Table 6 Summary of findings regarding physician-reported perspective about why they use imaging to manage back pain
TDF domains | TDF sub-domain | Specific theme from the study | Studies (participants) | Confidence in the evidence | Explanation |
|---|---|---|---|---|---|
Social influence | Social pressure | The patients ask for an image (in some cases because they want a diagnosis) and the GP feels pressured to request one. “A reason mentioned in all focus groups … was that patients with low back pain often expected, and sometimes even requested or demanded, these tests, despite the physician’s explanation that an imaging test was not (yet) warranted.” | 9 (252) | High | No or very minor concerns regarding methodology, coherence, adequacy and relevance. |
Intergroup conflict | GPs will order an image to avoid conflict with a patient’s wishes. “GPs might order ‘non indicated’ X-rays …to limit conflict.” | 3 (104) | Very Low 1,2,3 | No or very minor concerns regarding relevance. Moderate or serious concerns regarding methodology, coherence, and adequacy. | |
Beliefs about consequence | Consequences | GPs fear blame or legal action if they do not send for scans. “GPs said they ordered radiography because of…. possible legal actions.” | 4 (126) | Low 2,3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy. |
Consequences | GPs may order an image if they thought it would improve trust in the doctor-patient relationship. “If they thought that ordering an imaging test would enhance patient’s trust (or that denying one might undermine it), a test might be ordered when it was not strictly medically indicated” | 5 (101) | Low 2,3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy. | |
Outcome expectancy | GPs believe scans will reassure patients that nothing is wrong. “Sometimes an x-ray can take away the fear, and thus prevent chronicity.’ Another agreed. ‘When patients worry, that is a heavy argument; you need the reassurance (gained from further tests) to go on with the patient” | 6 (175) | High | No or very minor concerns regarding methodology, coherence, adequacy and relevance. | |
Skills | Skills | Lack of communication skills to convince the patient that there was nothing wrong. “If it seemed unlikely they would not be able to convince the patient with a reasonable effort, they would simply order the test” | 3 (101) | Moderate 3 | No or very minor concerns regarding methodology, coherence and relevance Moderate or serious concerns regarding adequacy. |
Skills | GPs thought they used radiography because they lacked skills in clinical examination of the back. “Some GPs thought they overused radiography because they lacked skills in clinical examination: We have got so much to work with that…many (of us)…will never be any good at examining a back.” | 1 (13) | Low 2,3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy. | |
Environment context and resources | Resources | GP’s do not have enough time to negotiate or explain the diagnosis so they order an x-ray. “Sometime I find myself referring a patient for X-ray in order to clear the waiting room and allow myself two minutes of breathing time. Meanwhile the patient keeps quiet, while I write the referral. Sometimes you find yourself doing this and it goes against any reasoning or logic” | 6 (179) | High | No or very minor concerns regarding methodology, coherence, adequacy, and relevance. |
Resources | If GPs perceive a long wait for an image, and they may eventually want to order one, they may order it early, even if not indicated at that time. “They indicated if they perceive there was a long waiting period for a service the patient might eventually need (such as a CT, or MRI scan), they might order one earlier than they thought was really necessary just to get the patient in the queue.” | 2 (38) | Low2,3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy. | |
Resources | There is no alternative to offer the patient instead of the image. | 2 (?) | Moderate 3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy. | |
Organisational culture | GPs would refer if the patient may need them for medico-legal cases, e.g. if the patient needed to make an insurance claim later on. “GPs also ordered radiography to secure documentation in case the patient claimed for insurance compensation…” | 4 (72) | Moderate 3 | No or very minor concerns regarding methodology, coherence and relevance Moderate or serious concerns regarding adequacy. | |
Organisational culture | GPs refer for an image if other treatment providers (physiotherapists, specialists) required a scan before evaluating the patient. “GPs said physiotherapists might want radiography before giving (further) treatment, surgeons before evaluating patients clinically, and radiologists before or in addition to performing CT.” | 4 (93) | Moderate 3 | No or very minor concerns regarding methodology, coherence and relevance Moderate or serious concerns regarding adequacy. | |
Organisational culture | GPs reported sending for scans if they were required for sick certification or short-term disability. “Social security might request radiography to establish facts before considering (continued) sickness certification or disability pension (…contributing to and endless dance in the X-ray corridors). To help patients get further economical support, GPs usually complied with such pressures, although they often found radiography unnecessary by clinical criteria.” | 2 (23) | Moderate 3 | No or very minor concerns regarding methodology, coherence and relevance. Moderate or serious concerns regarding adequacy. |