Table 1 Summary of relevant domains (including belief statements and supporting participant quotes)

Beliefs about consequences

Managing patients with NSLBP with imaging is a waste because it won't help patients or change their course of treatment; most will get better on their own. (6)

What do you think would happen if you managed patients with non-specific low back pain with imaging?

Physician: “Nothing. I don’t think there would be any change in outcomes…Fortunately, most people get better anyway.”—LBP001

Physician: I would create a lot of paper work, and I would create more time problems for myself reading all the x-rays. It wouldn’t help the patient’s pain and it wouldn’t resolve anything.—LBP002

Ordering images for NSLBP is a waste of time, costly to the health system, and clogs up the waitlist for patients who do require images. (7)

“Negative things would include a crippling cost to the healthcare system”—LBP005

“I guess negatively, you’d be clogging the system. You know, the resources to x-ray everybody’s back for something that’s, you know, you look at it – what’s the number I needed to treat as such, or the number needed to do, to pick up something. It’d be phenomenal, right? So it’s kind of an irrational thing to do as a policy.”—LBP006

Imaging exposes patients to radiation which poses a risk to their health. (7)

“Um, and I think that, you know, there are risks associated with doing a whole bunch of x-rays. I think radiation exposure is an issue, um, and so I think we always have to be aware, you know, what is the necessity for doing imaging – especially CTs.”—LBP003

“I don’t want to expose people to radiation…you don’t want to be imaging…and taking up time for the patients that are just like unnecessary, so, and then like it adds up right? Every time you’re like ‘oh, it’s just one x-ray’, like next thing you know, someone’s had like a hundred x-rays. Like that’s a lot of radiation. Um, so definitely over the long-term, doing like, doing imaging can be an issue. So I think that managing without imaging has that benefit as well from a patient safety point-of-view.”—LBP007

If I image a patient with NSLBP I may find something serious that I would have otherwise missed or avoid contributing to the development of chronic pain. (3)

I do feel like there is, you know, there is a segment of the population that they are so convinced that this pain is not going to go away…that I will end up doing an x-ray earlier than I would because I feel like if I leave it for six weeks then they will develop chronic pain.”—LBP003

“You would like to have…every kind of avenue covered. So even if I’m 98 per cent certain that this is non-specific low back pain, it may not be. It could be a small chance that there’s something else starting up that’s going on here, I’m just missing it because I’m not doing an x-ray. So that does nag at you.”—LBP006

Using imaging to manage NSLBP leads to overdiagnosis due to incidental findings which may cause increased suffering for the patient. (4)

“Incidental findings could show up which require further investigations or tests or interventions, which otherwise not have shown up and actually turn out to be benign.”—LBP005

“You find other incidental findings that are irrelevant and then you sometimes…sort of lead the patient down the garden path of other investigations.” LBP008

Ordering images for NSLBP decreases patient anxiety and frustration and increases patient satisfaction. (6)

“Sometimes people get really frustrated and…the negativity and the angst that its creating [makes it] worth doing the x-ray because the negative impacts of what it’s doing to them psychologically may outweigh the balance of, you know, ‘I really don’t think this is going to show anything and I don’t think it’s going to be helpful’.”—LBP004

“I’m not certain but a possibility is that it would be more reassuring to patients. Despite…that most of them are reassured there’s probably some that are…not completely reassured by what I say and so there a might be a little bit more reassurance [provided by the imaging] that we’re not missing something serious.”—LBP009

Ordering images for patients with NSLBP saves me time because I can avoid explaining to patients why they don't need one. (3)

“You’d spend less time [on the appointment] because it takes time to talk somebody out of a test than it does to give them the test. Which, could be one of the reasons why people are getting tests, right?”—LBP006

“It’s a lot faster to fill out the slip and send someone for a test than it is to talk to them and educate them and talk about weight reduction and muscle strengthening and what’s their diet, like very time consuming so it’s so much easier to do tests than to not do tests.”—LBP008

The radiation risk associated with x-ray is actually very small. (1)

