The lexicon of medicine

Pain is not a vital sign—let’s not treat it as one, AMA says

AMA recommends dropping “pain as the fifth vital sign” from professional usage, urges that questions about pain be removed from patient surveys.

In June, the American Medical Association House of Delegates adopted an AMA Board of Trustees report recommending that the “AMA advocate that pain as the fifth vital sign be removed from professional standards and usage.”

Increased attention to patient pain and the notion of pain as the “fifth vital sign”—alongside pulse, blood pressure, temperature and respiratory rate—began in the ’90s, according to the AMA report (login required). In the early 2000s, the U.S. Veterans Health Administration released a pain management toolkit for health care professionals that noted, “pain as the fifth vital sign is a screening mechanism for identifying unrelieved pain,” and the Joint Commission released updated accreditation standards requiring organizations to provide appropriate pain management and assessment for their patients.

Since then, the nation’s opioid epidemic has grown at alarming rates. As a result, the house of medicine needs to talk about pain and approach pain management differently, the report’s authors concluded. They also recommended that the AMA “strongly support timely and appropriate access to non-opioid and non-pharmacological treatments for pain, including removing barriers to such treatments when they inhibit a patient’s access to care.”

Unintended consequences

Joy H. Lewis, DO, PhD, the chair of the AOA’s Bureau of Scientific Affairs and Public Health (BSAPH), understands that pain is not literally a vital sign to be measured as an index of a person’s health and stability. Still, she says the message sent along with this decision may have negative unintended consequences.

Joy H. Lewis, DO, PhD

“I am concerned that this will be interpreted as a message to stop checking for pain,” says Dr. Lewis, who is also a professor at the A.T. Still University-School of Osteopathic Medicine in Arizona in Mesa. “This would be a grave mistake. Pain should be assessed on a regular and ongoing basis. A comprehensive evaluation will include an evaluation of pain.”

In addition, de-emphasizing pain as a means to reduce opioid prescriptions is a misguided approach, Dr. Lewis says.

“Opioids are not the only treatment for pain,” she says. “The treatment of pain should be comprehensive and many methods, including osteopathic manipulative treatment, should be used.”

The BSAPH will soon be discussing potential AOA policy resolutions on this issue. In addition, the bureau plans to further research the evidence for osteopathic manipulative medicine as a pain treatment and prevention modality.

Pain and patient satisfaction

The AMA report also recommended that the AMA advocate for removing pain management questions from patient satisfaction surveys that are related to payment and quality metrics. The rationale behind the recommendation was that physicians can be punished for receiving low patient satisfaction ratings when they don’t prescribe opioids.

The report’s passing came on the heels of news that the Centers for Medicare and Medicaid Services has proposed dropping pain-related questions from its patient surveys tied to hospital payments, a move the AOA also supports.

Questions about pain management on patient surveys typically fail to provide a comprehensive picture of the patient’s experience, Dr. Lewis notes.

“A simple rating on a survey or a question asking if the patient received what they were expecting for pain control should not be tied to physician reimbursement,” she says. “Instead, the questions should get at what was actually done and how it helped or didn’t help over time. Patient satisfaction with chronic pain control should not be evaluated on a single post-visit evaluation.”

5 comments

  1. I agree pain shouldn’t be a vital sign. Since the 1990’s we have been “taught” the stepwise approach to pain management. Family physicians trying to treat the whole patient are now prescribing narcotics for chronic pain patients and having to randomly urine test patients and doing pill counts. 98 percent of patients are passing these tests. I am floored that there is no law stating we all have to do this monitoring just “best practice.” Harm will come to patients by a few unscrupulous doctors if laws aren’t devised.

  2. In my practice, I long ago learned not to ask about “pain. ” Instead, I ask, “how’s your comfort?”
    If you ask someone to assess their pain – they focus on it. If you ask about comfort, same thing: we can create the expectation for either.
    It’s comforting (pun intended) to hear that “pain as a vital sign” may go away. When that initiative was launched years ago, I worried that it would create an expectation that all pain needed “treatment,” and that “adequate” pain relief meant “one or zero” on a 10-point scale. Lots of our front-line providers felt the pressure to treat aggressively with controlled substances, and it’s no surprise that we find ourselves in a hole of our own digging. It’ll be a long hard climb out – but at least this will be a good start.

    1. Treating vital signs is never a good approach. Any D.O. that gets their patients hooked on narcotics because they felt they had to treat a pain scale number really needs to take a step back and try to remeber all that “patient is a unit… rational treatment” stuff they were taught in medical school instead of just throwing prescriptions at people.

  3. How about medicine in the patient s interest or perhaps medicine that works , instead of the popular p.c. Practice paradigms of the week The most important thing a doctor can do is to remove accute and esp chronic pain Which robs people of sleep , immunity, mental clarity and quality of life Osteopaths can accomplish more with Hands on Manual omt than neurologists can with morphine and its addictive derivatives, And yes there’s a place for drugs as well It sickens me as a healer to see how corrupted and spineless we as a profession have become to political rather than scientific or just plain common sence answers to health care issues Collectively we must grow a spine or there will be little left to medicine of the future other than Minit-clinik at cvs drugstores Take back your profession before its all gone No one but you has the right or the expirience or the moral authority to lead healthcare Grow a pair
    Dr Ron klatz MD DO pres and founder a4m America acad of antiaging medicine 26000 members in 120 countries worldwide

  4. Is there any other ways of making doctors jobs easier. Let’s all put our heads together to find ways. Turning a patient’s problems against them has had good results so far. Saying learn to live with it has been used to death. Sometimes at the detriment of the people that have the unrealistic expectation of receiving quality, compassionate health care with problems they couldn’t fix with prayer or home health remedies. Ganging up on people with no where else to turn to is easy and profitable for many in the healthcare profession. Just because the public has paid for all of the advancements in medicine, doesn’t mean they should benefit from the knowledge used by doctors. Especially when less is more profit for doctors who take an oath to do no harm, doing nothing is guaranteed safe success and money in the bank. Teaming up with insurance companies and government helps in legally turning problems back on the people they profess to help.

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