Table 4 Domains of lesser relevance
Domain | Theme | Example Quote |
|---|---|---|
Social professional role and identity | Behaviour the participant identifies as part of another profession’s role | “The chiropractors aren’t allowed to work on them unless they know that there’s no fracture.” [FP09] [making referral] “We’ve seen your patient, this is what we’ve clinically diagnosed them with, this is what we’ve been doing to work with them and the response to date is not in keeping with our expectations of improvement. I have concerns for x, y, z. Please evaluate and refer for imaging as you deem relevant.” [CH17] “I can’t prescribe imaging I would just tell them, ‘okay, I can write a note to your physician.’ And I’ll leave it up to them and kind of defer that back to them.” [PT07] |
Behaviour the participant identifies as part of their profession’s role | “It’s a fairly important part of the assessment and the discussion with a patient.” [FP11] “I think this is my bread and butter. It’s kind of like a cavity is to a dentist. It’s kind of what I do. I do a lot of it.” [CH18] “It’s my job to just provide them with the best education I can give them, based on experience and you know the research. And it’s up to them to decide what’s best for them. And that’s perfectly fine.” [PT09] | |
Optimism | Perception, optimism or pessimism of value of imaging | “I think that it’s not useful in the majority of people who present to me.” [FP08] “Regardless of imaging, I think it [imaging] can add to the information and also help with education of the patient.” [CH12] No, I don’t feel that any images actually will help me with low back pain…. acute low back pain [PT11] |
Reinforcement | Incentives or disincentives | “I’m not aware of any incentives to do or not to do investigations.” [FP09] “There’s no financial because we use a lab and it’s partially covered by OHIP.” [CH18] “I don’t bill or collect for any of my x-ray fees.” [CH17] “There’s no incentives.” [PT08] |
Previous experience about imaging was not low back pain | “I think both of my examples are not low back pain but other areas of the back. um like mid back pain or higher up, where it sounded mechanical, and it very well could have been mechanical, but it ended up actually being like a tumour. So in that instance, you know, imaging might have helped me if I’d ordered it sooner.” [FP01] | |
Specific experience that validates (or not) why imaging not needed | “But I’ve looked at somebody who really didn’t seem to have anything much, I can’t think if it was lumbar spine… but recently I had somebody that ended up having a stress fracture or something like that.” [FP06] “In 2 specific cases involved cancer where nothing in the history or examination suggested cancer, but there were routine x-rays that showed tumours that were the ultimate cause of the pain.” [CH13] “It’s getting worse and worse and worse. And they found out there was a fracture, in the low back.” [PT10] | |
Intention | Intention | [in response to a question about how many of the next 10 patients they would seek imaging for] “I’ll say for the minority, one or two maybe.” [FP04] “Less than one” [CH03]; “10” [CH01] “One or two.” [PT12] |
Intention about practice generally | “I think I’d like to look up the guidelines again. And you’ve alluded to handouts about imaging… it would be nice to look those up and use them.” [FP08] “I would definitely have educational materials on imaging necessity so that if they do have any questions or concerns” [CH11] “Educate more and keep myself up to date with new advances and techniques. There’s patients that could potentially not need uh x-rays and could be treated with any type of new advances in physiotherapy that would help with the back.” [PT03] | |
Goals | Having a focus on something other than imaging | “I’m very big into making sure the patient has orthotics in place, feet are intrinsically linked to back pain.” [FP05] “My first and ultimate goal is to reduce the pain with my modalities and physical or manual therapies and some education on things they can do at home to reduce the pain.” [CH14] “And I think empowering patients with the knowledge of their condition is really helpful in taking down some of the fear, which can actually aggravate the pain sometimes.” [PT13] |
Have a plan a priori | “And so, the first thing I need to do is to determine: do they have access to physio or not have access to physio?” [FP07] “Finding out really what the aggravating factor is very important, just because it gives you an idea of what might be causing their pain, right?” [CH05] “The main thing they need is to re-assure, to educate them how to self-manage. That should be the goal.” [PT10] | |
