Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Should "Standard of Care"
Be Standard?

Universally, physicians in our country are educated and trained with the idea of “standard of care.” This amorphous idea that often varies between cities, states, and regions supposedly provides practitioners with a flexible guideline in which to diagnose and treat various diseases. For example, it would be grossly outside the standard of care in the United States to treat a ruptured appendix with IV antibiotics alone. This is obvious. But what about other less apparent diseases? Should we follow our local standard of care? Should “standard of care” exist? If so, in what form? If not, what does this say about clinical practice guidelines?

	Tonight's Premier Lecture is Medical Documentation by Mark Beylin, DPM

Let's talk about an example: plantar fasciitis.  I was trained, have practiced in a few areas of the country, and listened to national lecturers talk about the following idea:

The standard of care for plantar fasciitis is to treat it nonsurgically for six months before attempting surgical intervention, all nonsurgical methods should be exhausted, and certain other diagnoses (radiculopathy, tarsal tunnel syndrome, stress fracture, etc.) should be ruled out preoperatively.  I have a few problems with this "standard."

1. Where's the evidence?  I've never read a study that demonstrated plantar fasciitis had to be treated for six months before doing surgery.  Correct me if I'm wrong, but six months is a general standard that we've stuck to for many years simply because that's how it's been done.  Where's the evidence for this idea?  Perhaps this comes from the time it takes to exhaust nonsurgical methods.  I guess if I'm conservative I could take six months to treat a patient with injections, shoe changes, orthotics, night splints, etc.  Is “standard” based on any solid research?
   
   
2. Time to relief of symptoms.  We know that nonsurgical treatment is successful in somewhere between 85-90% of patients with plantar fasciitis (depending on to whom you speak).  Hence the argument for exhausting nonsurgical methods.  But, for most of our patients TIME is a critical prescription in the healing process.  I think it's comparatively rare that our plantar fasciitis patients resolve their pain immediately and permanently after our treatments.  More commonly we see a gradual decline of pain as time progresses, varying between patients.  However, are we doing right by our patients by not surgically intervening earlier in their course?  Take, for example, the treatment of verruca plantaris.  In general it takes two years for a wart to resolve without treatment.  But who wants to live with it for two years?  I think many podiatrists would agree with me that they'll treat plantar warts (topicals, cautery, laser, etc.) without letting them self-resolve.  If we treat this potentially self-resolving problem why not do the same with plantar fasciitis?  Why do I have to wait six months to do surgery?  Granted some nonsurgical care is best, but for how long?  three months?  four months?  Does “standard” equate with “appropriate?”
   
   
3. Do we really have to rule out all other possible diagnoses?  When I first started practice I would order extraneous tests to rule out radiculopathy, tarsal tunnel syndrome, and stress fractures.  I would subject my patients to an EMG and a bone scan to rule out these diagnoses before planning heel surgery.  Why did I do this?  Strictly for medicolegal reasons and because it was the standard of care in my community.  Is this reasonable?  Is this good patient care?  I don't think so.  Whatever happened to our clinical skills?  Aren't tests supposed to be confirmatory and not diagnostic?  If I've treated a patient for some time period, thinking it's plantar fasciitis the entire time, and now I want to bring them to surgery, why should I have to order extra tests?  Do our primary care colleagues treating hypertensive patients order renal arterial ultrasounds on every patient just to be certain they don't have renal artery stenosis?  Of course not.  They rely on clinical judgment, ordering the test when clinically indicated.  Why should plantar fasciitis be any different?  If I have attempted what I deem in my professional judgment to be a reasonable nonsurgical course of therapy with continued failure, shouldn't I will proceed to a surgical recommendation?  Does “standard” lead to cost effective and reasonable patient care?

Where does this put clinical practice guidelines?  They are simply that: guidelines.  These are an informational resource for physicians, created by a committee of leaders in the field, based on the best available research (which isn't necessarily good research).  These guidelines are not a replacement for sound clinical judgment and experience.  Clinical practice guidelines are still very important, but by no means do they create a standard of care, whether local, regional, or national.   And in no way should a “standard of care” be used against a physician in a court of law. 

The very idea that “standard of care” varies by community and region tells me there's something wrong with either this concept or our understanding of medicine.  Why should plantar fasciitis treatment, for example, vary based on what part of the country in which we practice?  Is plantar fasciitis different in New York versus Oregon?  I don't think so.  If not, why should the treatment vary?  In essence this thought process leads us to a national standard of care.  Perhaps this very concept should be eliminated from our medical consciousness.  What do you think?  Is Shapiro barking up the wrong tree?  Or do we need to revise our thinking on standard of care?

What do you think?
Do we need to revise our thinking on standard of care? Join in on or any number eTalk Topics taking place on PRESENT Podiatry, or create one of your own.

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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