You check in for a doctor\u2019s visit and a nurse or physician\u2019s assistant leads you back to the exam room. There, they check your vitals \u2014 blood pressure, temperature, pulse, breathing rate. Maybe height and weight too.<\/p>\n
Most of us are so used to this routine that we don\u2019t think twice about it. Some of the core vital signs are as old as the field of medicine itself. Centuries ago, nobody used medical equipment to check if someone was breathing or had a pulse; you could simply watch for breathing from the mouth or feel for a pulse in the wrist. And before mercury thermometers, body temperature could be approximated by feel.<\/span><\/p>\n More recently, there have been campaigns to expand the list of vital signs to include new health metrics. So far, these efforts haven\u2019t broken through.\u00a0\u00a0<\/span><\/p>\n We talked to experts about the origins of the vital signs, how they inform patient care, and which vital signs (if any) might show up on your chart in the near future.\u00a0<\/span><\/p>\n Whether you\u2019re at the ER or your primary care doctor\u2019s office, most providers check <\/span>the four main vital signs<\/span><\/a>: heart rate, temperature, pulse and breathing rate.<\/span><\/p>\n \u201cThose are the things you can look at very quickly and tell right away is this person sick or not,\u201d says Dr. Allison Ruff, a primary care general internist and clinical associate professor at the University of Michigan. \u201cWe don\u2019t mean, <\/span>Do they have a cold?<\/span><\/i> We mean, <\/span>Is this a life-threatening situation?<\/span><\/i> Those four vital signs are the quickest way to figure that out.\u201d<\/span><\/p>\n \u201cThere are definitely limitations, especially when it comes to blood pressure.\u201d<\/span><\/p><\/blockquote>\n We can trace three of the four vital signs, body temperature, pulse and respiration, back to the earliest days of medicine.<\/span><\/p>\n \u201cEven hundreds of years ago, pulse was always used to measure the basic presence or absence of life,\u201d Ruff says. \u201cRespiration is the same. Is this person breathing or not?\u201d<\/span><\/p>\n Blood pressure as a vital sign <\/span>came later<\/span><\/a>. By the early 20th century, doctors began using stethoscopes and cuffs to measure patients\u2019 <\/span>systolic and diastolic blood pressure<\/span><\/a>.<\/span><\/p>\n Today, providers track the four core vital signs at most visits, including routine checkups, specialist appointments and emergency care.<\/span><\/p>\n In primary care, providers monitor vitals at every visit to identify trends, such as a patient\u2019s pulse or blood pressure readings increasing or decreasing over time.<\/span><\/p>\n \u201cLow heart rate in the outpatient setting often means someone has excellent exercise tolerance and their heart is able to pump more efficiently,\u201d Ruff says. On the other hand, chronically high blood pressure could be a sign of a condition that requires treatment.<\/span><\/p>\n ER care teams rely on vital signs to get a snapshot of a patient\u2019s condition at a given moment.<\/span><\/p>\n \u201cWe\u2019re looking for abnormal patterns,\u201d says Dr. Justin Johnson, an emergency medicine and critical care doctor at Mercy Medical Center in Baltimore. \u201cWhen [your heart rate] gets to 40 or below, I don\u2019t care if you\u2019re an athlete or not, that\u2019s a problem. In the emergency department, we\u2019re looking for extremes that would make us concerned. In the primary care office, they\u2019re looking for changes from baseline.\u201d<\/span><\/p>\n An emergency care provider might also look at additional indicators, depending on your reason for showing up to the ER.<\/span><\/p>\n \u201cGlucose is not a vital sign, but it\u2019s something that we use like a vital sign in almost every patient that comes into the emergency department,\u201d Johnson says.<\/span><\/p>\n Height and weight aren\u2019t technically considered vital signs either. But most providers measure them over time as well, Ruff says, to come up with a patient\u2019s body mass index (BMI). This calculation measures your weight relative to your height, and its clinical value has spurred debate in recent years. \u201cOftentimes [BMI] correlates to health markers, but <\/span>we know it doesn\u2019t always<\/span><\/a>,\u201d Ruff says.<\/span><\/p>\n Although the four core vital signs offer a reliable, quantifiable way to evaluate a patient\u2019s health, they aren\u2019t perfect.