Summary of the results
Chiropractic conservatism
This survey shows that chiropractic students attending an undergraduate institution in close collaboration with a medical faculty generally do not subscribe to the conservative chiropractic concepts. To our surprise, however, they have picked up some other tenets that are not part of their curriculum. Approximately 20% answered ‘inappropriately’ about the connection between spinal manipulation and its ability to intervene with the nervous system in instances such as adjustments can: prevent diseases in general and help the immune system. Some also believe that adjustments can: prevent degeneration of the spine and improve the health of infants. However, this pattern improved with academic year of study and was limited to only three students placed in the highest conservatism group (group 4).
Clinical appropriateness
The included chiropractic students were generally able to identify non-indications and contra-indications to spinal manipulation, albeit some did not recognize that a patient with only minor improvement and a possible underlying depression should be referred out. Mostly, the students also appropriately identified an upper motor lesion case as unsuitable for treatment but were less inclined to suggest that a patient who gradually gets worse should be referred out and should also be considered a potential contra-indication for treatment. As for indications, they would treat a simple mechanical neck pain case on their own but were more reluctant to do so when the pain radiated towards the shoulder. No statistically significant changes appeared when controlling for sex and academic year of study.
Chiropractic conservatism and clinical appropriateness
While the level of conservatism was not statistically significantly associated with the ability to determine appropriate clinical decisions, we observed a tendency that the higher conservative groups had difficulty regarding the management of non-indicated cases. In general, the clinical appropriateness appears to improve with increasing academic year of study. The three students (2%) who belonged to the highest conservative group (group 4) were treated as outliers, and their replies should raise cause for concern, as patient safety was jeopardized in at least two of the answers they provided. These findings indicate that approximately a third of the students in the Danish course adhere to at least some of the original chiropractic ‘philosophy’ [3].
Comparison with previous surveys
The chiropractic conservatism profile in this study was quite similar to that of the students from two other university-based courses in Australia [8]. Both have inappropriate tendencies on the ability of spinal adjustments to improve the health of infants and help the body function at 100% of its capacity. However, this cohort was very different from that reported in the study of the European non-university based course [9]. In fact, there was a remarkable inverse pattern for the four groups, as the majority of the Danish students were placed in the two lowest conservatism groups while the majority of the private college students were in the two highest groups (Fig. 4).
The Danish students’ clinical choices were similar to those reported in the previous studies from the private chiropractic college [9] and the university-based institutions in Australia [13]. With all three cohorts scoring appropriately on the upper motor lesion case. The private college cohort scored more appropriately than the two University cohorts on the case of pain aggravation. Concerning the indications, an overall agreement was found. However, the two university cohorts struggled in identifying the maintenance care patient compared to the private college. Comparable to this cohort, the level of conservatism at the private college did not significantly modify the responses for the indicated cases [9].
Discrepancies between the conservative and non-conservative students regarding the management of non-indicated cases were found in the Danish study and the private college [9], whereas this association was not tested in the Australian study. In the Danish university student cohort, which was not very conservative, these results never reached statistical significance. Contrary, in the very conservative private school, exceptionally strong associations were observed between a firm adherence to the chiropractic conservative belief system and the willingness to treat non-indicated cases. For example, in that course, students in the highest category of conservatism were 20 times more likely than those in the lowest category to offer children treatment to prevent diseases from developing [9]. This suggests that the Danish students’ level of conservatism had a lesser impact on their clinical appropriateness than for private college students. While the two state universities [13] did not provide conservatism scores or included the cases with preventive treatment for a 5-year old, their scores concerning the patient with depression were comparable to this and the private college study. In contrast to the other cohorts [9, 13], the Danish students had no issue terminating treatment for a simple mechanical low back patient.
