The Fifth Vital Sign: How the Pain Scale Fails Us

Last October, I slumped in a chair at the doctor’s office while a nurse asked me if I felt any pain on a scale of 1 to 10. I wrinkled my forehead, and responded, “Is exhaustion painful?” I, like most others, often experience less than ideal sensations. From a broken arm when I was three and fell from my sister’s shoulders, to stress headaches, to rollerskating-induced scraped knees, to a body exhausted from walking across campus, forgotten lunch sitting in my refrigerator at home – all of these hurt, but in different and incomparable ways.

Pain is hard to describe. Think about the last time you had a headache: you might describe it as throbbing or sharp. Such descriptions are qualitative, and they might differ greatly from someone else’s experience of headaches. There’s no one objective way to understand or experience pain, yet every time you go to the doctor, you’re expected to answer the pain scale question.

There are four vital signs doctors use to assess a patient’s wellbeing: body temperature, pulse rate, respiration rate, and blood pressure. These standard metrics of patient wellness are relatively objective; the numbers garnered from these assessments indicate how far from baseline health a patient is. Body temperature has been used as an indicator of patient wellness since at least 1851 in western medicine, and pulse rate has acted as a marker of wellbeing for thousands of years globally. Blood pressure was first evaluated in the early 1700s in Europe, and a century later became better understood and more standardized. Respiration rate (how many breaths a person takes per minute) can be traced back to, at the latest, 1892, when abnormally rapid breathing began to be diagnosed as tachypnea. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), established in 1951, accepted these four vital signs as sufficient for over half a century. It wasn’t until 2001 that the JCAHO introduced patient pain as the fifth vital sign. Pain as the fifth vital sign didn’t quite fit with the others; while the other vital signs focused on standard quantitative metrics of wellness, pain was typically self-evaluated by patients, based on their own metrics. This new assessment shifted doctors’ goals when it comes to pain: try to decrease a number on a scale, rather than find underlying causes of patient pain.

A 19th-century engraving of an instrument, known as a sphygmograph or pulsometer, used to record graphically the features of the pulse and variations in blood pressure. (Courtesy Wellcome Collection)

This new vital sign is the only one that’s subjective. All other vital signs are derived from standardized medical technology that quantify how bodies function. Temperature, heart rate, respiration rate, and pulse can give us a standard idea of a patient’s wellness. But because we all experience pain differently, there’s no true standard for it; yet the pain scale is now customary across the nation. In the past twenty years, the pain scale has been used to determine if a patient’s complaint is urgent. But even this assessment of urgency is misguided. In the National Pain Report, columnist Liza Zoellick writes, “What if my ‘7’ sounds like I’m lying? What if they think I want more drugs? … When presented with this scale it feels like you are trying to fit my pain into your version of what you think it should be.” Doctors’ perceptions of patients will inevitably infiltrate how they understand someone’s assessment of pain.

As such, the pain scale treats suffering as a spontaneous, curable, physical sensation. This model fails to account for other experiences of pain that might be psychosomatic. For example, pain might feel different for people with mental illnesses like anxiety, depression, or other mood disorders. While mental illness might not cause abrupt, physical pain, the consequences of these disabilities can put significant strain on our bodies. Comparing a broken arm to chronic fatigue, or a stubbed toe to nausea, seems inadequate, if not outright harmful. The physical pain scale helps doctors to minimize pain via a numerical assessment, but this kind of one-shot diagnosis is unlikely to help people with ongoing mental illness.

The pain scale also contributes to medical discrimination. Assumptions about race, gender, and ability affect how doctors legitimize (or minimize) pain. While more privileged individuals are likely to be believed and treated with care by doctors, marginalized people are often treated as if they’re overreacting or lying about their pain. For centuries, doctors have disbelieved women, people of color, and people with disabilities in their claims of suffering and illness. We know that marginalized communities receive less and worse care than their more privileged counterparts. The medical industry allows for bias to be understood as objective fact via the pain scale. Doctors are less likely to believe marginalized patients in their assessments of pain, meaning the pain scale acts as a justification for discrimination.

