Modulating beyond or between evidence: Using qualitative methods to explore physician prescribing decisions

Chapter 1. How and why do physicians modulate evidence? When making prescribing decisions for a number of common medical conditions, all general practitioners will at times knowingly modulate (modify or ignore) evidence-based guidelines. In the first chapter of this thesis, a typology for prescribing decisions was developed, which included three types of decision-making; evidence based decisions, beyond evidence decisions, and between evidence decisions. Evidence based decisions are scientifically based and unmodulated by the physician. 'Beyond' decisions are decisions in which the physician is aware of a guideline, but chooses to modify or ignore the guideline based on the context of the physician-patient interaction. They react to the context of this interaction. 'Between' decisions are decisions in which the physician perceives a lack of clarity in the evidence. He/she is making decisions between different pieces of evidence. He/she will actively seek additional information from the context of the interaction to help choose between the evidence.;Chapter 3. How and why do physicians knowingly modulate the evidence 'between' polypharmacy and under-prescribing for seniors? In Chapter 3, focus groups, telephone interviews, and observations of physician-patient interactions were integrated to generate evidence that shows how 39 physicians across Ontario modulate 'between' the risk of polypharmacy, and the risk of under-prescribing medications for seniors who are consuming more than five medications. The guidelines for prescribing the individual medications were clear, but there was little evidence to support the physician in determining the appropriate balance of multiple medications for a senior patient. Unlike in Chapter Two, where the evidence presupposes a reasonably clear black and white decision, the physicians in this study feel unsupported by the evidence, and must therefore make decisions between 'shades of grey'. (Abstract shortened by UMI.).;Chapter 2. How and why do physicians knowingly modulate 'beyond' the evidence for prescribing antibiotics for URTIs? In the second chapter of this thesis, semi-structured qualitative interviews of 34 physicians in Eastern Ontario were used to explore their accounts of prescribing decisions for viral and/or indeterminate upper respiratory tract infections. The guidelines for antibiotic prescribing were clear, but physician participants in this study moved beyond the evidence to adapt to the emotional context of the interaction.