Pressure from patients and doctor-patient relationship | 29 articles [2,15,26,29,30,31,34, 37,38,43,44, 46,47,49,50,51,53–55,57,64,65,68,70,71,76−79] | “It can reduce the anxiety and prevent representations to the hospital, helping to keep them from coming in with chest pains”[29] “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”[37] “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”[37] ““So they see it as their right to have it”[46] “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”[46] “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”[47] “Patients absolutely drive test ordering...”[47] “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”[51] “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”[51] “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”[64] “Can improve relationship between patients and doctor”[65] “Check-ups are largely patient driven secondary to media/public health generated anxiety”[65] |
Guidelines, protocols and policies | 21 articles [25,28,29,43,44,39,38,46,42,47,50–52,64,66,68,78,72−75] | “There are situations where I’ve ordered an echo when I otherwise would not have because guidelines mandated”[29] “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”[39] “I think people are wary of practicing not in line with that and then they have potential then for criticism”[46] “There’s plenty of guidelines, but they’re all different and there’s nothing official...there’s no hard and fast rule”[46] “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”[64] |
Financial incentives | 20 articles [1,2,7,10,15,16,28−30, 34,42–46,49,53,65,67,73] | “Identifying more disease means more business”[15] “If I went around having my 10 minute discussion with all my patients about why not to do PSA testing, I will make less money than [a GP] who does the 30 second— here Jack, that’s a good idea, here, have the PSA test” [46] “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] |
Pressure from colleagues (and medical culture)‡ | 13 articles [3,28,29,37,38,43,45, 46,51,68,73,76,78] | “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”[29] “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”[37] “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”[37] “If you’re not going to order it, the next doctor will”[51] “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”[51] “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”[51] |
Time constraints, (physical vulnerabilities and language barriers)† | 13 articles [3,16,26,29,37,39, 44,47,49,51,57,65,68] | “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”[29] “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”[39] “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”[37] “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.”[47] ““They do a lot of catscans because they don’t have time to observe patients… work them up, get them out the door.”[51] “A major concern that it could increase workload which would diminish time for treating ill patients”[65] |
Availability, ownership and ease of access to tests | 11 articles [3,15,28,29,30,44,39,37,69,75,77] | “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?”[37] “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.”[39] “It would probably be valuable to make the process less convenient because the threshold is so low to order CTs”[39] |
Pre-emptive testing for subsequent care | 10 articles [26,29,43,46,47,51,63–65,73] | “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”[43] “People are used to sort of being screened...so we’re tacking this onto the discussion basically”[46] “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”[47] ““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”[51] “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”[64] “You only realize the importance once you do it—the yield of significant results is surprising”[65] |
Contemporary medical practice and new technology | 5 articles [7,28,29,43,77] | “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”[29] “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”[43] |
Following expert focus group discussion: † “medical culture” was grouped with “pressure from colleagues” ‡ “physical vulnerabilities” and “language barriers” were grouped with “time constraints” |