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Use "Standard of Care" with Respect

Paul S. Koch, M.D.

A friend asked me to notice at the recent ASCRS meeting how many times the phrase "standard of care" was bantered about, especially regarding procedures or devices new to the marketplace. "The Acme Glauc-O-Matic, introduced yesterday, is already the standard of care!" was a typical declaration. I counted eight times that I noticed a blatantly inaccurate misuse, thereby prompting this discussion.

Compliance with standard of care is what we are supposed to practice, and violation of standard of care can be considered both unprofessional conduct and malpractice, each with its own penalties. Therefore, the phrase "standard of care" must be respected and used only when accurate and appropriate.

Standard of care is a living and moving target. Wearing gloves for surgery is standard, but did not used to be, and with improved scrubs and latex allergies it might not be in the future. Phacoemulsification might be considered standard now, but did not used to be, and still is not for all cataracts.

Whenever there are many options for therapy, they exist because none is accepted as the best. For there to be a standard, we have to agree that one way actually is the best way. There must be a consensus across the board if something is to be a standard of care, and it should be nearly unanimous.

Maybe we should invoke the rule of statistical significance to standard of care, accepting a standard only if it falls with two standard deviations of unanimity (P<.05), and is used greater than 95% of the time. Less than that makes it a common and accepted practice, but not standard of care.

Do physicians in that last 5% violate standard of care? Not necessarily. Some deviation is necessary to advance medical knowledge and surgical technique. Among that last 5% are our progressive outliers, physicians who are dreaming beyond cookbook medicine and expanding our horizons and skills, and they should be commended.

But also among these 5% are the sad little ostriches, who did not keep up and have fallen far behind even their most laggard adapter colleagues. These are the ones we need to keep a watch out for, and assist in bringing them along, or gently urge into retirement, because they are not keeping up to where they should be.

Something is not standard of care because it is good, better or even best. It is standard because our entire community recognizes it as the way things should be done, even as we constantly move the boundaries through innovation and research. Unless accepted by nearly all, it remains only an option, albeit perhaps a common and excellent one, but not the standard of care.