Sir,

In Western Europe, approximately 10% of the population experience disability of some kind. Disabling conditions typically encountered by Physical and Rehabilitation Medicine (PRM) specialists are: trauma; neuroloical disorders, including stroke; acute and chronic pain, musculoskeletal diseases; and age-related deterioration (1). In Europe, approximately 6% of the working-age population rely on disability benefits and the unemployment rate of people with disability is twice the overall level (2). Rehabilitation is defined by the World Health Organization (WHO) as “instrumental in enabling people with limitations in functioning to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life”. (3) In turn, PRM is “an independent medical specialty concerned with the promotion of physical and cognitive functioning, activities (including behaviour), participation (including quality of life) and modifying personal and environmental factors” (1). Both definitions emphasize the comprehensiveness of rehabilitation and the nature of our speciality. Regardless of that, splitting rehabilitation into medical, social, vocational, and educational is common practice, even though it is artificial. Such separation reflects administrative systems rather than aspects of functioning in real life. For example, a person with chronic low back pain may need a multidisciplinary rehabilitation intervention. A physiotherapist helps the patient to plan a physical exercise programme, a social worker assists the person to clarify insurance benefits, and a rehabilitation planner helps him to obtain medical devices and housing modifications to enable living at home. If needed, a psychologist may estimate the skills for a potential vocational re-education. At the end of the procedure, a physician may write a statement concerning work ability supporting a rehabilitant’s decision to switch his profession to one that is less physically demanding. Is such a procedure medical, social, vocational, or educational? According to the biopsychosocial model, functioning and rehabilitation cannot be divided into separate parts and vocational rehabilitation should be embedded into the rehabilitation process.

At first glance, the White Book on Physical and Rehabilitation Medicine in Europe supports this holistic way of defining the core of PRM. The primary goals of PRM are defined as follows: “The two fundamental outcomes of rehabilitation that have to be demonstrated are the person’s well-being and their social and vocational participation” and later: “PRM specialists use specific diagnostic assessment tools and carry out many types of treatments, including pharmacological, physical, technical, educational and vocational interventions” (1). In other words, vocational rehabilitation should be recognized as a fundamental dimension of PRM and it should play a substantial role in our training and practice. Are we acting according to our own definitions? How well are vocational rehabilitation issues covered in PRM training?

We conducted a rough evaluation on how broadly teaching vocational rehabilitation topics is covered in PRM training in European countries. The short informal survey was sent to all national managers on the European Board of PRM. As the European Board of PRM is responsible for harmonization of pre- and postgraduate PRM education in Europe, it was thought that Union Européenne des Médecins Spécialistes (UEMS) delegates are a good source of such information. The survey contained 4 questions concerning the role of vocational rehabilitation training in both pre-graduate phase and amongst PRM trainees. The managers were asked: (i) if pre-graduates have any exposure to vocational rehabilitation issues; (ii) if PRM trainees have any exposure to vocational rehabilitation issues during their training; (iii) what is the intensity of this exposure; and (iv) if vocational rehabilitation issues are covered by a national PRM certification examination. Of the 33 national managers, 14 responded. The responses have been received from the representatives of Georgia, Portugal, Romania, Poland, Czech Republic, Italy, UK, Germany, Ireland, Belgium, Bosnia-Herzegovina, Hungary, Netherlands, and Croatia. After adding Finland on the list (author MS being a national representative in the International Society of Physical and Rehabilitation Medicine (ISPRM)), data on 15 European countries were analysed. The answers were unified and roughly dichotomized. Responses like “only few” were considered as a “no”.

Fig. 1 presents the results of the survey. In 2 countries only, pre-graduate medical training contained some vocational rehabilitation topics. Only every fifth country embedded vocational rehabilitation into their PRM training systematically. The intensity of vocational rehabilitation training was generally small. Only 3 countries included vocational rehabilitation issues in their PRM certification examinations systematically. Some responses also showed that the concept of vocational rehabilitation was assumed to be something more limited, such as “occupational therapy”.

The results of this survey were expected. While the White Book on Physical and Rehabilitation Medicine in Europe mentions the importance of vocational rehabilitation in PRM, the concept of vocational rehabilitation is not defined. The PRM logbook recommended by the European Board of PRM does not include vocational rehabilitation topics in the curriculum of studies and theoretical knowledge (4). Ergonomics at workplaces and work-related disorders are the only 2 items that cover topics somehow related to vocational rehabilitation in that logbook. According to the examples published on the European PRM Board web site, it is obvious that vocational rehabilitation issues are also covered poorly in European PRM examination (5, 6). It is not known how often PRM specialists working in different settings and countries encounter vocational rehabilitation problems in their daily practice. It could, however, be assumed that competence to deal with vocational rehabilitation issues may be affected by insufficient training. As far as we know, vocational rehabilitation topics are also not a systematic part of residential training in Physical Medicine & Rehabilitation in the USA (7).

The role of vocational rehabilitation in PRM training should be re-estimated. Both pre-graduates and PRM trainees need a comprehensive view on functioning including vocational rehabilitation as an important tool in maintaining work ability. Increasing and deepening education of vocational rehabilitation may also change the practice routines of a PRM specialist. We do not suggest that PRM specialists would replace other parties involved in vocational rehabilitation, such as social workers, insurance officials, occupational therapists, or occupational physicians. Neither should we concentrate only on vocational rehabilitation in our training and practice. We suggest that vocational rehabilitation should always be associated with our holistic understanding of functioning. Thus, the bias possibly existing in our speciality training, a risk of having imperfect understanding of functioning, can be corrected. We could train our students and trainees to take into account vocational rehabilitation issues with all patients, not only when working in separate vocational rehabilitation units. Our clinical examinations and recommendations do not need to stop at the point where vocational rehabilitation issues arise. Where should we begin? For example, from arranging interdisciplinary vocational rehabilitation teams, lectures, seminars, workshops on work ability assessment, and support by seniors for pre- and postgraduates. We should remember what makes PRM so special. If we limit our field to “medical rehabilitation” only, the essential focus of our speciality – comprehensive understanding of functioning – may be lost. Let us admit that vocational rehabilitation issues are vital for understanding of functioning. The starting point of this change may be simply following our own definitions and guidelines the White Book on Physical and Rehabilitation Medicine in Europe.

The authors declare no conflicts of interest.

Accepted Aug 17, 2016; Epub ahead of print Sep14, 2016.

Mikhail Saltychev, PhD, MD and Katri Laimi, PhD, MD

From the Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland

E-mail: mikhail.saltychev@gmail.com

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