On coercion and ethics

NB: this post is opinionated.  It represents my own opinions and not those of my employer, my colleagues, my family or my dog.  It’s mine all mine.

If there is something that gets me really riled up, it’s bullying.  Maybe I had too much bullying when I was a kid, maybe I just believe in justice, but for whatever reason I get very grumpy when I see bullying.  Unfortunately this time, I think I’m being bullied – and not by a small-time bully either.

This is a very large organisation that refuses to pay an invoice for services provided because of a paragraph I wrote in the final report.  The paragraph is factual and directly related to the issues the patient raised during the pain management programme.  It just doesn’t suit some members of the organisation that have received it.

I’ll name no names, and I’m being deliberately coy about details, but I’m not a happy woman.

What did I say that was so dreadful?

I said that functional capacity evaluations can’t be used to predict daily function.

A couple of weeks ago I posted on this topic saying that the cumulative evidence over years has not changed: functional capacity evaluations, no matter how well they are carried out, do not have good predictive validity. I’m not going to say it again, once is enough!  In fact, a document that a colleague and I produced for a very large health purchaser in 1999 came to the same conclusion, and produced a set of guidelines for case managers to use when considering a referral for FCE.

Could it be that this report was written for the same corporation that wants me to withdraw my comment? My lips are sealed!

I wrote about this  for RTW Matters just recently.  The fact is, we don’t have any magic way to find out whether someone can or can’t return to a job except through doing it.

I understand that it’s incredibly difficult to determine whether someone deserves a benefit on the basis of whether they are incapacitated.  One author calls doctors who decide this ‘designated guessers’. The main reason health providers find it so difficult is that the decision is not a medical one.  It’s a socio-political one.  It’s based on  a ‘contract’ between members of a community.  It’s fraught with issues of honesty, intent, morality – and yes, in the case of ‘invisible illnesses’, it has the potential to be abused.

But is that something I need to think about when I write a report about things relevant to a client’s pain management programme?  It seems that I do, when the organisation paying for this report uses FCE as part of its process to decide whether someone has ‘capacity for work’.

Let’s put that aside for a moment and consider some of the ethical issues that I think are being challenged if I do what this organisation wants.

  1. Not accurately recording the issues relevant to the client’s programme
  2. Not disclosing the limitations of an assessment process
  3. Denying the client social justice by not providing him with information relevant to the assessment he has completed (I have to ask what the provider of the FCE was thinking about in terms of ethics: isn’t there a responsibility to advise people about the limitations of any assessment?)
  4. Asking me to collude with providing an inaccurate representation of the client’s concerns and content of the programme

There could be more..but that’s enough, don’t you think?

I guess the most worrying aspects of this whole affair are these:

  • this organisation isn’t saying I’m inaccurate in what I say about FCE – they just don’t like it, and think I shouldn’t say it.
  • they are using (and abusing) their position of power to coerce me into doing something that I think is unethical.
  • at the same time they’re trying very hard to deny a client the information he should have access to in order to defend against the opinion of the FCE provider.
  • AND the organisation is prepared to require this client attend another unnecessary programme just so they can get a report that suits their purpose.

What am I going to do?

If I was expressing an opinion, I might change or temper what I said.

If the client hadn’t raised this as a specific concern during the programme (and hadn’t identified ‘establishing functional abilities for work’ as a goal from the Plan of Action), I might have reconsidered a little.

But by not paying for the whole programme and report, and by suggesting the client might be required to go through another programme (unnecessarily) with another provider just to get a report this organisation likes, I’m Not Happy Indeed.

If I worked as a private practitioner in a solo practice, how would I respond to this kind of – well, let’s be honest, bullying?  Who would support me against a large organisation with a lot of purchasing power?  And who’s looking after the interests of the client?

At this stage the client doesn’t even know about the furore (and is probably wondering why the report hasn’t reached him yet – we’re not allowed to give him a copy of the report directly).

What do you think about it?  I’m keen to know your thoughts.


    1. Thank you so much kmom!! It just shouldn’t be allowed IMHO. And that there is no organisation that works to counter the actions of this purchaser makes it quite a challenge. The client doesn’t even know about the furore and is probably wondering why the report has taken so long to reach him. I’m just remembering: breathe in, breathe out, breathe in, breathe out!!

  1. Tough situation – but common nonetheless. We do FCEs in my adult practice and I agree that they are little more than snapshot perspectives on how a person decided to perform in my clinic at a given time. Now that being said, there are certain aspects of FCE where a therapist can look for internal consistency in performance and in that sense I find that they are sometimes quite helpful for identifying patterns of suboptimal effort.

    They are also useful for clients who truly want to go to work and who are interested in a cooperative process to determine their readiness for return to job activities.

    For everyone else – they provide mildly useful information – at best. I don’t know how your system works there but in the US system if I started writing that FCEs weren’t predictive right in the report I might as well be tossing figurative bombs at the State Worker’s Compensation division. In effect, you are dismantling the system by speaking the truth that you know.

    So, if it is true that there is a place and time for opinion and policy then I would suggest that you might try to share that kind of information in a forum other than the actual evaluation. You may be very correct – but they just don’t want you to be that overtly ‘correct’ in that evaluation context!

    What I do is document the truth that I see in the evaluation context. When I am called up for deposition or witness situations then I will talk about reliability and validity of results openly. I don’t believe that you are ‘hiding’ truth by failing to disclose the information right in your report. You would only be guilty of ‘hiding’ truth if you failed to properly disclose such limitations of evaluations while engaged in discovery or while being deposed.

    In the meantime, you can always lobby for change in another context.

    I hope you find a satisfying solution to handling this.


    1. I’m not critiquing the use of FCE in a compensation environment in the report I wrote – I simply stated that there are limitations to FCE interpretation.
      There is no evidence that I can find to demonstrate that therapists can accurately identify consistency of performance in one individual – if there are demonstrable differences, attributing it to ‘inadequate effort’ is an intellectual leap I’m not prepared to make, given the knowledge we have about kinesiophobia and the idiosyncratic beliefs people have about their pain and causal factors. So, I can’t agree that it’s possible to identify inconsistencies in performance within an assessment (at least, I haven’t seen any evidence to support this), and as a result I’m not comfortable with drawing conclusions about ‘suboptimal effort’. There can be multiple reasons for someone to NOT ‘do their best’ – like ‘I’m afraid this will really hurt’; ‘My doctor/physio/surgeon said I shouldn’t do X/Y/Z’ (or that’s what I’ve heard); ‘if I do this, I’ll have a terrible night’s sleep’; ‘I haven’t done this for ages and I’m not sure that I can’ – and all of these are quite valid reasons for not performing at maximal strength.

      I do recognise the usefulness of FCE for the client/patient. I’ve never said FCE’s are useless – just that they have significant limitations, notably of predictive validity and reliability.
      I don’t provide FCE’s any more – I’ve been trained using Isernhagen system and I’ve researched others – and if I did I’d have to preface any report with the limitations to interpretation that I know of. That’s ethical – just as psychologists do around cognitive testing and other psychometric assessments. So I’m guessing a purchaser who wanted to use the findings from FCE to establish capacity for work would NOT refer to me!

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