Memory, attention and decision processes | Concept of a criteria that would prompt them to order an image | “If it’s very prolonged, if the person has had pain you know, more than a few months. It’s not really getting better as expected, sometimes I’ll end up ordering an MRI.” [FP11] “I believe in manual care for a few weeks and see if there’s any changes in the patient. If nothing is working, if the patient is experiencing more and more pain then I would investigate and order imaging.” [CH15] “If I can’t help them with any of their symptoms, if there’s no position and there’s no movement, I can’t help them with, then I strongly think that they’ll need an imaging test.” [PT01] |
Talking through the decision-making processes generally | “I ask them ‘How do you think that might help you? Is there any particular thing you’re worried about?’ So I try to explore the why before I get into it. And then I tell them about, the usefulness of imaging, when we might order it, what it might do for us.” [FP06] “So, the main thing is first trying to get an idea of how the issue occurred. Getting all the details on what makes it worse, what makes it better, if this is an incident that’s happened to them before, how it occurred.” [CH12] “I just go based on the cluster of questions that we’re all educated to ask, based on mechanism of injury, if there’s some form of trauma that I’m thinking maybe there’s a fracture or instability, then yes, I ask about subtle paresthesia, cancer-related questions.” [PT09] | |
Environmental context | Access to ISAEC or rapid access low back pain clinic | “I do send patients exercises so I’ve got prescribed exercises that are, I believe, from the ISAEC [Interprofessional Spine Assessment and Education Clinics] team.” [FP12] “Both clinics that I’m practicing at it are multi-disciplinary, so myself as well as two physios, traditional Chinese medicine practitioners, massage therapists, all these things.” [CH14] “But I work in a clinic that we provide, hydrotherapy; i.e., pool exercises.” [PT06] |
Availability of imaging | “I think that’s a resource issue, right? Because we just don’t have the availability of that. It’s just not that readily available.” [FP06] “I think the wait times are a big deterrent as well.” [CH10] “Then they have to wait six months for MRI. For no reason you’re sending them for MRI.” [PT10] | |
Statements about time spent or needed when imaging ordered | “I’ll say that it probably lengthens the visit because it’s often patient requested. And then it takes extra time for me to explain why imaging is usually not helpful.” [FP12] “We want to get to know the patient, we want to get to know the mechanism of injury, about their lifestyle and, just take our time with the physical examination. I definitely think there’s plenty of time for that.” [CH15] “The actual ordering is no big deal. The only thing would be if I do think they warrant having an MRI, and then there’s the screening questions that we do have to ask them.” [FP01] “I don’t think it has any impact.” [PT08] | |
Use of handouts (or not) | “I have two handouts that I use, but neither one of them talk about imaging.” [FP14] “I have a different sort of handout that I give them that explains their injury.” [CH12] “Not for imaging recommendation, only for the home exercise program; I give handouts.” [PT02] | |
Emotions | Emotional response for patient seeking care elsewhere | “Sometimes I do feel… I hate to say it, but like almost like a little bit like irritated. Like ‘not this again’ like kind of feeling.” [FP15] “Obviously, that frustrates me somewhat, but patients become emotional and make those decisions on their own.” [CH18] “It feels a little frustrating …’cause it feels like there’s no trust, right?” [PT06] |
Fear or doubt of missing something important | “Sometimes I worry that I haven’t been through enough or really listened to the patient enough with their history…. I would feel awful if my patient actually turned out to have multiple myeloma or multiple compression fractures and a secondary cause of osteoporosis.” [FP15] “You might miss something…I think that might be the positive [of imaging]. You might catch someone with an incidental anomaly, right? Whether it’s an abdominal aneurysm that is growing or it’s a soft tissue mass.” [CH17] You might miss something that is very pathological. [PT04] | |
Good or bad feelings about ordering imaging / avoiding imaging | “Those frustrating discussions where, we did this test but it’s not gonna help us manage your condition or you have this incidental finding and it could be this, that, or the other thing.” [FP15] “I find it rewarding when I’m able to give them that information that that’s not necessary and that there are other ways of determining what their problem is without having that unnecessary full spine imaging or low back imaging.” [CH12] “But it can be frustrating and not always because it’s a patient, but just because of how the system is.” [PT08] |