Flip No. 2

Assess new vital signs

Get to the root cause of a health problem, consider a patient’s total well-being.

By Flip the Clinic

In the clinic, care providers routinely gather data about how their patient’s body is performing—monitoring blood pressure, weight, and inhales and exhales. But these outputs offer a woefully incomplete picture of all the elements that contribute to a person’s health. Sure, the numbers may help reveal a problem like high blood pressure. But beta-blockers, which are prescribed to lower blood pressure, are just a band-aid if the root cause of the patient’s hypertension remains untreated.

For 15 years, Dr. Jordan Shlain, an internist and entrepreneur based in San Francisco, has been asking his patients a set of five questions about the stresses and pressures present in their lives. He’s found immense value in starting a short personal conversation with patients outside of the normal scope of the doctor-patient interaction.

By discussing difficulties with a boss or struggles at home, “It humanizes or de-medicalises the relationship,” says Shlain.

But more importantly, a patient’s answers can reveal that several interconnecting health issues might have one root cause. While the provider may not be able to treat the underlying problem, just the act of identifying it can drastically alter a patient’s health—and their overall wellbeing.

How do you fit an extra question-and-answer period in an already jam-packed clinic visit? While Shlain walks through the exercise with his patients himself, the new vital signs can also be gathered by a nurse, assistant, or someone else on staff. By spending a little extra time with the patient now, you’re decreasing their need for medical attention later on.

Case Study

Consider the example of a man in his mid-60s with high blood pressure, difficulty sleeping, and a small, untreated stroke on record. He’s on blood pressure medication and blood thinners. His health is managed, but he’s still he’s not healthy. During a visit to the clinic, his health care provider asks about his relationship with his wife, to work, and sleep. All are lousy, he says. Why? His wife is having an affair, he says, which is a distraction at work and the likely source of his insomnia.

The provider responds by suggesting that the patient see an expert trained to help with the core problem, in this case a couples counselor. “If you present someone with suggestions that they’d never thought of, you open a door for them,” says Dr. Shlain. If the patient follows through, he could improve a lot more than just his marriage.

The New Vital Signs

Step 1

Ask the patient to rate their relationship to the following categories on a 0-5 point scale.

This can be done by a doctor, nurse, assistant, or someone else on staff.

Step 2

If a score falls in the 0-2 range, ask the patient to elaborate on their situation.

Following up on a low score may reveal a health issue's root cause. Ex: New financial pressures may trigger a patient's insomnia.

Step 3

Record the information in the patient's medical record.

Keeping track of how the patient is doing outside the clinic can add valuable information to clinic visits over time.

Step 4

Help a patient draw connections between their answers and their health.

The connection between a patient's overall well-being and their health is not always intuitive. Pointing out the relationship between the two can help a patient make life choices to improve both.


  • http://www.volumesf.com Eric Heiman

    This is great.

  • Susannah Fox

    I like this idea!

    I use a daily app developed by Vic Strecher to personally rate my sleep, presence, activity, creativity, and eating on a 1-5 scale. I wonder if this is a little like measuring your blood pressure at the clinic vs. measuring it more regularly at home. In other words, it’s good to have a professional do the reading every once in a while but it’s the everyday that really matters.

    The clinical conversation can be a trigger (like Vic’s book On Purpose was for me) and the clinician can be a guide, but even better is a broader, ambient awareness of these issues in your life.

  • Wayne Caswell

    I like the wellness survey and Susannah’s response. And I like seeing Sleep at the top, because of its association with all sorts of health conditions, as well as safety and school or work performance. Sleep is one leg of the three-legged stool of Health that also includes nutrition and exercise. And a related three-legged stool of Wellness includes body, mind and spirit, so I liked the other survey questions too.

    As to getting to the root cause of our nation’s healthcare problem (a bigger question), it comes down to incentives – either incentives that cause patients to make the lifestyle choices they do, or the profit incentives of a Sick Care system that is focused on disease management and seems to conflict with a Health Care system focused on wellness and prevention.

