Table 1 Summary of belief statements and sample quotes from anesthesiologist and surgeons assigned to the theoretical domains identified as relevant

Social/professional role & identity

My Colleagues agree/do not agree with my opinion about Pre-op testing.

‘…I mean all my colleagues would agree with my general principles.’ (A1)

9

‘I know my anesthesiologists….no I have had surgeries cancelled where we the patient comes in.’(S3)

‘Many of my colleagues have a preference for doing more pre-operative investigation than I do.’ (A6)

6

I don't need to see an ECG or CXR to do my job.

‘Doing a chest x-ray and EKG are not part of my job per se.’ (A4)

8

‘No, I don’t (feel it’s an obligation to order certain tests)…’ (S4)

I don't play a role in the ordering of tests.

‘Well I don’t make (the decision to order tests or not).’ (A11)

2

‘So, that role being part of the team means that some of the tests will be ordered regardless of whether or not I order them.’ (A6)

Beliefs about capabilities

It's very easy for me to order tests.

‘I pick an order sheet from the desk, I write it down and it happens…’ (A1)

16

‘It is dead easy to order tests during a pre-op evaluation. We just write it in and that’s part of that’s part of why things are the way they are. ‘(S1)

I am confident that I can perform a pre-op assessment on a low-risk patient without pre-op tests.

(Are you confident that you are able to perform a pre-op evaluation for a low-risk surgery without pre-op tests?) ‘In the low-risk patient, absolutely.’ (A8)

11

‘Definitely. (I am confident that I am able to perform a patient evaluation for a low-risk surgery without ordering pre-op tests).’ (S2)

It's difficult to cancel/not order because most often the tests are completed before I see the patient.

‘It is more difficult (to cancel) because some of them are ordered pre-operatively by the surgeons so the test is complete by the time you get to see the patient.’ (A4)

7

‘Well I mean for me it’s almost impossible to cancel…because they’re done before I see them.’ (A3)

It's very easy for me to cancel/not order tests.

(How easy or difficult is it for you personally to cancel or order no tests as all?) ‘Very easy.’(A10)

7

‘Easy (to cancel or order no tests at all).’ (S3)

I prefer to have routine tests for patient having general anesthesia.

‘If the patient is going to have a general anaesthetic for a lap-chole even though the surgery is low-risk, I may still feel better if I had some further investigations especially the ECG.’ (A2)

2

I can't cancel tests that were ordered by another physician.

‘Well if another physician has ordered a test…so I can’t cancel someone else’s order.’(A4)

2

It's difficult to cancel because it's time consuming to track down the doctor.

‘Because usually what you do if you are going to cancel a test that somebody else has ordered I think it’s your responsibility to phone the surgeon or whoever ordered the test to let him know what you are doing (right) and that takes a lot of time. You may not be able to contact people so that makes it you know often more difficult to cancel tests.’ (A6)

1

Beliefs about consequences

If tests are ordered I never/sometimes/always review them.

‘It would be expected only if it had been ordered but it certainly wouldn’t be an expectation of mine for you know for every patient.’ (A2)

5

‘…if it’s been done then it behoves you to know the results of it. But it isn’t a requirement for me to proceed. Like I wouldn’t order it and I wouldn’t require it.’ (A3)

4

‘In relation to low-risk surgery, I would say no (it's not expected).’ (A6)

3

‘I know I’ll probably want to see an ECG.’ (A1)

1

Reducing routine tests would save money.

‘Well, I mean on the positive side it’s going to save us money.’ (A4)

11

‘The negative effects of pre-op testing, well the cost is one.’ (S3)

Reducing routine tests would result in little or not change in outcomes.

‘In the vast majority of patients nothing, they would just come through surgery and nobody would care.’(A2)

10

‘If I didn’t order any at all…I don’t think it would make a heck of a lot of difference.’(S5)

Reducing tests may delay or cancel a patient's surgery.

‘So if somebody has a personal belief that they think every person should over 40 should have an ECG and if they arrive on the day of surgery and they haven’t gotten one and they’re going to delay surgery in order to get one, then that’s a bit of a problem.’ (A3)

9

‘The worst thing that can happen the day of there’s a bit of surprise in the patient’s medical condition and they get cancelled, (right) that’s the worst thing that can happen.’ (S2)

Reducing routine testing would avoid unnecessary investigation.

‘Another positive is that it would avoid unnecessary investigations or delay in proceeding to the surgical procedure without changing the management.’ (A6)

5

‘One of the reasons I don’t like ordering lots of tests is I get false positives and then I have to investigate them and I’m not crazy about investigating false positives especially in areas that I don’t practice in.’(S3)

Reducing routine tests would save patients' time.

‘I suspect that patients would like the fact that their waiting times would decrease in the pre-op consultation clinic because they don’t have to do any blood work or chest x-rays.’ (A1)

5

‘Yes…because the negative aspects waste a patient’s time…’ (S2)

Reducing routine tests may result in missing an underlying condition that may complicate surgery/recovery.

‘I must say I look at everybody’s just as a matter of routine because I’ve been caught before in somebody who had electrocardiogram changes and I didn’t see it until after I put the patient to sleep and that was when I was a junior resident. And so from then on I’ve been very wary about looking at the electrocardiogram.’ (A7)

4

‘I mean the issue at that point is you know is it safe to do the surgery, is there some unexpected finding that means we shouldn’t be doing the surgery on that basis or is there something that would change our decision.’ (S1)

Tests are ordered routinely because there pretty cheap.

‘…it just doesn’t cost me anything, I’ll do it.’ (A6)

2

‘I mean…personally I don’t see much of an issue in doing a non-invasive test like an EKG which would also be relatively low expense as well.’ (S4)

Environmental context and resources

Time is/is not a factor in my decision to not order tests.

