Professionalism remains a significant issue in the medical education and research communities.1 Although much of this research has focused on the education setting, interest has been growing in the behaviors and attitudes of physicians in practice.2,3 In addition, attention in the lay press to this topic has increased in response to articles and commentaries suggesting that physicians do not always uphold professional standards and are not always honest with their patients and others.4–7 These studies have been instrumental in bringing critical issues to our collective attention, and the interest in them (from the point of view of the public and of the profession) is not hard to find. What is not well understood, however, is why and how physicians come to make these seemingly “wrong” decisions in practice.3 The issue of context has long been recognized as critical to understanding individuals’ behaviors,8–10 yet we do not know what contextual factors underpin practicing physicians’ decisions to act, especially in ways that are discordant with the values they endorse.
According to several studies, physicians do not always endorse all elements of the Physician Charter on Medical Professionalism,11 and their behaviors do not always conform to the standards they endorse.4 For example, over a third of respondents said they would order an unnecessary test if the patient insisted on it, and, despite most respondents agreeing that they should report an impaired colleague, only half noted doing so in practice. In addition, another study attempted to explore physicians’ rationales for these behaviors by offering response options, such as a belief that someone else would take care of it, that nothing would change, and a fear of retribution.5 These responses helped to clarify, to some degree, the rationales that physicians may endorse to explain or justify their responses. However, the nature of survey research allows for only a limited number of rationales to be presented, and, although respondents could select several options, we do not know the relative influence of each option or how they might interact in a given context. Finally, in a third study, the authors explicitly stated that, to avoid burdening respondents, they did not offer opportunities for participants to explain themselves or “to provide more nuanced” responses.6
With this in mind, we set out to explore how practicing physicians respond to typical professional challenges, with the specific goal of illuminating the nuances of their decision making. In particular, we were interested in how and why physicians come to particular decisions in the face of professional dilemmas, especially when those decisions seem to involve doing something that may appear to contravene the Physician Charter on Medical Professionalism. This type of inquiry is well suited to qualitative research, and, in this case, we chose a constructivist grounded theory approach,12 in which we used scenarios depicting professional challenges in a focus group setting to explore participants’ responses. In our primary analysis, we found that participants’ responses were influenced by guiding principles, such as patient welfare, keeping patients happy, and being available and accountable.13,14 However, we found these responses to be quite malleable, and they often were modified by many other factors, such as the risk of harm, one’s relationship with a particular patient, and even the type of patient (compliant versus challenging, simple versus complex problems, etc.).
After completing this primary analysis, we were struck by participants’ discussion around decisions that they felt were wrong or might be perceived as wrong. This issue seemed to arise quite commonly in discussions of scenarios involving, among other issues, stewardship (i.e., just distribution)11 of finite resources. This discussion is particularly important given the recent implementation of two national initiatives: the American College of Physicians’ High Value Care initiative and the American Board of Internal Medicine’s Choosing Wisely campaign.15,16 The ultimate success of these campaigns is, to some extent, contingent on an understanding of why physicians might not do the “right” thing.
We therefore conducted a secondary analysis17 around this particular theme, which we named “doing what might be wrong.” As this analysis proceeded, we drew on the theory of planned behavior (TPB) to help situate our findings in a broader context.18 According to this established theory, behaviors are strongly predicted by one’s intention to act, which is in turn shaped by one’s attitude towards the behavior, subjective norms, and perceived behavioral control. Therefore, in this article, we will explore the theme of “doing what might be wrong” in the context of the TPB.
As we described elsewhere, we created a series of scenarios representing common challenges to professionalism in practice, based on areas in which physicians are known to struggle.13,14 The research team developed the selected domains into scenarios using an iterative process, with an overall goal to ensure that the scenarios were authentic, typical, and challenging. Practicing internists pilot-tested the scenarios prior to use in our study (see Box 1 for a description of the scenarios used in this analysis). We chose focus groups instead of individual interviews because we wanted to encourage discussion and debate amongst participants and to allow them to challenge and refine each other’s responses. In May 2011, the research team conducted five focus groups of 8 to 10 board-certified, clinically active physicians (n = 40). An external agency used purposeful recruitment to create two groups of primary care internists (one hospital based, one ambulatory), two groups of specialists (one hospital based, one ambulatory), and one mixed group. During each focus group, the moderator (a member of the research team) asked participants to respond, individually and as a group, to five or six of the scenarios that were relevant to their practice setting. Participants were asked what they would do in each situation and why. The Essex institutional review board, Lebanon, New Jersey, granted ethics approval to our study.
