00:01
Switching gears just a little bit.
00:04
We’ve seen a change in how we look at pain
and how we treat pain in the last 10 years,
and part of this was intentional.
00:13
Patient’s gained more power
in their relationship
nd they said our pain is not being
treated adequately by physicians
and they lobbied and they worked
within the political system
to change how we look at pain.
00:26
And about 10 years ago, we labeled
pain as a vital sign
even though it’s subjective, even
though there’s no measure.
00:34
The American Pain Society was
one of the leaders
that brought attention to this calling it
“an epidemic of untreated pain,”
and talking about how much more
we could do for people
if we gave them more narcotics
and treated their pain more.
00:47
The problem is, it’s a subjective sign
and we don’t have a number.
00:52
We don’t have a reproducible
way of monitoring it
between practitioners and between patients,
and one person’s 4 is another person’s 10,
and one person’s 10 is another person’s 21.
01:05
So getting an accurate measure
is going to be important.
01:09
With patient’s saying, “Treat us, Treat
us! Make us feel better,”
it became a vital sign—the 5th vital sign.
01:17
And we started saying if a person
says they have pain,
they need to get treated.
01:23
We also saw the Joint Commission say that
every hospital needs to assess pain
on every patient that’s treated.
01:30
It gave the patients more power, more input,
and also took the objective form
of assessing individual health
and threw a subjective measure in there.
01:42
This got bad in 2004,
when a number of state governments
said that not treating pain
should be punishable,
and they took it out of
the realm of science
and out of the realm of medicine.
01:54
We are trying to take it back saying that
objective signs should be objective
and mixing the two becomes very confusing
and very inappropriate.
02:03
So the AMA is supporting that
a subjective vital sign does not exist.
02:08
We also know that people react
to rewards and punishments.
02:12
If you say you’re going to be punished
for not treating pain,
and you’ll be rewarded for treating pain,
people are going to start treating it.
02:20
And the default is to do more.
02:22
The default is to treat,
and if you have a question, it’s
okay to give narcotics.
02:26
That’s going to be considered good
whether you overtreat it
or treat it mildly inappropriately.
02:34
And the patients wanted the input,
particularly patients who became addicted.
02:39
They wanted an easier way to
continue to get the medicines
and the patients were in control.
02:45
They said when care was complete,
they said when the pain was gone,
and they interpreted what their body
was feeling and took it forward.
02:53
The Joint Commission which
accredits hospitals
said that every patient, every shift, should
be asked if they had pain,
and if they said yes, they should be treated.
03:01
They also asked for standardize pain scales.
03:04
Standardized pain scales doesn’t
say standardized treatment
or standardized assessment,
so you can ask them 1 to 10,
you can ask them with smiley
faces to sad faces—
it still doesn’t make it objective.
03:16
It’s just a slightly more
reproducible number.
03:21
And patients satisfaction which included
how was their pain being done
became part of how we rated hospitals,
how we said how well hospitals were doing.
03:31
It’s called the HCAHPS Score and
it’s publicly identified data
on, they said, the quality of
care of the hospital,
but if the quality measure is not
directly related to the health
that we see as important
and where the subjective assessment
of how someone was treated,
we’re coming into conflict between
patients and doctors,
and we still need to come
to a better answer
in addition to just pain is
not a vital sign.
03:58
So the HCAHPS Scores does include pain.
It’s become much more common.
04:02
It’s seen everywhere and available
on the internet,
and it’s also overriding the
individualization of a plan
in terms of what should this person
with this disease need?
Somebody who comes into the hospital for
a toothache is going to be different
than someone who comes in to the hospital
pregnant and in labor
or with some other condition
that’s causing discomfort.
04:27
And we’re still fighting over whose
going to be in control
of deciding how the person is treated.
04:34
One of the problems with
labeling pain a vital sign
is the Hawthorne Effect.
04:39
Anything we pay attention to, anything
we do something for—
people feel that it’s improved just because
attention was paid to it
and their focus is on it,
and they feel that there’s some concept
of own transfer of responsibility.
04:53
They’ve told the healthcare provider—
it’s now up to the healthcare
provider to fix it
and giving up that responsibility,
feeling that it’s been addressed
helps a patient usually for about 8 weeks.
05:06
The downside is
particularly with manipulation
in patients with fibromyalgia.
05:12
How much do you get them better?
And if you’re getting somebody
better for 2 or 3 hours,
is that your goal?
Well the patient may like it
and then they feel better in the morning
and want to come back in the afternoon.
05:23
But what kind of benefit should
you get from treatment
to say it’s worthwhile?
And the other danger is addiction
not just to manipulation, but
addiction to opiates
and other pain medicines.
05:34
It happens, it’s real, and it’s getting worse.
05:37
The goal of healthcare is to make patients
comfortable and make their lives easier.
05:43
Patients want optimal health and function.
05:46
The goal of the patient and the
provider need to be aligned,
but you do need to talk to the patient
and come to a common goal.
05:53
The patients want input,
the doctors want to understand
what they’re doing
and know that it makes sense, and fits
within their scientific way of thinking.
06:02
So we’ve got a common goal, for the most part,
we need to talk about it and work
together to get to an answer.
06:10
Thank you.