The grounded theory analysis revealed three main reasons (i.e., categories) for why physicians use LVC. Each category consisted of three or more subcategories. We describe the categories and subcategories in the following and present a conceptual model that illustrates the relationship between the reasons.
Uncertainty and disagreement about what not to do
In the analysis, we identified several aspects (subcategories) leading to situations when the physicians felt they were questioning what they should not do.
Being unaware of the LVC status
Simply not being aware of a practice regarded as LVC was one aspect that made it difficult for physicians to know what to do and what not to do. The process of keeping updated on the latest guidelines for all different patient categories was perceived as challenging. The physicians described a complex process that included reading articles, discussing with colleagues, listening to experts, and subscribing to newsletters. One of the participants described it like this:
“Every time I participate in education, I think to myself, this is completely new knowledge to me. It is a scary experience since we are expected to be updated on so many different topics”. (IP2, FGD1).
They claimed that it was almost impossible to keep updated on new information and to know when they had the correct information or not. One participant described it as the following:
“But we do so incredibly many things, so how do you know – out of the thousand million things I do – what is a habit and what is something that I ought to question? It is absolutely impossible!” (IP3, FGD1).
Guidelines perceived to be conflicting
Guidelines and routines exist at different levels of the health care system (e.g., national, regional, and at the center), and these sometimes contradict each other. For example, one of the lab tests defined as LVC–AST was included in a local clinical guideline, sending the message that it should be done. The ordering system for lab tests furthered this problem with preset local standards. One participant formulated it this way:
“We get such mixed messages from different sources” (IP15, FGD3).
Guidelines perceived to be irrelevant for the patient population
Guidelines could be difficult to interpret and were sometimes not regarded as relevant for the patient group within primary care. One participant described it like this:
“But the problem is that the guidelines are relevant for a fairly small portion of our patients”. (IP27, FGD5).
The patient population within primary health care was viewed as different from the populations in specialized care because this patient group often presented symptoms that could be related to a variety of diagnoses that make it difficult to follow guidelines for each possible scenario. One participant described it like this:
“I believe that many of those writing the guidelines are organ specialists and work based on a selected patient sample, and then they expect us to do the same within primary care” (IP13, FGD3).
Moreover, some guidelines recommending a low use of a specific practice were considered irrelevant for a certain patient population. One example was the prevalence of tuberculosis in the uptake area of the health care center, which, according to the participants, could warrant a higher level of prescriptions of ESR.
“Spontaneously, it is difficult to compare, because we need to prescribe vitamin D and ESR tests more often because a lot of our patients have tuberculosis, or it is more common, and other inflammatory parasite-related illnesses, and we have many more who have a vitamin-D deficiency” (IP 8, FGD2).
Lack of trust in the source of the guidelines
For some of the guidelines, the physicians did not trust the source of the recommendation or guideline. Physicians sometimes knew which expert had been involved in constructing a specific guideline. They expressed doubts about the correctness of the guidelines or personal anecdotes on the process behind the construction of the guidelines, furthering the difficulty in following a specific guideline. One participant described the process behind the guidelines with regard to how personal conflicts had influenced the instructions in the guideline recommendations.
”But this (guideline) is some sort of compromise in order to avoid people getting angry”. (IP6, FGD1)
The participants even talked about the development of guidelines being driven by individual physicians’ agendas. One participant expressed it this way:
”I feel that the discussion about AST and ALT that has been promoted nationally by a (specific) physician is fairly uninteresting” (IP 2, FGD1).
Perceived pressure from others
The second reason, perceived pressure from others, had three sources (subcategories).
Two types of scenarios were described by the physicians. Some patients expressed clear expectations for a specific practice, and some expressed expectations in receiving any kind of procedure. This was often related to their previous experiences of successful practices or based on information that the patients gathered before the visit. One participant provided this example:
“It is the expectations from the patients. Many of them act as if they are ordering some sort of merchandise”. (IP29, FGD6).
Not receiving the requested practice was not always accepted and could result in unsatisfied patients, which was something the physicians wanted to avoid. Not accommodating the patient’s request could furthermore lead to the patient seeking care from another physician for the same problem. One of the participants described it in this way:
“Every time, I diagnose the patient based on my competence and experience, but the patient is not satisfied and wishes to take lab tests. It is always much easier to accommodate the patient and order those tests or examinations” (IP 21, FGD 4).
Pressure from other physicians
Specialist physicians from outside the center sometimes requested certain tests as a criterion for accepting a referral for a patient. Not complying with the request implied not being able to refer the patient to the correct care provider. One participant described it this way:
“Most of the time they (specialists) do not accept the patient before we have ordered the lab tests and the examinations that they requested” (IP8, FGD2).