Potential reasons for chiropractic conservatism at a university program closely collaborating with a medical faculty
During their years of study, students are exposed to many different and exciting chiropractic concepts. Vitalism and its inherent promise of helping many varied and challenging conditions, despite the state of current scientific evidence suggesting otherwise, would clearly appeal to some students’ altruistic nature. However, the purpose of chiropractic education should include providing students with a scientifically acceptable and clinically realistic view of their future profession. This does indeed appear to be the case in the Danish course, where scientific evidence and clinical plausibility becomes more evident in the latter academic years, whereas this was not shown in the other state university setting [8], and was not reported in the private chiropractic college study [9]. Arguably, this highlights the potential value of close collaboration with a medical faculty.
Nonetheless, quite a few Danish chiropractic students still hold at least some unusual beliefs that would surprise the university faculty and, most likely, the Danish health authorities. This was unexpected, when considering the educational setting of these students, which includes a curriculum that does not contain conservative chiropractic ideas, and where concepts like spinal ‘subluxations’ are taught exclusively as objects of historical interest. Furthermore, both the course management and student organization are signatories of the International Clinical and Professional Chiropractic Education Position Statement [26].
Whether this chiropractic conservatism among students results from factors acting within the institutions [27] or are concepts picked up from outside is difficult to say. This might also partly be an intrinsic problem, inherent in the student body. Altruistic students with an acceptance of alternative treatment approaches may well become attracted to an alternative to the scientific approach in the information material of an educational institution, and they could become accepted into the pre-graduate course, particularly if there is a need for large student intake, as there is in private colleges. However, at the Danish university, a conscious effort is exerted in informing applicants on the musculoskeletal and scientific focus of the education [28]. Nevertheless, although admittance procedures for the education at the Danish course have been tightened in recent years, the selection process of students could be inadequate.
The degree of conservatism in the surrounding chiropractic profession, as well as the type of non-scientific courses offered by non-university educators, which students attend in their free time, may also play a role. Indeed, we noted a greater difference in conservatism between 3rd year students and 5th year students than between 3rd year students and postgraduate interns. This could reflect the introduction of new, external influences on the interns, who during the internship, work with other practicing chiropractors and only return to the university for periodic meetings. If website content can be taken as a measure of conservatism, the prevalence of conservative chiropractic ideas among practicing chiropractors in Denmark is surprisingly higher than anticipated [29], and this could exert an unduly influence on clinical interns. It is also possible that students pick up conservative chiropractic convictions and ideas through social media [30]. Finally, external lecturers working within the university may also include non-evidence-based concepts and views in their teaching of students, thus bypassing the university methods of “vetting” new lecturers. Most of these arguments were also raised regarding the two other student cohorts [8, 9, 13] as potential causes for the non-evidence-based reporting.
The sine qua non of clinical chiropractic is spinal manipulation, which plays a central role in the often tricky process of adopting an identity as a chiropractor. Ascribing wider effects to spinal manipulation than that allowed by the evidence and with a mechanistic approach could potentially help smooth such a transition for some students. It could even be argued that because Danish chiropractic students spend the majority of their time in class together with their medical counterparts, who later go on to work in specialties ranging from child-psychiatry to forensic pathology, a chiropractic scope of practice limited to musculoskeletal pain could be restrictively narrow for some. This, in turn, could open the gate for charismatic conservative chiropractic lecturers and opinion-makers, who offer a gold-trimmed chiropractic identity rooted in spinal manipulation as a panacea. Regardless of the reasons, it appears necessary that the course work given on the indications for spinal manipulation, in particular, has to be extended from simple contra-indications to include lectures on when it should be applied and, more importantly, when it should not be applied.
