Evaluator and patient having a discussion

Improve the Beginning to Improve the End of a FCE

Jan 26, 2017

Vic Zuccarello, OTR/L, CEAS II


The initial interview is the foundation of a functional capacity evaluation. A busy evaluator can conduct thousands of interviews in a practice lifetime. Even a modest improvement in interview style can greatly affect evaluation outcomes. George Engel, developer of the Biopsychosocial Model of Patient Care once said, “the interview is the most powerful, sensitive, and versatile instrument available to the clinician.” Apparently, patients are less concerned with how much the clinician knows than with how much the clinician conveys care and concern. Conveying a bit of caring during the interview can have a positive effect on outcomes.

FCEs are often litigated messes. The patient is lawyered-up, they are suspicious of the motives of physicians’ and therapists’ evaluations and inquiries, and they can be extremely fearful of re-injury. At worst, their behavior can range from guarded to hostile. But, even challenging patients deserve courtesy, respect, and meticulousness in the interview. The interview must be thorough not only because of quality concerns, but also for potential litigation concerns.

The Four Habits Model:

Researchers Frankel and Stein describe such an interview approach in their article “Getting the Most out of the Clinical Encounter”. It is derived from empirical and conceptual work on the interview and represents a synthesis of the available literature on interviewing effectiveness plus the authors’ clinical and teaching experience.

The “Four Habits Model” refers to the interview technique of the clinician to establish rapport/build trust, facilitate the exchange of information, demonstrate caring and concern, and increase the likelihood of patient compliance.

Habit 1: Invest in the Beginning

  • Create Rapport Quickly
    • Introduce yourself to the patient and their companion. Offer a handshake.
    • If the patient had to wait, acknowledge the wait time and apologize if late.
    • Review the chart ahead of time and convey knowledge of the problem(s).
    • Attend to the patient’s comfort. Inform them of where the restrooms and drinking water are and give them the opportunity to use them if needed.
    • Make a social comment or ask a non-medical question to put the patient at ease, “Did you have any trouble finding us?”
    • Adapt your language, pace, and posture in response to the patient.
  • Elicit the Patient’s Concerns
    • Start with open ended questions or statements
      • “I understand that you’re here for…..”
      • “Tell me about what the physician told you about this evaluation.”
      • “Could you tell me more about we got to this point?”
    • Speak directly with the patient if using an interpreter.
  • Planning the Visit
    • Repeat concerns back to the patient to check understanding.
    • Let the patient know what to expect.
      • “How about if we start with talking about….then I’ll do an exam, and then we’ll go over what I saw? Sound OK?”
      • Make sure the patient knows that their effort will be evaluated.
    • Prioritize when necessary.
      • “Let’s make sure we talk about X and Y. It sounds like you also want to make sure we cover Z.

Habit 2: Elicit the Patient’s Perspective

  • Ask for the Patient’s Ideas
    • Assess the patient’s point of view.
      • “What do you think is causing your symptoms?”
      • What worries you most about this problem?”
    • Ask about their interactions with significant others
      • Be careful, in the event the significant other is an enabler.
  • Elicit Specific Requests
    • Demonstrate the patient’s goal in attending the evaluation.
      • “When you’ve been thinking about this visit, how were you hoping it would go?”
  • Explore the Impact on the Patient’s Life
    • Check the context.
      • “How has the injury affected your daily activities/work/family?”

Habit 3: Demonstrate Empathy

  • Be Open to the Patient’s Emotions
    • Assess changes in body language and voice tone.
    • Look for opportunities to use brief empathic comments or gestures.
  • Make at Least One Empathetic Statement
    • Name a likely emotion, “That sounds you are frustrated.”
    • Compliment the patient on efforts to address the problem.
  • Convey Empathy Non-Verbally
    • Use a pause, touch, or facial expression.
  • Be Aware of Your Own Reactions
    • Use your emotional response as clue to what the patient may be feeling.
    • Take a brief break if necessary if you feel angry or frustrated.

Habit 4: Invest in the End

  • Deliver Feedback on Their Performance
    • Frame their demonstrated limitations in terms of patient’s objective effort.
    • Test the patient’s comprehension of what you are saying.
  • Provide Education When Possible
    • Review possible side effects from the FCE (i.e. soreness), and what they can do to enhance their recovery.
    • Recommend things they can do to improve their condition.
  • Involve the Patient in Discussing Return-to-Work
    • Discuss vocational goals.
    • Listen for the patient’s preferences regarding the existing or different job.
    • Set limits respectfully
      • “I can understand how your continued pain and discomfort makes you frustrated and angry. I cannot recommend medical testing, but I believe you should make a list of questions and discuss this with the physician when you return for a visit.”
    • Assess the patient’s ability and motivation to get better and return to some type of gainful employment.
  • Complete the Visit
    • Ask for additional questions
      • “What questions do you have for me?”
    • Assess satisfaction
      • “Did I address the lifting/handling and movement demands of your job? Is there anything I missed?”
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