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.

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.

Tsundoku

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.

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]

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. [Update: This paragraph is untrue. See my post of 3/23/17.]

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 77,000 [Updated on 3/23/17] 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?

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?

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.

What can be done about letters of recommendation?

Many surgical educators feel that letters of recommendation are not particularly helpful in evaluating applicants or predicting eventual resident performance.

Among the issues are lack of uniformity of content, excessive use of superlatives, reliability—if the writer is not known to the recipient—and more.

Even if the writers are well-known academic surgeons, the degree of their personal knowledge of the applicants is not always clear.

During an extensive Twitter discussion over the weekend, someone mentioned that in an attempt to deal with this problem, emergency medicine had developed a standardized letter of recommendation.

A recent paper from the EM Standardized Letter of Recommendation Task Force shows that there is still work to be done. From the abstract:

For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine."

I've written before that dean's letters are more like public relations press releases than accurate assessments of a student's performance. You will rarely find negative comments in them. But another recent paper by a group of psychiatrists found that The presence of any negative comments in the dean's letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the dean's letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.

These problems are not new. A 1983 New England Journal opinion piece about recommendation letters entitled "Fantasy Land" is remarkable for its validity even today. Here are a few choice quotes.

It's a land where everyone is "a pleasure to work with," has "excellent initiative," is "enthusiastic and conscientious," and possesses and "above-average fund of knowledge."

No one is ever poor, fair, or average; they are all "very good" or "excellent."

The author, Dr. Richard B. Friedman, said letters of recommendation were useless and advocated doing away with them.

A brief JAMA essay by Dr. Henry Schneiderman in 1988 called for more openness in describing students but acknowledged that negative comments were often "the kiss of death."

He proposed a new system of categorizing medical student performance. Here are just a few examples.



@AmirGharferi suggested this:

"Dr.G, do you feel comfortable writing me a strong letter?"
"No."
"Ok, I'll find someone who is."

That works if the student is aware enough to ask, and the faculty member is honest enough to say no. In my experience, even the most marginal of students can find someone—in addition to the dean, of course—to write a good letter.

I am no longer involved in the process of selecting residents. I have no suggestions.

What is your solution to this problem?

True grit

In case you haven't noticed, a hot new topic in education is "grit." In order to reduce the long-standing 20% attrition rate of surgical residents, some say we should select applicants who have more grit or conscientiousness.

A recent paper in Surgery reported residents who dropped out of programs had decreased levels of grit as measured by a short-form survey. But due to unexpectedly low attrition rates in the surgical programs participating in the research, the study was underpowered to show a statistically significant difference in outcomes of high- vs. low-grit individuals.

It's hard to argue with the premise that choosing applicants with high reserves of grit might lead to better retention and performance of residents.

I blogged about this three years ago in a post called "Harvard says train residents and medical students like Navy SEALs."

Unfortunately, identifying who has grit will be much more difficult than simply testing those applying for surgical residency training.

Below is the eight-item grit survey, which is scored on a 1 to 5 Likert scale.

What to do with abnormal PSA results in a young man?

A 45-year-old man in excellent health with no family history of prostate cancer had a screening PSA done three years ago which was in the range of 4.0 ng/mL. He has been followed by a urologist, and the test was repeated several times without much change.

In June of this year, his PSA was 4.6 and the free PSA was 0.6 for a ratio of 0.13. He was given a course of antibiotics for presumed prostatitis, and repeat testing a month later showed a PSA of 3.8 with a free PSA of 0.5. Because the PSA was less than 4, a ratio was not calculated.

The patient obtained copies of the reports. The from June one states the following: "When total PSA is in the range of 4.0-10.0 ng/mL, a free PSA/total PSA ratio of less than or equal to 0.10 indicates a 49% to 65% risk of prostate cancer depending on age. A free PSA/total PSA ratio of greater than 0.25 indicates a 9% to 16% risk of prostate cancer depending on age." It does not comment on the significance of a ratio of 0.13, which I have looked up. The cancer risk is in the area of 20%-25%. However, no source gave estimates for men under the age of 50.

On examination, his urologist can feel no nodules. He has recommended that the patient undergo an MRI of the prostate.

Stating that an MRI is not indicated in a man of his age with his history, the patient's insurance company will not pay for the test and suggested a trans-rectal ultrasound. The urologist advised the patient not to have an ultrasound due to his age and the potential for complications. A hospital quoted him an out-of-pocket price of $2500 for the MRI.

The urologist has told him that random biopsies may not be accurate and there is a risk of complications.

When he had his first PSA done three years ago, I had expressed surprise and wondered why it had been offered to him. The patient said his internist told him he should have the test.

He is concerned about these recent results and has asked me for advice which I am not qualified to give.

What would you advise?

Follow-up August 6, 2014

Numerous urologists responded on Twitter with more than 60 tweets about this post. Suggestions for the next step were as follows: trans-rectal ultrasound (TRUS) and biopsy as mentioned by Dr. Cooperberg below; going ahead with the MRI; repeating the PSA in 3 months; go for a second opinion by a recognized expert in prostate cancer.

One urologist emailed me to point out that even if the patient has cancer, it is probably not an aggressive type because his PSA has not risen in 3 years.

Another urologist gave me the name of an expert in the patient's geographic area. 

The patient has already scheduled an appointment for a second opinion.

Board passage rates and residency program quality

On my "Ask Skeptical Scalpel" blog, a medical student wonders if a program's board passage rate is a good measure of whether its graduates can practice independently.

You can read that post here.

Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but it's true.

A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years.

The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion.

The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. The genrally accepted upper limit of normal is 200 mg/dL.

After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL.

Can hypocholesterolemia cause health problems? How low is too low? No one knows for sure, but cholesterol is a constituent of cell membranes and many hormones.

I've blogged before about the overuse of medical care, particularly Pap smears, in Florida.

Why does Medicare pay for all these unnecessary tests and drugs? Medicare probably has no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months?

It's probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012).

The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. There's potential for a lot of money to be wasted.

As one of its Choosing Wisely items, the Society of General Internal Medicine has recommended that routine general health exams not be done for asymptomatic adults.

A Cochrane Review of 14 studies comprising 182,880 patients came to the same conclusion and noted that important harmful outcomes of routine check-ups were often not studied or reported.

In June I wrote about the doctors who received seemingly excessive Medicare payments identified by various journalists and wondered why Medicare couldn't have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why can't Medicare do something?

PS: For all you fans of rating doctors according to patient satisfaction scores, the patient in the above anecdote really likes his doctor and is worried that, because he is fed up with everything about the practice of medicine, he may retire.