Table 2 Summary of irrelevant domains (including belief statements and supporting participant quotes)

Knowledge

The guidelines indicate that I should not image patients with LBP unless their pain has lasted for over 6 weeks, and/or I suspect red flags, and/or they are not candidates for surgery. (8)

“to the best of my knowledge, the guidelines are: if there’s no red flags and the pain doesn’t resolve within six weeks, then plain film might be warranted. And I think certainly if a patient then develops any more severe neurological symptoms or something like that, then potentially move on to a CT.”—LBP003

“unless there’s red flags you probably wouldn’t consider any imaging for about at least 6 weeks”—LBP008

Recommendations suggest I should not routinely image LBP patients. (1)

“Choosing Wisely…is is very much against the doing routine imaging…” LBP007

I should provide conservative care to NSLBP patients. (4)

“you try to educate them on the hygiene of that care. Then, in terms of medication, keep it simple. I’m sort of like a Tylenol type person, sometimes I will use anti-inflammatory, and again, this is keeping with the risk of the person. I will keep it at the lowest dose with the minimum time possible…”LBP001

“many will recover with the conservative therapies I’ve outlined and in the absence of red flags, that is appropriate.” LBP005

I am aware that there are clinical practice guidelines for the treatment of NSLBP. I believe that guidelines and recommendations for the management of LBP are evidence-based. (7)

“The one that I have that I tend to use is the one that the College of Physicians and Surgeons put out. I think the CPSNL has guidelines for low back pain.” -LBP002

“I know there are some. I can’t say I’ve totally used them.”—LBP004

I believe that guidelines and recommendations for the management of LBP are evidence-based. (6)

“Do you believe those guidelines to be evidence based?

Physician: Yes.” LBP002

“Do you believe that these guidelines are evidence-based?

R: The ones that I’ve seen are.”—LBP006

I am aware of the Choosing Wisely recommendations re: reducing imaging for LBP. (5)

“guidelines around lumbar…x-rays…they’re kind of part of the choosing wisely…unless you have any alarming symptoms you don’t need imaging on your back, and you know”- LBP004

“I’m aware of the imaging guidance around, in the Choosing Wisely recommendations around back pain”—LBP009

I am not aware of clinical practice guidelines for the management of NSLBP. (2)

“Are you aware of any guidelines about managing patients with non-specific low back pain?

R: [pause] I read articles on it. I don’t know if any of them were guidelines.”—LBP005

“Are you aware of any guidelines about managing patients with non-specific low back pain?

Physician: Um, other than Choosing Wisely probably not”—LBP008

I have no knowledge of or question the strength of the evidence supporting LBP guidelines. (3)

“I suspect that there’s evidence that goes in to producing the guidelines but I don’t think they’ve been studied in a randomized trial setting to determine whether they’re safe.”—LBP009

“would you know anything about the interpretation of the evidence that supports them?

R: No, I don’t”—LBP003

Skills

I believe that family physicians have the training they require to manage NSLBP when they complete their formal education. (6)

“I think we have enough training when we graduate that we should competently, comfortably, and confidentiality manage low back issues.”-LBP001

“what training would someone need to feel competent in managing patients with non-specific low back pain [without imaging]?

R: A family medicine degree.”-LBP005

I believe that family physicians require good clinical skills (e.g., history-taking, physical exam, symptom recognition) to manage NSLBP patients without imaging. (7)

“I mean, certainly that sort of initial history and physical exam.” -LBP003

“Stuff that you’d learn in clerkship, right? Which would be basic history, physical.”—LBP006

I believe that family physicians require good communication skills to manage NSLBP patients without imaging. (3)

“A patient-centered approach, where you can listen to the patient, find out what their experience of the illness is and what their goals are. Um, and also you need to knowledgeable and able to describe their situation from your perspective as a physician as to what you think might be wrong with them, what are the reasons for recommending whatever treatment plan or imaging or other investigations that you might need so that they can make an informed decision themselves. And working with the patient to come up with the best plan that makes sense for them.”—LBP005

“there’s no question that’s important actually the way we communicate these things to patients probably affects their confidence in us as diagnosticians and managers of their pain as well as their perception of the severity of their problem and their reassurance about the severity of the problem and therefore there, the degree to which they push for imaging, or some other diagnostic test.”—LBP009

Social professional role

Managing NSLBP patients without imaging is a part of doing my job. (9)

“If you are monitoring a patient with non-specific low back pain and you don’t order a CT or an x-ray, do you think you are doing your job?

R: Yes! That is my job!” -LBP003

“If you were monitoring a patient with non-specific back pain and you don’t order a CT or an x-ray, do you think you’re doing your job?

