“Is your pain a 7 or a 10?”

My brother-in-law Vincent is now off on a short hospital stay due to an infection. Decades of morbid obesity compromised the circulation to his legs. He’s thus susceptible to chronic infections and sores that require IV antibiotics and other interventions. The hospital nursing staff has been quite kind. Vincent is having a good stay, made more enjoyable by friendly banter with the kind and appealing nurses who are providing most of his care.

At some point in the evening, one of these nurses asked Vincent: “Is your pain a 7 or a 10?” Vincent responded with embarrassment, looking to my wife for an answer. He remembers all of the nurse’s names, but he does not know whether ten is greater than seven. He cannot process numerical information that way. Like many men and women living with intellectual disabilities, he requires different strategies for pain assessment. This is a well-known challenge, with many potential solutions.

This wasn’t a big problem, but it wasn’t unimportant, either. Vincent’s leg was hurting, and he wanted some pain reliever for it. And this mundane encounter underscored a broader difficulty. Doctors and nurses must come up to speed regarding people who live with  intellectual and developmental disabilities, not to mention people who live with communications disorders and related difficulties. These  issues are a part of life in 2016 America. We can do better.

Grand theft: Diet Pepsi
Grand theft: Diet Pepsi

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

6 thoughts on ““Is your pain a 7 or a 10?””

  1. Even for people with mathematical facility, those scales are lousy (is the pain that keeps me up at night a 3, because I could imagine being mauled by a bear, or is it a 7, because by morning I am a complete wreck? And if I can power through it and answer the questions, does that mean it's no more than a 4 or a 5?). Does Vincent do better with the icons?

  2. "Doctors and nurses must come up to speed regarding people who live with intellectual and developmental disabilities," The metaphor illustrates the cultural problem. Professionals – and not only they – must slow down to get the communication handshake, not speed up.

    Many people living in a foreign country with partial fluency in the language face this problem every day. I'm not stupid, I do understand Spanish, but please slow down. IIRC 110 words per minute used to be the standard for the BBC World Service in English. Many people, especially from Mediterranean cultures, talk at 130 or more.

    Harold, thanks for posting a photo of Vincent. We have read a lot about him, and wish him well.

  3. Similar issues arise when the patient has dementia. And the extent of the dementia will be different at the next MD visit or hospitalization. And there are good days and bad days. My aunt, a retired internist, could on some days describe her symptoms accurately; other days she was unaware that she was having symptoms. Ironically, before her retirement she had cared for many patients in nursing homes and with cognitive disabilities.

  4. Isn't that what the smiley faces are for?

    The numerical scale is a poser even for numerate people. After having an infected eardrum rupture, I never rate my arthritic ankle higher than a two, but I wonder if they really understand that "two" would have been a five or six back when the worst pain I knew was stubbing my toe?

  5. I'm hearing echoes here of a previous discussion on learning assessment: (1) "we need a specific, objective, scalar way of assessing patient pain that can be communicated easily on a write-up for other medical professionals involved in the patient's care"; (2) "numbers are specific, objective,* scalar, useful for assessing things, and are easily communicated"; (3) "therefore, assigning a number on a 10-point scale is the best way to assess and communicate patient pain".
    *Yes, yes, I know. But a surprising number of people think that numbers are objective because they are numbers without considering that they cease to be either specific or objective if people are working from different scales, as has been pointed out by both paulwallich and Brett_Bellmore.

    1. For me (and probably others) the icons aren't that good either. I know they're supposed to be in increasing order of pain, but only because they correspond to increasing numbers. The faces don't really read either linear(ish) or monotonic for me. (I was just in doc's office this morning, describing knee pain as up to 4 or 5, which meant enough to stop thinking about anything but getting off my feet…)

      So sorta back to Harold Pollack's original line: if the standard reporting methods are problematic for people like the commenters here, who enjoy high levels of able-to-appear-neurotypical cognition, then how much more do we need to use better methods for folks who aren't so lucky.

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