“Realistically we probably over-emphasize the risks of radiation sometimes to our advantage. The measurable risk of the radiation from the x-ray, a plain film x-ray is essentially non-existent. The risk of radiation from a CT scan is much, much greater than x-rays but even the risk, the measurable risk of cancer is pretty small.” LBP009

If I ordered an image for all cases of NSLBP my colleagues would look down upon me. (1)

“I would be practicing outside evidence-based medicine and therefore rightfully be ashamed with myself as a clinician…my colleagues would look down upon me…if I was known to image every single low back pain that came through my door.”—LBP005

Ordering an image may help me avoid litigation. (1)

“I think that’s, you know, becomes more of an issue…from a litigations point-of-view. That’s another thing that physicians are, kind of, I think more hesitant about because we have access to all this imaging and then I said ‘listen, it looks okay to me. Let’s give it a couple of weeks. If it gets better.’ And they come back in a couple of weeks and it’s worse, and now I image them and they have a fracture and now they’re saying that they missed work for two weeks and if they imaged earlier, they could’ve done this, and they’re…runs into issues with, you know, complaints and things like that. And I think that those play in the minds of physicians.”—LBP007

Emotion

I feel comfortable managing patients with NSLBP without imaging. (6)

how do you feel about managing a patient with non-specific low back pain without imaging? Would you be worried or concerned?

R: “No, not at all.”—LBP004

“Whenever I decide that I don’t want imaging like I’m, I feel confident in my decision, I don’t kind of think about it after and say ‘oh maybe I should’ve’.”—LBP007

I worry about not imaging. (3)

“I spend a lot of time worrying that I’m doing the wrong thing and that I’m… missing something that could be serious.—LBP003

“There’s still an element, in physicians, of a fear of missing something bad, even with reassuring, all reassuring signs and symptoms, you can never say, I say this to patients as well, I can never say 100% in medicine.”—LBP009

I am fearful of not imaging. (1)

“There’s also this culture of being right a lot and so if you do miss something serious then it’s just frowned upon negatively, there’s the possibility of lawsuits and increase in malpractice over the years, more and more lawsuits all the time and this is our fear of being sued, is a factor as well.”—LBP009

I find it gratifying to avoid imaging. (1)

How important is it to you to manage patients without imaging?

Physician: “It’s a matter of pride. I want to do the right thing so it’s important to me.”—LBP002"

I would feel ashamed of routinely imaging NSLBP patients. (1)

I would be practicing outside evidence-based medicine and therefore rightfully be ashamed with myself as a clinician. -LBP005

I am not emotionally affected by managing patients with NSLBP without using imaging. (1)

“I don’t think I have much emotional attachment either way around imaging.”—LBP005

Beliefs about capabilities

I am confident that I can manage my patients with NSLBP without imaging. (6)

“For the most part I find it easy. I feel like if you take time to do a good history and physical and explain to the patient what you feel is going on, advise the follow-up appointments in a few weeks. Know that they can call if it’s getting worse. Like I feel like once you kind of reassure the patient, they’re pretty agreeable to it.”—LBP007

“It’s something that I put a lot of thought into and I don’t find it hard to do on a day-to-day basis, you know?”—LBP005

I do not always feel confident managing patients with NSLBP without imaging and may consult a colleague for reassurance. (1)

"If I’m being realistic and I think about how I am in reality, I think the biggest problem is feeling confident in my decision. Often I will… I will refer someone to like an adjunct professional, like a physiotherapist or a chiropractor – just so somebody else is looking at it… to make sure that there’s not something that I’m missing and I’ll often…run it by colleagues…just to feel…more confident.- LBP003

It is sometimes difficult for me to convince patients that an x-ray is not indicated. (1)

"The difficult part is sometimes dealing with the patient who very much wants imaging and sometimes they’ll look at you and say ‘I’m not leaving this room until I can get an x-ray’. So, that’s when the decision becomes more difficult because sometimes you’re like…’Is this x-ray really worth the fight’?” -LBP007

Reinforcement

Years of experience in managing patients with NSLBP help physicians to avoid imaging. (4)

Are there a lot of cases where you feel you can’t convince them?