  • disqus_s18WFM2FBN

    I like this….I would consider adding a line about food— as this is so important to health.

  • Jo Ann Woodward N P

    How about bringing the service to the people. Health fairs , workplace service , and school based clinics are some examples. Who can think of more ideas ?

  • http://contextcommunication.com femelmed

    i like the questions, and i wish that employers and primary care providers were better connected. while a provider might be aware of available public health resources, how aware are they of what employers provide their employees? not at all. figuring out how to bring employer-provided resources (and by this, i mean beyond health & well-being benefits and to include manager relationships, workplace flexibility, etc.) into this conversation could be very meaningful and valuable.

  • http://survivorsharingstrength.com/ Michele Renee Renaud

    The “New Vital Signs” are indicative of a persons overall well being that includes personal, social, mind, body, and spiritual balance. These key factors in health or lack thereof, directly impact the individual over the course of their wellness journey, and are useful tools in identifying long term exposure to that which ails them. Cumulatively speaking, where financial or food insecurity, housing or employment instability comes into view, so does sleep complications or nutritional deficiencies that may develop along the way with potential for promoting chronic stress or illness. Internal or external pressures directly interfere in immeasurable ways upon the body and its functions.

    Its good to figure these questions into the foundation base of assessing a patients state of being to better clarify what is unseen outside of the clinical setting that may be negatively impacting their possible obtainment of healthy outcomes. Short term complications if not identified, ultimately morph into long term adverse affects upon a persons core. Wellness surveys like this could prove quite beneficial in fostering a proactive approach to healthcare.

  • B.Eldridge

    I think this would be an extremely beneficial tool in engaging with patient. I work in the ED, and I know that between the triage nurse’s initial assessment, the primary nurses assessment, and then the physician. There is information lost and additional problems added. But most times, there is a root cause that are one of the things listed above. It would also promote (like it was previously pointed out) better communication with the patient and their primary care doctors. They could the be referred to a different provider if necessary.

  • Kelly Siplinger

    I feel this is a great flip. We already use a question module similar to this, but I feel this could also better improve my relationship with my patients and helping the doctor decipher the root cause of the problem, and in turn the patient receiving better care that gives good results. This a flip definitely worth trying out!

  • etsn123

    Focusing on the disease will not fully help the patient heal. Assessing and assisting with the whole picture will not only help us better understand our patients but to better know how to help them. This is a good flip to have incorporate into the care of our patients.

  • Andrea

    Great suggestions and very much in keeping with the movement to integrate behavioral health services into medical care settings. It’s much easier to “open the can of worms” if your team includes a behavioral health clinician that you can trust as a partner in the patient’s care.

    More info here: http://integrationacademy.ahrq.gov/atlas/What%20Is%20Integrated%20Behavioral%20Health%20Carea

  • Andrea Bradford

    Great suggestions, and very much in the spirit of efforts to integrate behavioral health services into primary care settings. It’s much easier to “open the can of worms” if your team includes a behavioral health clinician whom you can trust to partner in the care of your patients.

    More info here: http://integrationacademy.ahrq.gov/atlas/What%20Is%20Integrated%20Behavioral%20Health%20Care

  • Bill Stalker

    This is a necessary tool to use for any patient in any setting. I currently work in the psychiatric field as a nurse and have been working in the behavioral health arena for many years. I find that there are many links to physical health issues that might stem from stressors in daily life. My field is well versed in asking these questions as it is part of our daily assessment with our patients. But if you do not come from a behavioral health background, how often do you attribute mental health issues to a physical ailment? I am not saying that every physical health issue is linked to a mental health issue. I am saying, however, that the body works as a whole and segregating it into different parts to treat only one area is only applying a band-aid to what could be a bigger issue that often goes undiscussed. I believe that this is a necessary flip that should be used in all healthcare settings and is just the tip of the iceberg towards discovering a patient’s total well being.