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Doing What Might Be “Wrong”: Understanding Internists’ Responses to Professional Challenges

Ginsburg, Shiphra MD, MEd; Bernabeo, Elizabeth MPH; Holmboe, Eric MD

doi: 10.1097/ACM.0000000000000163
Research Reports

Purpose: To develop a deeper understanding of the complexity of physicians’ decision making when faced with professional challenges.

Method: Using constructivist grounded theory, the authors conducted a secondary analysis of transcripts from focus groups with 40 internists in 2011. Participants responded to scripted professional challenge scenarios. The authors analyzed the transcripts for instances in which participants discussed “doing what might be wrong” (i.e., something that goes against their values or others’ expectations). They used the theory of planned behavior (TPB), which posits that intention to act is predicted by attitudes, subjective norms, and perceived behavioral control, to understand the findings in a broader context.

Results: The theme of “doing what might be wrong” was pervasive, particularly in response to scenarios involving stewardship, nonpatients’ requests for advice or care, or requests for e-mail access. Participants’ rationales for suggested behaviors included a desire to keep patients happy and be (or appear) helpful. Modifiers of those responses included type of patient, physician’s relationship with the patient, and comfort level with the request. Consistent with the TPB, attitudes or beliefs about the intended behavior, subjective norms, and perceived behavioral control influenced decision making.

Conclusions: Physicians often do what might be wrong when they are asked to do something that goes against their values and beliefs, by patients, others, or as perceived by their organizations. Actions are often rationalized as being done for the right reasons. These findings should inform the development of educational initiatives to support physicians in acting in accordance with their ideals.

Dr. Ginsburg is professor, Department of Medicine, and scientist, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada.

Ms. Bernabeo is a research associate, American Board of Internal Medicine, Philadelphia, Pennsylvania.

Dr. Holmboe was chief medical officer and senior vice president, American Board of Internal Medicine, Philadelphia, Pennsylvania, at the time this study was conducted. He is currently senior vice president for Milestones evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois.

Funding/Support: The American Board of Internal Medicine Foundation provided funding for this study (and in part for Dr. Ginsburg). The funding agency had no influence on the study design, data collection, analysis, or reporting.

Other disclosures: None reported.

Ethical approval: The Essex institutional review board, Lebanon, New Jersey, granted ethics approval.

Previous presentations: These findings were presented as an oral abstract presentation at the Research in Medical Education Conference at the Annual Meeting of the Association of American Medical Colleges, San Francisco, California, November 2012.

Correspondence should be addressed to Dr. Ginsburg, Mount Sinai Hospital, 433-600 University Ave., Toronto, ON, Canada M5G1X5; e-mail:

© 2014 by the Association of American Medical Colleges