‘I wouldn’t say that (time constraints) ever influenced me in what test to order, if I ever thought something was necessary I would order it.’ (A1) ‘Not really…(there aren't any competing tasks or time constraints).’ (S2)

7

‘Time efficiency…(is important). And you know as long as clinics are that busy, you have to focus on flow through, so I sort of view ECGs as pretty cheap tests all things considered.’ (A9)

5

‘So there’s no question that time … [play a big role] mainly just kind of default to what you’ve always done.’ (S1)

The Medical directive at this hospital dictates that no routine testing/routine testing for low-risk surgeries.

‘The only tests that happen are through medical directives.’ (A6)

7

‘I mean I complete those forms.. just tick the box, it couldn’t be easier, and then put in some blood work and chest x-ray and cardiogram if those are, you know, flip through my mind in the 2 or 3 seconds. (S1)

‘…we have mandated that in this hospital no pre-operative testing is done.’ (A10)

3

There is nothing in my clinic environment that influences whether I order tests or not.

‘There’s no impediment to us ordering these tests and having them done pre-operatively.’ (A8)

9

‘Not really - (there anything that impedes or advances)’ (S4)

The medical directive at our hospital is that the surgeon orders the tests.

‘Not typically true, I mean our department has developed a guideline that’s it’s followed. The guideline is the surgeons if they order a test, if any test is ordered will be done. If there’s no test ordered, the patient has the guidelines followed.’ (A8)

3

‘Yes so we would in our institution typically the surgeons would have ticked off the order sheet.’ (A11)

Social influences

The opinions of others do/do not influence my decision to order routine tests.

Might the views/opinions of others affect you ordering certain tests for a pre-op evaluation for patient having a low-risk surgery? ‘It doesn’t affect me.’ (A5)

11

‘I find that yes I would listen to them and say okay let’s order it and see what it shows and maybe I’ll learn something from it as well.’ (S2)

‘…when I’ve signed that nobody’s going to say oh he doesn’t know what he’s talking about. They’re going to say oh geez, he doesn’t know what he’s talking about but we’d better do it anyway.’ (S1)

4

‘Uh only the anesthetist (would influence whether or not I order certain tests).’ (S4)

Patient emotions do/do not influence whether or not I order routine tests.

‘The nurse will sometimes say in the pre-op clinic thing that a patient is highly anxious but that would never make me do further investigations.’ (A3)

12

‘No - patient emotions don't influence whether or not I order certain tests.’ (S5)

‘They do. You know I’ve got a philosophy to tell patients they know their body better than I do…’ (S3)

3

I order test I feel are unnecessary because my conservative colleague may be in the OR the day of the surgery and want to see the routine test that I would not.

‘It means that I may not be the anaesthetist doing the case. So I have to not only make a judgement as to what would be appropriate for me, but also what might be appropriate for my colleague as well doing the anaesthetic.’ (A1)

6

‘…because we see patients for each other so.you always have to think about what each of your colleagues may want and everybody has a little bit different practice… based on my colleagues I might be inclined to order a few more tests than I would if I knew that I was going to do the anaesthetic…’ (A9)

.’.I might anticipate that the anaesthetist would want particular tests, or a report that anaesthetists in general might want a particular test.’ (S4)

3

I'm reluctant to cancel test ordered by other physicians.

‘But it is one of the issues because of course, if a surgeon ordered it, I’m somewhat more reluctant to cancel one of their tests even though I don’t feel it’s that necessary.’ (A4)

4

‘Sometimes they are ordered and then (I) might be reluctant to cancel some of the tests because I’m not privy to the thought process initially went through the other individual’s mind and so…I may hesitate because I think well does he have a good reason for ordering this test that I’m not aware of.’ (A2)

Because you work with a group we have to come to an agreement as to what test are required.

‘…the important thing is you need to decide as a group when you work as a group you have to decide what everybody agrees upon for what tests are required.’(A7)

3

‘So I think that they’ve been quite good in supporting you know their colleagues that way. So most of the time that works well.’ (S3)

Behavioural regulation

We need policy that takes the test ordering out of the hands of the surgeons.

‘Right now we don’t have a medical director of our pre-op clinic and that’s probably something, you need someone dedicated to the role to address these kinds of questions.’ (A7)

7

‘I think they would be evaluated during their pre-operative assessment or that assessment would either be done by an anaesthesiologist’ (A10)

‘Well probably take it largely out of the hands of individual surgeons and make it a matter of policy.’ (S1)

There needs to be better evidence that show testing isn't necessary in low-risk patients.

‘The better way probably which is accumulated evidence suggests that the tests aren’t really necessary in the low-risk the low the low-risk patient undergoing low-risk surgery.’ (A5)

5

‘I think if we had more data to support the fact that testing is not necessary that would go a long way.’ (A3)

Nature of the behaviour

I typically do/do not review tests when ordered.

‘In relation to low-risk surgery, I would say no (reviewing an CXR or ECG is not an expected part of my check).’ (A1)

7

‘No. (I don’t typically review a CXR or ECG before my patient’s operation?) (S4)

‘If ordered, yes.(I review tests)’ (A6)

6

‘It would be expected only if it had been ordered.’ (A2)

I typically do/do not order tests.

‘Yeah, for these patients I would not, for the true low-risk patients I would not order the tests automatically.’ (A3)

7

‘I’m actually one of the people who is in favour of not ordering tests that are not needed…in a low-risk patient.’ (S4)

‘The default is…the default is to order…’ (A4)

3

Typically all tests are order before I see the patient.

‘On a standard basis they would be ordered by the surgeon’s office.’ (A5)

9