R: Oh, absolutely.” LBP007

Part of my role as a primary care physician involves considering resource utilization and avoiding low-value care. (3)

I think…we shouldn’t be doing any tests we don’t need that are not going to have any value.” -LBP004

“One of the roles of primary care in the health system is to improve the efficiency of the health system and we do that by triaging appropriately and using our clinical skills rather than relying on diagnostic tests.” LBP009

As a physician and among my colleagues, using my clinical skills and avoiding unnecessary images for patients is practicing good (evidence -based) medicine. (7)

“Good medicine is educating people and you know, and being aware of guidelines and following them unless you have a reason not to.”—LBP003

“You wanna be a good manager in the system and you don’t wanna subject patients to unnecessary investigations if they don’t need them.” LBP008

My involvement with Choosing Wisely has likely influenced by my rate of ordering. (2)

“Well I’m on the Choosing Wisely committee! I’d be pretty sheepish going in, if I’ve got the highest rate of back x-rays. Oh yeah, I mean, part of it is that I’ve, you know, I’m involved with this stuff. That’s helped, you know.”—LBP006

“Certainly…all the talk around Choosing Wisely recently in the news and my involvement with it…has probably influenced the rate of ordering. It’s not really been formal training but just what we’ve come across in our practices and the news that’s circulating about Choosing Wisely that’s probably influenced yep.” LBP009

Because I am a salaried provider, I can schedule more time to see patients that FFS docs which may help me to keep imaging rates lower. (1)

“Probably one of the biggest factors I would say that makes my ordering, I suspect less than most other or many other doctors anyways is that I have, I’m a salary provider, I usually schedule a bit more time to see patients than …most fee for service docs would, take a bit more time to examine them and ask more detailed history and counsel them and, so I suspect that likely is the biggest thing that translates into lower ordering than the fee for service docs.” LBP009

Since I am an older physician, patients may be more willing to follow my suggested treatment. (2)

“Sometimes experience helps with that and bit older physicians, so they tend to believe me.” LBP002

"Maybe just the fact that I’ve got a bit of grey hair and I speak with more confidence than I used to 15 years ago when I first graduated, it’s more reassuring to patients that what I’m saying is probably true, that might be part of it as well.”—LBP009

Optimism

I think that managing patients without imaging is a good idea. (6)

“I think it’s good. I mean, we shouldn’t be doing any tests we don’t need that are not going to have any value. And I think it’s equally wrong to subject patients to tests that don’t have a real clinical indication.”—LBP004

“I think it’s a good idea. I think that we over-image to an extreme. It’s bad for the patient, it’s bad for the healthcare system so I think that managing patients with non-specific low back pain without imaging is good overall both for the patient as well as the healthcare system.”—LBP007

Intentions

I intend to manage patients with NSLBP without using imaging. (7)

“As long as they truly meet all those non-specific criteria then, yeah that would be the intent to manage them that way [without imaging].-LBP009

“ Yeah, so going into it, I plan to not have any imaging. Like unless, like I said, unless there is something specific that I need it.” LBP007

Goals

I want to manage patients with NSLBP without using imaging. (7)

“How important is it to you to manage patients without imaging? That group of patients

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

“I think it’s important. Especially the acute cases, like, I feel like as a society we’re dumping way too much towards diagnostic imaging and physicians are forgetting that we worked with our hands long before we had x-rays.”—LBP007

I want to use resources wisely. (5)

“Are there any personal incentives for you to manage patients without imaging?

R: trying not to waste people’s time. Government money.”—LBP004

“I guess we always just use their slogan like choose wisely, you wanna be a good manager in the system and you don’t wanna subject patients to unnecessary investigations if they don’t need them.”—LBP008

My priority is to ensure my patients receive the care that they need which may or may not include avoiding imaging. (2)

“Using resources appropriately is an important part of an office visit, you know, I…but there’s a lot of other things you’re trying to accomplish. Some of which is the doctor-patient relationship – the therapeutic relationship – and keeping somebody kind of offside and in cooperating and so sometimes I will sacrifice that for a bigger cause. The bigger cause may be this relationship is going to go south if I don’t…the patient really wants this and they’re anxious and they’re upset. If they don’t get an image they’re gonna be…so to me, that’s a higher order thing to address than the x-ray. So it’s all about, you know, you have to weigh – you’re weighing things out all the time. What’s the priority here? What’s the problem here? Can I not do it without sacrificing something greater? If that’s the case then, you know, I’m trying not to do it but it’s not the most important thing.”—LBP006

“It’s not really a priority to manage it without imaging, it’s um, I mean priority is the patient feeling better.” -LBP008

Memory, attention, and decision processes

I consider patient characteristics (e.g., age, comorbid conditions), patient symptoms, and/or physical exam findings when deciding whether to order an image. (7)

What aspects of the family practice environment influence your choice of ordering for non-specific low back pain?

