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Skeptical Scalpel
Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 7200 followers on Twitter.
Skeptical Scalpel (click to view)
This has been bothering me for many years.
No, pain is not the 5th vital sign. It’s not a sign at all.
Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature. What do those four signs have in common?
They can be measured.
A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.
How did pain come to be known as the 5th vital sign?
The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001. Pain was allegedly being under treated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .
This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.
Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following:
Diseases have been discovered that have no signs and with pain as the only symptom.
Pain management clinics have sprung up all over the place.
In 2010, 16,665 people died from opioid-related overdoses. That is a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.
Meanwhile in the 10 years from 2000 to 2010, the population of the U.S. increased by less than 10% from 281 million to 308 million.
Doctors are caught in the middle. If we don’t alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.
Some states now have websites where a doctor can search to see if a patient has been “doctor shopping.” I once saw a patient with abdominal pain in an emergency room. After looking up her history on the drug use website, I noted that she had received 240 Vicodin tablets from various doctors in the 4 weeks preceding her visit.
That’s a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself.
What is the solution to this problem?
I don’t know, but as long as pain is touted as the 5th vital sign, I do not see it getting any better.
Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 7200 followers on Twitter.
There was a paper I read about this by Charles Lucas & Anna Ledgerwood in 2007. Talks about the balance between over and under medicating for pain.
“Kindness kills: the negative impact of pain as the fifth vital sign.”
I work with both physicians and nurses, and as a clinical ethicist who has lived with chronic pain for the past 25 years, I find all the comments on here disheartening. Physicians have a fiduciary duty to their patients, and I don’t give a damn what you think of your place in the power structure; its irrelevant to your duty, which is first and foremost to the best interests of the patient; if you don’t like it, get in another line of work. And while the opioid mismanagement epidemic is a grave issue, take a look at the data; a 2009 review of 67 studies found abuse/addiction rates among chronic pain patients with no prior history of abuse to be 0.19%, and yes, that decimal is in the correct place. The prescribers are more likely to become addicts than properly screened patients.
Perhaps the doctors believe they are holding to their “fiduciary responsibility to their patients” by not prescribing opiates. You can’t get addicted to a pill you never ingest.
Seriously flawed stats. I, myself, have probably had 16 opioid prescriptions in the last year. My Doc has to write a brand new one every month, because there are no refills allowed. The author might instead compare the total number of patients on opiods to the total population, not the number of individual scripts written.
That’s a good point. I am not sure when the no rills policy for opioids came into general use. It does not diminish the number of opioid-related deaths though.
It is very interesting to note that our current opioid abuse epidemic is due to JCAHO pencil-pushers and clipboard nurse administrators feeling jealous and wanting to obtain power over physicians. Making it a mission to label physicians as “disruptive” is another way. Too, having DNP’s with only 1/4 the training of Family Medicine physicians circumventing the process of extensive training and testing to lobby governments and hand them over the same authority and prescribing privileges is the coup de gras. And, now, doctors are even going to jail further demeaning our profession. The hostile nurses out there must be licking their lips that they have won.
Both Nietzsche, in his talking about people’s Will to Power, and Sartre, writing about the ressentiment–hostile resentment–of people wanting to overthrow those in power, predict such unfortunate matters in this case might occur. The result is that physicians, who effectively have more education than just about any other profession out there, are being denigrated. The end result is that patients will ultimately suffer.
I do agree that the nursing profession has championed the horrible pain scale, but as you said, those “champions” are the “clipboard administrators”, not bedside nurses. We pretty much despise the pain scale, as our Cheeto munching patients assure us they have pain level of a “10”. The Joint Commission is the biggest offender , coming up with more and more nonsense to keep us from actually doing patient care.
Thanks for the comment. I agree that many organizations led by the Joint Commission are responsible for the pain-opioid debacle and the never-ending proliferation of BS that must be “documented.”
First of all, just to make it clear – the subject was “Is Pain Really The 5th Vital Sign?” and the issue of increased opioids use, not MDs vs. RNs.
