Bridge between hospital and home

After the surgeons have saved a life, it is rehabilitation physicians and the multidisciplinary teams they work with who take over the long haul care returning patients to a functional life

A young man is coward-punched outside a nightclub and is admitted to hospital with a traumatic brain injury. Though he is saved by the neurosurgeons, he is left with speech difficulties, short-term memory loss, poor motor control and poor bladder control, dependent upon his carers to help him dress and feed himself. What happens next? Who takes on the long-term task of helping the young man return to an active, functional life?

Welcome to the world of rehabilitation medicine.

It’s a world inhabited by rehab physicians, physiotherapists, speech therapists, occupational therapists, psychiatrists and psychologists, nurses and more, where multidisciplinary teams are not just desirable, but essential.

It’s also a world largely undervalued, underresourced, and misunderstood by other specialties, governments and the general public, at least by those who are lucky enough not to need rehabilitation.

“We are the missing link between acute care and the community”, says Professor Fary Khan, director of rehabilitation medicine at Royal Melbourne Hospital.

“Rehabilitation medicine is not a ‘sexy’ specialty, not one of the ‘cool’ ones everyone wants to do”, she tells the MJA.

“Disabilities are not pretty and, to a large extent, it is a case of ‘out of sight and out of mind’.”

The Australasian Faculty of Rehabilitation Medicine (AFRM) has about 400 fellows and has been part of the Royal Australasian College of Physicians since 1993.

President-elect and chair of the AFRM’s policy and advocacy committee, Associate Professor Andrew Cole says there are not enough rehabilitation physicians, particularly in rural and regional areas.

“There are enough to make a decent impact on those patients who are still in hospital”, Professor Cole tells the MJA. “But there are certainly not enough out there in the community.

“And, like most specialties, there are parts of the country’s rural areas where there are not enough rehab physicians, particularly in north of the south-east of Queensland, for example.”

The importance of rehabilitation medicine is growing with the ageing of the Australian population, Professor Cole says.

“As society ages, more people are getting medical problems associated with ageing, such as frailty syndrome, strokes and more chronic diseases.

“There is also an increase in the onset of not being able to do things — staying mobile, for example.

“That’s rehabilitation’s core territory.

“Those with catastrophic illness and injury are being brought back and are living longer than they used to in the past.”

Professor Mary Galea, professorial fellow at the University of Melbourne’s Department of Medicine, and a senior principal fellow in the Florey Institute of Neurosciences and Mental Health, says multidisciplinary teams are the heart and soul of rehabilitation medicine.

“The patients who need rehabilitation usually have a very complex series of problems”, Professor Galea tells the MJA.

“They are the patients who can’t go home for one reason or another and they usually have multiple comorbidities.

“Teamwork is much more necessary because everything is not only more complicated but more long-term as well.

“Rehabilitation medicine is bridging the gap between hospital and home.”

Rehabilitation is grossly undervalued by the medical community, governments and the general public alike, Professor Galea says.

“The reason for that is that it’s what someone once called a ‘muddy product’”, she says.

“It’s not clear-cut.

“A surgeon replaces a hip and that’s it — the outcome is clear.

“For someone with a major disability it is much harder to work out what the outcome is — there are outcomes on many levels, they change over time and they are quite subjective.”

Research in rehabilitation medicine is hard to fund and hard to conduct because of that subjectivity, Professor Galea says.

“When it comes to doing trials, that [subjectivity] has to be taken into account and therefore you tend to need more participants.

“There is starting to be a body of research, but it is hard because we are not well funded.”

Professor Khan says taking a health economics view should encourage governments to put more funds into rehabilitation research.

“There are savings for taxpayers in funding rehabilitation medicine”, she says.

“Getting people out of hospital and back into their homes and communities reduces the burden of care and saves money in the long term.

“It’s a very expensive resource because there are many people involved, but whatever you and I and other taxpayers spend on rehabilitation is recuperated in a matter of months.”

The discussion about economics is part and parcel of health administration in the current political climate, but Professor Khan, like her colleagues, says “it’s not about money, of course”.

“It’s really a privilege to work with people with disabilities”, she says.

“They don’t really have a voice and they have inequitable access to health care. I’m going to keep at it no matter what anyone says. I’m passionate about it.”

Professor Galea says that politicians often liked to visit rehabilitation centres because there was always a lot of activity and good photo opportunities.

“But they don’t appreciate or understand how hard it is to do [rehabilitation medicine] well”, she says.

There is also an attitudinal issue at work, Professor Galea says.

“There is sometimes an attitude that, for example, if someone can’t use their hand, then why bother giving them rehab — a “cut your losses” attitude.

“But that’s a cop-out, because if you’re aggressive with therapy early enough, then progress can be made.

“We spend a lot of money on keeping people alive and yet, if in the end the patient is alive but can’t participate in life, in the community, is there a point?

“There’s got to be the follow-up, to give people purpose.”

Professor Cole is optimistic about rehabilitation medicine’s future.

“The time for rehabilitation has arrived”, he says. “It’s still seen through the prism of older people — strokes and fractures of the neck of the femur, for instance — rather than younger people with spinal cord injuries and head injuries, but things are changing.”.

“I ask my students, ‘how long do you think a stroke lasts?’. The ones that say about 3 minutes are heading for pathology, the ones that say 7 to 10 days are heading for a career in hospitals. And the ones that say ‘a lifetime’ are interested in rehabilitation medicine.”