The term “gold standard” is frequently heard within a veterinary setting, but what exactly does it mean? Furthermore, is it a good thing? Let’s discuss.
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What does “gold standard” mean?
Gold standard refers to the “perfect” option. In the context of veterinary medicine and surgery, gold standard commonly refers to the best diagnostic test or treatment method possible. This commonly includes state of the art equipment or cutting-edge technology for example the advanced imaging of MRI or CT.
Essentially, a gold standard level of care is a standardised approach to perfectly cure or diagnose a patient on paper. For example, the gold standard treatment for disease A is medicine B. A gold standard approach often requires intensive or extensive medical or surgical intervention and commonly utilises several tests, medicines or modalities at once.
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Is the term “gold standard” problematic?
Simply, yes. There are several reasons for this:
1) A “gold standard” approach risks overtreatment.
As we have discussed above, “gold standard care” requires many different tests, medicines, or modalities at once, therefore is sometimes synonymous with “maximal care”. In other words, employing the maximal level of diagnosis or treatment – using and utilising everything possible at once. Therefore, theoretically, there is risk of “overtreating” the patient. Often, a patient does not need every test or medicine going, therefore utilising everything at once is not required nor is it justifiable.
2) “Gold standard” does not consider the individual.
In real life, every patient does not present the same, rarely appearing as it does in textbooks. Each has a unique circumstance, therefore, to treat all patients exactly the same would be inappropriate. Patients vary by age, history, temperament, health status (they may have several health problems at once and may be on several different medications) and subsequent quality of life.
The following was taken straight from the linked debate paper by A. Skipper et al., as it perfectly illustrates this point. (Please see the end of this article for a link to this paper).
“In the case of [cancer] in an elderly dog with [kidney] failure, whose owner has limited income and no insurance, few vets would recommend referral for radiotherapy treatment [a type of cancer treatment available at referral hospitals using concentrated radiation which often causes severe side effects], but in the case of a young and otherwise healthy dog, whose owner has a substantial medical budget, this might be an entirely appropriate course of action.” In other words, what is an appropriate course of action for one patient may be entirely inappropriate for another.
3) The term “gold standard” is fundamentally discriminative and potentially insulting.
What happens if an owner cannot afford the so called “gold standard” level of care? Does that mean the vet should provide a lower standard of care? Meaning the patient subsequently receives a lower standard of care? Of course not. The care we provide as vets is tailored for the individual patient and circumstance. If the owner cannot afford a specific medicine or test, we adapt our plan. The amount of care we provide is the same for every patient.
4) “Gold standard care” varies depending on environment, staff and training.
At vet school we are taught the “gold standard” level of care for various diseases and conditions, but the exact details taught will vary depending on university, country, teacher and year. Veterinary science, as with human medicine, is constantly evolving due to new research and learning; what is today’s “best” may not be perfect tomorrow. Additionally, what vet students are taught in one university or country may be different to another depending on their staff expertise or local understanding. One is not necessarily better than another, just different.
What term should be use instead of “gold standard”?
Recent efforts have been made to replace “gold standard care” with “contextualised care” – i.e., the best care in context of the specific patient. Vets provide contextualised care every day, to every patient, so is more appropriate to use than “gold standard care”.
Conclusion
The difference between “gold standard” and “contextualised” care can be considered as splitting hairs, i.e. somewhat pointless, as vets provide the same level, or degree, of care to all patients, irrespective of terms used. However, the difference between these terms is important when considering how we as vets approach care, and how we teach such approaches to students. So in conclusion, contextualised care is the application of care to the individual patient, in their particular circumstance, and is preferable over the term “gold standard” for the reasons discussed above. Each patient is unique, so they deserve tailored consideration and care, which we as vets provide on a daily basis.
Discussion