First of all, let’s define objective in the context of medicine. Objective means a finding that is obtained by subjecting a patient to an examination. Examples of examinations used in medicine are the physical examination, laboratory tests and radiology tests. These findings are all subject to physicians interpretation, based on that doctor’s years of experience and training. Physicians report all of these findings, including the physical exam, in the “objective” portion of a medical report. They are not placed in the part of the medical report labeled “subjective.” That portion of the report is reserved for the history that the physician elicits from the patient, including the patient’s self-reporting of pain.
Eliciting signs
Physical examination works by eliciting signs. In a stroke patient that sign might be physical weakness. In a patient with heart valve problems that sign might be a murmur. In a patient suffering from pain the examination is designed to elicit a painful response in order to be positive. It is the elicited response to a purposeful physical maneuver, such as palpation, range of motion or a straight leg raise test that is recorded as an objective finding.
The response to the physical maneuver itself has several components, all measured by the physician in determining positivity. The most common form of displaying a painful response is simply to communicate the response. A patient will say “I have pain when you do that.” While communication is important, non-verbal clues can be equally important when examining a patient. These may take the form of a facial grimace, a hiss or gasp, pulling away from the examiner or guarding against the stimulus. When these non-verbal clues are present it usually equates to an increased degree of pain intensity.
Interpreting signs
A physician determines positivity to an examination maneuver by measuring the appropriateness of the response to the physical stimulus. Most specialists have years of training and experience to determine how to properly conduct an examination. When we are looking for clues to certain injuries, we know where to touch patients and we know how hard to touch them. If the response is appropriate to the honed examination we are performing it is reported as “positive.” If there is no pain it is reported as “negative.” If the response seems exaggerated or suspect we will report it as “exaggerated.”
In an objective test like a blood test a machine measures a variable. When provoking pain in a physical examination, the physician serves as the machine. The doctor elicits a value of pain or no pain and interprets the meaning of that value.
Subjective vs objective pain
Pain is not the only variable that can be reported as both subjective and objective. For example, a patient might say “I have chest palipitations.” That is a subjective finding. When the physician places a stethoscope over the heart and measures the palpitations, that is an objective finding. Likewise, complaining of pain is subjective, whereas eliciting pain on a physical exam maneuver is an objective finding.
A common ploy employed by defense attorneys is to confuse the reporting of pain during an examination maneuver as subjective, simply because pain is also reported on the subjective portion of the history. The goal is to discredit the finding. This ploy can be countered by showing that verbalization is but one component of eliciting an objective pain response. Other components include a precise physical examination maneuver and a physician’s interpretation.
Conclusion
Physical examination used to elicit pain is an objective finding. It has been the convention of medicine for thousands of years, before MRI’s and blood tests, to record these findings as objective. The use of language to communicate the pain response does not make pain on examination subjective. The response being elicited, and its interpretation, requires a highly trained individual. That individual is a physician and anything interpreted by a physician is an objective finding.
Mark Hall, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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