Not only do healthcare providers’ assessments leave room for provider bias, but their assessments also can’t account for individuals who are always in some level of pain. For people with disabilities like Ehlers-Danlos syndrome, arthritis, or endometriosis, pain operates differently than for those who are able-bodied. For example, what does a zero on the pain scale mean for someone who experiences chronic pain? If someone is constantly in pain, is that their baseline? The pain scale doesn’t take into account the varying degrees of pain that different people live in. Having no set standard for approaching pain leads to insufficient, bias-informed, and ever-changing assessments of pain. By attempting to standardize pain, doctors fail those with chronic illness who may never experience a zero.

“What does a zero on the pain scale mean for someone who experiences chronic pain?” One version of the pain assessment scale.

In tandem with bias, the pain scale also enforces pain as exemplary of something that needs to be fixed immediately, rather than symptomatic of a larger picture of wellness. Imagine if a doctor took a look at a patient’s pulse rate, and instead of attempting to tackle what that pulse rate might indicate, they simply gave them beta-blockers to slow their heart down. Healthcare providers would be at risk of missing a larger problem, might harm a patient by giving them insufficient medication, and might cause a fatality. The pain scale acts as an impetus to encourage similar action. Instead of looking deeper to understand why a patient might be in pain, some doctors seem to treat opioids as the ultimate fix.

Historically, doctors’ emphasis on pain management has risen in tandem with the overprescribing of opioids. Because doctors focus so heavily on minimizing pain, even if unrelated to patients’ reasons for visiting the doctor, there has been a steady rise in the overprescription of opioids. In 2001, the year that the pain scale became standardized by the JCAHO, 126 million prescriptions for opioids were in circulation. By 2010, that number had almost doubled. The pharmaceutical companies weren’t sly with their profit motive: if doctors became more reliant on opioids, the pharmaceutical industry would flourish with their pill-pushing. But for many individuals, especially those with chronic illness or disability, pain will never go away. The reliance on pain as something to be fixed, rather than just one factor in the overall synthesis of patient health, hinders the full picture of an individual’s medical needs and consequently encourages doctors to overprescribe opioids to patients who might not need them.

It is clear that two problems have arisen in parallel to one another. First, pain is often minimized (especially for marginalized patients), and second, pain is also often exaggerated to a point where doctors feel the need for an immediate fix. But picking a number on the pain scale is unsuccessful in its aims. While problems with the pain scale go much deeper than just one issue with the medical industry, there are actionable steps to better serve patients while the entire system of medicine incrementally shifts to better serve everyone, regardless of identity or social location.

The medical industry can better serve its millions of patients by reframing descriptions of pain as qualitative rather than quantitative. These pushes for qualitative descriptions of pain are already occurring. Columbia University’s Department of Medical Humanities and Ethics houses the Division of Narrative Medicine (DNM), which advocates for healthcare professionals to take an alternate approach to assess patient pain.

Instead of trying to use the pain scale as an objective measure of wellness, the DNM program emphasizes personal accounts of illness. When patients describe their pain in an in-depth, subjective narrative, healthcare workers can focus on understanding a bigger picture of that client’s health. Science tends to shy away from anything that doesn’t feel objective, but these personal accounts can be incredibly useful in recognizing the inherent subjectivity of the human condition. In this model, the pain scale is no longer utilized as one of the vital signs. Instead, patients are given the agency and opportunity to be involved in their doctor visits. These qualitative descriptions will serve as a clearer and more accurate means to support patients. While ridding the medical industry of the pain scale will help make healthcare more comprehensive, it should also be accompanied by extensive training on implicit bias, disability justice, and the history of oppression within the medical industry.

A bigger-picture understanding of patient wellbeing (paired with a plentiful serving of unlearning socially-developed assumptions and biases) will better serve patient health, satisfaction, and equitable access to medical support.

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One Comment

Susan Cutler

What a wonderful concept. I have pain 24/7 fron RSD/CRPS. On one pain scale, it’s listed as higher than cancer pain. It’s a constant, burning pain that can not be treated. As if you’ve put your hand in lighter fluid, lit it on fire, and let it burn. Forever. Mine affects both my legs and feet. I’ve had 11 surgeries before being diagnosed. It’s been 20 years and I’m still fighting the pain. There is no treatment. And no place on the “pain scale” to satisfy that pain level.

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