28 Jul 2026
Mary Fraser BVMS, MRes, PhD, CertVD, MAcadMEd, FHEA, FRSB, FRSM, FRCVS considers the similarities between NHS Scotland’s Realistic Medicine framework and a contextualised care approach in vet practice.
Mary Fraser
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Veterinary professionals deal with many different challenges on a daily basis – working at the intersection of advanced medical capability, financial constraint, ethical complexity and client expectations.
In recent years, the concept of contextualised care has, thankfully, replaced the gold standard and enables veterinary professionals to deliver care that is personalised for both patient and owner.
But how does this compare to the world of human medicine, and is there anything that we can take from that? The NHS faces similar pressures of patient expectations, advances in health care, financial burdens and limited manpower.
Realistic medicine, as a concept, was put forward in 2017 by the chief medical officer in Scotland, Catherine Calderwood1, and offers a useful way of thinking about what good care should look like in human medicine.
Rather than assuming that the most intensive intervention is always the best one, realistic medicine asks clinicians to focus on care that is beneficial, proportionate and meaningful to the individual circumstances of the patient. Although it emerged in human health care, its principles resonate strongly with a contextualised care approach, where clinicians must regularly balance animal welfare, owner values, practical limitations and medical uncertainty.
In many ways, veterinary teams may already be practising forms of realistic medicine, even if they do not always use that term. The concept provides a language and framework for examining how care is negotiated, personalised and ethically grounded in everyday practice.
Realistic medicine is often described through six connected principles (Table 1):
At its core, realistic medicine is a shift away from a paternalistic model of care in which the professional simply decides what should happen. Instead, it asks a more human question: not only “What is the matter?”, but also, more importantly, “What matters to you?”
In Scottish health care, this approach is closely tied to values-based care, informed choice, and a recognition of uncertainty. These ideas translate readily into veterinary settings. Although animals cannot state their own preferences, veterinary clinicians still work in relationships shaped by values, priorities and constraints.
The owner becomes a surrogate decision maker, while the clinician remains responsible for advocating for welfare and offering evidence-based guidance. As a result, veterinary medicine is already a field in which care must be tailored, negotiated and justified in context.
Shared decision making is perhaps the clearest area in which veterinary practice already reflects the principles of realistic medicine. In human medicine, shared decision making involves an informed conversation between clinician and patient. In veterinary medicine, that process is necessarily different, with owners making decisions on behalf of animals, while veterinary surgeons provide options, discuss possible outcomes and act as an advocate for the animal. This makes veterinary decision making inherently relational and contextual.
The so-called gold standard treatment may exist in theory, but in practice it must be weighed against affordability, feasibility, owner capacity and the likely impact on the animal’s quality of life. A technically optimal plan that cannot be sustained at home may be less appropriate than a simpler one that the owner can realistically follow.
Chronic dermatological disease – especially canine atopic dermatitis –illustrates this point particularly well. Canine atopic dermatitis is a chronic, relapsing condition which may not have a simple cure and often requires long-term multimodal management rather than a single decisive intervention. Research has shown that the condition can substantially affect both dogs and their owners, shaping sleep, stress, treatment satisfaction and overall quality of life2,3. In such cases, the best treatment is not always the most intensive or expensive option, but the plan most likely to be sustainable, humane and achievable within the realities of the owner’s life. Discussions about bathing routines, medications, diet trials, flare management and follow up are, therefore, not merely technical conversations; they are negotiations about what form of care can genuinely be maintained over time. This is highly consistent with a realistic medicine approach because it acknowledges that adherence, context and meaningful outcomes matter just as much as theoretical efficacy.
Clinical reasoning becomes not merely protocol driven, but relational, negotiated and responsive to lived circumstances.
Compassion and communication are central to this form of realistic care. Realistic medicine is fundamentally relational because good decisions depend on understanding not only disease processes, but also the burdens those diseases place on households, otherwise known as the burden of care.
In veterinary practice, this means listening carefully to owners, recognising distress without judgement and appreciating the emotional labour involved in caring for an unwell animal.
In conditions such as atopic dermatitis, the burden may include interrupted sleep, frustration with flare-ups and feelings of guilt when treatments do not work as hoped. Compassion is therefore not separate from clinical expertise; it helps clinicians identify what care is realistic and sustainable. Trust, continuity of care and compliance are more likely when owners feel heard rather than blamed, and when plans are shaped with sensitivity to the realities of everyday life.
Another important contribution of realistic medicine is its emphasis on reducing harm and waste. In veterinary medicine, this does not mean offering less care for its own sake; it means avoiding investigations, treatments or repeated interventions that are unlikely to improve outcomes and may instead add stress, cost or confusion. Over-medicalisation can diminish welfare, damage trust and create financial toxicity for owners.
In chronic disease management, repeated ineffective therapies or burdensome monitoring plans may leave both owner and animal worse off.
A realistic approach asks whether an intervention is proportionate to the likely benefit and whether it supports outcomes that are actually meaningful. In this sense, more intervention is not always synonymous with better care. Judicious, transparent and welfare-focused treatment planning may sometimes represent the highest standard of care, rather than a compromise of it.
At the same time, applying realistic medicine in veterinary practice is not without challenges. Veterinary professionals may worry that adapting treatment plans to practical or financial realities could be interpreted as compromising standards. Client expectations, social media narratives and fear of complaints can all push practice towards more intervention rather than better judgement. There is also a risk that appeals to realism could be misused to justify inconsistency, inequity or poor-quality care. For that reason, realistic medicine should not be confused with a lower quality of care. It requires skilled communication, ethical reasoning, professional confidence and transparency about uncertainty.
The aim is not to lower standards, but to make decisions that are honest, defensible and centred on welfare and meaningful benefit.
Overall, veterinary medicine increasingly requires partnership, realism, compassion and contextual reasoning.
The principles of realistic medicine offer a valuable framework for understanding what many veterinary professionals are already doing: providing care that is evidence based, but also personalised, proportionate and sustainable.
Realistic medicine emphasises shared decision making, personalised care, reducing harm and waste, managing risk, tackling unwarranted variation and encouraging improvement and innovation.
When translated into veterinary practice, these principles help balance clinical evidence, owner realities, animal welfare and humane care.
Ultimately, realistic medicine in veterinary practice may mean recognising that good care is not defined solely by what medicine can do, but by what genuinely helps animals and the people who care for them.
Mary Fraser graduated from the University of Glasgow in 1994 and has worked across small animal practice, veterinary dermatology, veterinary nursing, research, education and medical education. She holds the RCVS Certificate in Veterinary Dermatology, a PhD in canine atopic dermatitis, and an MRes in Clinical Veterinary Research. Mary is an honorary clinical associate professor at Glasgow, and until recently was executive director of education at the Royal College of Physicians of Edinburgh. She founded Vet Your Decisions to facilitate more discussions around clinical reasoning in veterinary medicine, and she hosts the Animal Welfare Conversations podcast.
