Background
Methods
Context
The research team
Recruitment
Data collection
Data management and analysis
Step | Description of step | Action |
---|---|---|
Familiarization | • Reading the transcripts • Creating a preliminary framework based on some transcripts • Testing and adjusting the framework against new transcripts | All authors read the transcripts. In addition, IØB and BMH listened to the recording of several interviews ERA, AMK and EK subsequently discussed the content of the transcriptions and created a preliminary framework The framework was further adjusted in light of further transcriptions by adding transcriptions by ERA, EK, AMK and BMH |
Indexing | • Indexing data relevant to the objective according to the framework | IØB and ERA indexed interviews 1‒6 separately according to the framework, and discussed the indexing practice until a consensus was reached. The team (IØB, EK, ERA and BMH) discussed the indexing on two occasions IØB indexed all transcripts using NVivo software (release 1.6.1, QSR international Pty Ltd., 2022) |
Charting | • Making summaries of the indexes • Creating matrixes with summaries: participants in rows, and the indexes in columns • Refining the framework according to the matrixes | Summaries of the indexed data were placed in matrixes consisting of the participants in rows, and the indexing in columns. All authors discussed and rearranged the matrixes, resulting in a new, condensed framework The new framework consisted of 3 categories and 21 codes (Additional file 3) |
Mapping | • Reorganising the summaries in line with the new framework • Identifying key elements based on summaries • Grouping key elements into key dimensions • Creating categories from key dimensions | All summaries were reread and reorganised by IØB Key elements were identified and sorted by IØB IØB and EK extracted key dimensions based on the key elements All authors discussed the content in all mapping steps, creating categories from the key dimensions |
Interpretation | • Discussing the meaning of the content in the categories • Refining the categories • Looking for linkages between categories • Checking findings against the transcripts | All authors participated in the interpretation, discussed and refined the categories by reorganizing key dimensions and by looking for linkages between categories IØB verified the findings against the transcripts |
Summary | Key elements (elements detected in the data) | Key dimensions (broader, more refined categories) | Categorization |
---|---|---|---|
It is no longer sufficient for the patient to only show clinical improvement. It must be verified by diagnostic imaging as well. Referrers have expectations and need images | -Not enough with clinical improvement -Referrers expect and need images | -Clinical examination -Just to be safe | Defensive medicine |
Ethics
Results
Occupational group | Details | N participants |
---|---|---|
Authorities | Health authorities | 2 |
Norwegian Radiation and Nuclear Safety Authority | 2 | |
General practitioner | Public general practitioner office | 5 |
Specialist | Orthopedist | 1 |
Oncologist | 1 | |
Neurologist | 1 | |
Medicine | 2 | |
Radiologist | Hospital | 3 |
Radiographer | Hospital | 3 |
Private imaging centre | 1 | |
Manager | Hospital | 5 |
Private imaging centre | 1 | |
Total | 27 |
“I think that there are many drivers, and they exist on different levels. They are with the patient, with the families, with the referrers, and with the radiologists”
Healthcare system and culture
Organization of the healthcare service
“The first years as a GP, I worked on an island, far off the beaten track (…). Back then, I preferred to see the patient the next day to see how the patient is coping, because it was a day’s journey to get an X-ray. Whereas where I work now, it’s only one hour from a place they can get an X-ray, so of course I use it much more now”
“There will always be people who make choices with medical consequences (…) where some of their motivation is something other than medical, for example financial incentives”
“Guidelines can be a clear driver for radiological examinations”
“Chest X-ray has always been misused, almost as an administrative tool. I used to work in a hospital where we were told by the specialty registrars in internal medicine that they had learned to order a chest X-ray to get a quick and effective overview of all new patients”
Communication
“We do not have an effective communication channel with the referrers. That applies to both internal [in hospitals] and external referrers. That’s probably the most frequent reason why referrals don’t get rejected”
“We do not have a shared image archive (…). If we had access so we could see which [examinations] patients have done around the country when they are referred, we would have avoided a lot of unnecessary diagnostic imaging”
Competence
“I think that the referrer does not know that [MRI] is a poorer examination for the purpose [arthrosis], but thinks that the modality that gives the best overview of anatomy in general also gives the best overview of pathology”
Expectations
“Expectations are a driver. In other words, the population, both referrers and patients expect aggressive examination and monitoring”
“One reason [for the referrer] to refer to imaging (…) could be to buy time. The patient will experience that something is happening.
“GPs are afraid of losing their customers. These are not just patients, they are also their customers”
Defensive medicine
“The 0-point something percent chance of overlooking a rare tumour trumps the probability of a false positive finding, or low incidence, and the fear of overtreatment it leads to. Nevertheless, it appears more important to rule this out. And, if you get a false positive, you still get a pat on the back, you are the hero after all. There is a terrible asymmetry there”
“One has an inherent tendency to trust an image more than the clinical assessment and one’s own knowledge”
Referrals and referral assessments
Roles and responsibilities
“The referrer is very important for us radiologists because we have an obligation to assess all referrals we receive. It is clear that we are allowed to reject them or change the requested modality, but the threshold for rejecting is relatively high as we respect that the referrer knows the patient and has the total picture”
Referral quality and time constraints
“In a sense, a ‘no’ has only negative consequences. You get an irritated referrer, an irritated patient, lost income, and you may miss [diagnosing] a disease. There is almost nothing positive about saying no”
“Sometimes it can be easier to image than to spend a lot of time getting hold of additional information. On occasion we send referrals back, and then they are returned with a bit more information, and then it [the examination] will be taken anyway”
“Ideally, there should be enough capacity and resources for us [radiologists] to assess absolutely all referrals. However, it costs a lot of money. And when there are too few radiologists and a long report time, it becomes a trade-off.”