REHABILITATION
BEDBROOK
COMMENTS O N REHABILITATION G. M. BEDBROOK Chairman, Department of Orthopaedic Surgery and Senior Spinal Surgeon, Royal Perth Hospital and Royal Perth Rehabilitation Hospital
HAVING had time t o consider the editorial comments on the "College and Rehabilitation" (Hughes, 1977) and t o read the excellent reviews published in that issue, I should like to make a few comments on this important subject. Recently 1 completed a brief survey in various regional cities of Australia, where there is no doubt that rehabilitation resources are inadequate. Thus claims by the stated reports, both by the Senate and Woodhouse (1974) as quoted, have factual support. Regretfully, I can only endorse the findings of the Woodhouse Report, Volume 2, p. 73: "a striking lack of awareness on the part of many doctors of what rehabilitation is and what it can achieve". This statement reflects the attitudes of some in the Royal Australasian College of Surgeons, in whom, regretfully, the prowess of surgical techniques apparently reigns supreme. I had hoped that the editorial comment (Hughes, 1977) regarding the average Australian and New Zealand surgeon was correct, but my experience and investigations lead me t o believe that criticism as above stated is fair, and should be a challenge to the Royal Australasian College of Surgeons t o increase materially the content of training in rehabilitation via its speciality boards. So far, any real action has been small. The Woodhouse criticism (Volume 2, p. 74): "those areas in which there are first class medical rehabilitation facilities. . . are often due to the initiative and leadership and enthusiasm of the individual doctor", is, I am sure, more applicable to the area of rehabilitation than activities in other areas. In my Windsor address, "The Final Responsibility in Emergency", (Bedbrook, 1976), I have already pointed out the reasons and the solutions. It is reassuring to know that such criticism by the Woodhouse Commission, levied fairly by very competent well-qualified investigators, has been drawn to surgical attention. Ausr. N.Z.J. SURG., VOL. 48-No.
1, FEBRUARY, 1978
Recently, the National Specialist Qualification Advisory Committee decided after much debate to recognize rehabilitation medicine as a major speciality. I believe this was done in an attempt to stimulate further both physicians and surgeons. Rehabilitation centres have been clearly defined by the Woodhouse Report in Volume 2 on pages 33-34 and pages 3 9 4 0 . Medical centres should not be isolated from hospital practice, but general or vocational centres, such as those exemplified in the Sheltered Workshop Movement, should be away from the usual hospital atmosphere. Such need medical support and interest. M y recent regional investigations showed that although interested and willing, many surgeons are weighed down by acute surgical problems, and thus the priority of life outweighs the rehabilitation priority. Trueta showed in his biography of Girdlestone and Sir Arthur Keith also showed in his classic Menders of the Maimed, that rehabilitation medicine has always competed badly for priorities in delivery of services and so it does still. It is less dramatic to us as surgeons, but quite dramatic to the recipient. At present, most of the Chairs of Surgery in Australia make little reference to the subject as part of the therapeutic process. At the Jubilee Seminar on Rehabilitation held in Perth, the absence of academic interest, and indeed, of great surgical interest, was noteworthy. No single advisory body could become expert in all fields. Unless the present Chairs increase their rehabilitation content quickly, I believe the Royal Australasian College of Surgeons should actively support Chairs in Rehabilitation Medicine, to be held either by surgeons or physicians of either Royal College. This will be the only way in which medical students will get exposure to a neglected area. The working party in Western Australia referred to by E. S . R. Hughes, whilst 93
BEDBROOK
REHAB I LlTATl ON expressing the view indicated by him, also agreed that an academic position in this field was a practical necessity and recommended so accordingly in Recommendation 2. I quote: "It was recommended that the University establish a Chair of Rehabilitation. It was considered that the appointee to the Chair could come from any clinical discipline, that such a person should be academically and clinically well qualified in his o w n discipline, . . . the new Professor would be placed in an existing University Department, probably the Department of Medicine and Surgery." Professor Sir Edward Hughes asks of surgical areas that need help. There are a number that can be easily stated as indicated in my Presidential Address t o the Australian and New Zealand Orthopaedic Associations in Hobart, in October 1977. They are areas where surgeons should be more actively engaged: surgical neurology; spinal pain; prosthetics; orthotics; appliances; restorative