Using a constructivist grounded theory approach,19 as in our primary data analysis, we reanalyzed the focus group transcripts for a particular theme, “doing what might be wrong,” by rereading line by line and identifying instances in which participants themselves, or others commenting on their responses, suggested that the actions described were either wrong, could be perceived by others as being wrong, or were justified as being right. By characterizing responses as “doing the wrong thing,” we did not mean to imply that there was an absolute right or wrong response; rather, “wrong” behaviors were ones in which the participant expressed going against his or her own values or against expectations or requests from the patient (or other individual), the institution, or guidelines and evidence, etc. One researcher (S.G.) was responsible for the primary reanalysis, and a second researcher (E.B.) independently conducted a similar process and cross-checked the primary reanalysis findings. They resolved differences by discussion and consensus.
Once this reanalysis was complete, we analyzed the data further to identify examples of the three elements of the TPB—attitudes, social norms, and perceived behavioral control—as expressed by participants.
The theme of “doing what might be wrong” was pervasive in our focus group transcripts. It arose in every focus group and in response to nearly every scenario. It was particularly prominent in discussions in response to the three stewardship scenarios (2a, 2b, and 2c), which all had as their focus a patient who requests an unnecessary test or medication. The second most potent trigger for “doing what might be wrong” discussions was scenario 5, which involved a neighbor asking for a prescription and medical advice. The theme also commonly arose in discussions prompted by scenario 8, in which a patient requests the physician’s e-mail address, and scenario 7, in which a physician has to discuss confidential information with a patient in a hallway of the emergency room. Simply put, physicians often do what might be wrong when they are asked to do something wrong—or at least something that goes against their values and beliefs—either by patients, friends, or family members, or as perceived by their institutions.
Rationales based on guiding principles
When we searched for reasons why physicians do the “wrong” thing, we found many overlapping and interdependent issues underlying their responses. The most dominant discourse involved decision making around whether someone was a physician’s own patient or not, and usually involved nonpatients making requests of physicians—for medications, advice, or access. Closely related to this issue were the rationales behind physicians’ decisions, with the most salient being a desire to keep their patients happy, their institutions happy, and to build relationships; and the very nature of being a doctor—that is, to be helpful. See Table 1 for additional examples and representative quotes.
Consider the following example—a participant reacted to the discussion sparked by scenario 5, in which an acquaintance asks for medical advice and treatment, by saying:
So sometimes, I get into trouble that [someone is] telling me something, I’ll give advice, and like, “Ooh, I didn’t have to do that.” But, it’s in our nature to give. I don’t feel guilty for saying that I think what I do, is I do what’s for the right intention. I may be wrong sometimes, but I feel obligated, or I feel I’m supposed to help fix it.
Another participant stated that: “For most of us, we probably went into medicine to help people. And I definitely have a sense of guilt if I don’t.” These responses suggest that helping and trying to fix people is innate to being a physician, and therefore when opportunities arise to help, physicians take them, even when it might not be the right thing to do. A third exchange also illustrates this point:
I think all of us recognize that when you do that [prescribe for a nonpatient] there’s a small risk. You could be making a terrible mistake. They could have a horrible reaction to a drug, but you’re allowed to take small risks if you feel like the overall benefit is, generally speaking, worth it.
So he’ll take little tiny risks if he thinks that the risks are worth it.
There’s really no upside. You’re doing somebody a favor.
That’s the upside.
In addition to these sentiments, participants also admitted that sometimes keeping the institution or practice happy was an underlying motive behind keeping individual patients happy. For example, one participant explained that:
One of the reasons that we end up yielding to the patient is the reputation of the institution and all that. If you won’t do it, the patient is not going to come back.
Another participant described difficulties in dealing with requests from “more educated” patients, who he felt were more demanding. This physician said that:
They’re the ones who may make comments to your hospital board, they’re going to speak to your medical director. And your medical director is going to say, “Off the record, you did fine. You’re doing the right medicine.” On the record, they have to come and yell at you, because they want to get the potential donation, from these donors.
This quotation suggests that keeping patients happy may be beneficial from an institutional perspective, even though it might indeed be wrong.
The theme of “doing what might be wrong” also arose quite commonly in discussions around whether or not to follow evidence-based guidelines, as in the three variations of scenario 2, in which patients ask for or insist on treatments or tests that are clearly not indicated in evidence-based guidelines. One recurrent theme was related to the idea of building a relationship with a patient by doing something that might be interpreted as beneficial to him or her, even though it is not the right treatment decision based on current evidence. Consider the following example:
If a patient insists that she needs an antibiotic, like this vignette says, then this patient needs an antibiotic, from you or someone else. And frankly, my feeling, generally, is to give it. Not because it matters for this illness, but because when they might have cancer down the road, or might be losing weight down the road, is if you’re taking them seriously about it, later on, they already know that you give a crap about the stupid stuff. But they know enough [to know it] was stupid, and you did what they wanted, and you cared about them and took care of them.
