This study shows that chiropractic students with higher levels of conservative beliefs are significantly more likely to make inappropriate non-indicated clinical decisions for SMT, when compared to those with lower levels. New information is that conservative attitudes and beliefs seem to be influenced by individuals’ intrinsic factors. Thus, students who have a tendency to engage in ‘magic thinking’ are also more likely to resort to conservative thinking, and are, not surprisingly, more likely to accept for treatment also cases that are outside the scope for SMT.
However, having a closer look at the students who scored high on MHB, only 30% of them were also high on ChiroCon indicating that they could also be looking for other chiropractic-magical opportunities such as those described in the background text.
Strong association between chiropractic conservatism and a limitless scope of practice confirmed
This study, thus, confirmed that chiropractic students with higher levels of chiropractic conservative beliefs are significantly more likely to accept a wide scope of practice. As compared to students with lower levels of conservative chiropractic beliefs, when faced with an asymptomatic 5-year-old child, they were 4 times more likely to recommend SMT to prevent future spinal disorders and 7 times more likely to believe they can prevent future diseases.
This link between ChiroCon and a LLSoP has been previously shown, both in a setting with students showing a large preference for conservative chiropractic thinking  and in a study with only a minority of students thinking in this way . As in the present study and in the other two study settings, this type of conservative chiropractic clinical rationale meaning was not encouraged, it does not appear to be entirely the ‘fault’ of the educational institution.
This is the second study at this Australian university to explore conservative thinking in chiropractic students . The current study had a larger percentage of responding final year students when compared to a previous study and when viewed together, it suggests that the most likely interpretation is that conservative thinking declines somewhat over the educative process. This decline is also seen in the Danish chiropractic program . The pattern was also seen in magical thinking but not so for intolerance of uncertainty. This suggests that although magical thinking and intolerance of uncertainty are both attempts at dealing with the unknown, they are measuring differing constructs.
Consequently, it would appear to be overly simplistic to think that providing an evidence-based curriculum alone will inoculate students against conservative attitudes and beliefs. Not surprisingly, this is backed by the literature, as it has been shown that the Knowledge-Attitudes-Behaviour model performs poorly, when tested in real life .
Rather, it appears to be a matter of the much more difficult task of changing a person’s world view. This has been studied in detail and has now produced several meta-analytic and systematic reviews [36, 37] and should be considered as the basis for interventions for chiropractic educators to further research.
Magical thinking drives this approach
This appears to be the first study to investigate the reasons for chiropractic conservative thinking and LLSoP. Magical thinking, rather than intolerance of uncertainty, or academic achievement, explained some of this confidence in the preventive powers of SMT for non-MSK conditions.
To have confidence in one’s ability to help suffering patients ‘magically’, is, in our opinion, beautifully idealistic but unfortunately unrealistic. However, since magical thinking may be an intrinsic personality trait, it is unlikely that mere education and information will change it more than marginally. In our study, as has been previously shown [2, 11], there was a small but gradual decline of magical thinking over the years of academic study (data not shown).
Can we trust these findings?
Whether our results can be trusted would depend mainly on (i) the representativeness of the study sample and the external validity of the results, (ii) the quality of the data, and (iii) the choice of statistical analyses and the interpretation of data.
Representativeness of the study sample: A response rate of nearly 75% was obtained after the exclusion of the first-year cohort. No opposition to the study had been voiced among the students, so the non-response probably reflected only that all students do not attend all lectures all the time. It was not possible to sample non-responders, but a previous study has shown that there were no differences between this university-based chiropractic program and another university-based program in Australia, so these results are likely applicable to both  and therefore represent two of the four Council on Chiropractic Education Australasia accredited programs. It would be relevant to validate the generalizability of the findings to national and international chiropractic students and practitioners but, in our opinion, our findings have a strong face validity.
External validity: Previous studies in this Australian university chiropractic program have not demonstrated any significantly different attitude or personality traits, when first year students were compared to the second or third years [18, 38]. Hence, we are confident that the exclusion of the first-year cohort has not significantly impacted on our findings.