“Not usually. Sometimes experience helps with that.”—LBP002

“I think that being a physician in my first five years…I probably image more than I will in 20 years’ time because of a fear that I am going to miss something.”—LBP003

My previous experiences with either missing a serious problem or picking up on a problem I didn't suspect may have increased my use of imaging. (3)

“I think it was probably after…it might’ve been three months by the time I imaged that one…It turned out to [be] a cancerous mass in the muscle that we thought was muscle strain. So that would push me to want to probably order a little bit sooner than I otherwise might.” LBP005

“There has been an occasion where I’ve found an aortic aneurysm that wasn’t ruptured but was asymptomatic by taking a plain x-ray. Historically, most of us have picked them up by doing x-rays on backs – for back pain – which wasn’t necessarily aneurysm pain, it was just low back pain. And we’ve seen ‘this person’s got a 5 cm aneurysm on the x-ray’. Because you see calcification come out. So, I’ve picked up aneurysms that way, which were significant and, um, that is…that kind of thing, right.” LBP006

The way I am paid (more visits = more money) discourages me from taking the time required to follow current guidelines re: imaging for NSLBP. (3)

“In fact…the system would reward me if I just imaged everybody. If somebody came in and said ‘my back hurts’ and I handed them an x-ray slip and, you know, and a prescription for Tylenol 3 s, they’d be out of my office in two minutes. Whereas I take…10 min to do a really good history and…physical exam and…10 or 15 min to explain…why they don’t need [imaging and/or narcotics]…and how to appropriately manage this and what they need to know, and when they need to come back. And so…there are very significant systemic disincentives to practicing good medicine, particularly in this respect, I think.”—LBP003

“Physicians are not remunerated well in this province so they have to see a lot of people and the faster they do it the better it is for them.”—LBP002

There are no system-level incentives to encourage physicians to reduce imaging for NSLBP. (4)

“There is no incentive in our organization to be good.”—LBP004

“Nothing, not even internal to our practice that we look at about comparing imaging ordering rates between colleagues and things so.”—LBP009

I haven't had any negative experiences (e.g., missing a serious health problem) related to not imaging NSLBP patients. (5)

“I haven’t had the bad experiences in the sense that I haven’t had something that kind of bit me in the butt. Like, whenever I manage without imaging, they tend to improve, most times I don’t even see them by six weeks. They’re telling me that everything is fine. So that’s been kind of reassuring…”—LBP007

“I can’t think of an example in 16 years of practice and in my residency prior to that where a delay in ordering imaging resulted in a delay in diagnosis of something serious with back pain.” LBP008

In my experience, imaging has not resulted in benefits for my patients with NSLBP which reassures me that I do not need to image patients. (2)

“In my experience it hasn’t been widely beneficial, so why do it?” LBP005

”The patients that I have had a suspicion of something more serious have not had anything serious. There’s a patient I had that had urinary retention that I was worried about a cauda equine syndrome but…[they didn’t]. This urinary retention was probably a result of their opioids. It was…a pretty major undertaking to get her a CT scan and so that practice has made me less likely to order more advanced imaging.”—LBP009

Environmental context and resources

I can easily order images for NSLBP; there are no barriers to ordering images in my clinical practice environment. (7)

“Where I work there’s no barriers to ordering imaging.” LBP002

“I can get a cat scan from my office today or tomorrow. We have really easy access to imaging here.” LBP004

I sometimes image NSLBP patients because my patients without insurance cannot access appropriate treatment modalities/professionals in my community and don't improve. (4)

What might make it difficult to manage a patient with non-specific low back pain without imaging?

