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Are Physicians' Decisions Affected by Multiple Nonclinical Factors?

Ami Schattner

Physicians' decision-making during patient encounters is multifactorial and complex. Decisions may be affected by multiple nonclinical factors but the scope of these influences and their potential effects remain unclear. Qualitative interviews with clinicians were analyzed and complemented by MEDLINE search. Fifteen clinicians raised many undue nonclinical factors agreeing that they were often operative and relatively recent. Altogether, 75 nonclinical factors and barriers that may adversely influence the quality and objectivity of clinical decisions today were identified. Many were highly prevalent. They were grouped into 4 major domains: outside forces (n=13); components of the encounter (n=22); physician's personal and cognitive factors (n=22); and patient-related factors acting on the physician (n=18). A significant impact on the quality of care, resource utilization and patient-physician relationship is suggested by the interviews and literature. Unwarranted practice variation which is ubiquitous may also be related to nonclinical factors. Most research is limited, based on physicians' surveys and response to vignettes. Alternative prospective methods are suggested. Thus, decision-making by physicians appears to be often affected by multiple, ubiquitous, and potentially inappropriate nonclinical factors. Meanwhile, multifaceted educational efforts and system changes are feasible and likely to reduce the potential untoward effects which may be substantial.