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.”
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.
“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.”