workshops; urinary dysfunction; and manipulative therapy (Bedbrook, 1977). If w e are numerically overtraining surgeons in some speciality groups, perhaps the College could take action soon in this area and encourage surgeons to help t o fill the vacant posts in rehabilitation around the Commonwealth of Australia with those whose training befits such practice, or ensure further training t o fit men for an area where surgeons traditionally, after times of world conflict, did take up the challenge. Please don't let us repeat history when a Royal College effectively closed a rehabilitation hospital in 1926 and turned a blind eye t o the therapeutic process (Bedbrook, 1976). The prevention of disability, as Robert Jones said in 1926, should be, and thankfully is, our goal, as the June 1977 volume of the Australian and N e w Zealand Journal of Surgery showed. There are countless numbers now, whose disability has been prevented and relieved by members of the Royal Australasian
94
College of Surgeons by surgical techniques, but what of those w e could not relieve? The recent seminar on rehabilitation engineering at the University of New South Wales, organized by the National Advisory Council for the Handicapped, is a pointer t o new advances. Regretfully, few surgeons thought it valuable enough t o attend. The Royal Australasian College of Surgeons, if it wishes t o maintain the views expressed in the editorial comment, must take up the challenge more practically in all specific areas, and take action quickly to see that well-trained and qualified surgeons play their role in the increasing problems of surgical disability over long periods of time. If complete rehabilitation is the aim of all surgeons (regretfully, it probably won't be), I believe no segregation in rehabilitation medicine is necessary, but some will have greater interest than others. I trust the College will stimulate this individuality within the practice of surgery so that at least all patients-if not all surgeons-do receive complete care and not at times, as at present, incomplete care. Perhaps the Conjoint Surgical Board of the College could debate this whole subject with those w h o have reviewed the whole area broadly and fully for the Woodhouse Report.
REFERENCES BEDBROOK, G. M. (1976). Med. J. Aust.. 1: 107. G. M. (1 977). Presidential Address-"On IndiBEDBROOK, vidualism" delivered at Combined Australian and New Zealand Orthopaedic Associations Meeting, Hobart, 1977. (To be published). COMPENSATfON A N D REHABILITATIONIN AUSTRALIA (1974). Rehabilitation and Safety, Woodhouse Report, Volume 2: 33, 39, 73, 74. HUGHES. E. S. R. (1977). Editorial Comment, AUST. N.Z. J. SURG.,47: 264. KEITH, A. (1919). Menders of the Maimed, Oxford Medical Publications, London. TRUETA. JOSEPH(1971 ), Garthorne Robert Girdlestone, Oxford University Press, London.
AUST. N.Z.
J. SURG.. VOL.
48-NO.
1, FEBRUARY, 1978
BEDBROOK
COMMENTS O N REHABILITATION G. M. BEDBROOK Chairman, Department of Orthopaedic Surgery and Senior Spinal Surgeon, Royal Perth Hospital and Royal Perth Rehabilitation Hospital
HAVING had time t o consider the editorial comments on the "College and Rehabilitation" (Hughes, 1977) and t o read the excellent reviews published in that issue, I should like to make a few comments on this important subject. Recently 1 completed a brief survey in various regional cities of Australia, where there is no doubt that rehabilitation resources are inadequate. Thus claims by the stated reports, both by the Senate and Woodhouse (1974) as quoted, have factual support. Regretfully, I can only endorse the findings of the Woodhouse Report, Volume 2, p. 73: "a striking lack of awareness on the part of many doctors of what rehabilitation is and what it can achieve". This statement reflects the attitudes of some in the Royal Australasian College of Surgeons, in whom, regretfully, the prowess of surgical techniques apparently reigns supreme. I had hoped that the editorial comment (Hughes, 1977) regarding the average Australian and New Zealand surgeon was correct, but my experience and investigations lead me t o believe that criticism as above stated is fair, and should be a challenge to the Royal Australasian College of Surgeons t o increase materially the content of training in rehabilitation via its speciality boards. So far, any real action has been small. The Woodhouse criticism (Volume 2, p. 74): "those areas in which there are first class medical rehabilitation facilities. . . are often due to the initiative and leadership and enthusiasm of the individual doctor", is, I am sure, more applicable to the area of rehabilitation than activities in other areas. In my Windsor address, "The Final Responsibility in Emergency", (Bedbrook, 1976), I have already pointed out the reasons and the solutions. It is reassuring to know that such criticism by the Woodhouse Commission, levied fairly by very competent well-qualified investigators, has been drawn to surgical attention. Ausr. N.Z.J. SURG., VOL. 48-No.
