Who Should Lead the Rehab Team?

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By Judith Philipps Otto

Should the rehabilitation team leader be a physiatrist? Other physician specialist? Prosthetist/orthotist? Nurse? Some healthcare professionals give their opinions and
reasons for their choice.

Although other specialists may be called in as needed on a case-by-case basis, the core team remains physician-prosthetist-therapist, according to Joan Edelstein, MA, PT, FISPO, a senior research scientist in New York University's Department of Prosthetics & Orthotics from 1961 through the program's close in 1991. Sometimes, the physical therapist may not be needed, she notes, but the physician and prosthetist are always key members of the team.

Edelstein explains, "If we are discussing somebody who is getting a prosthesis for the first time, legally a physician must prescribe the prosthesis so that payment can be made; the prosthetist makes the prosthesis; and the therapist trains the patient in its use. Now, if we are talking about somebody who has worn a prosthesis for several years and knows how to use it and simply wants to replace a prosthesis that is worn or does not fit anymore, then the responsibility of the physical therapist is considerably less, because the patient already knows how to use the prosthesis. If he's going to be learning new skills--maybe he wants to engage in sports, for example--then, again, the therapist can be very helpful. So it depends on the particular patient."

Joan Edelstein, MA, PT, FISPO
Joan Edelstein, MA, PT, FISPO

A team leader is a necessity, agrees Edelstein. A leader is required "simply for orderliness, but also for administration and for ultimate responsibility, which is financial responsibility--and that person is the physician. While the de facto leader may indeed be the prosthetist, and in rare instances, the therapist, the de jure leader is always the physician."

In the past, the physiatrist would serve as the team leader, tying the whole team together, explains Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Prosthetics & Orthotics Inc, headquartered in Bethesda, Maryland. However, depending on the location, it's not always possible to have a physiatrist as leader--since not every town has a physiatrist. Often someone else has to take the role of team leader, whether it's a physical therapist, prosthetist or orthotist, occupational therapist, or physician. He points out that the ultimate team leader is, of course, the patient.

Kevin Carroll, MS, CP, FAAOP
Kevin Carroll, MS, CP, FAAOP

"Today, fortunately, we're dealing with an educated consumer; however there are still a lot of people out there who are unable to manage on their own as that team leader," Carroll says. "They've just gone through an amputation, and often they don't have the push' within them. However, if the patient is the team leader and they're a sharp individual, they get a lot of things done."

Carroll continues, "Often, we forget about the primary care physician, yet he or she is the one who has all the history of that particular individual from Day One. In the most rural areas across the United States, you always have the primary care physician who can step up to the plate as team leader."

Diverse Background Needed

Colm Roe, LPTA
Colm Roe, LPTA

"Although it will vary from case to case, team leadership should definitely be in the hands of somebody who has a diverse background," says Colm Roe, LPTA, physical therapist assistant, who is currently a case manager at a central Florida hospital and rehabilitation center. "There are moves under way right now within my organization to have, for example, physical therapists co-train and be qualified as nurses. Ideally, we would have somebody with an eclectic and multifaceted background--whether it is a social worker and a nurse, or a physical therapist and a prosthetist--who could be seen as a leader and respected as a leader by all of the team."

Leader Like a Movie Director

A unique view of team leadership is presented by Harry Webster, MD, chief, Division of Pediatric Rehabilitation Medicine, Tufts-New England Medical Center Hospital, Boston, Massachusetts, and assistant professor of rehabilitation medicine and pediatrics at the Tufts University School of Medicine. "The ideal person is normally an RN," says Webster. "But they are extremely expensive--almost more expensive than doctors, because of their contracts. The role of coordination and running' is different than the actual provision of service," Webster cautions.

Mildred Hake, transfemoral amputee, is assisted by Kevin Carroll, CP, and Eddie Traylor, MEd., physical therapist.
Mildred Hake, transfemoral amputee, is assisted by Kevin Carroll, CP, and Eddie Traylor, MEd., physical therapist.

He likens the rehab team's work to making a movie: "The director of a film doesn't really show up in the film--it's the actors. And we are the actors, who provide service and recommendations at the professional level. We're the people who are onstage with the patient. But the director should be the person most skilled in moving the actors around and getting the stage set, etc. And just as the director of the film knows everything from stage crew, lighting, dealing with difficult actor personalities--he is not trained in any of those areas," Webster explains, "the rehab team leader is someone who has that sort of systems view' of things and has interpersonal skills and enough technical skills to match the patient to the necessary specialist. If I had a large grant to set up a clinic, and I could hire anybody I wanted for that leadership role, I would probably look for a PA [physician assistant] or a RN with some administrative experience to take on that role."

As an example, Webster is also the medical director at a skilled nursing facility with a $5 million annual budget. However, the administrator--the coordinator--is an RN, "so she can understand what I need and why, and how to get it physically done. I admire those people who respect what we do, but have other skills to bring into the mix."

Webster concludes, "Really, the credentials could be quite varied, but probably the worst person to coordinate and run the clinic would be the physician!"

Judith Philipps Otto is a freelance writer who has also assisted with marketing and public relations for various clients within the O&P industry. A graduate of the University of Missouri School of Journalism, she has been a newspaper writer and editor and