The Wong Baker Scale has become universal and is required by the Joint Commission (formerly JCAHO) to be present at every patient's bedside. Most often it is on the wall where it is unavoidably seen whenever the patient's eyes are open.

This visual pain scale was actually developed in a smart, caring, rigorous, innovative way. (More on that story here.) Wong and Baker created the scale visually by asking children to draw pictures of how they felt at different levels of pain. They then made a composite of those pictures, which became the scale. It was a smart approach because it circumnavigated literacy limitations (which can affect children but also adults with literacy challenges or who speak another language) -- and it was developed in partnership with the patients themselves. 

Sadly, the common usage of the pain scale is very much in conflict with this original approach. The scale is hung so prominently, with so little context, and with such a focus on pain, rather than healing, that the original intention is lost. We will look at the effects on a patient's healing (how badly does it hurt vs. how do you feel?) in a future post. However, we wish to focus on another aspect of the imagery: one that builds a schism between provider and patient.

Of note, is that the images portray not only a description of pain, as intended, but also an element of anger. When the patient is continually oriented toward a literal picture of pain -- with the doctor positioned as the gatekeeper or arbiter of treatment -- then the provider and patient are in opposition when it comes to care. Of course, then a patient with a difficult problem becomes a "difficult patient."

It's not surprising that provider burnout is at an all-time high. Almost all healthcare providers went into the field because they want to help people -- and the subtle message that they are on "the other side of the table" from the patient will wear at compassionate caregivers. Further, this type of positioning starts to make the patient the enemy as well -- the provider begins to focus on "fixing the patient and getting her out the door" rather than embarking on a course of treatment in a journey taken together. 

With similar motivations and implementation as the pain scale, satisfaction surveys also help to manage the patient, but simultaneously shift the focus from success to failure. The surveys have even been found to fuel the opioid epidemic by creating adversarial incentives. Besides contributing to burnout, low satisfaction scores can correlate with low pay with unintended consequences. Again, this isolates the patient from the provider to the detriment of both.

The schism is at odds with current value-based care initiatives. If providers and patients are both looking for an outcome that is truly one of better health, the provider and patient are certainly on the same side, moving forward. Rather than the model of fixing the patient, managing the pain, and getting a good satisfaction score, would it not be better to keep the patient in the loop and keep their assessment as part of the solution?

Healthcare and medical collaboration is finally being recognized as a way to improve our health care system. We must design tools that at low cost and high effectivity include everyone irregardless of degree, title and position. We believe that when it comes to telemedicine, medical collaboration, and telehealth, it's absolutely essential that the patient be deeply involved as a part of the solution. In iClickCare, one of the simple four buttons to be clicked is “Invite Patient”. The true meaning of "invite patient"? Perhaps the button should really say, "invite the patient and family to add to the discussion of the patient's care, as providers of all types work together to come to the best possible approach to care". Further collaborative thoughts among all members of the team, can then be rapidly assessed and appropriately integrated into the patient's care.

Whatever tools you use for the patient, we hope that you make the choice to engage the patient in the solution. It may be action that is "against the tide" but it won't be for long -- you're just a pioneer in making it a reality. 

To experiment with including patients in care discussions, click here to use iClickCare for free:

Image from osseous on Flickr, used under Creative Commons rights.