After every knee surgery I’ve had, there’s this strange period where you float in and out of awareness. Those moments where my eyes are open rearrange themselves in time, like one of those puzzles where you have to slide a tile out of the way to make room for another one. But one of the constants is the first question: “How’s your pain level? On a scale of one to ten, how do you feel?”
The patient pain scale is has been called the fifth vital sign. Today, we often see the scale as a range of faces — from grimace to smily —on the walls of inpatient rooms. Asking about pain, on a scale of one to ten, is a pretty good assessment of how someone is feeling in that moment.
Unlike pain, we don’t have a great way to indicate our true goals, the outcomes we want. In fact, the term outcome has different meanings depending on our frame. To a provider, a successful, safe, infection-free surgery could reasonably constitute a great outcome. Oncologists may see the completion of radiation therapy, particularly when a patient is in remission, as a successful outcome.
But what about skiing?
For me, being cleared to ski has always been the canonical milestone after knee surgery. Six months, that’s the minimum amount of time which must pass, regardless of surgical site healing or amount of physical therapy, before someone can ski after an ACL repair. Making those first turns, hopefully on hollywood snow on a blue bird day, is what I call a successful outcome.
When my dad and I stood at the top of Vail Mountain, in February 2012, we hugged and cried. That was the end of being a cancer patient for him. That milestone, skiing again, was his goal during treatment.
Goals vs Outcomes
Are goals and outcomes different? I suppose, on some technical level, yes they are. If you believe in dictionaries and particulars and whatnot. Still, fundamentally there’s an important connection.
Rehab therapies have been practicing goal attainment for a long time. When you start PT, a therapist is likely to ask: “so, what activities do you want to be able to do again?”
That’s an important question for two reasons. First, it’s part of motivational interviewing. The patient is establishing their own goal, rather than being told what to do by the provider. It’s like deciding I’m going to eat better vs being told by your doctor you need to diet and lose 20 lbs. We’re more likely to work towards choices we make ourselves.
Secondly, it builds an important bond between the provider and the patient. If I tell you I want to ski again, you know skiing is important to me. You know a little about me now too. I probably like adventure sports and travel. (Actually, I just like the aprés ski part). Now we’re working towards something together.
why scales matter
The nice thing about a scale is it allows for a range. Our idea of ideal goals for outcomes change depending on our circumstances. If you arrive at the hospital via ambulance, during an emergency, your goal may simply be to receive the best clinical care possible - to have your life saved.
After a week-long inpatient stay, your goals may be to return home. It may be to attend your child’s wedding, or to hold your grandchildren. It may be to have your own children.
The circumstances around a visit might also effect our answer - type of visit, type of doctor, check up vs chronic vs acute.
Having a scale allows us to reframe our goals based on our health circumstances.
The patient goal scale
What if there was a patient goal scale? On a scale of save my life to climb Mount Everest, what are your goals? What moment or activity are you most looking forward to after treatment or discharge? And what would happen if that scale were as visible as the pain scale to both you and your doctor? Would it help build a deeper connection between you both? How might your treatment plan be affected, based on your goal, your definition of a successful outcome?
I polled twitter and Facebook about the idea of goals and what matters:
@nickdawson Stairs, like a normal person.
— Sarah (@BubblyHeart) July 22, 2013
— Dana Symons (@dsymons) July 22, 2013
@nickdawson Hold a hair dryer.
— Janet Graham (@Janet_graham) July 22, 2013
— Erin Gilmer (@GilmerHealthLaw) July 22, 2013
I’m no graphic designer, but it might look something like this…
- it was in every waiting room, and you could ponder your goals and identify them before each visit?
- it was on the bedside of every inpatient room, and you could write out your goal, so everyone entering your room knew what you were working towards?
- there was an app with examples from others and simple questions to help you identify goals?
- and you could share your outcome goals with your doctors, friends and family?
How else might this work?
Orthopedic Surgeon and healthcare social media expert, Howard Luks, MD, wrote a blog post pondering a similar theme. Its well worth a read to understand the physician’s perspective.
What would you list as your outcome goal?
Edited to include this absolutely brilliant idea:
— Dana Symons (@dsymons) July 22, 2013