUnderstanding disease progressionIdentifying impairment and assessing prognosisManaging uncertainty |
Deciding when to interveneEducation of patients, managing ideas, expectations and concernsInterdisciplinary working |
Risk assessment |
Identifying and managing risk |
FallsPressure areasFoot careContractures and spasticityNutritionOccupationalRelationships |
Medical management |
Analysis of impairment and disability |
Symptom control eg for pain, spasticity, respiratory distressIdentifying triggers for spasticityPsychological and psychiatric complic-ations eg depressionManagement of skin integrity, contractures and incontinenceSecondary prevention |
Leadership |
Working within an inter-disciplinary teamLeading teamsManagement roles |
Medical accountabilitySharing common goals within the team, which may involve conflict, negotiation and different levels of accountability |
Advocacy |
Listening and planning care including end of life careManaging expectationsAssessment of capacityNegotiationCommissioning services |
Dealing with conflict and negotiating an ongoing planDealing with ineffective services or treatments |
Enablement |
Access the equipmentRecognise the need for adaption and involve the teamCo-ordinating teams and communication |
Motivational interviewing,Dealing with loss of patient autonomy and roles |
Counselling |
Understanding and supporting individualsCounselling and consultation skillsProviding continuity of careUnderstanding family working and patient dynamics |
Dealing with loss, despair and hopelessnessLoss of the therapeutic relationship |
Public health |
Advising NHS Trusts and commissioners on disability related issuesConsidering management from a community perspective |
Considering the iniquity in the access to servicesSpecial needs in hospital |
Essentials - when you start
Register with the JRCPTB and the Royal College Physicians as this will give you access to the NHS eportfolio, which you will need for your ARCP (Annual Review of Competence Panel ) and to complete your WBPAs (workplace based assessments). You can pay one lump sum for JRCPTB or annually as an addition to RCP membership. In the past, the advice has been that you can claim tax back on the annual payments but not the lump sum, but the latter protects you from a fee increase.
Make the curriculum your friend. The RM curriculum is undergoing revision at the time of writing but contains a wealth of information in addition to outlining the competencies required for completion of training. Some would recommend reading it over and over again.....!
We would recommend joining the British Society of Rehabilitation Medicine (BSRM) www.bsrm.co.uk. The BSRM website not only contains details of courses, educational events and consultations but also useful information about the structure of the BSRM itself and it’s constitution. There are links to several essential documents and standards.
It is worth considering your eportfolio personal library and organising your personal library with folders that assist the ARCP and assessment process.
Revalidation is linked to the ARCP and completing your ARCP successfully complements the revalidation process.
Getting involved
National Trainee Representatives (BSRM NTR) and Special Interest Group Representatives (SIG reps).
There are two National Trainee Representatives elected by BSRM trainees via an informal email ballot. Any trainee member can stand and every trainee member is entitled to vote. Elections are run on an as needed basis and tenure of posts is 2-3 years but may be less as trainee representatives move to CCT. Representative roles offer an excellent way to network and work within the BSRM.
National Trainees Representatives communicate via a national email thread, Facebook 'Rehabilitation Medicine Specialist Trainees', the doctors.net rehabilitation medicine forum and Twitter. We also have shared resources in 'Dropbox'.
It is likely that trainees within the same training board (the old term being 'Deanery') also communicate with each other through local educational events and email threads. For example, there is an Oxford, Wessex and London (OWL) email thread.
The role of BSRM National Trainee Representatives (NTR)
These are excellent, motivating and privileged roles encompassing numerous skills essential for consultant life including leadership skills. The 'representative' aspect of the role is key, and we would emphasise how much feedback and sharing views underpin what we do and shape our responses in national meetings. NTR’s can be in unique positions to influence national policy.
Aspects of the NTR role
1. Chair of the National Trainee meeting at the annual BSRM conference submitting agendas via the national email thread and other communication platforms. All trainees can propose agenda items and the aim is to discuss any national issues or matters pertinent to trainees.
2. Provide feedback regarding trainees’ views at the following national meetings and to write reports and communicate to all trainees important points from these meetings:
BSRM Executive Committee
Joint Specialty Committee of the Royal College of Physicians
Specialist Advisory Committee – this is a sub-committee of the Joint Royal Colleges Postgraduate Training Board
Education sub-committee of BSRM
Research and Academic Affairs sub-committees of the BSRM.
Historically, the two representatives divide attendance at these committees between them, ensuring that at least one person is able to attend. On a practical note, cost to travel to the meetings is refunded by the BSRM and the national employment contract allows for five days of professional leave per year to cover attendance, (this is in addition to annual and study leave entitlement).
3. Write the trainee section of the BSRM newsletter (twice a year).
4. Keep the trainee list up to date for the national email thread.
5. Continue to develop trainee resources and the handbook.
6. Provide advice to trainees and support them through training. This may involve signposting trainees to appropriate resources or people who will be able to provide appropriate advice.
