Friday, February 09, 2007

Are You In Pain?


Or:
I Can't Think for Myself
Or:
One Great Way to Kill Trees
At the institution where I work, there is a requirement by JCAHO that all patients be assessed for pain. What this means, in practical terms, is that every patient at every visit in every department of the hospital is given a form and asked to mark off on a numerical scale how severe their pain is. For patients who can't negotiate that, there are smiley-to-frowny faces drawn and one can circle the face that best approximates one's degree of pain. Unlike the photo depicted above, my institution does not have the scale in color, and our smiley faces do not wear bow ties. You must sign the form at the bottom. I don't know what happens if you refuse, and the form is placed in your chart. We won't discuss what this does to the size of the charts, but hey, they pay me to be here.
I'm a psychiatrist, everyone who walks in the door, at least for the first time, is in pain. No No No No! Not that kind of pain, it has to be physical pain or it doesn't count! Does your body hurt? Now if the pain is more than a 3 out of 10, the patient is to be asked if they want to see a doctor. Oh, I am a doctor. 8 out of 9, maybe 9, It's that arthritis or maybe the chronic migraine. Yup, they have medicine for it. Okay, so now it's checked, they've seen the doctor, the sheet is signed, and it gets filed in the chart. Three cheers for us, we're JHACO compliant. Damn the trees, that's what Oregon's for.
So a patient comes to see me. The patient, John YoungGuy, is 27 years old. He has no significant medical or surgical history, he's here at the psychiatric clinic to get his mental illness treated. He's not in any physical pain (--He signed so it's a fact). The next week, Mr. YoungGuy returns to see me. I should ask him if he hurts? Why would he hurt? Wasn't I listening last week when he said he was healthy and had no pain. Really, he circled the zero and signed. Do I think he wouldn't tell me if he'd broken an arm on Saturday? By the fifth visit, by the fifth request to look at the demeaning smiley faces and sign off of that really, truly, he's not in any physical pain, might Mr. YoungGuy wonder if I'm not listening? If I'm not anything other than some idiot RobotShrink who sits there with a checklist (yup, I do, but at least a few of those questions are relevant, but trust me, the state-mandated 90 med check doesn't count if it isn't written up on the yellow sheet of paper).
I believe the intent of the mandate was good. Attention to pain, treatment of pain-- they are important things in medicine. The kneejerk phenomenon of signing off on a condescending smiley-face form, however, creates a culture where the goal is Compliance with regulatory agencies, not one of caring, attentiveness, creative solutions, or even of compassion. We shouldn't neglect pain, we (meaning all of us form-filler-outers from the orthopedist to the psychiatrist to the dermatologist) should enable relationships of trust and openness where the patient tells us they are in pain, and we address it as best we know how.
By the way: I lied. I never fill the forms out, they go straight into the trash, unchecked, unsigned. I feel way too foolish to even ask. Please don't tell anyone. You can, I hope, feel my pain.
--And by the way, has anyone seen Roy?