Clinician Insights

Many Physicians, Nurses Want Pain Removed as Fifth Vital Sign

Alicia Ault

February 21, 2017

Almost half of physicians and half of nurses strongly agree that pain should be eliminated as the fifth vital sign, according to a Medscape survey.

Medscape received more than 2100 responses to an online survey conducted in December 2016, a few months after the American Academy of Family Physicians (AAFP) Congress of Delegates voted to eliminate pain as a fifth vital sign. The AAFP delegates said the pain measurement — which has been used for decades — is subjective and has likely led to overprescribing of medications.

Respondents to the Medscape survey were asked directly whether they supported the AAFP vote. While 47% of physicians — who were from multiple specialties — said they strongly agreed, 17% said they somewhat agreed, and 19% said they strongly disagreed.

For nurses, 45% strongly agreed with the AAFP, 22% somewhat agreed, and 19% strongly disagreed.

"I applaud the AAFP for this common sense decision," said Marissa Ball, a registered nurse, in commenting on the survey. "Measuring pain by functional status is the way we were taught in nursing school and after three decades in nursing, I find it is still an accurate indicator."

Respondents were also asked about how often they use pain scores and functional status when assessing a patient's pain. More than half of physicians — 55% — said they often or always use pain scores, while 71% said they often or always evaluate functional status. Only a very small single-digit percentage said they did not use either measure.

For nurses, the numbers were reversed. The majority — 80% — said they used pain scores often or always. Fifty-three percent asked about functional status replied often or always.

Peggy Hollis, a clinical nurse specialist, said that evaluating function is just one part of the equation. "I believe strongly that we need to consider function as part of the assessment of pain," she commented, but "without a subjective grading of intensity, how do you titrate treatment to goals?"

Added Hollis, "Only the patient can describe at what intensity pain is tolerable. It is up to us to negotiate with the patient to identify a realistic goal for the patient."

Registered nurse Michele Fortune agreed that the patient should be at the center of a balanced and all-encompassing approach. "Pain is what the patient says it is!" she commented. "Yes — use functional status as well when assessing pain. Be holistic!"

Pain management specialist Ralph laraiso, MD, commented that patients don't use the Visual Analogue Scale in the way it was originally developed, "while others have learned to manipulate that scale to obtain the maximum amount of narcotic medications."

Dr Iaraiso said he relies more on functional status. "Many of these patients have psychosocial issues that will not be relieved by pain pills, but they will not admit to that nor seek appropriate professional services on their own, or, when referred, they are resistant," he said.

Others argued for keeping pain scores. Kritika Doshi, MD, an anesthesiologist, said that pain scores are important for patients, and "even more vital for physicians and surgeons to keep them sensitized to inadequate patient comfort." Added Dr Doshi, "Discontinuing pain as [a] fifth vital sign would be a sad blow to underdiagnosed and under-reported pain."

Keeping pain scores may also "be of value in knowing whether there is an immediate impact on the pain intensity by the medication prescribed," said Gilbert Mwaka, an anesthesiologist. But, he said, assessing functional status is a better tool to assess the efficacy of a therapy. "We should create more awareness through training that better equips medical practitioners with a tool for functional status assessment," commented Dr Mwaka.

Pressure to Prescribe?

Survey participants were asked how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high.

For physicians, 28% said often; 29%, sometimes; and 6%, always. About a third said they never or rarely felt that pressure. Nurses felt similar pressure. Thirty-percent said they often felt a need to prescribe; 23%, sometimes; and 12%, always. Thirty-five percent said they never or rarely felt pressured to prescribe.

Mary Mavraganes, a registered nurse, said, "often we are forced to give pain medicine per family or patient request." This can be the wrong move in the elderly, as they "become very confused, which results in falls," said Mavraganes.

Another registered nurse, Debra Bork, said, "Since the opioid epidemic hit the fan, people want narcotics for every little pain they have and expect to get them."

How Influential Are Reviews?

The survey asked respondents about the impact of patient reviews — whether through online surveys or the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) reviews — on clinician evaluation at their practice setting.

Fifty-four percent of doctors said the reviews were slightly or not at all influential; 26% said the reviews were moderately influential, 14% said very, and 6%, extremely.

"Government involvement in healthcare, especially HCAHPS, has no real value, but utilizes subjective measures and no outcome data to hijack hospital reimbursement," commented Allen Coleman, MD, an anesthesiologist. "Pain scores are entirely subjective and leave us treating numbers, which is something good medical students learn not to do in clinical rotations."

The surveys seemed to carry more weight with nurses. Twenty-two percent said they were extremely influential, 27% said they were very influential, and 23% said they were moderately influential. Just 27% said the reviews were not at all or slightly influential.

Some commenters expressed dissatisfaction with the reviews. "I feel the HCAHPS and Press Ganey tools have been a detriment to providing care to patients," commented Helen Kuhns, a registered nurse. "If you fail to prescribe a pain pill they want or antibiotic they think they need they score you poorly."

"I think the bigger problem is basing reimbursement on patient satisfaction," said Chloe Jolliff, also a registered nurse. "Patient satisfaction is not a reliable indicator of medical efficacy.

"Of course, patients shouldn't be left to be miserable, but this situation has created a monster in EDs [emergency departments] and in places like labor and delivery, where patients have an unrealistic expectation that they won't have pain and if they do then it's the caregiver's fault," commented Jolliff.

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