Requests from other physicians also involved patients being referred to the center with a request for a physician to prescribe LVC. Physicians described this as easier to comply with than going against the other physician and doing their own assessment of the need for the specific practice. One participant described it this way:
“It can be problematic when new, inexperienced physicians within the emergency department order us to perform unnecessary tests. Some people may not critically evaluate the order and simply comply with the request” (IP31, FGD6).
Pressure from the health care system to perform unnecessary tasks
The physicians also mentioned multiple other practices that they perceived as LVC. Those were not listed as LVC in any clinical guidelines but were perceived as LVC since they cost time and money without any clear benefit. Examples of those practices included the following: patient visits for non-severe symptoms or rushed visits where patients were perceived as being able to wait longer before seeing a physician. Administrative tasks included the registration of patient visits in different digital systems in order to get the right financial compensation and routine follow-up visits for certain patient groups. Further, unnecessary visits yield more situations where the physicians can be influenced by pressure from the patients and a desire to do something for the patients.
“So that is what I feel perhaps is the most low value that we do (meeting) healthy people who should not be here that actually cost the most money” (IP27, FGD5).
The demands from the health care management entailed financial incentives for performed interventions and written directives asking for a certain amount of a specific intervention. Not complying with the demands from the management could result in less financial support for the center.
”It is not cheating the system – it is exactly the way it is designed to work. We simply have to shake hands with more people this year than last year” (IP 6, FGD1).
One example they described was the opportunity for patients to schedule their appointment themselves via the Internet. Those visits were often perceived as unnecessary and driving unnecessary practices.
“The more often you see a physician, the more likely you are to get a lab work, an X-ray, to get a treatment” (IP3, FGD1).
The pressure from patients, other physicians and the health care system was further enhanced through the lack of counter pressure from the system to not prescribe LVC. One of the participants described it this way:
“So many factors influence if we are updated or not, know our job or not, and if we do not get any support or help mistakes can happen. There is no control system”. (IP3, FGD1).
A desire to do something for the patients
Besides demands from others, a wish to do something for each patient was also a reason for providing LVC. This category was different from pressure from others since the participants described situations where no specific requests were made by the patients but the physician still wanted to do something for the patient. Three aspects (subcategories) leading up to this desire were identified.
The visit in itself prompts action
The scheduled visit with a patient could by itself be a reason for prescribing LVC. Participants described that providing a practice was part of the process. They also described that it was easier to refrain from prescribing a LVC if there was an alternative practice they could prescribe instead. One participant described it like this:
“..and that is the problem: if you are to remove a habit, it is always nice to do something” (IP1, FGD1).
Symptoms need to be relieved
Another aspect of this was the symptoms described by the patients. Some of the symptoms could be harmless to the patient but still experienced as painful; this created a challenge for the physician when he or she could not help reducing these symptoms. Sympathy for the patients’ symptoms was part of the reason for wanting to do something for the patients. One participant described it this way:
“It is enough to have had a bad cough after having had a cold yourself, trying desperately with a cough medication, and finally being able to fall asleep to feel sympathy for those who need it” (IP 2, FGD1).
Some symptoms would have a preferred but perhaps unavailable intervention. One of the participants described it this way:
“Moderate depressions, for example, where you prescribe antidepressants, instead of scheduling follow-up visits or when there are no available psychologist appointments” (IP13, FGD 3).
Patients’ emotions need to be reassured
Physicians described that not only the symptoms but also the emotions of the patients influenced the use of LVC. Anxious patients were difficult to calm without doing something despite the fact that they did not request any specific intervention. The physicians felt that the only way to help the patients with their worry would be to order some tests. One of the participants described it this way:
“It is easier to take a couple of tests so that the patient will let go of their worry and be reassured that everything is all right” (IP9, FGD2).
Why do they do it? – Interdependent reasons that combined explain the use of LVC
The analysis showed that the three reasons described above both independently and combined can explain why physicians use LVC (Figure 1). Uncertainty and disagreement about what not to do make physicians vulnerable to pressure from others to provide the practice (e.g., a treatment) and more likely to give in to the desire to do something for the patients. The perceived pressure from others can also influence physicians’ interpretation of guidelines, thus making them more uncertain as to whether a practice really should be considered LVC. Similarly, the desire to do something for the patient could also make physicians more likely to agree to the perceived pressure from others.
“It is easier when you have something to back it up when patients come and express a desire to get something, (saying) ‘but I got it from the previous (doctor)’. If there are clear guidelines, you can say no” (IP4, FGD1).
Avoiding the use of LVC was perceived as challenging, with no simple solutions for how to achieve it. The task is made even more complex due to influences emerging from different parts of the health care system, such as requests from other physicians and management. However, despite these multilevel influences on LVC use, the physicians reported that they felt left alone to manage the situation.