Pain: The Fifth Vital Sign or The Vital Symptom
I started my medical career in 1995 when I joined KMC, Manipal, one of the prestigious institutions in India. KMC, Manipal is in Karnataka,and people speak Kannada and Tulu. I remember the lecture in medical school when our professor explained the importance of integrating communication skills with the clinical skills. He emphasized the need to learn the local language. India is a diverse country with many languages and dialects. Our professor asked us a straightforward question, if we cannot understand the patient’s pain, then how will we treat it. He explainedthe difference between a symptom and a sign and made a funny acronym to describe the characteristics of both. Symptom has “p” in the spellings, and this is what the patient tells us, and sign has no “p” in it and is elaboratedby the doctor. I always wanted to improve my communication skills because I stuttered during my childhood, and I continued to stutter until 19 years of age. I couldovercome my stuttering with divine intervention. I took three months of training from a local teacher, “how to take history in Kannada?” Sometimes, I wonder if taking a course in Kannada communication skills laid the foundation of my communication and clinical skills course. It made me realize the importance ofpatients’ symptoms especially pain.
After my medical school, my brother—Harvinder Paul Singh (An Interventional Cardiologist), trained me in the art of history taking. He corrected my dictations and helped me improve my clinical and communication skills. Being a cardiologist, he taught me how to get to the differential diagnosis of the chest pain and to differentiate chest pain relatedto heartor pain related to lungs, covering of the lungs, esophagus, stomach, chest wall, or the skin of the chest. I had the privilege of working with him and learning his decision-makingskills. I remember a senior woman coming to his clinic with issues of heartburn and his methodical questioning skills and reaching to the diagnosis probably saved the life of the patient as she hada myocardial infarction. Not only I learned chest pain management from my brother, but I learned vital communication and clinical skills and how to elaborate on the pain history.
Duringthe internship, my third-year senior residents—Dr. Raj Dasgupta, Dr. Malar Vasanthan, and Dr. SiminBeg taught me S.O.A.P. note writing.
S.O.A.P. is an acronym for Subjective, Objective, Assessment and Plan. Thiswas widely usedduring the era of paper charts,andmedical students and interns were taught to use this template to provide a standardized structure.
Under Subjective, we assessed symptoms of the patient,and it included an elaborate history taking about the pain or the non-pain symptoms. I remember my senior residents and attending physicians (Dr. Laurence Feenstra, Dr. Carlos Tavera, Dr. Mimi Emig, Dr. Rima Shah, Dr. Sohail Qadir, Dr. Jeeva Subramaniam, Dr. Elizabeth Neubig, Dr. Nasir Khan, Dr. James Barron, Dr.Douglas Apple, Dr. Ashutosh Chaudhari) emphasizing the proper history taking and judicious use of the tests.
I carried this history taking skillinto my clinical practice and started teaching physician assistants and medical students. I used checklists to remember and recall difficult concepts in medicine. As I was teaching USMLE Step 2 Clinical Skills, I made (iCrush) Diabetes and PainGrade Vital Checklist. I used to quiz medical students about the clinical cases and one of the scenarios I have discussed here:
A 66-year-old patient comes to the clinic and complainsof 5/10 dull pain in his left flank. This flank pain is a constant 24/7 pain is non-cramping in nature and started three days ago. There is no specific time of the day whenthe paingets worse. He was pushing a lawnmower when this pain worsened, and the pain does not radiate anywhere. The pain does not get worse or better with food or passing stools. The pain does not increase or decrease in passing urine as well. According to the past medical history, the patient is a smoker and has a 40-pack-per-year history of smokingcigarettes and presently uses cigars when he goes to the golf course. The patient also has a history of drinking hard liquor as well. His colonoscopy done at 60 years of age was negative. He has a significant family history of colon cancer, and one of the relatives was diagnosedwith colon cancer recently.
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What is your next step?
- A. CT- Scan of the abdomen and Pelvis with IV and PO Contrast
- B. Blood work and Urinalysis
- C. Colonoscopy
- D. Ultrasound of the left kidney
Answer B is the correct answer; from less invasive to more invasive. Results of the urinalysis reveal that the patient has hematuria, proteinuria and red blood cells in the urine, for which creatinine is normal. Now the patient returns to the clinic for the results but also has increasing pain. You do a bedside ultrasound and found that the patient has mild hydronephrosis in the left kidney.
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What is the next step?
- A. CT Scan of the abdomen and pelvis with PO and IV contrast
- B. CT Scan of Kidneys with IV contrast a.k.a. CT UROGRAM
- C. CT Scan of Pancreas with IV contrast
- D. Colonoscopy
Answer B is the correct answer. Why would you do CT UROGRAM? You would do so because the patient has hematuria, proteinuria and the large amount of RBC.
You may be able to detect a kidney mass on a CT scan of the abdomen and pelvis, but this is not the correct test.
Why is the ordering of the exact test essential?
If your suspicion is a kidney mass, then order a CT Scan of the kidneys with an IV contrast
Why is this important?
A dedicated kidney CT scan requires a 100-second scan delay after the IV contrast while the CT Scan of the abdomen requires a 70-second scan delay. Therefore, getting the correct history and ordering the accurate test is of utmost importance.
Now, what if the patient presents with mesenteric ischemia history. The test to diagnose this is a CT Angiography. A CT Angiography requires a 25-second delay after the IV contrast is injected. If we just ordered a CT Scan of the abdomen and pelvis, this may be a wrong test,and you may be unable to diagnose the problem for the patient. You would also be exposing the patient to the radiation, wasting health care dollars and provide a poor patient experience. Getting a proper history from the patient is an art,and we must train medical students, physician assistant students, nurse practitioners from the start to save health care dollars and improve patient safety.
I am trained in one of the premier institutions—Spectrum Health, Grand Rapids and finished my residency in 2008. After that, I joined a hospitalist group. Though, my teachers had ingrained in me the proper art of history taking but often I was left surprised when I saw pain as “The Fifth Vital Sign” and used to wonder, “Why is a pain the fifth vital sign?”I always thought to myself the importance of the pain as the Vital Symptom but not the Vital Sign.
Objective examination entailed paying attention to Vital Signs and clinical exams. While I was still in residency from 2005 to 2008, the opioid crisis was already on the rise.
Start with Why of the problem: Pain, not just the number!
We need to use the Simon Sinek’s approach of “Start with Why” and get to the why of the problem. First, we need to define the problem.
Problem’s Why
The painwas just given a number. However, we now know that to improve patient safety and save healthcare dollars, we need to get to the bottom of the problem and not just address the number.
How can we overcome this problem?
Adding the functional assessment to the pain scale and elaborating the patient's pain story will not only improve the compassion of the health caregivers towards the patients but also help in reaching to the root cause of the pain and order accurate testing.
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What will be the benefit?
- 1) Health Caregivers are getting to the bottom of the patient’s pain story.
- 2) Adding functional assessment (activities of daily living and vigorous activities) to the pain number may improve empathy and patient experience
- 3) Assessment and plan depend on the patient’s history and physical examination. Proper assessment leads to accurate testing. Ordering appropriate tests improvepatient safety.
- 4) Patients are preparedwith the pain history and questions before the doctor’s appointment. This proactive approach will save the doctor’s time. This may help with Lean Healthcare.
- 5) It is decreasing healthcare costs.