Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Pain Rating Systems:
The Stuff That Dreams are Made Of

I'm annoyed. Typically when I sit down to write one of these editorials, I have to take a few minutes to consider a topic. Occasionally, though, a subject or theme jumps into my head unbidden. This morning, while rounding, was one of those days. Instead of discussing what the research literature might say about a particular topic, today I just want to feel. I guess you can say that today emotion is my muse. What's my emotion? Annoyance … frustration. At what is my annoyance directed you might ask.

Answer: Pain rating systems.

Yes, I know. It sounds anticlimactic. You might have been thinking about any of a number of other bigger issues, say the horrible state of healthcare in the US or the ridiculous reimbursements we receive from insurances. Yes, those are also angering, but I'm going for a more petty level.

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So, yes, it's pain rating systems.

Now, I've always been ambivalent about pain systems, whether it's the visual analogue scale (VAS) or the Wong-Baker FACES Pain Rating Scale, or any of a number of others. I've dutifully questioned my patients about their pain, asking them to rate it on a zero to ten level, and attempting to react to their subjective reports in as compassionate a manner as I could. I buried my frustrations because we are supposed to give our patients the benefit of the doubt.

Not today. My frustration has finally come to a head. Here's what happened. Yesterday afternoon, I did a transmetatarsal amputation and tendoachilles lengthening on a noncompliant neuropathic diabetic patient. The procedure went fine, and there were no immediate complications. I was cautious about my dressings and splint, making sure they were appropriately applied without sharp edges from the splint. The patient was placed on 1 mg of IV Dilaudid by the medicine resident who scrubbed the case with me (yes, we have family practice residents scrub our cases at this particular hospital). When I rounded this morning, I first looked at the chart and saw the residents had increased her Dilaudid to 2 mg. I was concerned.

However, when I walked into the patient's room, there she was, sitting up, smiling, pleasant, and happy to see me. There was nothing in her demeanor or physical presentation to support any significant pain level. Her vitals were completely normal (temp, BP, heart rate all perfect), AM blood sugars normal, no diaphoresis, no tachycardia, no grimacing, and no reaction when I moved her leg.

This was all belied by her telling me – here it comes – that she had a 10/10 pain level. "Really?" I asked, incredulous. "You have a 10/10 pain level?"

When she responded affirmatively I tried to be more clear. "A 10/10 pain is the worst pain you could imagine. A 10/10 pain is you want me to cut off your leg to get rid of the pain. Is that the level of pain you have right now? You want me to remove your leg right now?"

Of course, she answered, "Yes."

When I asked her again about scheduling her below the knee amputation, she declined the procedure. To me, this smelled similar to a malodorous brown material exuding from a horse's hind end.

I've seen many patients in pain. I've caused a good amount of surgical pain in my career, as has any surgeon. I know what pain looks like. Granted, she may have been in some pain, and I'll admit she pointed to her Achilles lengthening as the area of maximal pain (she did have retained sensation to this area). But her subjective numerical scale just did not match her objective physical exam.

I left my patient sitting comfortably in bed with her "10/10" pain. And here I am suggesting to you, fellow practitioners of the healing arts, that these pain scales amount to a pile horse &*^%. There's plenty of research "validating" these scales, but for a significant subset of patients and for a variety of reasons, they're useless. "Fifth vital sign" my butt!

For those of you who use pain scales, please feel free to continue. Don't let my rant dissuade you. I suggest, though, that just as with any other medical issue, the history and physical examination need to match. When they don't, something's wrong. Whether it's an atypical pain, a patient with a high pain tolerance, or secondary gain, be skeptical about any subjective evaluation. Another common example we've all seen is when we ask a diabetic about their blood sugar control. They all say, "It's good, doc." And then their hemoglobin A1c tells us something completely different. The objective test reigns supreme over the subjective complaint.

"Believe none of what you hear and half of what you see", the old adage goes. That may be a bit too cynical, even for me, but in cases like my experience above I can see why some might believe it.

Perhaps a better adage to end off with is "Trust but verify," and if you believe someone who says their pain is 10/10 while sitting there smiling at you, then I have some swampland in Florida to sell you.