“Here is the challenge and I run into this very frequently. You can try to refer to therapy, and then you will want to do your physio, chiro, and so forth. The problem is if [the patient has] no money or [they] do not have any insurance. If you got an insurance plan, you have money, I can have you into the chiropractor the next day, or two days, and physio is the same way. But, if you don’t, that’s my challenge.”—LBP001

“One of the problems we face here is that we don’t have ready access to physiotherapy for outpatients for people who are not on private insurance. So I have a patient with sciatica who is now six months waiting for physio. And I’ve had to image her because we’re six months into this…- LBP006

I sometimes image NSLBP patients because I don't have the time to explain to them why imaging is unnecessary. (5)

“The way medicine is practiced is not necessarily conducive to thinking through things. Management is often hurried and…they’re happy to get the x-ray…and you get out quick—LBP006

are there any other competing tasks or time constraints that might influence whether or not you use imaging for a non-specific low back pain patient?

“The next patient. How far behind I am in the clinic, how much time I can take to reassure a patient,…So, I think, so is the time available would be the main thing.”—LBP009

The way I am paid makes it hard for me to take the time needed with patients in order to avoid imaging. (2)

“Physicians are not remunerated well in this province so they have to see a lot of people and the faster they do it the better it is for them.”—LBP002

“I think that if I practiced medicine the way that the system wants me to, everybody would get imaging and opioids.”

Because of time?

“Absolutely. Time.”—LBP003

I sometimes image patients with LBP because it is so easily accessible to me and my patients. (1)

“Sometimes the convenience factor makes it, you know…easier…Sometimes convenience makes people slacker…” LBP004

The high cost of imaging to the health system makes me think more carefully about whether an image is required. (1)

“The financial that the state that the province is in currently [is] a minor factor in my decision making.” LPB009

I don't think ease of ordering influences my decision to order. (1)

“I doubt we’re really influenced much at all by ease of ordering, so ease of completing the paperwork.” LBP009

Social influences

Patient (and family member) requests for images influence my image-ordering decisions. (7)

“Sometimes I’ll do it because it is easy and because the patient wants it and I just run out of energy to argue.” LBP003

“The difficult part is sometimes dealing with the patient who very much wants imaging and sometimes they’ll look at you and say ‘I’m not leaving this room until I can get an x-ray.” LBP007

My colleagues do not influence my image-ordering decisions. (5)

Do you ever discuss the case with colleagues before deciding whether to manage a patient without imaging?

“Nope.” LPB001

Is there ever a time where you might discuss with your colleagues before your deciding whether to manage one of these patients without imaging?

“No I wouldn’t really discuss that with colleagues.” LBP008

Patients and/or their family members pressure physicians for imaging. (7)

“Except when the patient is persistent and you have to use all your might in order to persuade them not to have imaging.”

Interviewer: Would that be a common occurrence do you think?

“Yes. ‘I’m just here for an x-ray doc.’ ‘I’ve just come to get an x-ray on my hip I got back pain.’ Patients come with that expectation.” LBP002

“Usually the patient wants an x-ray….’cause everyone wants imaging. So then I just have a fairly lengthy discussion…” LBP007

I sometimes order imaging for NSLBP when referring my patient to other HCPs, at the request of other providers, or when my patient requires that documentation for an insurance company or workers compensation. (4)

“Sometimes when there is insurance or when workers compensation is involved that imaging might be appropriate.” LBP002

“I think sometimes I will order it if I’m going to be referring ‘cause I think that somebody else might be looking for it. I don’t hardly ever refer to surgeons, but I will refer to neurology. But also sometimes, um, you know, if I’m referring to physio or a chiropractor to just say ‘ok, well we did do the x-ray and the x-ray didn’t show anything’. LBP003

My image-ordering practices re: NSLBP are sometimes influenced by discussions with my colleagues and/or their ordering practices. (6)

“My colleagues would look down upon me, and rightly so, I think, if I was known to image every single low back pain that came through my door.”—LBP005

“There’s a discussion, or a talk a lot, especially in the academic circles I guess of how, in order to see patients quickly a lot of the faster docs will just order far too many imaging tests and it’s just seen as less, it’s not as good medicine and so ordering fewer tests is seen as higher quality medicine in those circles so.”—LBP009

