Describing and developing the field of competence in Physical and Rehabilitation Medicine (PRM) in Europe – preface to a series of papers published by the Professional Practice Committee of the PRM section of the Union of European Medical Specialists (UEMS)

1 English version

The field of competence (FoC) of specialists in Physical and Rehabilitation Medicine (PRM ¹

1 In some parts of Europe and the world the term “Physiatrist” is used as a short name.

) in Europe follows principles previously described in the White Book of Physical and Rehabilitation Medicine in Europe . An agreed basis for the FoC is the European Board curriculum for the PRM-specialist certification ( www.euro-prm.org ). However, there is considerable diversity in PRM practice between countries in Europe. Even within a country, the professional practice of the individual doctor may vary because of the specific setting he or she is working in.

Fig. 1 gives an overview of factors influencing the professional practice of a PRM specialist. As in every specialty, education and training forms the basis of professional practice. Following basic medical training, the PRM curriculum is based not only on traditional medical principles (diagnosis, functional evaluation, treatment and monitoring outcome) but also the ICF-model , and scientific evidence. Three additional factors influence professional practice:

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the nature of underlying health conditions as classified in the International Classification of Diseases (ICD) as well as the levels of functioning as classified in the International Classification of Functioning Disabilities and Health (ICF) ;
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the setting: this includes the facilities, programmes, equipment (as classified in the International Classification of Health Interventions ICHI) , and team structure;
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the public health strategy of the country or region including the health care system, funding systems, epidemiology of diseases, and disabilities as well as the general health policy.

Last but not least, continuous evaluation and quality management as well as ongoing scientific work are factors improving the quality of professional practice in PRM.

In order to describe and further develop the field of competence of PRM specialists, a series of papers will be discussed and approved in the UEMS-PRM-Section (especially in the Professional Practice Committee) in cooperation with other national and international bodies. These papers will deal with PRM work in specific setting (e.g. acute hospitals, interdisciplinary team work) and for specific indications (e.g. patients whose activities are limited by neurological disorders).

PRM specialists treat a wide range of pathologies and functional deficits . The remit of PRM is to address functional limitations affecting, for example, mobility, communication, activities of daily living, participation in work, and leisure activities (see below). This is achieved not only by treating the underlying pathology and preventing complications, but also by interventions at environmental, family, social, professional, and recreational levels Thus PRM is a “transverse” specialty with a comprehensive focus on all dimensions of functioning. PRM-programmes also include preventive strategies .

In order to reach these targets, different from one patient to another and tailored for each one, the PRM specialist has to be aware of a wide range of treatment modalities (drugs, physical therapies, orthoses and prostheses, assistive and rehabilitative technologies as well as in some cases, surgery) and to be able to coordinate interprofessional teams involving people from health, social, and technical fields . PRM specialists have also to cooperate with other specialist physicians in diagnosis of health conditions, evaluation of systems and of functions and specialized treatments, including embedded or interactive systems, signal and detection processing devices. This includes consultations as well as patient-centred team conferences ( Fig. 2 ).

PRM specialists need to have empathy to motivate and coordinate a team and to communicate effectively with patients, their families, with other professionals involved in the treatment and the follow-up. These skills are of uppermost importance and form part of the teaching and training programme of the PRM specialist .

PRM is supported by evidence-based medicine, which, in turn, is discussed within national and European PRM scientific societies. National and European guidelines are regularly edited . An UEMS PRM accreditation system for the accreditation of the quality of PRM programmes has been running since 2008 ( www.europrm.org ) .

PRM interventions are relevant during the acute phase of illness, the post-acute phase, and may be lifelong in some circumstances ( Fig. 3 ). PRM specialists may therefore work within acute care units, within post-acute care or in longterm facilities . They may also work in ambulatory (out-patient) facilities, or in community settings. PRM specialists may treat very different pathologies ranging from low back pain to brain injury, with the same objectives – to restore function and optimise participation and quality of life . In these diverse situations, with different life consequences, PRM specialists will nevertheless use the same evaluation process, based on clinical diagnosis using the International Classification of Diseases framework and the evaluation of disabilities, activity limitations and participation restrictions as related to the ICF-model .

The Professional Practice Committee of the PRM Section intends to publish a series papers aiming to describe and further develop the FoC of PRM and to make this information accessible for everybody interested. Main target groups are professionals in medicine, students, and residents as well as persons with responsibilities within health care system and health policies especially in the sector of rehabilitation. These papers will also be part of the ebook of the committee. The papers describe the role of the PRM specialist in general, in specific settings, and in persons with disabilities and defined health conditions. Thus it will not describe rehabilitation or treatment concepts in general but focus on skills, aptitudes, and competencies of PRM specialist.

The papers on FoC in PRM start from the premise that PRM activities are relevant to all sectors of the health system . They are based on general medical principles, specific skills, and aptitudes for the treatment and rehabilitation of people with disabilities and chronic conditions as well as on the comprehensive model of functioning as defined in the International Classification of Functioning, Disability, and Health (ICF) . Additionally, it takes into consideration that professional practice of the PRM doctor is influenced by scientific results and quality control as well as the context in which the work is done. This includes the micro- (level of the person to be treated, its pathologies, and level of functioning), meso- (level of services including facilities, programmes, equipment, and team structure), and macrolevel (level of health care systems, epidemiology of functioning, and health policies) .

The ebook on the field of competence will be one of three ebooks published by the UEMS-Section and Board of Physical and Rehabilitation Medicine. The other parts are the ebook on Quality of Care in Physical and Rehabilitation Medicine (editor: Georges De Korvin) and the ebook on Education in Physical and Rehabilitation Medicine (editor: Franco Franchignoni).

The editors of the series of papers and the ebook hope the publication will induce a debate on the field of competence of PRM in Europe and thus contribute to further development of PRM and hence to improvements that benefit people with disabilities and chronic disabling health conditions and to society.

2 Version française

Le champ de compétences (CC) des spécialistes en Médecine Physique et Réadaptation (MPR) en Europe suit les principes décrits précédemment dans le libre blanc de la MPR en Europe . Un socle agréé pour ce CC est le cursus du Board européen élaboré pour la certification des spécialistes en MPR ( www.euro-prm.org ). Cependant, il existe une diversité considérable des pratiques de MPR entre les pays d’Europe. Même dans un pays donné, la pratique de chaque médecin peut varier en fonction de son environnement de travail.

La Fig. 1 donne un aperçu des facteurs influençant la pratique professionnelle des spécialistes en MPR. Comme dans toutes les spécialités, l’enseignement théorique et pratique forment la base de l’exercice professionnel. Venant à la suite de l’enseignement médical de base, le cursus de MPR est fondé non seulement sur les principes médicaux traditionnels (diagnostic, évaluation fonctionnelle, traitement et suivi), mais aussi sur le modèle de l’International Classification of Functioning Disabilities and Health (ICF) et sur les preuves scientifiques. Trois facteurs supplémentaires influencent l’exercice professionnel :

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la nature de l’état de santé sous-jacent selon l’International Classification of Diseases (ICD) mais aussi les niveaux de fonctionnement selon l’ICF ;
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l’environnement : c’est-à-dire l’offre de soins, les programmes de soins et l’équipement (selon l’International Classification of Health Interventions [ICHI]) et la composition des équipes ;
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la politique de santé publique du pays ou de la région ce qui inclut le système de soins, le système de remboursement, l’épidémiologie des maladies et des incapacités et plus généralement l’organisation globale de la santé.