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Doing what might be wrong: A qualitative study of practicing physicians' approaches to professional dilemmas.


Ginsburg S. — University of Toronto

Bernabeo E, Holmboe ES. — American Board of Internal Medicine

Presented: Association of American Medical Colleges Conference, November 2012

Purpose: Recent articles have suggested that physicians do not always act in accordance with the basic tenets of professionalism, yet very little is known about how they conceptualize or embody professionalism and how they approach common professional dilemmas in practice. The goal of this study was to explore practicing internists' responses and approaches to common professional challenges in order to better understand their decision-making in this domain.

Methods: Five focus groups were conducted with practicing internists from primary care, specialty, ambulatory and hospital settings (n=40) during which they were asked to respond to several scenarios depicting common professional challenges (e.g., being asked for unnecessary prescriptions or tests; being asked to provide medical advice to non-patients; having to decide which patients to take on; use of e-mail with patients). Transcripts were analyzed using constructivist grounded theory.

Results: As physicians reflected on their professional behavior, they often expressed discomfort around actions that they felt were, or could be perceived as, inappropriate or “wrong.”  This discomfort emerged as a pervasive theme and when analyzed separately, revealed several factors that influence physicians when facing professional dilemmas, including: a desire to be helpful and/or to keep patients happy, the type of patient (including personality) and the nature of the patient's illness or condition. This discourse was quite nuanced, with physicians articulating the tensions they experienced, the pros and cons of ceding to requests, and the guilt they felt either way. This was particularly true in the context of whether or not to follow evidence-based guidelines.

Conclusions: Context is recognized as being critical to understanding professional behaviour. This study contributes significantly to our knowledge about the contextual factors specifically relevant to physicians in practice, that may underpin their decision-making when faced with professional challenges.

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