<\/span><\/p>\n \u201cThere are definitely limitations, especially when it comes to blood pressure,\u201d Ruff says.\u00a0<\/span><\/p>\n Ideally, blood pressure is measured in a dim room when a patient is seated with feet flat on the floor after five minutes of rest, Ruff says.\u00a0<\/span><\/p>\n \u201cWe know that is totally not how it happens in the doctor\u2019s office or hospital,\u201d she says. \u201cIf you\u2019re in the ER, chances are you\u2019re lying on a stretcher, you\u2019re super anxious, you\u2019re in the exact opposite setting of a relaxed, calm situation.\u201d<\/span><\/p>\n \u201cThe reason why vital signs are so vital is because they are not subjective. Your heart rate is your heart rate.\u201d<\/span><\/p><\/blockquote>\n Ultimately, it\u2019s important to interpret the vital signs in context, Johnson says.<\/span><\/p>\n \u201c<\/span>We often try to use tools or systems that give us easy answers: If your heart rate is <\/span>this<\/span><\/i> high, or your blood pressure is <\/span>this<\/span><\/i>, then you have to be worried,\u201d he says. \u201cBut you still have to take each one on a case-by-case basis.\u201d\u00a0<\/span><\/p>\n The signs of <\/span>sepsis<\/span><\/a>, for example, include elevated heart rate, respiratory rate and temperature. But those same signs could also indicate that you just got back from a jog. Vital signs have to \u201cbe applied appropriately in the correct setting,\u201d Johnson says.<\/span><\/p>\n Pain The campaign backfired, partly because the pain scale is subjective and pain is difficult to evaluate at a glance, Johnson says.<\/span><\/p>\n \u201cThe reason why vital signs are so vital is because they are not subjective. Your heart rate is your heart rate,\u201d he says.<\/span><\/p>\n But the biggest cloud over the campaign is its connection to the US opioid epidemic.<\/span><\/p>\n When the \u201cpain as the fifth vital sign\u201d campaign started, Purdue Pharmaceuticals was also <\/span>launching its own marketing campaign<\/span><\/a> for Oxycontin, which received FDA approval in 1995. These efforts coalesced with a Medicaid reimbursement structure that <\/span>rewarded hospitals where patients reported high levels of satisfaction<\/span><\/a> with pain management.\u00a0<\/span><\/p>\n The result: Doctors began prescribing more opioids to minimize patients\u2019 pain levels while increasing patient satisfaction. Many providers didn\u2019t hesitate to prescribe opioids that were initially marketed as non-habit-forming, Ruff says.<\/span><\/p>\n \u201c<\/span>Had you read about it at the time, it seemed like a good idea,\u201d Ruff said. \u201cThe problem is there was reimbursement tied to this, and we created this idea that people should have no pain \u2026 Pain as the fifth vital sign has been attributed partially to creating the opioid epidemic.\u201d<\/span><\/p>\n The campaign ultimately \u201cmade medicine into a business,\u201d Johnson says. \u201cPeople have less pain, they\u2019re happier, they come back, you make more money.\u201d<\/span><\/p>\n By 2016, the American Medical Association urged healthcare providers to <\/span>stop using pain as a vital sign<\/span><\/a>, pointing to the botched vital sign campaign as one driver of the overprescription of opioids.<\/span><\/p>\n “Exercise is super important, but so are lots of things. Why isn\u2019t smoking a vital sign? Unhealthy eating? It just becomes a slippery slope.”<\/span><\/p><\/blockquote>\n Today, your doctor may still ask about your pain, but most medical professionals have abandoned pain as a vital sign, Ruff says (and <\/span>multiple<\/span><\/a> studies<\/span><\/a> have found that opioids aren\u2019t any more effective than non-opioid pain medications).<\/span><\/p>\n \u201cWe still ask patients about their pain all the time, but we know now that pain is not in fact a vital sign,\u201d she says. \u201cYou can live and be a normal person and be healthy with some pain.\u201d<\/span><\/p>\n Exercise Moderate exercise \u201cmeans you\u2019re walking fast enough that you couldn\u2019t sing, but not so fast you couldn\u2019t talk,\u201d says Dr. Robert Sallis, a family and sports medicine physician at Kaiser Permanente Fontana Medical Center and the founder of <\/span>Exercise is Medicine<\/span><\/a>, an initiative promoting physical activity assessment in clinical care.