Neville Goodman’s Metaphor Watch: Time to come off the gold standard

neville_goodmanThis blog started with epidemic proportions. There are nearly 1800 PubMed articles written in English that have epidemic proportions in the title or abstract. Of the other metaphors I’ve dealt with, some are more common and some are less: there are 5000 drawbacks, 900 Holy Grails, 100 red herrings. But these pale before the gold standard: there are over 36 000. From its first appearance in 1979—interesting given that most countries came off the gold standard in the 1930s and the United States in 1971—its popularity just keeps on rising.

There were 671 gold standards in the year 2000; there were over 2000 in 2010, which was 0.35% of all articles published that year. By 2015 it was 0.45%.

The gold standard was a monetary instrument, by which the value of a country’s currency was defined by an existing and fixed amount of gold. By extension, the expression came to mean a “well established and widely accepted model or paradigm of excellence by which similar things are judged or measured.” This definition is taken from The Free Dictionary by Farlex (, which has tabs allowing the same word or expression to be sought in a dictionary, thesaurus, or in specialised dictionaries, including a medical dictionary and a dictionary of idioms. So what is wrong with writing gold standard, if it is such a well established paradigm of excellence?

The Free Dictionary takes its definitions from (and credits) other dictionaries: its medical dictionary uses Farlex Partner, Mosby’s, Segen’s, and McGraw-Hill, which all give some variation of paradigm of excellence; but the Medical Dictionary for the Health Professions and Nursing (© Farlex 2012) nails it: “jargonistic term meaning ideal or basic measurement; usage best avoided.” So best avoided—in my view—that gold standard, much like the business metaphors decried in my previous blog should never be used.

A quick scan of the many examples in PubMed soon shows that many of the gold standards are nowhere near. I found one article in which a new test was being compared with a gold standard that consisted of either one test or a different test. That is nonsense: the whole point of the gold standard was that gold was immutable gold (although even by its own definition the standard failed because the value of gold turned out not to be immutable).

The inappropriateness of the expression is inherent in its definition, “Any standardised clinical assessment, method, procedure, intervention, or measurement of known validity and reliability, which is generally taken to be the best available, against which new tests or results and protocols are compared.” But if the new tests or protocols are better, they become the gold standard—except that not everyone will necessarily agree.

The gold standard in medicine is a criterion standard; it is a standard against which a criterion is measured. If what you mean is the best method then write “best method.”

“Autogenous tissue is the gold standard for grafting materials”: no—autogenous tissue is the best grafting material.

“However, no intervention was identified as a gold standard”: no—no intervention was ideal.

“ . . . still acknowledged to be the gold-standard therapy for benign prostatic hyperplasia”: no—still acknowledged to be the best therapy for benign prostatic hyperplasia.

For more advice on the gold standard, see:

Neville Goodman is a retired consultant anaesthetist and a writer. He is co-author of a book on medical English.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that my only competing interest is my co-authorship of a book about medical English.