As an RN, BSN, and working on Joint Juris Doctor/MSN in Health Care law, with years of experience from ICU-ER/ED-Oncology to outpatient/primary care and Nurse Manager I do agree there is tension between nurses and MD’s, BUT bedside RNs DO know patients and their condition, pain much better than any physician because we are there with those patients at least 12 hours a day/night. In all the years of my experience I have yet to see any MD to spend even an hour by patients’ bedside. In a meantime 90-95% of physicians see RNs as “maids” who have to jump and run every time MD writes an “order”. With all those years of education MDs are the ones making most of the medication errors. Luckily RNs and pharmacists are able to catch them, but not all, and RNs are the ones who get blamed, fired, sued, and lose their license whenever those errors are not caught.
Back to the subject – “Is Pain Really The 5th Vital Sign?”, I agree that opioids are over prescribed, hence such a high number of addictions and O.D.s. Patients have unrealistic expectations and complain if they dont get complete %100 pain relief. Most refuse to understand it is almost impossible to be pain free with most chronic conditions and avoiding opioid addictions with all their side effects, and frankly don’t care.
It is a “damn if you do, damn if you don’t” situation that has to be addressed by everyone involved in patient care – from RNs to physicians to administrators.
I agree. This should not be about doctors vs. nurses. We are both caught in the trap of pain allegedly being a vital sign. Thanks for reinforcing the fact that 100% pain relief is an unachievable target.
Your hostility toward nurses is misplaced with respect to pain as the 5th vital sign. There was a terrific article in the WSJ in 2012 that shed light on how we got to this point. A Dr. Russell Portenoy and the American Pain Foundation, backed by opioid-producing pharma, led the charge on using pain as the 5th vital sign. They touted that chronic pain was grossly undertreated and that expanded use of opioids was the answer. They pointed to scant data to argue that the risk of addition was less than 1%. They repeated this so many times that it was accepted as truth by many, including the Joint Commission. So the truth is that we have our current opioid addiction problem as the result of physicians corrupted by consulting fees from big pharma. That being said, my experience working with physicians has been very colleagueal and respectful.
Wow, you sure do have a lot of disdain for the nurses who primarily care for patients don’t you!?!? I am a nurse, and I can tell you that I am happy being so. I love what I do and want nothing of what doctors have!!
SS – I appreciate your commentary and share your feelings and frustration. At the same time we are experiencing rage over the way legitimate patients and innocent physicians are victimized by the opioid debacle, many are moving away from opioids to a more effective and less costly form of treatment identified as electroanalgesia.
Not to be confused with TENS, this modality interupts the pain signal to the brain by depolarizing nerve cells, or causing the synapse in the peripheral nerve cell(s) to become so excited they fail to fire, preventing a signal from being transmitted to the brain. What opioids accomplish chemically, with side effects, and a limited duration of relief, electroanalgesia accomplishes within 25 minutes without any side effects.
Further, a series of treatments (8-12) typically provides relief for up to a year. Medicare reimburement for 12 treatments at about $40.00 each is equal to or less than the cost of a one month supply of opioids. There are over 100 peer reviewed and credentialed studies that attest to the efficacy of electroanalgesia. 3,000 physicians in the US use it, primarily in the Occ Med world. I also learned there are 6 NFL teams that have been using it for years to trerat multi-million dollar athlestes for pain related symptoms. There are also 20 very large and well reconized medical centers that utilize this mode of treatment across the country. We should know more about this solution.
We need to move away from the focus on opioids and all of their challenges to proven solutions that work, are less expensive, and have no side effects. Look for the Woessner or Schwartz electroanalgesia studies, they should open the eyes of those who seek a safe and viable alternative to opioids.
I would also acknowledge that masking pain as a symptom can leave an undiagnosed disease state to become a larger problem. Just like any responsible physician looks for underlying conditions before they prescribe opioids, physicians should only use electroanalgesia responsibly after performing a comprehensive evaluation of the patient.
You posed a question in your comments. What is the solution to this problem ? This in my opinion is at least one of the answers to your question.
Thanks for commenting. I was not aware of that device. I will have to investigate.