Normally when I hear about “standard of care,” I think, “Oh no, it’s something to do with medical malpractice.” Indeed, it is true that the concept of standard of care is involved in medical malpractice suits. To sustain a claim of medical malpractice, a plaintiff must prove, among other things, that violation of (or negligence in meeting) the standard of care occurred. However, standard of care, as it relates to our day-to-day work lives, is our friend. Let me explain.
We do not make medical decisions and implement treatment plans in a vacuum. We don’t have the luxury of entering a sheltered mental space that allows us to commune in silence only with our own thoughts as we weigh what is best for the patient. Rather, we make important clinical decisions in a cacophonous space filled with the expectations and pressures voiced by the patient, the patient’s family, the patient’s friends and important others, and insurance companies. It’s our daily challenge to make decisions as we’re cajoled, seduced, bullied, advised and pressured by all these actors. It can take a mental and emotional toll. It often leads to second guessing our decisions.
I submit that treating the standard of care as your decision-making touchstone will ensure you make good decisions with less stress. A touchstone is a type of rock (a schist or jasper) that was used to test alloys of gold. Different proportions of gold in the alloy left different marks when rubbed by the touchstone. Now, metaphorically, a touchstone means a standard against which something else is judged. Thus, what I’m really saying is to treat the standard of care as your decision-making standard. This is so obvious, it may be a point not worth making. But I have found for myself that it is a point worth keeping in mind when making each and every clinical decision we are asked to make. The standard of care is our – to change metaphors – guiding light on the choppy seas of choosing what is best for our patients. Here’s an example:
Patient with Alcohol Use and Generalized Anxiety Disorders
A patient comes in with symptoms of alcohol use disorder (currently with nine months of sobriety) and generalized anxiety disorder. Your evaluation discloses that the patient has been anxious for as long as he remembers and recalls having symptoms of separation anxiety and school refusal between kindergarten and second grade. You tell him you would like to prescribe escitalopram for his GAD. He agrees but asks for lorazepam in addition because he’s really anxious and says that it’s worked for him in the past. You tell him you won’t prescribe lorazepam because the risk of his relapse to alcohol is too great. He again repeats lorazepam worked for him in the past, did not lead to a relapse, and that if he doesn’t get it now, “it’s going to lead to relapsing.” You again say no and the patient looks increasingly anxious and desperate. He keeps repeating that he really needs it and that you will be responsible for his relapse if you don’t prescribe the benzo. He alternates between pleading, implicit bullying, and laying a guilt trip on you.
Now, there are different ways of weighing the risks and benefits of benzodiazepines in this case. But let’s say based on the evidence*, you judge that the risk of lorazepam is too high in this patient’s case. You can then tell the patient something like, “I appreciate your point of view. I understand you are anxious right now and feel you cannot wait for the relief that will come from the antidepressant. It is important we discuss additional possible medications and non-medication approaches to help you in the meantime. However, in my professional judgment, prescribing you a medication like lorazepam at this time places you at too high a risk of relapse. It is my duty to you as my patient to give you options that we as a profession believe will help you more than may hurt you.”
The ball is now in the patient’s court. He can either tell you he’s willing to consider these other options or he’ll get upset and storm out. Of course, he can just play along and never follow up or fill his escitalopram script.
In any case, you can feel more secure in your decision. You are placing yourself in a position of weighing the risks and benefits, and freeing yourself from the pleading and bullying that accompanies decisions unpopular with patients. Taking this stance also minimizes second guessing yourself. No matter what you decide about which treatment to recommend and implement, some patients will do poorly. Some patients in our care relapse, take counter-productive actions, or hurt others or themselves. The only way we could know whether prescribing a different treatment for a patient would have led to a better outcome is to run alternate universes in which different patient clones receive different treatments, and then assessing the differences in outcomes among them. Such a possibility does not exist. We don’t know, and will never know, what otherwise “might have been.” Our only touchstone is making a choice based on what we believe is most likely to benefit the patient and least likely to lead to serious harm. We do this after conducting a careful assessment and weighing the available treatment options. Usually there several treatment options that meet the standard of care and many more treatment options that do not meet the standard of care. Our job is to choose the former instead of the latter no matter what the patient, family, friends or insurance companies say.
Until next time,
“Effective decision-making can be seen as an optimal link between memory of the past, ground-realities of the present and insights of the future.”
– Amit Ray
“To be careless in making decisions is to naively believe that a single decision impacts nothing more than that single decision, for a single decision can spawn a thousand others that were entirely unnecessary or it can bring peace to a thousand places we never knew existed.”
– Craig Lounsbrough
“Never give up if your heart and your head tell you are right. People can disappoint you, but your heart and your head will never. Make them your best friends.”
– Chika Unigwe