The impact of chiropractic conservatism on appropriate clinical decision making
In our study, the association between conservatism and the ability to make appropriate clinical judgments did not reach statistical significance, possibly due to the low number of highly conservative students. On first look, our data, therefore, suggest that the impact of conservatism on critical clinical judgments (non-indications) was limited. Nevertheless, just as in the previous survey [9], those with the highest conservatism score were shown to have a higher unsuitable clinical decision pattern. The authors of the private college study argue that these findings fit the profile of the original philosophical subluxation-based model where “everything” is treatable [9]. The authors of the study on the students from the state universities, who also had difficulty identifying non-indications, suggests that this could be due to the students having a “try it and see how it goes” approach, were overconfident, or utterly lacked knowledge regarding when not to administer treatment [13]. Overall, the students in our cohort had no substantial issues with non-indications, except for the case concerning a depressed patient. While the other arguments are plausible, due to the integral part that Danish chiropractors play in the healthcare system, we would add that the Danish students see themselves as becoming gatekeepers and would rather collaborate on a solution for the patient as opposed to merely terminating the treatment. This could account for their reluctance to terminate treatment for the patient with underlying depression and the patient experiencing pain aggravation.
Recommendations
In what would arguably be a ‘flagship’ for a modern chiropractic university program, the presence of some’ conservative’ views clearly shows that conservative chiropractic concepts need to be dealt with up-front and transparently with the consequences it may have on patients foremost in mind. Therefore, the sources of influence that give rise to the adherence to such viewpoints must be identified and dealt with accordingly to ensure that young students become safe and ethical practitioners.
Methodological considerations
An obvious strength of the current study is the ability to compare our findings with those of other studies [8, 9, 13]. Nevertheless, a full comparison of all items was not possible, as the data reporting was not identical across studies.
There are some potential weak points to consider regarding this study. It is possible that the opinions of non-responders could have altered the results, but as this was an anonymous survey, it is not possible to conduct a responder/non-responder analysis. The response rates per year of study ranged from acceptable to good, and we have no reason to suspect that the students who either were absent on the day of invitation or were uninterested in responding would have a remarkably different profile that could substantially change the results. However, 8 students chose to terminate their survey in the initial section for reasons unknown. We speculate that these students did not understand the questions or disliked responding to the questions. However, judging by their intermediate score, they did not appear to be highly chiropractically conservative.
The clinical cases in the questionnaire, which had already been administered in two other student settings [9, 13], was translated to Danish in an appropriate fashion, and piloted before use. However, some uncertainty may have arisen due to the lack of clinically oriented detail. In general, it is possible that the items used in this and previous questionnaires [9, 13] had poor content validity [31] despite having gone through pilot-tests. For instance, the question adjustments can improve the health of infants, might have been interpreted to specifically refer to infantile colic, a condition very commonly treated by chiropractors in Denmark [32]. Thus, answers may reflect a conviction that ‘adjustments’ improve the health of infants in specific circumstances, and not as a general effect. This is speculative, of course, and would require further research to clarify. However, the fact that the score of conservatism (0–10), when tested in one of these studies [9], corresponded in such a logical manner with the inability to respect a number of chiropractic non-indications, indicates that the ten items, on the whole, validly capture individuals who accept the chiropractic conservative concepts.
Lastly, and related to content validity, while the terms ‘subluxations’ and ‘adjustments’ are not typically included in the Danish chiropractic curriculum, we assume that the students would have picked up these terms from their international reading material, and the pilot-tests did not reveal any such problems.
Therefore, we suggest a qualitative follow-up study to investigate i) the validity of items and ii) what sources of influence gave rise to the approximately 20% who answered ‘inappropriately’ on some undoubtedly antiquated viewpoints.
As our data were collected cross-sectionally, our suggestion of the differences between 3rd, 4th, 5th years students and postgraduate interns is not necessarily indicative of development over time. Obviously, only a longitudinal study can establish whether students change over time.
Another potential limitation is that we compared the results only to other chiropractic institutions and not with a similar healthcare profession. Perhaps a fraction of medical students also believe in nineteenth century medical concepts such as smoking is good for you, and ‘miasmas’ are the cause of cholera, and other theories that became obsolete around the same time as chiropractic conservatism emerged [33,34,35].