Opioid crisis possibly fueled by patient surveys and pain viewed as the’ fifth vital sign.’

If you have ever been a hospital patient, you will recall completing a survey asking you to rate your stay and overall experience at the hospital. As it turns out, the patients’ answers can impact on how much the hospital is paid and, in some cases, even what the doctor earns.

The “patient satisfaction survey” which is government mandated is meant to reward quality and effective care, but some doctors are concerned that it has had an unintended consequence: that of fueling Americans’ dependence on prescription pain pills.


The misguided acceptance of pain as ‘the fifth vital sign’ has been and still is, the single biggest misconception in the history of modern medical pain management, and this has directly impacted pain medication dependency, and then, in turn, the performance of hospitals.

In the early ‘90s, the American Pain Society opined that there was a national epidemic of untreated pain in the nation’s hospitals and the association announced – without much foresight – that pain should be classified as ‘the fifth vital sign’.

This assertion is flawed on so many levels. The term ‘vital sign’ refers to a precise clinical measurement, specifically: a pulse rate, body temperature, respiration rate and blood pressure. These accepted vital signs all indicate the state of a patient’s essential body functions.

The above clinical measures are an exact science and are based on relevant numerical values. Pain, on the other side of the spectrum, is a subjective feeling that is impossible to measure either accurately of quantitatively across any patient populations. Therefore, for providers to assess pain as a ‘vital sign’, they must be able to ascribe a numerical value to it, such as zero to ten based on the Universal Numeric Pain Scale. Along with recognizing pain as a vital sign, medical practitioners must then come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale. Facilities, however, were not informed as to how to assess the pain accurately and medicate accordingly: pain should be considered the fifth vital sign and treated on the zero to ten pain scale. Even more short-sightedly, and with the support of the Joint Commission, The Federation of American Medical Boards urged individual state medical societies to make the undertreatment of pain punishable by law for the first time.

With this external pressure by state and national oversight agencies, American hospitals and medical professionals were unwittingly steered toward the over- treatment of acute and chronic pain. Failure to comply with the Joint Commission and The Federation of American Medical Boards was perceived as patient abuse and was punishable by citations from medical boards and the Joint Commission.
Thus, this “virtual” national epidemic of untreated pain and subsequent adoption of pain as the fifth vital sign has resulted directly in a national opioid and heroin crisis. Since healthcare professionals were not given a detailed option to be more discerning when dispensing and how and when to prescribe pain medication, the number of prescriptions for opioids has escalated from around 76 million in 1991 to nearly 220 million in 2011. It has subsequently led to one of the country’s most concerning drug addiction crises, and all that brings with it.

It stands to reason that coupled with this adoption of pain as a ‘vital sign’, it is the surveys filled out by patients who claim that their pain needs are not being met that adds fuel to the fire.

Appalachia is regarded as ground zero for the country’s opioid-abuse crisis. Two million Americans are hooked on pain pills, and overdoses kill more people than gun homicides, reports CBS News’ Brook Silva-Braga.
Dr. Mark Woodard, resident in the ER at Bristol Regional Medical Center in eastern Tennessee says that he sees people seeking drugs on every shift. And these are not isolated incidents. He sees two or three a day.

According to some doctors, turning away ‘drug-seekers’ is potentially bad for the hospital as a business, in part because of the reactions on patient satisfaction surveys. In addition to asking if the nurses are polite and whether the hospital is clean and meets hygiene standards, the survey also asks questions like: “How often did the hospital staff do everything they could to help you with your pain?”

Drug-seekers prevalent in ER’s

Twenty-eight percent of the nation’s doctors are assessed for bonuses based on patient satisfaction, according to the industry group physicians practice, and hospitals with better scores get bigger payments from Medicare and Medicaid.

Drs. Dana Barlow, Rimon Ibrahim, and Joe Smiddy have practiced medicine in Appalachia for a combined 98 years and say more and more of their patients have become addicted. When interviewed on the issue of Press Ganey surveys, they had the following to say:

From left to right, Drs. Dana Barlow, Rimon Ibrahim, and Joe Smiddy have practiced medicine in Appalachia for a combined 98 years.

“It’s getting worse year after year,” Ibrahim said. Barlow admitted that the pressure on hospitals to score well on these surveys led to pressure on doctors, including him, to prescribe opioids.

They spoke openly of the pressure from above to make sure that everyone in the emergency unit is happy and the pain relief is a priority. There is overt pressure on them to get the scores up and to keep them there. They even spoke of incidents known to them where physicians have been fired for not addressing pain management in accordance with stipulated requirements.

Researchers at the University of Wisconsin found one in five doctors reported their jobs had been threatened over the scores.

It was announced that Medicare and Medicaid will stop paying hospitals based on their pain scores beginning October 1. But many hospitals will continue to use the scores to rate their doctors by using reports created by private survey companies as some in positions of authority still believe that competition is healthy as it makes doctors more accountable.

Dr. Jim Merlino, president of strategic consulting for the biggest of those companies, Press Ganey, shares this opinion. He questions a physician who would allow a patient to suffer from acute pain for the sake of not succumbing to this over-prescription. For him, it is more about knowing that as a service provider, he needs to ensure that his patients are receiving the necessary treatment, in accordance with their suffering. For Merlino, the emphasis on business competency is paramount. And a hospital can only flourish as a business if the patients are happy. He is not against the idea of doctors being compared to other doctors based on survey scores. “I think getting data points out to physicians is important, yes,” Merlino said.

Back in Tennessee, Woodard, who leads a team of ER doctors, has negotiated a compromise with his hospital. When patient satisfaction bonuses are calculated, questions on pain are omitted and performances are assessed without the possibility of these impacting financially.

When questioned about why he would choose not to be graded on satisfying a patient’s pain needs, he responded that he would be put under pressure in terms of his integrity, and making a morally right choice, or making an easy decision just for the sake of keeping the patient (and hospital administrators) happy, getting a good score and then being rewarded financially. For him, it is a no-brainer. To include questions of this nature would place him under unnecessary pressure.

Doctors’ groups have admitted that these types of arrangements that do not factor in the pain questions are becoming more common. But with no national rules about how the scores are used, it remains a hospital-by-hospital decision as to what to do about doctors with low pain management scores.

At the same time, when the shackles of state and federal oversight pressures are finally removed, it cannot stop here. Those among the more ethically inclined believe that it is necessary to embark on a national education program, with the primary emphasis on effectively and safely managing patients suffering from acute and chronic pain.

For a start, the medical fraternity must work together to remove ‘pain as a vital sign’ out of the medical lexicon and begin a new campaign to manage pain in a way that is accurate and ethical. Inaction is not an option. When faced with the embarrassing fact that the United States makes up just 4.6 percent of the world’s population yet consumes more than 80 percent of the global opioid supply, it is obvious that a change in the pain treatment paradigm is urgently needed.

Time to take a stand!