Physician: “Symptom and physical examination driven. I should be influenced by the symptom presentation, the physical examination, and the results.”—LBP001

“The patient’s past history,…whether or not they had a malignancy before or what their other comorbidities would be,…there’s also factors like um patient expectations, um like what you’re thinking of in the differential diagnosis.”—LBP008

I determine if that patient is a surgical candidate to help me decide if I should order imaging. (2)

“My jump out point as I said in the beginning is…[to]] put them in surgical or non-surgical…”—LBP001

“When I’m ordering a CT it’s probably because…things are not settling out. They’ve got what I think is mechanical low back pain – and I say that simply because that is the vast majority of back pain that comes in. Um, and it’s gone on long enough and it’s been severe enough that it is possible they may be a surgical candidate.”.-LBP005

I assess the patient for red flag conditions before ordering imaging. (4)

What guides your decision to use imaging with non-specific low back pain patients?

R: “Red flags. Length of time they’ve had it.” -LBP005

“The big thing that goes through my mind is…red flags for back pain, right? So if I’m seeing any… red flags, then I’m going to image”.-LBP007

I do not automatically order images for patients with NSLBP. (7)

Is ordering a CT or an x-ray an automatic decision or is it something you take time to think about with your patient?

Physician: “No. I think about it all the time.” LBP002

When you do order a CT or an x-ray, is it an automatic decision or is it something you take the time to think about with non-specific low back pain

R: “I take the time to think about. It’s not automatic.”—LBP005

It is not difficult for me to decide whether to order images for patients with NSLBP. (7)

“Generally it’s pretty clear if something’s got to be imaged.—LBP006

“Most times I would say it’s easy.—LBP004

I consider the patient's response to previous treatments when deciding whether to order images. (2)

“I’ve seen a patient with sciatica and the first three months, I think I managed her without any imaging. But three months she was still having significant leg pain and I couldn’t really control the pain. So then you start talking about things like imaging.” -LBP006

“If the anti-inflammatories work – then we’re done. If physio works, then we’re done. If they’re not making significant improvement after a month or two and having tried those things then…and potentially depending on the nature of the pain and its location, and the physical exam – potentially massage or acupuncture, other things as well – then after a month or two I might get an x-ray.” LB005

I consider resource utilization when deciding whether to order images. (3)

“Its not the most important thing but using resources appropriately is an important part of an office visit.” -LBP006

“The financial that the state that the province is in currently makes us think carefully about the image and tests we order. It probably shouldn’t, but it’s a minor factor in my decision making.”—LBP009

Ordering imaging is a difficult decision to make. (1)

Is it typically an easy or a difficult decision to make?

“I find it really hard, yeah. I find it really hard.”—LBP003

I try to determine if the patients’ pain will persist when deciding whether or not to order an image. (1)

“But then the other huge factor is ‘do I think that this person’s pain is going to persist if they don’t get an x-ray because they believe that it will’?”—LBP003

If I have any doubt or concern about my patient at all I will image. (1)

“I think sometimes if I am referring and there is a, you know, question in my mind or there’s something, you know, that maybe is not what everybody has but still, you know, wouldn’t fall under the category of a red flag or something like that, then I will sometimes do imaging…”—LBP003

Having easy access to imaging does not influence my decision making. (1)

“Accessibility is not part of [my decision]. I have the CT available to me 15 min down the road [but] that makes no difference to me.” LBP001

I use guidelines in combination with my knowledge of the patient's needs to help me decide whether to image. (1)

"You know,… there’s a lot of other things you’re trying to accomplish. Some of which is the doctor-patient relationship – the therapeutic relationship – and keeping somebody kind of offside and cooperating and so sometimes I will sacrifice that for a bigger cause. The bigger cause may be this relationship is going to go south if I don’t…the patient really wants this and they’re anxious and they’re upset. There’s no sense, you know, keeping someone from an x-ray and losing a patient in the sense of losing their trust or their…the two don’t equate.”-LBP006"

I am more judicious when ordering CT scans than when ordering x-rays. (1)

“I don’t want to give the impression that I just throw around x-rays. But I am even more judicious in my use of CT scans because of the increased cost to the healthcare system because of the increased amount of radiation that the patient will receive in the process.” LBP005