Quality of data: The variables of interest demonstrated acceptable levels of internal consistency as tested statistically. Students appeared to be accurately reporting their academic ability. Nevertheless, academic ability could perhaps be measured differently to confirm our findings. We chose not to create the four ChiroCon Groups, as used in previous studies, to obtain larger subgroup sizes for statistical purposes. Obviously, larger numbers will address this as well as confirm the Cronbach Alpha finding for the ChiroCon scale. Larger numbers would also allow further statical exploration (e.g., factor analyses) to address concerns raised with Cronbach Alpha such as its ability to determine uni-dimensionality . Differences in findings between the study years might indicate a learning curve or may be a mere cohort effect or a combination of both. Longitudinal investigations would be needed, if anybody wants to confirm trajectories over time. Also, this would need to include the transition to practice to confirm that these findings for a student population also apply to practicing chiropractors.
Statistical approach: Although the authors, at this stage, have negative opinions regarding the use of SMT for non-MSK disorders, any bias this could have induced in the analyses was avoided with the assistance of an independent statistician. We made maximum use of our data by performing analyses on predictors using both continuous and categorical data and made an effort to present the data clearly with explanations to make the text understandable also for people without knowledge in statistics.
This study had a sufficient sample size for the logistic regression analyses and indicators of violation of basic assumptions were not observed.
Although we consider our results trustworthy, ChiroCon would not be the only explanation of a LLSoP. Others who belong to this group would include those who will attempt to treat various non-MSK disorders via the autonomic nervous system, and the group that claim to treat the brain with SMT and other stimuli. Thus, if we take into account also, at least, these other groups, the number of chiropractors who do not keep to the MSK area becomes considerable . That there is a link between magical thinking and ChiroCon was shown clearly, but all magical thinkers did not belong to the ChiroCon group.
Perspectives in the light of the different types of chiropractic education
Although some chiropractors consider this a problem, some do not. Over the years, we have noticed that chiropractic organizations claim to be evidence-based-friendly, yet they accept pseudo-scientific approaches. An example is when the World Federation of Chiropractic (WFC) states: "We commit to an EPIC future for chiropractic: evidence-based, people-centered, interprofessional and collaborative." in their declaration” Our Principles” ” but are not prepared to close the door on those chiropractic programs that continue to teach the old chiropractic beliefs by stating in the same document "... and we champion the rights of chiropractors to practice according to their training and expertise ". The latter statement may seem inoffensive to the public, but all chiropractors know that many chiropractic institutions sometimes teach, what we and others consider, highly suspect methods of diagnosis and treatment . It is just part of the chiropractic ‘heritage’ and not really questioned.
Our suspicion is, therefore, that this evidence-friendly approach could be seen as paying lip service to evidence-based medicine, which seems to be specific to chiropractic, as clearly out-dated and non-evidence based ideologies would not be included in the curricula of mainstream healthcare professions and, if used in practice they would be challenged, and not, as in chiropractic, discretely accepted.
Further, the ‘overseeing’ organization, the various Councils on Chiropractic Education (owned by and run by chiropractors) have been shown to have an approach that, generally, provides a ‘big tent’, making it possible for chiropractic institutions that range from very ‘chiropractically’ conservative to not at all conservative to be ‘accredited’ as equals [41, 42]. This phenomenon is referred to as “professional diversity”, as defined in principle 12, in the same document from the WFC (36) and “respecting the past, embracing the future” is one of its strategic points, according to their Strategic Plan 2019–2022.
Thus, contrary to medicine, where hundred-year clearly outmoded practices are ousted without too much ado, in chiropractic there is obviously a strong support for, at least, some of the old concepts and the ‘you-never-know’-approach. In fact, there seems to be an unwritten requirement that the conservative groups be left alone, and that ‘respect’ is due towards them, described as ‘diversity’ [42, 43]. Thus, it appears that the LLSoP is firmly anchored in the chiropractic profession.