The term “Standard of Care” has been misused and abused. It is time to replace it with a phrase which more accurately conveys the realities of modern medicine.
The term “standard” has become ubiquitous in our everyday conversation. In some cases, the term is used appropriately. For example, it is standard treatment to give antibiotics for bacterial pneumonia, and it is standard management to provide PCI or thrombolytics for a STEMI. However, the more that we look at syntax and semantics, the more we realize that the term “standard” isn’t quite … well … standardized. Standard socket sets all have the same sizes, but standards of living vary dramatically between countries. Even in what we consider “standard” treatment for pneumonia, there is considerable variance. Should patients with bacterial pneumonia receive ceftriaxone, levofloxacin, piperacillin/tazobactam, azithromycin, vancomycin, another antibiotic or a combination of antibiotics? The answer can’t be defined by a single “standard” but instead becomes an inquiry as to what is a reasonable practice under the specific circumstances. Perhaps a healthy patient with a community-acquired pneumonia might only need azithromycin, a child would benefit from high-dose amoxicillin, a patient with multiple co-morbidities would require hospitalization and multidrug treatment and a patient with HIV might also need pentamadine and prednisone. In another variation on the theme, statisticians created the concept of a “standard deviation” realizing that samples in a data set may vary considerably.
Within the medical community, one phrase that is frequently misused is “standard of care.” It’s easy to allege that a practitioner failed to meet the “standard of care,” but in doing so, we have to consider the meaning behind those words. A standard is a “model” or “example” to be emulated. But there simply aren’t many “standards” in medicine. For example, there are many acceptable ways to manage hypertensive patients, to prescribe medications and even to physically examine patients. The problem with the notion of a “standard” is that it assumes everyone should be doing it all the time. That simply isn’t the case … legally or professionally.
Not only is the term “standard of care” often misused, it is often misunderstood. Consider a patient suffering from an acute ST elevation myocardial infarction. While the “standard of care” may dictate that the patient receives aspirin (even though, with a NNT of 42 , it is clear that not everyone benefits from this intervention), the same “standard of care” would dictate that the patient NOT receive aspirin if the patient was aspirin-allergic, the same “standard of care” would dictate that the patient SHOULD receive aspirin if the same “allergy” was merely GI upset, the same “standard of care” would be that the patient NOT be given aspirin if the patient already received aspirin in the ambulance on the way to the hospital, and there probably wouldn’t be a “standard of care” at all regarding whether the patient should receive aspirin in the hospital if he took aspirin with his other morning medications 6 hours prior to symptom onset. An expert who testified that there is a single “standard of care” regarding aspirin administration in acute myocardial infarction is either being untruthful or is incredibly naïve.
The legal definition of the “standard of care” is that which a reasonably competent and skilled physician would administer under the same or similar circumstances. Failing to meet the standard of care is simply another way of stating that a physician was negligent. However, it seems that many people don’t understand this nuance. In more than one deposition, I have seen experts testify that a physician acted “reasonably” but also violated the “standard of care” – as if these are mutually exclusive concepts. Another problem with the idea of a “standard” of care is that it may penalize innovators and early adopters who advance the knowledge of medicine. If a paper is published today that strongly supports a new intervention, and you order that intervention tomorrow, you’re providing reasonable medical practice and probably helping a patient, even though what you’re doing cannot yet be called “standard.”
Finally, medicine is as much an art as it is a science , focusing not only upon the medical pathophysiology but also upon each patient’s unique body, mind and soul. For this reason alone, each medical interaction is distinct, and there can be no “standard” that applies in every circumstance.
When the meanings of words become prone to misunderstanding or misuse, they should be removed from our lexicon. It is time to retire the notion that there is some mythical “standard” of care to which every physician should adhere and be judged. The “standard” by which all human interactions are judged is one of “reasonableness,” and medical care should be no different. Reasonableness does not require perfection. Reasonableness only requires ordinary care and prudence.
For these reasons, we propose that the term “standard of care” be retired and replaced with “reasonable practice.” The terms are legally equivalent, but “reasonable practice” is far less prone to misinterpretation by experts and juries.
Beginning next month, we will be running a new column in EP Monthly by the same name: “Reasonable Practice.” We encourage you not only to adopt this new terminology for judging medical practice, but also to read the column to weigh in on whether the cases presented represent reasonable medical practices.
- Lancet. 1988 Aug 13;2(8607):349-60. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. http://www.ncbi.nlm.nih.gov/pubmed/2899772
- Panda SC ‘Medicine: Science or Art? Mens Sana Monogr 2006 Jan-Dec; 4(1):127-138