In 1971 two leading pain experts created what became known as the McGill Pain Questionnaire. The problem they addressed was that, while physicians could use all manner of instruments and their own senses to detect and diagnose most pathological conditions, they were reliant entirely upon the patient’s testimony when dealing with the most distressing symptom: pain.
Pain narratives from patients by this time were viewed as inadequate by doctors keen to demonstrate their scientific prowess, and medical literature throughout the first half of the 20th century shows an increasing mistrust of the value of a patient’s ability to describe it.
Author of The Story of Pain Joanna Burke highlights the complexity of the body, the assumed untrustworthiness of patients (often regarded as malingerers with a propensity to under- or over exaggerate) and the inherent difficulties of language as the three key reasons why pain narratives disappeared and “objective” disease-focused diagnosis prevailed.
The McGill Pain Questionnaire was an attempt to give a voice back to patients by providing 102 different words to describe pain. The results were improved consistency of description and it was claimed sufferers were grateful to have a language to communicate with. Within a decade it was ubiquitous and it has had plenty of supporters and detractors ever since.
The arguments on both sides are very similar to the current debates on the usefulness of risk profiling questionnaires. Indeed, the background to the development of both is similar. In the investment world, there is inconsistent, limited and difficult language available to explain an attitude to risk, complexity of needs, financial services and products, and a fear of repercussion caused by misunderstanding or deception.
The criticism of the McGill Pain Questionnaire includes some points already addressed by risk profiling questionnaires, such as the difficulty in calibrating it from one language and culture to another. A questionnaire with international reach would need to test and prove this beyond simple translation.
A further criticism is there is no proven correlation between the choice of words used and the specific diagnosis due to the effect of stress on the patient in pain. This should be less relevant for a risk questionnaire taken under normal conditions, although worth bearing in mind when assessing client attitude during particularly stressful or vulnerable times.
The most significant criticism of pain questionnaires, however, also rings true with poor use of risk profiling questionnaires and tools. Over time the use of a questionnaire can constrain language and take away the individual, colourful and more useful descriptions contained within lengthier narrative-driven stories.
In reality, your clients might possess a far richer language than available from a questionnaire. What is more, too frequent use of the same questionnaires with the same client might teach them how they ought to describe their attitude to risk, not how they experience or perceive it. Ironically, this loss of language is exactly the same problem the introduction of the questionnaire was designed to resolve.
The answer lies in a sense of balance. The introduction of questionnaires, both for pain and risk, is a positive step in communication for those without the words to do so. However, this is not a substitute for listening. Overreliance on the output of a questionnaire creates a false sense of security for advisers: an attitude is always subjective and personal, however measured.
Recording and repeating your clients’ own words on risk throughout the advice process, to supplement any questionnaire outputs, ensures that does not happen. At the same time, a questionnaire is a useful safeguard against adviser biases creeping into conversation.
Use of questionnaires is neither right nor wrong. They can be helpful and they can be unnecessary from one client or patient to the next. We all learn and communicate in different ways.
In the 20th century patients were regarded as unreliable witnesses to their own suffering. By the start of this century there was speculation that police-style interrogation techniques might be required. Let’s not let risk profiling get that far.
Phil Young is managing director at Threesixty