1, FEBRUARY, 1978
Recently, the National Specialist Qualification Advisory Committee decided after much debate to recognize rehabilitation medicine as a major speciality. I believe this was done in an attempt to stimulate further both physicians and surgeons. Rehabilitation centres have been clearly defined by the Woodhouse Report in Volume 2 on pages 33-34 and pages 3 9 4 0 . Medical centres should not be isolated from hospital practice, but general or vocational centres, such as those exemplified in the Sheltered Workshop Movement, should be away from the usual hospital atmosphere. Such need medical support and interest. M y recent regional investigations showed that although interested and willing, many surgeons are weighed down by acute surgical problems, and thus the priority of life outweighs the rehabilitation priority. Trueta showed in his biography of Girdlestone and Sir Arthur Keith also showed in his classic Menders of the Maimed, that rehabilitation medicine has always competed badly for priorities in delivery of services and so it does still. It is less dramatic to us as surgeons, but quite dramatic to the recipient. At present, most of the Chairs of Surgery in Australia make little reference to the subject as part of the therapeutic process. At the Jubilee Seminar on Rehabilitation held in Perth, the absence of academic interest, and indeed, of great surgical interest, was noteworthy. No single advisory body could become expert in all fields. Unless the present Chairs increase their rehabilitation content quickly, I believe the Royal Australasian College of Surgeons should actively support Chairs in Rehabilitation Medicine, to be held either by surgeons or physicians of either Royal College. This will be the only way in which medical students will get exposure to a neglected area. The working party in Western Australia referred to by E. S . R. Hughes, whilst 93
BEDBROOK
REHAB I LlTATl ON expressing the view indicated by him, also agreed that an academic position in this field was a practical necessity and recommended so accordingly in Recommendation 2. I quote: "It was recommended that the University establish a Chair of Rehabilitation. It was considered that the appointee to the Chair could come from any clinical discipline, that such a person should be academically and clinically well qualified in his o w n discipline, . . . the new Professor would be placed in an existing University Department, probably the Department of Medicine and Surgery." Professor Sir Edward Hughes asks of surgical areas that need help. There are a number that can be easily stated as indicated in my Presidential Address t o the Australian and New Zealand Orthopaedic Associations in Hobart, in October 1977. They are areas where surgeons should be more actively engaged: surgical neurology; spinal pain; prosthetics; orthotics; appliances; restorative workshops; urinary dysfunction; and manipulative therapy (Bedbrook, 1977). If w e are numerically overtraining surgeons in some speciality groups, perhaps the College could take action soon in this area and encourage surgeons to help t o fill the vacant posts in rehabilitation around the Commonwealth of Australia with those whose training befits such practice, or ensure further training t o fit men for an area where surgeons traditionally, after times of world conflict, did take up the challenge. Please don't let us repeat history when a Royal College effectively closed a rehabilitation hospital in 1926 and turned a blind eye t o the therapeutic process (Bedbrook, 1976). The prevention of disability, as Robert Jones said in 1926, should be, and thankfully is, our goal, as the June 1977 volume of the Australian and N e w Zealand Journal of Surgery showed. There are countless numbers now, whose disability has been prevented and relieved by members of the Royal Australasian
94
College of Surgeons by surgical techniques, but what of those w e could not relieve? The recent seminar on rehabilitation engineering at the University of New South Wales, organized by the National Advisory Council for the Handicapped, is a pointer t o new advances. Regretfully, few surgeons thought it valuable enough t o attend. The Royal Australasian College of Surgeons, if it wishes t o maintain the views expressed in the editorial comment, must take up the challenge more practically in all specific areas, and take action quickly to see that well-trained and qualified surgeons play their role in the increasing problems of surgical disability over long periods of time. If complete rehabilitation is the aim of all surgeons (regretfully, it probably won't be), I believe no segregation in rehabilitation medicine is necessary, but some will have greater interest than others. I trust the College will stimulate this individuality within the practice of surgery so that at least all patients-if not all surgeons-do receive complete care and not at times, as at present, incomplete care. Perhaps the Conjoint Surgical Board of the College could debate this whole subject with those w h o have reviewed the whole area broadly and fully for the Woodhouse Report.
REFERENCES BEDBROOK, G. M. (1976). Med. J. Aust.. 1: 107. G. M. (1 977). Presidential Address-"On IndiBEDBROOK, vidualism" delivered at Combined Australian and New Zealand Orthopaedic Associations Meeting, Hobart, 1977. (To be published). COMPENSATfON A N D REHABILITATIONIN AUSTRALIA (1974). Rehabilitation and Safety, Woodhouse Report, Volume 2: 33, 39, 73, 74. HUGHES. E. S. R. (1977). Editorial Comment, AUST. N.Z. J. SURG.,47: 264. KEITH, A. (1919). Menders of the Maimed, Oxford Medical Publications, London. TRUETA. JOSEPH(1971 ), Garthorne Robert Girdlestone, Oxford University Press, London.
AUST. N.Z.
J. SURG.. VOL.
48-NO.
1, FEBRUARY, 1978
