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Table 3 “Environment/context 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
Guidelines, protocols and policies 21 articles
[33, 36, 37, 45, 47, 49, 50, 53,54,55,56,57,58,59,60, 62, 64, 66, 71, 72, 86]
“There are situations where I’ve ordered an echo when I otherwise would not have because guidelines mandated” [37]
“I think there’s more, as much as we’ve developed these decision rules—I think there’s a lot to be said about just experience” [47]
“I think people are wary of practicing not in line with that and then they have potential then for criticism” [60]
“There’s plenty of guidelines, but they’re all different and there’s nothing official...there’s no hard and fast rule” [60]
“Because I work in a teaching practice, my residents are very devoted to guidelines. A lot of them are driven by the more recent guidelines” [66]
Financial incentives and ownership of tests 21 articles
[1, 2, 7, 15, 21, 23, 36,37,38, 42, 49, 50, 55, 60, 64, 65, 69, 70, 73, 83, 85]
“Identifying more disease means more business” [21]
“If I went around having my 10 min discussion with all my patients about why not to do PSA testing, I will make less money than [a GP] who does the 30 s— here Jack, that’s a good idea, here, have the PSA test” [60]
“To be perfectly honest, I only do it because of patient expectation as a business decision, not as valid evidence based medicine” [65]
“A lucrative source for the private hospitals” [65]
Time constraints, (physical vulnerabilities and language barriers)a 13 articles [3, 23, 34, 37, 46, 47, 53, 59, 62,63,64,65, 70] “Some days patients want tests that I feel are not necessary but I want to avoid discussions or I’m tired and I will order tests anyway” [37]
“If you had enough time to do a thorough history-taking of all these people … People would say ‘“I think I’ve been well understood, listened to, and examined”, and need far fewer further investigations. But that is much too time consuming” [46]
“You see many exams ordered, “Rule out PE [pulmonary embolus],” and that’s all that you have … we often just go ahead and do the exam, to be honest, because it ends up creating a lot of lost time” [47]
“They do a lot of catscans because they don’t have time to observe patients … work them up, get them out the door” [59]
“If I’m really busy and I have ten people in the waiting room, and if I feel pressured and overwhelmed, I can say,‘Yep, here is a requisition for the MRI [magnetic resonance imaging], let’s get it done and move along” [62]
“A major concern that it could increase workload which would diminish time for treating ill patients” [65]
Availability and ease of access to tests 10 articles
[3, 21, 36,37,38, 46, 47, 57, 64, 67]
“Checking boxes on the lab form, I often go, let’s do this one too, and that one” [3]
“When you’re ordering lab tests, it is easy to just order some more tests” [3]
“The patient is already being sent for another test to the diagnostic centre, which creates a low threshold for doing more testing … so why not?” [46]
“I think for any test if it’s very, very available and it’s fast and it’s easy to do and it doesn’t take a lot of time and there’s more turnaround on the report— then we’re just more likely to use it more.” [47]
“It would probably be valuable to make the process less convenient because the threshold is so low to order CTs” [47]
Pre-emptive testing to facilitate subsequent care 10 articles [34, 37, 49, 55, 59, 60, 62, 65, 66, 82] “I am glad that I can refer to something … And you could describe that as medical overuse to some extent. Because we are talking about tests which were not totally urgent or rather luxurious given the specific symptoms at that time. But it can be really helpful to have this reference point” [49]
““We order tests because we feel we have to get everything up front, because it’s just too painful to do things too slow, to do things as a series” [59]
“People are used to sort of being screened...so we’re tacking this onto the discussion basically” [60]
“They will tend to steer on the side of getting a test, even though it may be unnecessary, because they fear they will not be able to get the patient referred” [62]
“You only realize the importance once you do it—the yield of significant results is surprising” [65]
“Often I’m doing [BMD tests] at menopause time in a woman’s life when things sort of come up. I get a baseline maybe at menopause” [66]
Contemporary medical practice and new technology 5 articles
[7, 36, 37, 49, 63]
“There is less emphasis on clinical examination. Nowadays we hear murmurs, and we try to quantify their severity which leads straight to ordering an echo … However, this can result in overuse of imaging” [37]
“The greatest challenge will be to put more emphasis on history taking and physical examination again … This is the prerequisite to avoid further unnecessary investigations” [49]
  1. Following expert focus group discussion:
  2. a “physical vulnerabilities” and “language barriers” were grouped with “time constraints”