Examples like this one were particularly common in response to scenario 2a—most physicians seemed to recognize that it was wrong to prescribe antibiotics. They described in detail the tensions between wanting to help, and to please, their patients, needing to run an efficient practice, and trying to practice evidence-based medicine. One participant said, in response to a question about caving to a patient’s request: “I mean, it happens. Oh, God, it happens, and you try not to.” Several others chimed in with support, responding with “We all try not to” and “Yeah, but we always give them.”
Rationales based on modifying factors
We also found a striking relationship between “doing what might be wrong” and the modifying factor we called type of patient, especially a consideration of whether a patient was compliant versus challenging. For example, in response to scenario 1, in which physicians have to consider how to absorb a partner’s patients into their own practice, one participant stated: “I think it’s tempting to say what you said: [some] patients are difficult. It’s very tempting to jettison difficult patients.” This participant went on to say, “I think I would have a hard time doing that,” recognizing that it would seem wrong.
Although in most cases we noted tension in responses, in some instances, the participant asserted that what he or she was proposing was actually the right thing to do, rather than the wrong thing. In response to the stewardship scenarios, especially 2b and 2c, which involve ordering tests, some expressed serious doubt about the validity and utility of evidence-based guidelines. Comments such as “evidence is only 15% of what we do” or, in the case of colon cancer screening, “10 years is a long time [before having a repeat colonoscopy]. Things can change … as more literature that comes available,” suggest physicians’ anxieties around relying solely on guidelines. Participants often framed these responses as doing what was right for patients either by responding to their anxiety around waiting for a test or by potentially catching something that would otherwise be missed. In these responses, occasional undercurrents reflected their fear of getting sued, especially if a patient was insistent on a test, the doctor refused, and a complication ensued. Overall, however, expressions of fear of lawsuits were quite uncommon, whereas responses that focused on helping patients were much more common.
Application of the TPB
We drew on the TPB to situate our findings and to further understand physicians’ responses. This theory posits three independent determinants of intention. The first is attitude towards the behavior and refers to “the degree to which a person has a favorable or unfavorable evaluation or appraisal of the behavior in question.”18 We found numerous examples of attitudes that explained why physicians do not always follow evidence-based guidelines, such as “the evidence is only 15% of what we do” and “I don’t see a problem doing it, if the patient’s not [experiencing] any harm by violating the guidelines. So if the patient’s preference is to have a scan in three months, then.…” In the first example, the participant echoed a commonly expressed theme—the evidence just does not apply to most patients. In the second instance, she did not think the behavior—to violate the guidelines—was wrong in the first place. Expressions of attitudes and beliefs most commonly arose in response to scenarios 5 and 8 (neighbor request and e-mail access). Below, we discuss these scenarios further.
The second determinant of intention is a social factor, subjective norm, which “refers to the perceived social pressure to perform or not perform the behavior.”18 Not surprisingly, we found many instances of this theme as well, although it was not as prominent as the other two predictors. Participants often made reference to “what the other doctors” would do, even while admitting that they do not always know what other doctors would actually do. One stated, “It’s funny, because I think behind closed doors a lot of physicians will say it’s easier for you to write amoxicillin than spend five to seven minutes,” and then trailed off without completing what others understood to be the logical end point of that thought. Another participant talked about how he has done a particular procedure when he knew the results would be normal, to which someone else echoed that “a lot of people do that.” In explaining why, he said, “because my partners have insisted that it get done.” Subjective norms were expressed most commonly, but not exclusively, in response to the three variations of scenario 2 (the stewardship scenarios).
The third determinant of intention is the degree of perceived behavioral control, which refers to the “perceived ease or difficulty of performing the behavior” and incorporates past experiences as well as anticipated impediments.18 One participant explained why she sometimes prescribes antibiotics for viral illnesses, saying that it depends on the patient and how sure they are that they have a bacterial illness: “If I know for sure [it’s viral], I won’t give it. But if I can’t prove without a doubt that [the patient] might be right, I do cave in.” In this example, the patient is quite insistent and the physician knows it is not possible to “prove without a doubt” that the illness is not bacterial, so she caves to the patient’s request. In another example, a participant explained how hard he tries to not treat friends as patients:
I had that rule for the first seven years of my practice.… I will take you to the doctor. I will not be your doctor.… Until about six years ago, because I am a doctor. And everyone knows it. And they start pounding on your window and your glass.… And I’ve just sort of let it go.
Participants expressed this theme most frequently in response to scenario 5, as illustrated by the quotation above, as well as in response to scenario 7, in which there is a lack of privacy for a sensitive discussion. We found frequent references to “the way things are,” with participants using expressions such as “it happens all the time,” “we face this a lot,” or “it’s not ideal,” painting a picture of an environment with many obstacles and impediments to overcome and, as in the example above, a sense of futility regarding their efforts. Another potent trigger was scenario 3, in which the physician suspects a colleague of impairment or incompetence. In response to this scenario, participants expressed multiple competing concerns—regarding patient welfare, legal responsibilities, availability and access to care, and the nature of the colleague’s potential illness, among others—that all seemed to contribute to their sense of great difficulty in doing the right thing by reporting the colleague.
