The Moderating Role of Patient Induced Pressure in Medical Specialists’ Testing Behavior in Response to Medical Specialists’ Experience of Medical Uncertainty.

Running Head: MEDICAL UNCERTAINTY AND EXCESSIVE TESTING

The Moderating Role of Patient Induced Pressure in Medical Specialists’ Testing Behavior in Response to Medical Specialists’ Experience of Medical Uncertainty.

Ruben Timmerman (s2547910) University of Groningen

Department of Human Resource Management and Organizational Behavior Nettelbosje 2, 9747 AE Groningen, The Netherlands

E-mail: Ruben_tim@hotmail.com

WORD COUNT: 5678 (excluding abstract, references, appendices and tables)

Author Note

The present paper is my master’s thesis and is written under the supervision of L.

Maxim Laurijssen. Correspondence concerning this thesis should be addressed to Ruben

Timmerman, Ruben_tim@hotmail.com

Abstract

In this research, medical uncertainty and the forth-flowing competence threat that medical specialists experience as a result of it is related to excessive testing behaviors that medical specialists demonstrate. What is more, this research also looks into the possibility that this excessive testing behavior is amplified by the existence of pressure from the side of the patient who request, or even insist upon, the medical specialist to order a test or to follow through with a certain treatment. To test whether such a relationship exists, this research will use a questionnaire following the critical incident technique. The questionnaire was

distributed amongst medical specialists with different specializations. Results indicated that there is no direct link between medical specialists experience of uncertainty and excessive testing behaviors. In contrast, the present research shows evidence for a significant positive relationship for medical specialists experiencing uncertainty and a feeling of lack of control (competence threat). In addition, it was shown that there is a significant negative relationship between competence threat and excessive testing.

Keywords: Medical uncertainty, competence threat, locus of control, excessive

testing, patient involvement, medical specialist.

The Moderating Role of Patient Induced Pressure in Medical Specialists’ Test Behavior in Response to Medical Specialists’ Experience of Medical Uncertainty

Worldwide, healthcare costs are increasing (Weisbrod, 1991; Glied, 2003; Bodenheimer, 2005). Comparatively, the cost to employ and retain medical specialists are rising the fastest (Harshbarger & Bohmer, 1999). The present research argues that medical specialists’

decision-making plays a large role in this. Specifically, medical specialists experience uncertainty in their work (Ghosh, 2004) and recent research showed that they tend to test excessively when test results are unreliable or inconclusive (Sah, Elias, & Ariely, 2013). I argue that this excessive testing is the result of medical specialists’ experience of a lack of control – competence threat - due to the uncertainty they experience in their work.

Uncertainty is omnipresent in medical practice (Fox, 2000) and is associated with negative outcomes, such as the inability of medical specialists to prevent, diagnose, and treat the patient (Fox, 2000). Indeed, medical specialists are realizing that uncertainty is present in almost every aspect of their daily work, ranging from diagnostication to selecting the right test and eventual treatment (Ghosh, 2004). Recent research seems to suggest that uncertainty may be related to feelings of a lack of personal control. According to Friesen, Kay, Eibach, &

Galinsky (2014), people have a basic, structural need to perceive the world as one in which structure and order are omnipresent. Ma and Kay (2017) showed that people may experience the uncertainty they sense in their work as intolerable. They argue and show that the lack of structure blocks them from experiencing control and their ability to predict, and deal with, events happening around them. However, even though people often like to perceive themselves as having control over events that happen in their daily lives (Landau, Kay, &

Whitson, 2015), medical cases can be very complex and medical decisions can be very hard

to make (Schneider, 1998). As a result, medical specialists are prone to experience some form

of uncertainty and lack of control in their work. I argue that medical specialists’ tendency to

engage in excessive testing is a compensatory means to deal with the lack of control they experience in their work due to the uncertainty that abounds in their clinical practice.

Furthermore, there has been a shift in the power-relation between medical specialists and patients (Dickerson & Brennan, 2002). The patients of today show a tendency to self- diagnose and search for their ailments on, for example, the Internet (Dickerson & Brennan, 2002) and to push for, or even insist on, certain medical treatments (Hafemeister &

Gulbrandsen, 2009). This pressure that patients put on their medical specialist to perform may yet be another factor contributing to the lack of control medical specialists experience and their subsequent testing behavior. That is, the present research argues and shows that medical specialists’ excessive testing behavior due to their lack of control is exacerbated by the pressure they experience from their patients.

