Vital Signs: Where does pain fit?

by Tyler Cymet, DO, FACOFP

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    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.

    About the Lecture

    The lecture Vital Signs: Where does pain fit? by Tyler Cymet, DO, FACOFP is from the course Osteopathic Principles and Tenets. It contains the following chapters:

    • Vital Signs are Vital – Where Does Pain Fit?
    • Joint Commission and Pain
    • Addiction to Treatment

    Included Quiz Questions

    1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
    2. APACHE (Acute Physiologic Assessment and Chronic Health Evaluation)
    3. MELD (Model for End Stage Liver Disease)
    4. CIWA (Clinical Institute Withdrawal Assessment)
    1. Hawthorne effect
    2. Placebo effect
    3. Butterfly effect
    4. Golem effect
    5. Osborne effect
    1. Pain
    2. Blood pressure
    3. Temperature
    4. Heart rate
    5. Respiratory rate

    Author of lecture Vital Signs: Where does pain fit?

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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