On a scale of 1 to 10, what would you rate it? Beyond NRS (Numerical Rating Scale) in medical interviews

This is Dr. Unagi.

By the way, for those reading this,

“On a scale of 1 to 10, how are you feeling today?”

This question, “What would you rate it on a scale of 1 to 10?”, is one that
all medical professionals are familiar with,

• used in the NRS (Numerical Rating Scale).

• It is also used in the VAS (Visual Analogue Scale).

I use it often in clinical practice as well.

It’s the question,

“On a scale of 0 to 10, what would you rate your current pain?”

that I ask.

When I was a rookie, I used to ask it
“On a scale of 0 to 10, what would you rate your current pain?”
suddenly, just like in the textbooks.

Sometimes they answer smoothly, but
if my intent isn't conveyed,
it leads to discrepancies, misunderstandings, or confuses the patient.

“Does zero mean no pain at all?”
“I’m always in pain anyway. Compared to that, I guess it’s a 2 or 3?”
“My jammed finger hurt, and my toothache hurt too, so what am I comparing it to?”
The interview wouldn't go smoothly like that.

At that time, a senior doctor (who was a master of medical interviews) gave me this advice:

“Unagi, what’s your favorite food?”

“Beef bowls.”

“On a scale of 1 to 10, what would you rate a beef bowl?”

“Huh?”
(First of all, I’ve never thought about that before)

“Then, which beef bowl do you like?”

“Sukiya!”

“Then, if Sukiya’s beef bowl is a 10, what would you rate Yoshinoya’s?”

“Hmm, that’s tough.
Sukiya has a lot of toppings, and Yoshinoya has that deep, traditional flavor...”

“I don’t need those details.”

“Well, if Sukiya is a 10, I’d rate Yoshinoya an 8 or 9 based on my preference.”

“...You see, you have to create a standard for the patient like that.”

The human brain is better at relative judgment than absolute judgment.
Creating a standard like “compared to X”makes it easier to answer.

That’s why, during a medical interview,
if you provide a “lead-in,”
it becomes easier for the patient to provide a number.

“Think of 10 as the most intense pain you have ever experienced.”
“Let’s set 10 as that time you were in so much pain you couldn’t move.”

“If we set the throbbing pain of a toothache as 10...”

By handing them a standard like this,
the patient can escape the state of “searching for the correct answer.”

I believe most therapists use the question
"On a scale of 1 to 10, what would you rate it?"
using the NRS or VAS.

Whether it is for pain assessment,
as a benchmark for recovery,
or as an NRS (Numerical Rating Scale),
this is surely a "classic of classics."

It is easy for patients to answer,
and it is easy for us to track progress.
It is a very convenient question.

However, I have always had
a nagging feeling in the back of my mind.

"This alone is nothing more than gathering information."

"Isn't there room to make better use of this for treatment?"

So, I thought about it a lot and went through a process of trial and error.

As a result,
I found a way to "dramatically change clinical practice"
by adding just one single phrase.

After the patient answers with a number,
you just need to add one more thing.

What I am doing
is truly simple.
I don't use any new tests,
difficult theories,
or special psychological techniques.

But since I started including this phrase,
the atmosphere of the interview has changed.
The way treatment progresses has also changed.

And above all,
the patient's stance has changed.

Patients who were previously
the "ones being evaluated" or "the ones being treated"
now step forward just a little bit.

The dynamic shifts from the therapist unilaterally deciding
"You're getting better" or "Not yet," to a "collaborative effort"
where we ask, "What should we aim for next?"
Don't let the NRS or VAS

end as a mere exchange of words.

Use it fullyas "material" for treatment.

That is the
single phrase to achieve that.

It is...

After asking, "On a scale of 1 to 10, what would you rate it?" and
the patient answers, "It's a X,"

just ask, "So, what would be a passing score?"

and that's it.

Then, things that were previously invisible
will come into view.

What can you learn by asking for a passing score?

For example,
if you ask, "On a scale of 1 to 10, what would you rate your current condition?"
and the patient answers,
"It's a 6."

How do you interpret
this "6"?

In university or vocational school exams, a score of 60 isn't a failing grade, but
is a patient's score of 6
a passing grade or a failing grade?

Is the patient
satisfied with their current state, or are they not?

By asking for their "passing score" as well,
you can understand
how the patient views their current state.

If the patient's thinking is,
"My current state is a 6, and my passing score is a 4,"
even if the maximum is 10,
there is a high possibility that the patient is satisfied with their current situation.

If they say, "My current state is a 6, and my passing score is a 9,"
the patient feels their current situation is "not good enough yet."

You start to see one of the
"pieces of the explanatory model" inside that patient's head.

And if
"the current state is below the passing score,"
"What could we add to reach a passing score?"
"What is needed to pass?"
By asking these, you can involve the patient
and get them to participate more in their treatment.

The therapist's goal is not the patient's goal

Therapists
tend to decide on goals unconsciously.

• Pain becomes 0

• Range of motion returns to this level

• Tests come back negative

Of course,
I think that is an important perspective as a professional.

But the patient
might not necessarily have that as their goal.

• "It's enough if I can do housework"

• "It's enough if I can go on a trip"

• "It's enough if I can sleep without anxiety"

By asking for the passing score,
the patient's "realistic objective" becomes visible.

And from here,
treatment suddenly becomes something you "create together."

Asking for the passing score makes treatment easier

If you don't ask for the passing score,

• The therapist's goal

• The patient's goal

These two things often end up
continuing to run while misaligned.

As a result,
"I'm doing everything right, but they aren't satisfied"
"For some reason, it doesn't lead to the next visit"
creates a quietly difficult situation.

Asking for a passing score is
not for the sake of evaluation.
It is a question to share the goal.

From "treatment done for the patient" to "treatment moving forward together"

"What is your score right now?"
is a question to know the current location.

"What is your passing score?"
is a question to determine the destination.

Only when these two are present
does the treatment begin while looking at the "destination."

It is not a composition where the therapist walks in front
and the patient follows from behind,
but rather standing side-by-side, looking in the same direction.
It is a
very simple phrase for that purpose.

If you would like to improve your [Interviewing Skills], please continue reading this series.