<\/span><\/p>\n \u201cI would say that [exercise] is the most important of the vital signs because it takes into account virtually every organ system in the body,\u201d Sallis says. \u201cWhen people\u2019s activity level is low, they\u2019re at much higher risk.\u201d<\/span><\/p>\n If a patient doesn\u2019t meet the <\/span>CDC-recommended 150 minutes of weekly exercise<\/span><\/a>, they\u2019re flagged for a follow-up visit with their physician. If they also present with an issue like high blood pressure, prediabetes or depression, starting an exercise regimen could be a first-line treatment before turning to medication.<\/span><\/p>\n \u201cIf a doctor notices your blood pressure is high and you\u2019re doing zero minutes a week of exercise, they might say before we start you on a medication, why don\u2019t we start you on a walking program?\u201d Sallis says. \u201cAll of these chronic conditions call for regularly exercising. There\u2019s no medical condition that isn\u2019t helped by being more active.\u201d<\/span><\/p>\n Research suggests<\/span><\/a> that classifying physical activity as a vital sign could be useful for monitoring some health conditions and patient populations. But this approach has been slow to take off in healthcare systems around the country, Sallis says, and he attributes that in part to a lack of marketing and resources.<\/span><\/p>\n \u201cThere\u2019s no big pharma for exercise,\u201d he says. \u201cThere\u2019s no one making a lot of money and driving that prescription of exercise.\u201d<\/span><\/p>\n To some providers, however, exercise just doesn\u2019t make sense as a vital sign.<\/span><\/p>\n \u201cExercise is super important, but so are lots of things,\u201d Ruff says. \u201cWhy isn\u2019t smoking a vital sign? Unhealthy eating? It just becomes a slippery slope.\u201d<\/span><\/p>\n The subjective nature of self-reported exercise habits also gives some doctors pause.<\/span><\/p>\n \u201cPeople can say I exercise every day, but what does that mean to you? It might mean I walk from my couch to my mailbox,\u201d Johnson says. \u201cYou really need objective data points for the vital signs.\u201d<\/span><\/p>\n To that, Sallis says self-reported data informs medical care in plenty of other situations \u2014 so why not use exercise as a vital sign?<\/span><\/p>\n \u201cPatients self-report their smoking habits, drinking habits, sexual habits \u2026 certainly there\u2019s some reporting error,\u201d he says. \u201cWe know self-reported [data] is not perfect, but we have to rely on it.\u201d<\/span><\/p>\n Pain has largely been ousted as a vital sign, and relatively few health systems have followed Kaiser Permanente\u2019s lead and added exercise to the list. Should patients expect to see any new vital signs in their charts in the near future?<\/span><\/p>\n \u201cI think a nutrition vital sign would be helpful,\u201d Sallis says. \u201cIt\u2019s just so hard to get your hands around. You can\u2019t get five experts to agree on what\u2019s a healthy diet.\u201d<\/span><\/p>\n Technology could also lead to new vital signs in the emergency room, Johnson says, pointing to <\/span>pulse oximetry<\/span><\/a> \u2014 the oxygen content of a patient\u2019s blood \u2014 as an important sign when monitoring for sepsis. Decreased oxygen in the blood can also be a sign of COVID-19, and some experts encourage patients to use <\/span>an at-home pulse oximeter to monitor their levels at home<\/span><\/a> (but take heed: research suggests home monitoring <\/span>leaves room for error<\/span><\/a>).<\/span><\/p>\nThe core four<\/h3>\n
Vital signs in practice today<\/h3>\n
Limits of the vital signs<\/h3>\n
Efforts to add new vital signs<\/h3>\n
\n<\/i><\/strong><\/span>In the mid 1990s, the American Pain Society began advocating for the adoption of \u201cpain as the fifth vital sign.\u201d This campaign was <\/span>positioned as a way to improve treatment for both chronic and acute pain<\/span><\/a>. To assess pain, patients were asked to <\/span>rank their levels of pain<\/span><\/a> on a scale from one to 10.<\/span><\/p>\n
\n<\/i><\/strong><\/span>In 2009, the Kaiser Permanente healthcare system in southern California <\/span>began monitoring exercise as a vital sign<\/span><\/a>. At every visit, patients answer two questions: 1) How many days a week do you engage in moderate exercise. 2) On those days, how many minutes do you exercise, on average?<\/span><\/p>\nOther new vital signs on the horizon?<\/h3>\n