7. Provide careers support and information for trainees interested in a career in RM.
Special Interest Group (SIG) representatives
There are several SIG groups within the BSRM including vocational rehabilitation (VRSIG), musculoskeletal (MSKSIG), spinal (SCISIG), amputee medicine (SIGAM) and environmental control and assistive technology (SIGEAT). There is the opportunity to have a trainee representative on each group and these roles, akin to the national representatives, offer an opportunity to work on additional leadership skills required for consultant life and influence national policy.
The role of the SIG representatives is to provide feedback to trainees regarding the activity of SIGs and work within the SIG according to their respective agendas.
Local involvement
Trainees may also wish to get involved at a more local level and can discuss becoming representatives at Specialist Training Committees within their own training board areas. These will discuss the provision of education within the area and matters pertinent to training with the Deanery boundaries. If you are interested please approach your local training programme directors.
Outcome measures and databases
We hope this small and by no means comprehensive section serves to signpost new trainees to the use of outcome measures and the input of scores onto local and national databases that underpin some aspects of RM. The BSRM has provided a large ‘basket’ of appropriate measures to encourage a common language between RM centres. However, there is not a single all encompassing measure as it depends on what you are measuring, in which patient population and the setting where you are applying it. Trainees starting with neurorehabilitation may wish to familiarise themselves with the Rehabilitation Complexity Scale and FIM/FAM along with the UKROC initiative. Other databases that may be of interest include SSNP for stroke and TARN for trauma.
Other organisations you may wish to join
Trainees may wish to consider joining the following organisations:
The Society for Research in Rehabilitation (SRR) - www.srr.org.uk
Union of European Medical Specialties (UEMS) – www.euro-prm.org - highly recommended to join as the 10 day Marseilles course is free for members http://ehm.univ-amu.fr/diplome/european-school-marseille?destination=node/18
Oliver Zangwill Centre - for neuropsychology www.ozc.nhs.uk
ISPRM – www.isprm.org (NB BSRM is currently a member)
Headway - www.headway.org.uk
Time in Training – what to do?
Training in RM in the UK has reflected clinical services and where most of the jobs have been, that is, in neurorehabilitation. Traditionally, trainees have completed core training that included up to 24 months of neuro, 6 months musculoskeletal, 3-6 months spinal and 3-6 months limb loss with the additional time in the rotation spent with more time in your chosen career/ clinical interest and meeting the curriculum requirements for assistive technology, paediatrics, trauma etc.
There is much debate about what is adequate time in some sub-specialities for consultant jobs. Below is a guide - in general it is a really good idea to continually discuss your career intentions with your educational supervisor who hopefully will be able to guide you.
Neuro |
2 years + |
Spinal |
6 months + (some Trusts will appoint consultants with 6 months experience, some want you to do an extra fellowship, there has been no nationally agreed consensus) |
Musculoskeletal |
6 months + (worth considering the Trauma competencies ratified through the BSRM and likely to become advanced competencies in the next curriculum update) |
Limb loss |
6 months + |
Trauma |
Educated guess of 3-6 months |
Additional experience |
environmental control systems – 5 visits and assessments, paediatrics, community, specialist seating, specialist nursing homes |
Both nationally and in London it has been suggested that ‘core training’ should be 6 months in neuro, spines, MSK and limb loss respectively. Trainees can then move onto more specific training.
Training days
BSRM has developed a framework for a regionally delivered National Training Programme for RM. In London and in some other regions in the country this is delivered via a two year cycle of lectures and training days mirroring the curriculum. Other regions have their own training days implemented and delivered at a local level and trainees may wish to get in touch with their regional representatives about arrangements.
Courses
The curriculum highlights some courses considered mandatory for RM. The BSRM generally sends round robin emails to notify potential delegates of these and posts information on the relevant section of the website.
They include:
Specialist Rehabilitation Medicine Course in Derby
Advanced Prosthetic & Amputee Rehabilitation Course in Stanmore
Spinal Cord Medicine Course in Sheffield
Environmental Control and Assistive Technology course in Liverpool
There are good courses concerning prosthetics and orthotics in Strathclyde
http://www.strath.ac.uk/courses/undergraduate/prostheticsorthotics/
and trainees may also undertake practical courses in ultrasound or botulinum toxin injections.
Some trainees elect to do additional courses in generic skills eg teaching, leadership and may opt to gain additional qualifications in these areas.
Bibliography
McCann, J, Roy,C, and Ward, C; Consultant physicians working with patients: The duties, responsibilities and practice of physicians in medicine; Rehabilitation Medicine; Royal College of Physicians, 2013: Available at https://www.rcplondon.ac.uk/sites/default/files/rehabilitation_medicine.pdf
BSRM Cores Standards for Major Trauma Rehabilitation. BSRM London: October 2013http://www.bsrm.co.uk/publications/BSRM%20Core%20standards%20for%20Major%20Trauma%2024-10-13-NewLogo-chk-1-12-14.pdf