1.Challenge and learning as vital signs

Challenge and learning as vital signs in health care

The importance of vital signs for measuring health

The first device invented to measure a vital sign was one designed in 1602 by physician Santorio Santori, who was born in modern day Slovenia. With some likely assistance from his colleague Galileo Galilei, among others, Santori introduced the “pulsilogium”. Clearly, the value of measuring pulse, and understanding its meaning in health, was well established by this time.


In 1852, Ludwig Taube plotted the course of a fever, using a thermometer, and added respiratory rate to his observations; and in 1881 the Austrian Jewish physician Samuel Siegfried Karl Ritter von Basch invented the world’s first sphygmomanometer.


By the early 1900s, the idea of “vital signs” had begun to be embedded in health care. Other signs have been proposed and used since then, and occasionally reference to “fifth” and “sixth” vital signs can be found. These may include pain, oxygen saturation and gait speed. Despite that, reference to “vital signs” is generally taken to mean pulse, respiration, body temperature and blood pressure.


As a group, these are considered to be the most important indicators of the body’s life-sustaining functions; however, they are limited in scope to physiology and don’t include reference to many aspects of life such as emotional and psychological functioning, social connectedness and engagement, among others.


What value are steady and robust pulse and respiration, tropical body temperature and 110/70 if the owner of these vital signs is otherwise not engaged in a life that brings meaning? and forms the basis on which the person can use the resources of their health and wellbeing to contribute richly to the community in which they live?

Important measures of health besides vital signs

American College of Lifestyle Medicine (ACLM) Physician and Past President Dr David Katz has previously written about the importance of diet as a vital sign in health care. He argues very clearly that the objective quality of diet is the strongest correlate of all-cause mortality and disease risk. And it is uncommonly, if ever, measured in clinical practice.


Host of The GP Show podcast and President of the Australasian Society of Lifestyle Medicine, Dr Sam Manger, has developed a vital signs questionnaire for lifestyle medicine, with adaptation from the work of Dr Wayne Dysinger, also an ACLM Past President. The questionnaire focuses on the well-established pillars of lifestyle medicine and even ventures into the area of eudaemonic wellbeing – having a sense of purpose and meaning in one’s life.


One of the lessons from Lifestyle Medicine is the extent to which development and maintenance of great health depends on individual behavioural change. Not entirely of course – we know there are global, national, community and environmental aspects to health also. But we can change what we can change. And these efforts at behavioural change must be sustained and ideally generalised into other dimensions of the individual‘s life.

Challenge and learning: other signs of vitality

What else might be vital signs that we are fully alive, thriving and functioning optimally in daily life? I propose two dimensions of ‘being’ that are vital signs – or, if you will, signs of vitality – challenge and learning.


The idea of challenge is already embedded in some areas of health – for example, fitness. Trainers will point to the importance of doing more than “going through the motions” of exercise, and doing something that challenges the body; doing something that demands more of it than it’s used to giving, and thus readying it for an even greater (and perhaps unknown) challenge.


The process of responding effectively to challenge is a cornerstone of the development of self-efficacy. Albert Bandura, the author of a theory of Self-Efficacy, proposed that one of four pathways to the experience of efficacy is “mastery experiences” – the personal sense of success that arises from having applied skills, knowledge, resources, strengths, values and sometimes blood, sweat and tears to the accomplishment of a challenging task.


The best way – perhaps the only way – to experience this success is to apply oneself to a novel situation and steadily moves towards managing it and achieving an outcome. This nearly always involves dealing with challenges – some of which can be forecast and others not.


The second element – learning – involves the person being able to reflect on themselves and their actions. In doing this, they are able to identify the factors that led to success, and in which of those they had agency. Importantly, learning also comes from failure to achieve what was sought. Exploring such failures with compassion and empathy can support patients to identify a new way forward, to modify their approach, to learn something or to make use of other resources they hadn’t previously identified.


Learning from an experience becomes the thread which can bind together the challenge, the resources, the outcome, the next steps and the plan for the future.


A clinical exploration of challenge and learning is also an inherently patient-focussed approach, partially fulfilling one of the quadruple aims of healthcare. It has the capacity to significantly boost the patient experience of their own healthcare, by inviting them to “own” the values, strengths and determination they have brought to the table and the success with which they are walking away.

Assessing patient’s challenge and learning in practice

So if these are to be vital signs in health care, how are they assessed? In clinical practice, these two vital signs can be explored with straightforward inquiries which can then open into a broader discussion if so desired which will almost certainly increase the patient’s own self-reflection.


Next time you strap a sphygmomanometer cuff on a patient’s arm, ask them at the same time: “What challenges have you overcome since we last met?” and see what emerges from the ensuing conversation.


And when reviewing a patient’s recent management of their chronic condition, ask: “What have you learnt about managing [condition] since we last spoke?”. Be ready to take this exploration a little deeper by asking how they are now applying that learning, or how it has benefitted them.


Don’t be put off by either silence or “I’m not sure” as a response. The most powerful response from you may be silence, while your patient ponders ways in which they might have overcome a challenge.


Every inquiry along this pathway allows for the development of greater self-efficacy, agency, hope and self-confidence. And the experience of managing a challenge, of learning something new and being able to apply it, are surely two of the most important signs that someone is “vital” and fully engaged with their own life.


This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.

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