Doctor Knows Best? Not Anymore! Why the Montgomery Standard Matters

“Doctor knows best.”
It is a phrase we have all heard repeatedly. For some, it has stuck. For others, it has been challenged. But what does it really mean? And why is it wrong?

There was a time when, legally, if a doctor did something that other responsible doctors would have done, that was enough. That was the Bolam test. If your clinical decision was backed by a reasonable body of medical opinion, you were protected even if someone else might have done it differently.

The Bolam test came from a case in 1957. Bolam v Friern Hospital Management Committee. A patient suffered fractures during electroconvulsive therapy. The court ruled there was no negligence because what the doctor did aligned with accepted medical practice at the time.

In simple terms: if your peers agreed with your action, you were good. That was the legal standard. And to be honest, that still shows up in court today when expert witnesses are brought in to justify your actions. But something changed about 10 years ago, and it changed everything.

In 2015, the case of Montgomery v Lanarkshire Health Board changed the game and shifted power from the hands of the Doctor to the hands of the Patient, when a diabetic woman of small stature was not informed of the risk of shoulder dystocia during vaginal birth. The baby ended up with serious complications.

The doctor thought telling her might lead to her asking for a C-section, which he felt was not necessary at the time, and so he did not tell her. Therefore, she sued. And won!

The court ruled that patients are no longer passive recipients of care. They have a right to make informed decisions about their treatment. This was the Montgomery Standard. And it became law.

So, What’s the Real Difference?

· The Bolam Test made the doctor the centre of the decision.

· The Montgomery Standard makes the patient the centre.

Instead of asking, “What would other doctors have done?”
The question now is, “What would a reasonable patient want to know?” or “Was the patient informed of the risk?”

Instead of hiding behind consensus or experience, the clinician must now explain:

• What are the risks?

• What are the alternatives?

• Why am I recommending this treatment?

• What does the patient prefer?

This is This is the essence of shared decision-making, and it is the opposite of medical dictatorship.

Something you might be thinking if you are a physio is, “why does this matter in everyday practice and how does this concern me”? Or You might be thinking, “But I already do this.” And the truth is, maybe you do. But ask yourself:

• When you prescribe exercises, do you explain why you chose those ones?

• If you opt for a corticosteroid injection instead of exercises or imaging, do you explain the reasoning?

• Do you invite the patient into the decision, or do you expect them to just go along with your plan?

This is not about being defensive. It is about being collaborative.

Back in university, students would argue: “Who’s the most powerful person in the hospital?”
Some said doctors. Others said nurses.

But in reality?
It is the patient.

Their voice matters. Their consent matters. Their understanding matters. And every decision must go through them first. If you feel a patient would get better with exercises but the patient has opted for surgery, who are you to come in the way of that. You goal is to ensure that they are aware of the risk and benefits and that they are equipped to make the right decision.

So my dear physio in clinic.

• Listen better

• Explain clearly

• Involve patients meaningfully

• Document discussions properly

• Respect patient autonomy even when their choice differs from ours

In the end, this is what good clinical care looks like:
Doing things with the patient, not to them.