The veterinary podium: Gold, silver, and bronze standards of care

My name is Ignacio Mérida Isla, although everyone who knows me simply calls me Nacho. I’m originally from Santander, a small city in northern Spain, and I’ve spent more than 20 years practicing veterinary medicine across several countries. I currently live in the United Kingdom, where I work as a locum (relief) veterinarian. Working this way has allowed me to see different ways of approaching the profession, and, above all, has reinforced the same conclusion time and again: The most important problems in veterinary medicine are rarely found in textbooks; they tend to be in the exam room.

Not long ago, the Winter Olympics ended, and Spain celebrated something uncommon: a gold medal. The first one in 50 years. Bringing home few gold medals is not strange—most countries rarely see gold. Only a few live under the constant expectation of the podium. And above them all is Team USA, where only gold seems to count. The famous gold standard. Interestingly, in veterinary medicine, we also live under the same obsession.

We’ve grown accustomed to talking about the “gold standard” as if it were the only acceptable language of medicine: the best diagnostic test, the ideal surgery, the specialist referral, the perfect hospitalization, the MRI, the laparoscopy, the flawless medicine. And clinically, of course, that is often the best possible approach. No one disputes that.

The problem starts when we stop understanding the gold standard as the best possible option and start treating it as the only morally acceptable one. That’s when medicine stops being clinical and starts to look like religion. At that point, we leave too many clients behind.

Most pet owners do not live in the gold standard. They live in mortgages, inflation, fuel prices, school fees, car payments, and emergencies that never announce their arrival. They love their dog exactly as much as anyone else. They love their cat with the same emotional intensity as any other owner. But love does not pay a 4-figure vet bill.

And that’s where the term “spectrum of care” enters the conversation, as if giving it an elegant name somehow makes it easier to accept an uncomfortable reality. In truth, it does. Offering different levels of treatment doesn’t mean practicing worse medicine. It means making care possible. It means understanding that between gold and euthanasia, there is a vast middle ground.

There is silver.

There is bronze.

And lives are saved there, too.

The real problem is that almost nobody teaches us this. Veterinary schools still educate in binary terms: “This is how it is done.” “This is what is correct.” “This is what is indicated.” And although nobody says it explicitly, the message often feels almost accusatory: “If you don’t do this, you are a bad veterinarian.” “If you don’t accept this, you are a bad owner.”

Yet real clinical practice doesn’t work like that. Real medicine doesn’t happen at conferences. It happens in the exam room, with a geriatric dog in front of you, a worried family across the table, a credit card that declines, an uncomfortable decision to make, and someone crying while trying to decide what they can afford without feeling guilty.

At that moment, reciting protocol is not enough. What is needed is judgment, experience, the ability to prioritize, and the understanding that medicine and economics do not exist separately, no matter how much we were taught to believe otherwise.

One of the greatest frustrations for young veterinarians begins here—not from not knowing medicine but from discovering that real medicine looks nothing like veterinary school. They were trained to fight for gold, but most of the matches are played in silver and bronze. No one explained how to do that without feeling like they were betraying the profession.

That feeling destroys careers.

It creates guilt.

It creates burnout.

It creates the false idea that adapting medicine to what the client can afford means lowering the standard. In reality, it’s often exactly the opposite. It’s often the harder form of medicine to practice.

Recommending the most expensive test is easy. The difficult part is deciding which test actually changes prognosis. The difficult part is separating medicine from professional ego. The difficult part is accepting that we cannot always practice the ideal veterinary medicine, but we can still practice honest, pragmatic medicine.

There’s also another problem we rarely discuss: We have confused evidence-based medicine with blind obedience. Evidence-based medicine was one of the best things to ever happen to our profession. It was created to reduce clinical variability, help young veterinarians make better decisions, and shorten the distance between the newly graduated veterinarian and the clinician with 20 years of experience. It was a tool to facilitate the transition from knowing theory to actually practicing medicine.

It was a bridge—a way to prevent everything from depending exclusively on the famous phrase, “This is how I’ve always done it,” a sentence that has caused, and continues to cause, damage in everyday practice.

Somewhere along the way, we stopped using it as support and started using it as dogma, as if a published study were a divine order. As if questioning the applicability of a clinical recommendation were a form of professional heresy.

It’s not.

Many of the studies supporting our gold standard come from referral hospitals, tertiary care centers, universities, or highly specialized services where the type of patient looks very little like what we see in first-opinion practice. These are selected patients: highly committed owners, complex cases, environments with more diagnostic resources, more time, and often a completely different financial reality.

Above all, there is one variable that disappears far too often from the written study: who is paying the bill. Cost is also part of medicine, even if admitting it makes us uncomfortable. You cannot talk about the ideal treatment while ignoring the owner’s real ability to afford it. That’s not bad medicine. That’s bad clinical management.

Scientific evidence should help us think better, not stop us from thinking. It’s not about ignoring evidence or justifying poor decisions under the shield of clinical flexibility. It’s about contextualizing it. It’s about understanding that an excellent protocol in a university hospital is not always the best solution in a community clinic at 7:00 PM, with an owner who has $300 available and an urgent case in front.

Medicine doesn’t happen in the pages of a journal; it happens in the exam room. And there, in addition to evidence, we need judgment, communication, and honesty.

For years, we have sold the idea that offering alternatives was synonymous with lowering professional standards, as if the only ethical medicine were the most expensive one. As if the only way to show competence were to always recommend the most complete workup, regardless of context.

That’s not only false but profoundly unfair. It’s unfair to the owner, because it turns financial limitation into moral guilt. It’s unfair to the young veterinarian because it forces them to experience every consultation as a small betrayal of what they were taught. And it’s unfair to the profession, because it distances us from what should define us: solving real problems in the best way possible.

A veterinarian who only knows how to offer gold-standard medicine is not necessarily a better clinician. Sometimes, they have simply had wealthier clients.

A truly good veterinarian is one who knows how to navigate between gold, silver, and bronze without losing rigor, ethics, or the client along the way. They understand that the goal is not to impose perfect medicine on paper but to achieve the best possible outcome within the reality of each family.

That requires more knowledge, not less.

More communication, not less.

More responsibility, not less.

Because practicing spectrum of care is not about making medicine cheaper. It’s about better decision-making. It’s about asking what this patient truly needs, what this owner can realistically manage, and which intervention will have a real impact on prognosis.

Sometimes it will be gold, and that is fine.

Sometimes it will be silver, and that is also fine.

Sometimes it will be bronze, and that is still fine.

Good medicine is not always measured by how much money is spent but by the quality of the judgment behind every decision.

Perhaps it’s time to stop training veterinarians for an Olympic version of veterinary medicine that almost never exists, and start preparing them for the real exam room, where excellence does not mean always recommending the maximum but knowing how to build responsible solutions within imperfection.

The gold standard should not be a religion. It should be a reference—a lighthouse, not an imposition. Because between gold and euthanasia, there is a great deal of habitable ground, and that’s where most of the profession actually works.

It’s not second-rate medicine. It’s real medicine.