Physician personal characteristics
The physicians' decision-making process can be influenced by their own personal characteristics. For example, the personality of the physician may determine, at least in part, his or her approach to patient management. Physicians have been characterized8 as being either interventionist or oriented toward health maintenance. Interventionist physicians are disease-oriented, whereas health maintenance physicians are more likely to be patient-oriented. Generally, the interventionist is inclined towards immediate action, whereas the health-maintenance-oriented physician is willing to observe the situation.8
Physician's gender, age and ethnicity may play a role in decision-making. For example female physicians were more likely than male physicians to be influenced by the patient's psychosocial factors and expectations when making decisions.75 Younger physicians order more tests than older physicians.76 However, these two studies used hypothetical scenarios rather than real patients and may not reflect the practical reality. Female physicians spend more time with their patients,77,78 and the consultation is usually longer when there is gender concordance between the physician and the patient.78 Female physicians spend more consultation time on disease-preventive services and counselling than male physicians, and male physicians usually spend more time on technical practical issues and discussion of substance abuse.79
In Germany, Hamann et al.80 found that older hospital psychiatrists adopted new anti-psychotic medication earlier than their younger counterparts. The influence of patients' and physicians' characteristics on clinical decision-making were investigated81 regarding recommending percutaneous endoscopic gastrostomy (PEG) tube placement in patients with advanced dementia. Modi et al.81 demonstrated an influence of physician's race on clinical decision-making. Thirteen percent of Caucasian physicians recommended PEG tube feeding compared to 54.3% of Asians and 40% of African-American physicians, despite the evidence that PEG tube feeding does not provide clinical benefit for patients with advanced dementia.81 This disparity was explained81 as being related to cultural differences; African-American physicians tend to give more aggressive treatment than Caucasians in end-of-life situations because their spiritual beliefs play a more prominent role, including the concept that only God has the power to determine death.81 However, it may be that non-Caucasian physicians who were approached for this study were less familiar with the research evidence that PEG tube feeding does not provide clinical benefit for patients with advanced dementia. The differences might also be explained by differences in training and experience between Caucasian and non-Caucasian physicians. The authors also used hypothetical case-scenarios and the study therefore might not reflect real-life treatment recommendations.
Physician's professional interaction
A physician's interaction with his or her professional community can also influence medical decision-making. Physicians are more likely to be early adopters of new drugs if they are involved in the medical community, for example having regular contact with colleagues and hospital consultants.82–84 Another important influence is the influence of the pharmaceutical industry on physicians' prescribing. Pharmaceutical companies can influence physicians in many ways, for example by arranging interaction with a pharmaceutical representative,85 by giving drug samples86 or gifts to physicians,87 and by funding physicians for travel or attending educational symposia as well as by providing research funding.87 In the USA, it was estimated that 84% of pharmaceutical marketing is directed toward physicians,88 an average of $10,000 for each physician per year.89 It is self-evident that pharmaceutical companies invest these sums of money in the expectation of influencing physicians to prescribe their drugs.
Other physician-related influences
The decision to refer patients to a specialist is not based on clinical factors alone. The relationship between the referring physician and the patient and between the referring physician and consultants,90 the capabilities of the referring physician,91 whether the physician has the specialist board's certification92 and the insurance coverage accepted by the specialist92 all may influence the referral decision. Forrest et al.93 found that general practitioners with low tolerance to uncertainty had high referral rates.
Features of the practice
Clinical management decisions made by physicians may differ from one practice to another, depending on the size of the practice, the geographic location, the capabilities of physicians, treatment policies, and the organization of the practice.7 For example, there are higher referral rates in large towns than small towns due to the availability of more consultants in large towns.94
Private versus public medical practice
Clinical practices in the USA can be classified into client-dependent practices which are usually private and colleague-dependent practices which are often university based. Physicians practising in client-dependent practices respond more readily to the wishes of patients. On the other hand, physicians practising in a colleague-dependent practice respond to influences from their professional community.8 Murray95 found that in Chile there was a higher rate of Caesarean sections among pregnant women in the private sector than in the public sector or university hospitals. These findings were attributed to the greater influence of patient's wishes in the private sector, as well as to the preference of obstetricians to work in the private sector in order to increase their income, especially by performing surgical procedures.95
Management policies
There is pressure on hospitals, insurance companies, employers and physicians to consider cost when providing care to patients. There is a risk that these pressures may lead to reduction in the overall quality of care. For example, resource constraints in Intensive Care Units (ICU) might result in premature discharge of patients and this has been associated with an increased mortality rate.96
Management decisions may differ from one country to another due to differences in healthcare systems and treatment policies. The proportion of patients with actinic keratosis who receive treatment in Australia and Canada is much lower than in the USA. Lack of direct access to dermatologists and lack of reimbursement from national health services are possible explanations for this disparity.97 In addition, treatment guidelines may influence dermatologists' decisions to treat actinic keratoses. For example, Medicare health insurance in the USA stated that it would not pay for the destructive treatment of more than 15 actinic keratoses in a single visit.97 This encouraged dermatologists to decide which lesions are most appropriately treated in this way and may have resulted in them switching to another type of treatment.97
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