Friday, August 29, 2014

Pain is not the "5th vital sign"

No, contrary to what you may  have heard, 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 because pain was allegedly being undertreated. 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 with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, 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 US 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 prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four 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 during that month.

What is the solution to this problem?

I don't know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

Thursday, August 28, 2014

The solo general surgeon is a dying breed. What is next?

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Tuesday, August 26, 2014


Back in May, I posed this question, "Does anyone really read anything online?" Based on some data from various sources, I concluded that not many do. I also noted that many links I tweeted were passed along by others who could not possibly have read them in the elapsed time between my tweet and their tweet.

The problem may not be limited to online readers.

Have you ever heard of "tsundoku"? It's an informal Japanese word defined as "the act of leaving a book unread after buying it, typically piled up together with other such unread books."

This reminds me of a phenomenon which I observed among medical students and surgical residents over the course of many years.

Whenever a subject arose that they were not too familiar with, they would go off to the library and copy some articles about it and carry the articles around in their pockets for weeks. The papers would curl up at the edges and become as soiled as their white coats. But most of the time they were never read.

I would point out to them that photocopying an article, even though it can take a few minutes, was not a substitute for actually reading it.

I thought I might have been the only one to have noticed this, but recently a Twitter follower of mine, Terry Murray [‏@terromur], tweeted, "In the 1980s, the librarian at Hosp for Sick Children in Toronto urged 'neuroxing' (i.e., reading) instead of photocopying."

The Internet version of this phenomenon is facilitated by programs like Evernote, which make it easy to save links or PDFs for reading later. And you don't even have to go to the library.

I suppose some people eventually do read them. But I'll bet the majority don't.

Maybe the definition of tsundoku should be expanded to include the act of leaving a link unread after tweeting it, typically piled up together with other such unread links.

Friday, August 22, 2014

Should healthcare workers stop shaking hands and "fist bump" instead?

Some well-intentioned researchers from West Virginia University published a small study claiming that substituting a fist bump for a handshake might reduce the transmission of bacteria.

Since many illnesses can be transmitted by contaminated hands, the idea is plausible, but it's a good example of the media misinterpreting a study and misleading naïve readers..

They measured the surface area of open hands and fists in 10 subjects. Not surprisingly surface area of an open hand was significantly greater than that of the fist—30.206 vs. 7.867 sq. in. respectively, p < 0.00001.

They also measured the contact time of handshakes and fist bumps. The handshake took 2.7 times longer than that of the fist bump (0.75 vs 0.28 seconds). [No statistical analysis provided]

Wednesday, August 20, 2014

A paper of mine was published. Did anyone read it?

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasn't even sure that anyone had read them. He enclosed PDFs for me.

Not being an orthopedist, I cannot comment on their validity.

But I think I can explain why the papers have not created much interest.

Are you familiar with the term "impact factor"? If not, here is a link explaining what it is:

A journal's impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journal's influence.

The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 37th with an impact factor of 1.061. That means the average number of citations for any paper published in OTSR was about 1, and 36 orthopedic journals were more widely cited than OTSR.

A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals' peer reviewers. I believe this is true of papers in medical journals too.

I was unable to obtain any figures regarding the number of subscribers to OTSR, but I suspect it is not large. This may also account for the lack of responses to the papers. My own experience is similar. It was very rare to receive any feedback about any of the over 90 peer-reviewed papers, editorials, or reviews that I had written.

Consider this. A blog post of mine "Appendicitis: Diagnosis, CT Scans and Reality" which I wrote 4 years ago has received over 19,600 page views and more than 100 comments. I am certain that post has been read far more than all of my published research papers combined. In fact, my 550 blog posts have recorded over 1 million page views.

What does it all mean?

Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.

Will scientists' CVs be valued more for the number of page views their papers receive than the number of peer-reviewed papers they publish?

Monday, August 18, 2014

Are surgeons responsible for everything that happens to their patients?

Several months ago, a post called "Everything's my fault: How a surgeon says I'm sorry" appeared on KevinMD. It was written by a plastic surgeon who feels that no matter goes wrong with a patient, surgeons should never blame anyone else.

She gave some examples such as the lab losing a specimen, a chest x-ray that was ordered and not done, a patient eating something when he was not to be fed, and a surgeon having to cancel a case because the patient's blood pressure was elevated. She felt that all of these incidents should be owned by the patient's surgeon.

I agree that if I order a chest x-ray and find out later it wasn't done, I would accept the responsibility to have made sure it was done. I have always believed that you should not order a test if you aren't going to do something with the result.

But if the lab loses a specimen or a patient who was not supposed to eat does so, how is that my fault?

Wednesday, August 13, 2014

Applicant worries about the future of surgery

On my "Ask Skeptical Scalpel" blog, a medical student who is applying to general surgery programs is concerned about "The rise of the two M's—machines and mid-levels."

I talk him off the ledge. You can read the post here.