All in all, the present research aims to provide insights into the reasons for medical specialists’ excessive testing behaviors by investigating competence threat. In this research it is proposed that the amount of testing is amplified by the existence of pressure from the part of the patient. This research helps in gaining more insights into the consequences of feelings of a lack of personal control, as a result of medial uncertainty, on testing behavior of medical specialists, and what role the patients play in this relationship.

Medical Uncertainty and Competence Threat

Medical specialists are increasingly confronted with uncertainty in their work (Fox,

2000). Medical uncertainty mainly stems from the fact that medical cases can be very

complex and medical decisions can be very difficult to make (Schneider, 1998). Fox (2000)

claims that uncertainty in a medical setting can have detrimental effects on work outcomes,

the responsibilities of medical specialists in their work and, most importantly, on the fate of

the patient. As a result, medical specialists have become aware of the fact that uncertainty is

present in almost every aspect of their daily working life, from forming a diagnosis to

selecting the right testing procedure (Ghosh, 2004). In other words, medical specialists are prone to experience some form of uncertainty in their everyday work. Research seems to suggest that the omnipresence of medical uncertainty may induce feelings of a lack of control – competence threat – in medical specialists.

Generally, people have a strong desire to be in control. Compensatory control theory argues and shows that people have a basic, structural need to perceive the world in which order and structure are omnipresent, and that people experience control because of it (Friesen, Kay, Eibach, & Galinsky, 2014). People who believe that they posses the ability to affect outcomes of situations, and as a result feel like they are in control, are better at coping with stressful situations (Thompson, Nanni, & Levine, 1994). Competence threat refers to a situation in which people are prevented from experiencing control (cf. Deci & Ryan, 2000;

Kay et al., 2014). Competence can be conceptualized as “an organism’s capacity to interact effectively with its environment”. Brim and Hoff (1957) propose that people show a tendency to try to understand their environment and try to make it predictable. However, if the

environment is ambiguous and uncertain, one could experience competence threat. Recent research showed that uncertainty is related to perceived lack of control (Ma & Kay, 2017).

Ma and Kay (2017) claim that some employees may experience the uncertainty they sense in their work as intolerable. They claim that the lack of structure blocks them from having a sense of being in control and being able to predict, and deal with, events from happening in the world and will try to find ways to maintain the illusion of control.

For medical specialists, this could mean that they feel like they have no control over the outcomes in their search towards curing the patient, leading to medical uncertainty. As indicated earlier, especially in the medical setting, uncertainty can have seriously negative outcomes for the patients (Fox, 2000). Uncertainty may be linked to difficulties with

diagnoses, choice of tests to execute, and treatments to perform (Ghosh, 2004). Even though

thorough evaluations of the patient’s ailments have been performed, the inability to come to a definitive conclusion as to how to cure the patient creates anxiety not only for the patient, but also for the medical specialist (Ghosh, 2004). As a result medical specialists are likely to experience competence threat in their daily work.

Hypothesis 1: Medical uncertainty is positively related to competence threat.

Competence Threat and Excessive Testing

Unsurprisingly, given that people value having control so strongly, people go to great lengths to maintain feelings of control. When people cannot experience control directly, they will engage in compensatory behaviors to maintain the illusion of control. For instance, in their research, Kay, Gaucher, Napier, Callan, and Laurin (2008) claim that when people feel that their ability is threatened to influence, deal with, and control the environment, they may show the tendency to resort to secondary control strategies. For example, people engage in more superstitious behaviors and beliefs when they are prevented from experiencing control directly, in their attempts to experience some form of control. Another example can be found in the works of Kay, Gaucher, McGregor, and Nash (2010) and also in the one from Laurin, Kay, and Moskovitch (2008), in which they develop the argument and demonstrate that having a sense of personal control is linked to religion and belief in an interventionist God.

All in all, people have a desire for certainty and control and, as a result, show a strong desire to eliminate this uncertainty (Hollway & Jefferson, 1997).

