What Is The Standard Of Care?

The term “standard of care” has various definitions from state to state and from region to region. The term refers to a general concept of “what the average healthcare provider would have done under the same or similar circumstances.”

Some years ago, I was sitting in the hospital doctor’s lounge discussing the opinions of a plaintiff expert in a malpractice case. An older general surgeon looked at me and said “Jacobs, I’ll tell you what the standard of care is. It’s whatever the expert witness tells the jury it is.”

There is a great deal of truth to that statement.

Standard of care is important for directing patient care as well as medicolegal issues when someone calls patient care into question. The fact is that for many clinical problems, there are often many correct answers. In the Northwest, it is Lapidus for one and all bunions. Back East, it is an Austin for all. Scarf? Not in the East or West but in the Midwest, Scarf is very popular. Somehow, despite these regional variations, the majority of patients are getting good and excellent results from their bunionectomies. Why? Frequently, there is more than one correct answer.

In my opinion, standard of care should equate to “reasonableness” given the particular circumstance unique to each case. Were the evaluation and treatment reasonable — not perfect, not necessarily successful but reasonable — under the circumstances?

I recently participated in a malpractice case in which an Austin bunionectomy resulted in a malunion. At surgery, the surgeon encountered a large cyst that prevented ideal reduction and alignment. The podiatrist grafted the defect and aligned the osteotomies as best as he could under the circumstances. He informed the patient of his findings and actions. The podiatrist followed the patient to see if the malunion would be symptomatic and if so, he would revise the osteotomy. The plaintiff expert was of the opinion that unanticipated clinical circumstances or not, malalignment was never acceptable.
General guidelines are not standard of care statements. At times, physicians misinterpret guidelines as such. A common example is the use of the American College of Foot and Ankle Surgeons (ACFAS) preferred practice guidelines as a standard of care document.¹ It is not.

I recently acted as an expert in a case of a patient whose sural nerve was injured during an endoscopic gastrocnemius recession for plantar fasciitis. The plaintiff expert opined that there is no indication for gastrocnemius recession for the treatment of plantar fasciitis. When confronted with multiple publications from peer-reviewed orthopedic and podiatry journals to the contrary, his position was that if the procedure is not included in the ACFAS guidelines, one should not perform it.

Corporate influence in standard of care decision-making is a dangerous, more recent evolution. I was speaking at a meeting at which four different speakers, each sponsored by a different company, spoke on the use of orthobiologics to enhance bone healing. Each endorsed a different product. The final speaker actually said, “With what we know today, I think that it is malpractice not to use such products for all osteotomies and fusions.” My jaw dropped at that one.

Standard of care is frequently not an irrevocable standard. It is actually a moving target. Recently, Lamm and colleagues published a paper demonstrating the safety and effectiveness of almost immediate weightbearing following the Lapidus procedure.² Others, such as Blitz and Wang, had similarly suggested that under the appropriate circumstances, early weightbearing following the Lapidus procedure was achievable with sacrificing healing.^3,4 Twenty years ago, we would have considered early weightbearing following a Lapidus procedure or first metatarsophalangeal joint (MPJ) arthrodesis as malpractice.

According to the new Infectious Diseases Society of America guidelines, in many circumstances, antibiotics are adjunctive for the treatment of postoperative infection.⁵ Just incision and drainage? Are you kidding me? Why, that’s malpractice, a violation of the standard of care, or is it?

An extremely famous and accomplished surgeon in our profession once called minimally invasive surgery “a cancer that needed to be removed from our profession.” Today? Orthopedic surgeons as well as recognized podiatry thought leaders such as LaPorta and colleagues have published works advocating minimal incision bunion correction or minimal incision first MPJ fusion.⁶ This was heresy just a short time ago.

There is a story of a famous medical educator addressing students in his internal medicine class. “Gentlemen,” he said, “in 10 years, half of what I teach you today will be proven wrong. The problem is that I don’t know which half it will be.”

References
1. Thomas JH, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline — revision 2010. J Foot Ankle Surg. 2010; 49(3):S1-19.
2. Lamm BM, Wynes J. Immediate weightbearing after Lapidus arthrodesis with external fixation. J Foot Ankle Surg. 2014; 53(5):577-83.
3. Blitz NM, Lee T, Williams K, et al. Early weightbearing after modified Lapidus arthrodesis: a multicenter review of 80 cases. J Foot Ankle Surg. 2010; 49(4):357-62.
4. Wang JC, Riley BM. A new fixation technique for the Lapidus bunionectomy. J Am Podiatr Med Assoc. 2005; 95(4):405-9.
5. Steven DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):e10-52.
6. Siddiqui NA, LaPorta G. Emerging insights on minimally invasive hallux valgus correction. Podiatry Today. 2014; 27(9):26-32.

Dr. Jacobs is a Fellow of the American College of Foot and Ankle Surgeons, and a member of the Association of Physicians in Wound Healing. He is in private practice in St. Louis.  
Editor’s note: This column has been adapted from a previously published DPM Blog by Dr. Jacobs at https://tinyurl.com/pheensy .