Insight Into How Physicians Determine Effort In The Office: Part 2
Posted on Tue, Jan 10, 2012 @ 09:00 AM
We will continue our discussion from last week on the resources physicians use to make decisions regarding patient care, in light of the article Motivation Determination (Sincerity Of Effort): The Performance APGAR Model, published in Disability Medicine (Vol. 1, No. 2, September-December 2001). We will begin where we left off, going into more detail on the elements of the Performance APGAR: Acceptance, Pain, Gut, Acting, and Reimbursement. The following are summaries of each component:
Acceptance. This has to do with how a patient interprets residual pain after tissue has healed-whether or not they find it “acceptable” or “unacceptable”. Asking the patient; “If this just doesn’t get any better, what will you do?” lends insight into where the patient is along this continuum (referring to the Kubler-Ross theory). The article indicates that patients at the “unacceptable” end “often resort to more medical opinions, treatments, alternative health care therapies, or aggressive surgeries with marginal if any chance for improvement”. Another component of Acceptance includes job satisfaction, and that “those dissatisfied with their work or employer are more likely to have a prolonged recovery and more likely to never return to full capacity”. Instructions and scores for each sub-category are indicated with a cumulative core of 0-2.
Pain. Scoring for “Pain” uses several references; a pain drawing (the Ransford Pain Drawing or similar tool) looking for comparison to known anatomical distributions, using the Assessment of Pain Behavior from the AMA Guides (which includes: moaning, protective posturing, facial grimacing, using a cervical collar or cane-even when indicated, limping/distorted gait, stooping while walking). Scoring ranges from 0-2.
Gut. Scoring for the “Gut” portion of the APGAR includes findings for The Credibility Assessment Tool and acknowledges “It is a difficult process to attempt to determine whether or not a patient is reporting the truth. The determination becomes even more difficult as the amount of potential secondary gain increases. Experienced clinicians become skilled at the art of distinguishing between real and fabricated allegations.” Here, the 5 areas of the tool are further discussed and defined. Interestingly, under the “Opinions about function given by treating and examining sources in the record”, it is observed that “opinions about the true impact of symptoms on functional capacity will be valuable in the credibility assessment.” The article also points out that consistency is very important in determining credibility, however it obviously is not the only measure; “consistency is important in the history given at different examinations.” When considering (other) medical opinions, the article notes that; “Those that have examined the patient would be given greater weight than the opinions of those who have not (insurance company file reviews, etc.)”. Also noted is that a medical provider with a longstanding relationship and over several visits (PT/OT?) may be more familiar with the patient’s limitations. In addition, conclusions about function that provide supporting evidence should be given more weight, and that the opinion of specialists should be given more weight than generalists-even if the length of time spent with the patient is “much less”. All in all, it seems that the Performance APGAR section on “Gut” outlines a good deal of reasoning based upon evidence and facts in the record rather than intuition alone.
Acting. When rating this section, the physician is instructed to observe the patient entering and leaving the office, when distracted during the examination, to administer Waddell’s Non-organic Signs (as appropriate), and evaluate performance upon testing using dynamometry-with calculating CV’s, Bell shaped curve analysis and REG analysis. Perhaps most interestingly, the article states; “As a side note, it is interesting to note that many experienced examiners have developed a sense of a significant correlation between inconsistent behavior and tattoos”. More significant value is placed on Waddell’s testing, with a direct link to the results and scoring for Acting; 0-1 translates to 2 on the APGAR, 2 positive Waddell’s tests equate to 1 on the APGAR, and 3 or more Waddell’s tests translate to a score of 0 for the Acting section of the APGAR.
Reimbursement. Scoring for this section is directly linked to potential secondary gain. Scoring is calculated as follows; 0=Someone else liable WC, PI, Disability Application Attorney Representing. 1=Someone else liable WC, PI, Disability Application. 2=No one Liable. Significant weight on the retention of an attorney is substantiated by “Once this happens the patient is obligated to prove and preserve an alleged injury or illness. Medical recovery jeopardizes the ability to prevail in a suit. Additionally, the worker’s own credibility is placed at risk. Hence, the disability continues throughout the litigation process, even in the absences of any objective medical basis for the disability”.
The scores for each individual section are compiled, and a Performance APGAR score generated. Total scores of 8-10 is reportedly consistent with what is optimally expected from a motivated patient, a score of 4-7 indicates concern about motivation, and a score of 0-3 suggests poor motivation to improve functional abilities.
It appears to this reader that physicians and Functional Capacity Evaluators use a good number of the same tools to help in the management of cases where impairment, disability and function are evaluated. Key differences might include most evaluators do not think in terms of “truthfulness” and “motivation”, and within our area of expertise, assign levels of effort over relatively short durations of time (during an FCE) with a direct link to “function” rather than the entire course of a medical case. All in all, this article contains a plethora of useful references to other works, contains many assertions I have wanted references too (not regarding tattoos), and overall tends to support, rather than dismiss our services in the FCE field. Perhaps most telling from my own experience with the previously mentioned IME, it appears that the physician erred when he came to a Performance APGAR score without giving due weight to Gut; supporting evidence, the opinion of specialists, and spending time with the patient in an examination of functional tasks.
Share your thoughts on the differences between physician and Functional Capacity Evaluator evaluations and case management. What interpretations do you have on determining effort and functional ability in light of this article?
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