Fortess and Kapp (1985) and Bursztajn, Feinbloom, Hamm, and Brodsky (1990) were among the first to shed light on the phenomenon that medical specialists would excessively order diagnostic tests. Recent research by Sah and colleagues (2013) also revealed that

medical specialists engage in excessive testing. Medical specialists tend to keep ordering tests

when the test results remain vague or inconclusive. I argue that this excessive testing is a

response to medical specialists’ competence threat due to the medical uncertainty they

experience. That is, the excessive testing behavior by medical specialists may help medical specialists maintain a feeling or illusion of control even though objectively it does not help regaining control. Even though, objectively, excessive testing does not help negate the uncertainty as test results remain vague or inconclusive, medical specialists can, however, successfully order tests. This behavior may be a specific form of compensatory control behavior, namely a shift from outcome control to process control (Rothbaum, Weisz, &

Snyder, 1982). This becomes clear in, for example, the results of the work of Thompson and colleagues (1994), who investigated how individuals maintain a sense of personal control during stressful events. In their research, HIV-positive men maintained their perception or illusion of control by focusing on areas where they felt they had an influence on, even if these areas were not central to their problem. These patients showed a shift to controlling the process instead of the outcomes over which they had no control. Similarly, medical

specialists cannot always control the outcomes in their uncertain environments and complex, uncertain medical cases. However, medical specialists can successfully order tests, wait for the result, and evaluate the test result, regardless of the factual outcome. It is this process that facilitates feelings of control even though, objectively, the outcomes remain vague and inconclusive. As such, medical specialists’ excessive testing behavior is compensatory in that it does not objectively help regain control but helps to uphold an illusion of control (cf.

Landau et al., 2015). Consequently, I argue that medical specialists engage in excessive testing as a form of compensatory - process - control to boost their perceptions of control and that competence threat connects the link between medical uncertainty and excessive testing behavior.

Hypothesis 2: Competence threat is positively related to excessive testing.

Hypothesis 3: Competence threat mediates the link between medical uncertainty and

excessive testing.

The Moderating role of Patient Pressure

Furthermore, medical specialists’ excessive testing in response to competence threat may be further amplified by the pressure they experience from their patients. Patient pressure is the power the patient can exert over the doctor to satisfy their medical request (Hafemeister

& Gulbrandsen, 2009). Ample research has indicated that there has been a shift in power between patients and medical specialists (Emanuel & Emanuel, 1992; Dickerson, & Brennan, 2002; Edwards, Kornacki, & Silversin, 2002, Hafemeister & Gulbrandsen, 2009), leading to patients being in an increasingly strong position of being able to exert pressure on the medical specialist to order treatment (Hafemeister & Gulbrandsen, 2009).

One of the main factors contributing to increased patient pressure is the fact that information has become more readily available to patients, through, for example, the Internet and advertising (Dickerson & Brennan, 2002; Murray, Lo, Pollack, Donelan, Catania, White, Zapert, & Turner, 2003; Johnson & Ambrose, 2006; Hafemeister & Gulbrandsen, 2009;

Zhao, Abrahamson, Anderson, Ha, & Widdows, 2013). It used to be mostly the duty of the medical specialist to decide what was the best thing to do for the patient, because the medical specialist was expected to have the medical knowledge, competence, and experience

(Pellegrino, 1994). However, nowadays, instead of just obeying the medical instructions of

the medical specialist, the involvement of the patient has grown (Stimson, 1974). According

to Hafemesier and Gulbrandsen (2009), patients nowadays are much more aware of their

ailments and are more likely to ask for, or even insist on, specific kinds of medicines, tests, or

treatment. Medical specialists are more often confronted with patients that will not follow

their advice or make impossible demands concerning their desired treatment (Cherniss,

1995). Another source of patient pressure is the notion that patients who are not satisfied with

their medical specialist will oftentimes start lawsuits (Macklin, 1993; Hickson, Federspiel,

Pichert, Miller, Gauld-Jaeger, & Bost, 2002; Hafemeister & Gulbrandsen, 2009). Indeed,

many medical lawsuits are not even based on actual patient-experienced malpractice, but actually arise from some form of expression of anger about some aspect of the medical specialist-patient relationship (Virshup, Oppenberg, & Coleman, 1999).

Medical specialists may feel controlled as their professional judgment may be undermined in favor of patients who exert pressure to order a test or treatment or who threaten with litigation (Hafemeister & Gulbrandsen, 2009). In that sense, patient pressure may further exacerbate the competence threat that medical specialists experience. The demands of their patients instill an even further exacerbated competence threat. I argue that the link between competence threat and excessive testing is further amplified by medical specialists’ experience of patient pressure, which will urge medical specialists to comply with the demands of the patients to satisfy them, even though they might not agree with them (cf.