Patient pressures for imaging don't impact my ordering behavior. (2)

“Even if they’re really insistent, you would still say ‘look, you know, if things are not getting better with time, yes we would do that but right now there’s nothing alarming’.” LBP004

“I don’t really feel like it takes me a ton of time to convince patients that they don’t need an imaging test.”—LBP009

Patients sometimes influence me to delay imaging. (1)

“Then there’s some other people that it’s at the 6 week mark and you’re like okay you’re back and you’re not better or so maybe you know um maybe we’ll order an x-ray and the patient goes do I have to doctor I don’t like to get x-rays can I just carry on with physio for another few weeks and do more stretches or I’m trying to get back into walking or whatever…”LBP008

Behavioral regulation

We need easy access to good patient education materials to provide to our patients. (8)

“Maybe a one-page little hand out. ‘Why didn’t I get an x-ray today?’ something like that. A little resource sheet and attached to it back care exercise protocol.” Written information for the patient makes it easier."—LBP002

“There would be you know…somewhere that the person can go to, that would link in about eating healthy and types of exercise you could even do in one’s home…it is just simpler for patients to go to one place that they could read about back health…I think most people are going online for stuff these days…so if there’s good websites and stuff that they don’t have to go on doctor google that would be much better."—LBP008

Access to the healthcare professionals and community-based resources for the treatment of LBP would help physicians to avoid imaging. (8)

“Having a physiotherapy-based chronic disease management program I think would be really good for backs."—LBP004

“I think to have more accessibility to the allied health care services sometimes because a lot of times patients feel like you’re not doing anything."—LBP007

Improved clinical tools would help physicians avoid imaging for LBP. (3)

“A standard protocol. Like this is how we manage non-specific low back pain. So that everyone’s on the same page. I think that would be super important"—LBP007

“I guess the problem with a lot of online resources is that people don’t wanna go to a hundred different places and family doctors can’t keep track of a million type of resources. So, the more things are integrated into primary care systems base and stuff the easier it is for people to find."—LBP008

Improved access to other types of diagnostic imaging would help physicians reduce x-ray and CT imaging rates. (2)

"I’d order fewer CTs if I had access to MRIs and more appropriate imaging"—LBP005

Using fear-based strategies to curb patient demand will help physicians reduce imaging for LBP. (2)

"Realistically we probably over-emphasize the risks of radiation sometimes to our advantage when we don’t want to order. Certainly in x-ray I mean the risk of, the measurable risk of the radiation from the x-ray, a plain film x-ray is essentially non-existent. But, we mention that and with CT it’s, even the CT risk is pretty small when you quantify it. We do discuss that though when we’re talking about the risks of imaging. We do seem to get some mileage out of it I guess."—LBP009

Information about their ordering behaviors may help physicians avoid over-imaging for LBP. (2)

"I think it’s more just look at your current practice and see how that fits with Choosing Wisely, how it fits with current guidelines because if you do think like ‘ok, maybe I’m not doing this right’, then you do need to go back and look at what current guidelines are there to guide me. You know, what is Choosing Wisely saying about this? And you know, modify your practice based on that. Because lots of times, I mean, if you’re in practice twenty years you do things that you’ve always done and maybe there are new things, maybe there are ways to change"—LBP004

I encourage patients to do the work required to take care of their backs in order to help reduce need for imaging. (1)

"I put the onus on the patient to get better. If they are just sitting in an armchair watching TV and not being active they can’t expect to get better."—LBP002

Increased compensation for physicians will encourage them to take the time required to avoid imaging. (1)

“The truth of the matter is that I literally cannot afford to practice good medicine in rural Newfoundland. I literally cannot afford it.”

I: And is that because the education that you want to be providing takes time?

“Yeah."—LBP003

I don't use any strategies to help me reduce imaging. (1)

Do you have any steps or strategies that would encourage you to manage patients without imaging?

R:“No, I mean it’s not a first-line part of what we do for back pain”—LBP004