Wednesday, January 31, 2007

A job for the Department of Weights and Measures

You know the Department of Weights and Measures, that agency that goes around checking the accuracy of various scales, meters, weights, etc., all for the public good? That benevolent branch of the government that makes sure that gas stations don't rip you off by dispensing less gasoline than they claim? Well, I have a job for them, and it’s a consultation of some importance, if I do say so myself.

I’m not talking about Iraq, that disaster where our government in its rush to produce oil neglected to install meters on the oil pipes, making it impossible to know how much oil was actually flowing out. No, the Department of Weights and Measures actually requires meters in place before it can perform a consultation. Neither am I talking about medical school, which cost me something like $35,000 annually to sit in a lecture hall for the first two years and then run around hospitals helping out doctors in any way that I could for the next two. That one didn’t add up quite right either, I have to say, but unfortunately I don’t think the Department of Weights and Measures can do anything about it.

No, the consultation that I had in mind deals with the hospital pain scale, that simple yet practical measuring tool used to quantify the intensity of a patient’s pain. The pain scale comes in a variety of formats and colors, from the very straightforward one-to-ten numbered scale to the brightly colored face chart showing cartoon faces in different degrees of distress. (Instead of making the faces themselves, the patients point to the illustration that best demonstrates their degree of agony. Communicating human suffering has never been so easy!) Unfortunately, lately the pain scale has been causing me all kinds of grief, so let me explain the problem, starting with an example.

The other night when I was evaluating a patient with abdominal pain, I asked him to rate the severity of his pain on a scale of one to ten, with ten being the absolute worst pain he could imagine. The man furrowed his brow for a moment and then smiled, rubbed his belly, and looking as content as Drew Carey might look after finishing a bowl of ice cream, calmly reported an eight. Now, if I hadn’t already been acutely aware that my pain scale was having calibration problems, this would have greatly surprised me. "An eight?" I would have asked, bewildered. "You mean that as I’m standing here asking you these questions you are going through terrible, deep-to-the-bone, hand-on-a-hot-stove, weak-in-the-knees, soul-searching, gut-wrenching agony?” Maybe I simply have a particularly fertile imagination, but 80% of the worst possible pain I can imagine is still a heck of a lot of pain.

Instead I casually commented, "all right," and rather than running to find the nearest nurse to deliver a dose of that blessed panacea morphine, I nonchalantly continued onward through the next five pages of my history and physical questionnaire. It was just an eight after all. His experience, rather than that of having all of the hairs on his body savagely ripped out at once, was merely that of having 80% of his body hair ripped out. There’s definitely a difference. Not that I haven’t seen tens who looked more comfortable than this particular patient. Some of my tens, yawning, look more interested in taking their next nap than in pain relief. When that happens, I sometimes feel a need to add some urgency to the situation myself, to make up for their apathy and just to keep the situation from becoming farcical. “Wow!” I’ll exclaim. “Child birth kind of pain! I’m surprised you’re able to handle it so calmly, let me run right now and get something to try and take the edge off!”

The problem I seem to be having with my pain scale is that it is lopsided, falsely weighted towards the higher side, as if Shaquille O'Neal were sitting on the ten trying to seesaw with Peewee Herman sitting on the one. As supporting evidence, I submit the following fact: since I started clinical medicine four years ago, I've never once had a one. I must have used my pain scale thousands of times with thousands of different people, but never ever has somebody reported to me that their pain is simply a one out of ten. Oh, I've had hundreds of tens, scores of twelves, handfuls of hundreds, and even a few thousands. I did have a two once. I was ecstatic, besides myself, standing on the other side of the room. I shook the man's hand. “Sir,” I said "you are a fine specimen of a man. This may sound funny to you, but you are my first two, and although that may not seem remarkable, trust me, it is. You are a rare breed, a throwback to a different age, and a true gentleman if there ever so much as was one.” He apologized for having bothered me with a two, and I loved him even more for it.

Now, some skeptics out there might contend that although I’ve never had a one, I’ve never had an eleven either. Could it not be that my pain scale is working perfectly fine, and that it just so has happened that I’ve cared for a lot of patients who have had a lot of pain? To these naysayers I freely admit that it’s true, I’ve never encountered an eleven. However, eleven is not a number between one and ten and therefore cannot technically be considered a valid response on my scale. Therefore, I still must submit that the score distribution on my pain scale is very suspicious, and that I may indeed have a problem on my hands worthy of the attention of the Department of Weights and Measures.

I’ve come to realize that evaluating pain is a war of rhetoric between physicians and patients, and that it’s a conflict that is only escalating in degree. I'm not sure who started it, but I am keenly aware of being deeply entrenched in the battle. After becoming convinced that my patients were artificially inflating their pain scores in order to impress me with their pain, I decided to take action. I started deflating the numbers for them. I invented the “reality factor”, a carefully worked-out constant that corrects for the increased sensitivity to pain of the modern age. Let’s face it, men aren’t what they used to be, and neither are women. Therefore, in order to correct these systematically inflated pain scores, I began adjusting all scores by a factor of 0.8. A ten became an eight, a six a five. It was a stroke of genius.

Unfortunately, some of my patients are catching on. Sensing that I am deflating their pain scores (although I do believe that the details of the reality factor still remain secure), these patients are readjusting their scores preemptively to account for my “correction”. Where they might previously have reported twelves, these savvy guerillas are now reporting scores of sixteen, eighteen, even twenty. Frankly, I feel at a loss -- outdone and outmaneuvered. Don’t count me out entirely yet, though, because I’m planning a strategic move bolder than anything I’ve tried before, what I’m convinced will become a landmark victory for truth and accuracy in reporting. Just as Nabisco, in response to healthier snack foods encroaching upon its historical territory, launched its blockbuster product the Double Stuffed Oreo, so too am I going to raise my game to the next level. My brainchild? The "double dose of reality factor". The world will never be the same. This factor works its magic by taking the reality factor-corrected pain score and multiplying it by an additional constant of 0.6. When somebody reports a ten, the "reality factor" corrects the score to an eight, but the "double dose of reality factor" then corrects it further to a five (8*0.6= 5). It’s brilliant! Pain will never be treated out of proportion to its actual existence again!

Wait a minute, I'm confused. Little numbers are running around in circles in my head. I’m seeing ant wars, dancing turtles, flying headless chickens. Ok, a patient states his pain is an eighteen out of ten -- quick, how much morphine do I order? Fourteen milligrams IV? Twenty three milligrams PO? Nineteen milligrams SC? Uh . . . uh. . . uh. . . Help! HELP!

Dear Department of Weights and Measures, if you truly exist and are out there, hear my plea! I need a consultation, stat! Please bring your bag of tools, your measure-correcters, your scale-straighteners, in fact, all of the gizmos and gadgets at your disposal, because the problem that I have for you is one of monstrous proportions. I beg you, please come by my hospital once and for all and fix that broken and dysfunctional device that is the hospital pain scale.