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Table 2 “Interpersonal factors” affecting clinician test ordering behaviour, with number of articles and quotes from articles

From: Why clinicians overtest: development of a thematic framework

Factor Articles Illustrative quotes
Pressure from patients and doctor-patient relationship 29 articles
[2, 21, 34, 37,38,39, 42, 45, 46, 49, 51,52,53, 59,60,61,62,63,64,65,66,67, 70, 71, 73,74,75, 86, 87]
“It can reduce the anxiety and prevent representations to the hospital, helping to keep them from coming in with chest pains” [37]
“Now she had problems with her feet and arms, morning stiffness, pain in the joints. But there was no redness, no swelling, wasn’t warm, functioning was good. But she was still uneasy. I had to confirm this to her with a blood test, otherwise the discussion would go on and on” [46]
“But the GP lives in the community, has to continue caring for the patient. If you really mess things up, so that the patient switches to another doctor, that’s what affects me” [46]
“Patients come in and they say, ‘Oh, I have this, and I want a CT scan done.’ They’ll tell you what they want done” [59]
“If we order more tests and we make sure we have every test ordered that might possibly be needed, the patient’s happy and leaves in their ED [emergency department] stay” [59]
“So they see it as their right to have it” [60]
“There is a demand from patients for testing or medication or imaging that they’ve read about or they feel that they should get in order to be satisfied that they’ve been adequately cared for” [62]
“Patients absolutely drive test ordering...” [62]
“I guess I do it because...I want my patients to perceive that I practice good medicine...you do have to be seen to be proactive” [63]
“Can improve relationship between patients and doctor” [65]
“Check-ups are largely patient driven secondary to media/public health generated anxiety” [65]
“I’ll say “well you just had one two years ago, you’re on treatment, it was stable from the year before, and I don’t think you need one” … what does usually happen is that they usually win” [66]
Pressure from colleagues (and medical culture)a 13 articles
[3, 36, 37, 45, 46, 49, 53, 55, 59,60,61, 69, 86]
“Well, often the supervisor just says to run some tests, and I just accept that without question” [3]
“I recently ordered a lipase, but then the gastroenterologist called me and said: in this hospital, we always combine it with an amylase” [3]
“If an experienced cardiology colleague says we should do another echo, I would not feel strong enough to say no” [37]
“If the neurologist had written, “There’s nothing the matter” ... But how must I say “you have to accept it” if the neurologist says that perhaps the patient should be looked at by someone else” [46]
“If I get a letter from the diagnostic centre with the comment “You request 10% more than the average GP in Maastricht”, then you get critical. You wonder if we should wait a bit longer with this patient” [46]
“If you’re not going to order it, the next doctor will” [59]
“He would see the cardiologist every three months and would get a stress test every year...When he came to see me...I had to tell him ‘I don’t think that that’s necessary” [59]
“A lot of tests get done that probably don’t need to get done because our residents are afraid of not ordering something because they’ll disappoint us” [59]
  1. Following expert focus group discussion:
  2. a “medical culture” was grouped with “pressure from colleagues”