The Gold Standard

This is a blog about assessment and urine. Please stay . . .  

I was very proud of myself this morning for collecting a urine sample from Athena. She seems to be suffering from cystitis, which is common in cats in her demographic. By a bizarre coincidence I happen to have a UTI this week as well, which is a common occurrence in my demographic. The upshot of this is that on Wednesday I saw a GP deal with my case very effectively, and a vet deal with Athena’s case very effectively. Both practitioners impressed me.

In medical education we have a concept, Miller’s Pyramid, which describes the different levels of ability in a practitioner.

  • You know
  • You know how
  • You show
  • You do

Obviously the ‘doing’ is the most important part. Both my GP and my vet did an excellent job of doing, with a lot of similarities in how they handled their respective cases. Both were good at providing detail, providing treatment options, making me feel consulted, and both were respectively gentle with their patients (although I will say Athena was less grateful than she could have been). But large parts of that ‘doing’ is subjective, involving my feelings and Athena’s feelings, as best we can know them.

Let’s take a less medical example. An excellent question for a statistician might be:

Calculate the likelihood of a cohabiting 32 year old woman and 4 year old spayed indoor female cat presenting with cystitis on the same week.

A statistician would need to investigate the prevalence of these conditions in these populations and then calculate how often these populations intersect. We might then ask them to comment on the factors which may make this an under/over estimate, and see if they show enough awareness of the real world to realise that I’m probably more sensitive to Athena’s problems when I’m in pain myself.

Even with this example, which uses lovely objective maths, there isn’t a true ‘right’ answer for doing. You might use different estimates, for example, or you may bring in other information (such as the fact cystitis may be associated with stress, in cats, and possibly in women). The best you can do is give your estimate and outline your thinking as to why this is the case.

At the same time, it’s MSc marking season. We say the gold standard for an MSc is to be of ‘publishable quality’, but in line with #PeerReviewWeek18 (yeah, that is unbelievably a thing), we scientists can’t decide that amongst ourselves. A recent study has shown that as readers, scientists are reasonably good at guessing which papers will not be replicated, and yet we still allow those papers to be published – we are the ones who peer review them after all.

My GP and my vet were responsive to me, and both were very accepting of the ‘grey’ areas in diagnoses. My vet deeply impressed me by strongly recommending a painkiller for Athena (who is currently snoozing very comfortably on my left leg), and my GP was extremely good at parsing my confused jumble of “I’m not sure if this is a symptom or if I’m just overly-anxious today”.

When I was asked to collect a sample of Athena’s urine I thought back to when I used to perform similar tasks in the wildlife hospital I worked in over ten years ago. Then, the assessment criteria (that I perceived anyway) was to perform the task quickly, with economic use of resources and with a minimum of fuss. But this morning I wanted to do it calmly, inflicting as little stress on Athena as possible, and still get to my first meeting on time. Similar task, two different sets of criteria.

The same task in different contexts requires different definitions of ‘doing’ – and good practitioners are adaptable. But funnily enough, this week has made me a lot more confident in ‘assessing’ practice. You recognise good care when you get it, not necessarily because it ‘works’, but because afterwards you feel better. Athena and I feel better today, and even if our respective problems aren’t fixed, we’re better for having seen good health professionals. Vice versa, the next time I think a paper isn’t publishable, I’ll remember that I’m capable of recognising quality when I see it. 

And just an observation, it’s those ‘softer’ skills that my practitioners used to demonstrate their excellence . . . 

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