How do we differentiate between ‘gold standard’ and ‘the most’ treatment? - Veterinary Practice
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How do we differentiate between ‘gold standard’ and ‘the most’ treatment?

Gareth Cross is assured by the VDS that GP vets are judged by the standard of what another GP vet would have done in similar circumstances but finds himself entering some muddy waters.​​

I will admit to sleeping in a few lectures at vet school, and once missed a whole day as I and the rest of the potholing club were lost underground for most of a weekend and the following Monday, but I am sure that we never received any lectures in emergency locksmithing or commercial land law and mineral rights.

These are just two new areas of expertise I never knew I had but have been called upon to use in the last month.

The locksmithing episode was solved by judicious use of WD40 and my friend’s motto: “The bigger the hammer, the more you can fix with it.”

The mineral rights issue was not so simple. We have been looking at land to buy for the practice and have found a good site. The current owners, a large corporate, wanted to reserve mineral rights on the land. This was likely due to the current vogue for finding shale gas in unexpected places.

They took some persuading that we wouldn’t really want morning consults being interrupted by the arrival of a mobile drilling rig, but we eventually convinced them that this wasn’t a good idea.

In amongst those unusual episodes and the more run-of-the-mill ups and downs of trying to run a practice and treat patients, I have been grappling this month with the concept of “gold standard” care.

It came up in a conversation with the VDS (it’s been that kind of month) who assured me that as GP vets the clinical work we do will be judged by the standard of what another GP vet would have done.

If we are a specialist, we are judged by what other specialists would have done, and so on.

That’s all well and good in legal theory, but when faced with our clients who all have different notions of what they want, it gets a bit muddier. Especially when they have been self-referred to Dr Google, MRCVS.

It is also difficult for us to differentiate between “gold standard” treatment and “the most” treatment. Take an example relayed to me some time ago from a group practice in London.

The standard treatment for a cat bite abscess there was: admit to hospital, intravenous fluids, full blood tests and FIV + FeLV, general anaesthetic to flush and debride the abscess, culture and sensitivity testing and antibiotics and pain relief.

Each element of that regime is logical and possibly justified. But is it “gold standard treatment” or just the “most treatment”? A colleague attended a CPD course recently on gastroenterology and one of the lecturers asked the audience why all dogs with diarrhoea (but not vomiting) these days seemed to need intravenous fluids?

Clients bring with them their own perceptions of what they want from a vet, and what is their “gold standard”.

This was brought home to me quite forcibly this month, when I lost a client and another practice lost one to me, for exactly the same reason.

My client had a pet that had an incurable tumour, but he left our practice in a rage because we had not immediately referred the dog for specialist diagnostics, even though he understood this would not alter the outcome.

The same week I have gained a client, whose pet has a treatable tumour, because that person’s vet wanted to refer them to a specialist. (I did explain that this was the right thing to offer and they should continue where they were with their original vet, but they had made their mind up to change vets).

So in the typically illogical world of veterinary practice I was hero and villain for the same reason in the same week. Who received “gold standard” care there? In both cases the vets and patients were doing just fine, but the clients each had differing perceptions of what was the best care.

Difficult ethical position

Clearly money is a huge issue, and often as GPs toiling at the coal face we are obliged to offer what we know is not “gold standard” because the finances are not there to fund it. This puts us daily in a difficult ethical position with treatment of individual cases and running a practice.

To come back to the VDS’s comment about being judged by what our peers would do, that makes sense, but can anyone tell me how many GP or emergency service vets were sat in judgement on Mr Chikosi? Or Mr Baird? And where does the money come from to staff appropriately 24 hours a day as the RCVS recommended?

A lot of the judgement on these issues we have to make on the hop in practice, and experience plays a huge role. We also need more recording of what actually is done in practice.

We are educated and lectured to in a top-down way, but there is not much feedback from the ground up and no real mechanism for this. If I treat all cat bite abscesses in a similar way for 15 years, as I have been, with good success rates, how does this feed into the gold standard of treatment advised by our more educated colleagues?

How can I get my treatment method compared to other GP vets, including that described above, and from that find the gold standard treatment as opposed to the most treatment?

Another example is the bitch spay. How many of you out there use the three clamp technique as we were taught at university and drawn out in textbooks? One memorable boss was advising a new graduate; on her version of the operation she admitted she may not be the best scientist in the world, “…but by God I know how to spay a bitch” and having seen her spay seven greyhounds after lunch and be home before evening surgery had finished, I’d not argue with her on that point.

This brings up two points: I would argue that the gold standard in neutering technique is probably practised at a neutering clinic, not a university, and secondly how is that expertise fed back up the system to be assessed and, if validated, fed back down to those in practice and undergraduates?

That could equally apply to any common procedure or treatment carried out at GP vets. The human GP medical field is very adept at harnessing this information. GPs get paid partly on results and these results are taken from patients in real time.

A friend who is a local GP often complains that he is being used by the government as a mini epidemiologist. The human medical field, however, does not have financial decisions made on a case-by-case basis by someone with no medical training but who has the ultimate say on what is done in each instance, i.e. the client.

It is indeed a complex world in which we work and recently I have been trying to work out what is the best treatment for individual cases and what we could recommend to clients as the “gold standard” treatment without just recommending the “most treatment”.

We also all need to work out a way to feed back real case treatments and outcomes for the majority of the UK’s pet treatments which are not part of a clinical trial or research project.

Informally, online forums are a useful place to trade experience, ideas and results, such as found on, but a more formal route could be via the practice standards scheme clinical audit requirements, but not just yet as my inspection is coming up!

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