Clinical Judgment and the Standard of Care: Navigating Chiropractic Practice

Review Written by: James Demetrious, DC, DABCO

In the complex ecosystem of modern healthcare, the *standard of care* is a foundational concept, often defined as the level and type of care that a reasonably competent and skilled healthcare professional, with a similar background and in the same medical community, would provide under comparable circumstances.

While chiropractic boards, professional societies, and regulatory bodies offer frameworks to guide this standard, its practical application is often shaped by far more than published guidelines or legal precedent. Notably, physician training, clinical experience, and specialty orientation significantly influence how care is delivered, particularly in areas where scientific literature is
incomplete, conflicting, or absent.

Limitations of Evidence-Based Medicine

Evidence-based medicine (EBM) is indispensable for improving care quality and patient outcomes. Yet, it is not infallible. Gaps in the scientific literature, especially in complex or rare conditions, can leave physicians without clear direction. Many clinical guidelines rely on expert consensus rather than high-level evidence due to the lack of large-scale randomized controlled trials (RCTs).

According to Sackett et al., EBM is “The conscientious, explicit, and judicious use of current best evidence, but it must be integrated with individual clinical expertise, patient values and expectations to be effective.”[1].

Moreover, research bias, limitations in generalizability, and evolving clinical paradigms mean that even robust literature may not apply universally to all patient populations [2]. This creates a practical need for providers to draw upon their training, experience, and clinical reasoning.

The Role of Physician Training and Experience

Medical education and postgraduate training programs differ significantly by specialty. This divergence creates distinct lenses through which practitioners interpret diagnostic information and formulate treatment plans. A 2018 analysis by Djulbegovic and Guyatt emphasized that when EBM is insufficient, “clinicians must fall back on pathophysiological rationale, precedent, or expert opinion” which varies significantly by training background
[3].

For instance, a family physician managing chronic back pain may prioritize conservative care and pharmacologic options, while a physiatrist may employ interventional strategies, and a chiropractor might consider spinal manipulation or rehabilitation-focused interventions. Each of these approaches, though different, can be appropriate within the respective scopes of practice and informed clinical judgment.

Clinical Indications and the Influence of Specialty

Clinical indications, symptoms, comorbidities, functional limitations, and even patient preferences are central to determining appropriate care. Yet, the interpretation of these indications is often specialty-specific. A study by Sirovich et al. found that physicians’ decision-making can differ widely even when presented with identical patient scenarios, influenced by perceived norms within their specialty and prior experience [4].

These differences underscore that the standard of care is not monolithic. It is both situational and relational, shaped by the dynamic interaction between the patients condition and the providers competencies. Courts have long recognized this in malpractice cases, noting that clinical judgment, when reasonable and supported by professional standards, does not equate to negligence, even if outcomes vary [5].

Toward a More Inclusive Understanding of Standard of Care

Recognizing the legitimate diversity in care approaches helps avoid a reductive or punitive interpretation of the standard of care. It also safeguards innovation, interprofessional collaboration, and personalized medicine. The American Medical Association (AMA) notes that physicians should “exercise reasonable discretion in the face of medical uncertainty” particularly when evidence is lacking or evolving [6]

Rather than being strictly prescriptive, the standard of care should accommodate professional differences in training and reasoning, within accepted, reasonable practices and ethical responsibility. A rigid, one-size-fits-all approach risks undervaluing individualized care and may misrepresent what is reasonable or expected in complex clinical scenarios.

References

  1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based
    medicine: what it is and what it isn't. *BMJ*. 1996;312(7023):71–72.
  2. Ioannidis JPA. Why most published research findings are false. *PLoS Med*.
    2005;2(8):e124.
  3. Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on.
    *Lancet*. 2017;390(10092):415–423.
  4. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’
    views on US health care: a brief report. *Arch Intern Med*. 2011;171(17):1582–1585.
  5. Hall MA, Bobinski MA, Orentlicher D. *Medical Liability and Treatment Relationships*.
    3rd ed. Wolters Kluwer Law & Business; 2013.
  6. American Medical Association. AMA Code of Medical Ethics Opinion 1.1.6 – Quality.
    https://code-medical-ethics.ama-assn.org/ Accessed May 29, 2025.

PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is a distinguished board-certified chiropractic orthopedist, educator, author, and editor. 

Disclosure

The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment. Seek the opinion of your legal representative.

© 2025 – James Demetrious, DC, DABCO. Open Access. Unrestricted use, distribution, and reproduction are allowed in any medium, provided you give appropriate credit by citing the original author and source: Demetrious J. PostGradDC. Clinical Judgment, Specialty Training, and the Standard of Care: Navigating Chiropractic Practice. PostGradDC.com; 2025.