In our study of 40 practicing internists’ responses to professional dilemmas, the theme of “doing what might be wrong” was pervasive, and captured the uncomfortable discourse around the difficult decisions that physicians face in their day-to-day work. Our analysis is important in deepening our understanding of why physicians do not always do the right thing and will help to critically inform the High Value Care initiative and the Choosing Wisely campaign.15,16 In addition, we were able to tease out more nuanced reasoning behind several typically reported errors that physicians make, such as prescribing antibiotics for viral infections, ordering tests in contravention of evidence-based guidelines, and treating friends and family members who are not patients.
Our findings suggest that physicians at times know that what they are doing is wrong or could be seen and judged by others as wrong. In these situations, physicians expressed tension in their responses, recognizing how their actions might look to their peers. Importantly, even in these cases, physicians described deliberate and carefully negotiated approaches to professional challenges, responses that show a highly complex decision-making process and not one of impulse or malice.
Further, we also recognize that in many instances physicians may be trying to do the greatest good for the most patients; thus, caving to requests and moving on to the next patient may reflect not just doing what is easier but also an attempt to cut their losses and move on to help others. Although elements of conflict avoidance were present in many of these situations, we got an overall sense that physicians were striving to uphold their ideals—of being helpful, for example—and struggling to maintain a positive balance overall. This finding echoes the argument in a recent commentary in which the authors suggested that physicians often grant such requests because they wish to avoid confrontation, worrying that disagreement with a patient will threaten trust and a sense of goodwill.7
As suggested by Archer and colleagues,20 the TPB can be helpful in understanding professionalism, and, although it did help us to interpret our data, it also raised many questions for future research. As we discussed elsewhere,13 it is not usually possible to determine which of the many competing and interdependent factors in a given scenario are responsible for a physician’s ultimate behavior. Research on using the TPB to explain physicians’ behavior also suggests that the relative influence of each of the three predictors on behavior cannot be assumed. For example, in a series of studies on physicians’ willingness to adhere to clinical practice guidelines, researchers found that, for an asthma guideline, most of the variation in intended behavior was explained by the subjective norm element, consistent with previous research.21,22 However, when the guideline involved antibiotics, intention was most strongly predicted by perceived usefulness and beliefs about the evidence—that is, by attitude.21 Interestingly, in our data, expressions of attitudes and beliefs most commonly arose in response to scenarios 5 and 8, in which physicians felt that they were being asked for special favors (i.e., to help a neighbor in need or to provide extra access to some or all patients). Perhaps not surprisingly, subjective norms were evoked mostly in the stewardship scenarios. Perceived behavioral control seemed to be a major factor when a friend or neighbor asked a physician for advice and in dealing with a possibly impaired colleague.
These variations in responses suggest that we likely need to study in depth physicians’ responses to many different types of professional challenges in a multitude of contexts to develop a robust understanding of their decision making. Only then will we be able to develop strategies to assist them in addressing these sorts of dilemmas. Yet, more education alone is not the answer, as the problem may be one of attitudes, norms, or perceptions of the difficulties in carrying out any behavior.
Our study had several limitations. One important limitation is that we did not have the opportunity to probe in detail the nature of “doing what might be wrong” because this study was a secondary analysis. Also, as with any focus group study design, the possibility of social desirability bias exists, which could conceivably have been compounded by participants’ knowledge that the study was funded by the American Board of Internal Medicine. However, the extensive and often spontaneous discussion about doing the wrong thing makes this potential bias less of a concern. Despite these limitations, our focus group study design allowed us to observe participants as they tried out responses and built on each other’s ideas, often (but not always) in a supportive way, which is a distinct strength of our study.
Our findings are critical to deepening our understanding of how physicians respond to professional challenges, in particular why they sometimes act in ways that contravene the Physician Charter on Medical Professionalism or their own stated values. In the case of patients’ requests for nonbeneficial interventions, physicians engaged in a rich discussion and debate regarding the reasons that they cave to patients’ requests, including an often-stated desire to keep their patients (and their practices) happy, not only because it is good business but also because of the desire to help—to build trusting relationships with patients so they will come back if they develop something more serious or simply to help whoever needs it. Yet, there were expressed instances (and tacit undercurrents) in the discussions that suggest that other factors are in play, such as a fear of lawsuits. However, the fear of appearing unhelpful seemed to be more motivating than the fear of lawsuits. Future research should focus more in depth on physicians’ decision making when faced with common professional challenges, with the goal of developing effective strategies to support physicians and to help them maintain, and act in accordance with, their ideals.