Larsen & Rootman, 1976).

Hypothesis 4: Patient pressure moderates the positive link between competence threat and excessive testing, such that this link becomes stronger when patient pressure increases.

Method Respondents and Procedure

426 medical specialists took part in a questionnaire study. Due to missing data, 191 participants were excluded, resulting in a final sample of 235 medical specialists (26.4%

physiotherapist, 22.1% surgeon, 10.6% nurse, and 6.4% general practitioners). The mean age of the participants was 42.94 years old (SD = 11.98), ranging between 20 and 67 years old.

Of the participants, 56.4% were men and 44.6% were women. 56.8% of the participants held a master’s degree, 33.9% held a bachelor’s degree, 4.2% held a secondary vocational degree.

The remaining 5.1% of the participants held educations ranging from elementary school to

gymnasium.

Data was collected by approaching medical specialists via the researcher’s personal network. Respondents were offered the choice between an online questionnaire and a pen- and-pencil version. In this personal network, the researcher used a snowballing effect by requesting respondents to share the link to the questionnaire with colleagues, and to offer pen-and-pencil versions when desired. Furthermore, the social media platform of LinkedIn was used to recruit medical specialists. They were sent a direct message whether they would like to participate in the online questionnaire. Next to these approaches, the researcher also gathered data by emailing medical specialists and by visiting general practitioners’ offices in person to hand out questionnaires.

First, the participants read a short description about the subject of the study and the length of the questionnaire, which was estimated to be around 15 minutes. Participants were then informed that the data they would be providing would be treated anonymously and confidentially. Participants then gave their informed consent, completed the questionnaire, as well as demographical questions. Finally, participants were thanked for their participation and were provided the opportunity to leave their e-mail address for a follow-up questionnaire.

Measures

Medical uncertainty. The degree to which medical specialists experience medical

uncertainty was assessed by using Fox’s (2000) conceptualization of medical uncertainty, on which we based a self-constructed self-report scale that consists of 6 items (see Appendix A for all items). Example items of this scale include: “In my contact with patients, it is often unclear what is the matter with the patient” and “in my contact with patients, test results are often unclear”. The participants responded on a 7-point Likert-type rating scale (1 =

completely disagree, 7 = completely agree), and all items were averaged to form a single

medical uncertainty score (M = 3.37, SD = 1.16, α = 0.86).

Competence threat. The degree to which medical specialists experienced competence

threat was assessed by using the Competence Frustration subscale by Chen and colleagues (2015). Example items of this scale include: “In my current job, I often feel helpless in tackling problems that I experience” and “in my current job, I experience situations in which I feel incompetent”. The participants responded on a 7-point Likert-type rating scale (1 = completely disagree, 7 = completely agree), and all items were averaged to form a single competence threat score (M = 2.15, SD = 1.14, α = 0.87).

Excessive testing. In order to assess people’s tendency to test excessively, we used

the critical incident technique (Flanagan, 1954). We asked participants to recall a situation in which a patient suffered from unclear ailments. We then introduced our excessive testing follow-up questions that participants had to link to the story that they self-reported. Example items of this scale include: “How probable is it that you would use additional tests or

diagnostics for the purpose of diagnostics and potential treatment?” and “if test results are unreliable or unclear, how probable is it that you would use a different test or diagnostic instrument?”

The participants responded on a 10-point Likert-type rating scale (1 = not probable, 7 = very probable). The remaining items were averaged to form a single excessive testing score (M = 7.51, SD = 2.50, α = 0.81).

Patient pressure. Based on Hafemeister and Gulbrandsen’s (2009) conceptualization

of patient-induced pressure, a self-report scale was developed that consists of 5 items (see Appendix B for all items). Example items of this scale include: “I experience pressure from patients to use a certain diagnostic instrument” and “I experience pressure from patients to

1

In addition, we also asked participants whether they would repeatedly rely on the same test. The

present approach – the extent to which physicians engage in excessive testing via relying on different tests over and over – was chosen as a better indicator of excessive testing than relying on the same test, as it is

conceptually more similar to Sah and colleagues (2013) operationalization of excessive testing.

prescribe a certain medicine or start a certain treatment”. The participants responded on a 7- point Likert-type rating scale (1 = none, 7 = very much), and all items were averaged to form a single patient pressure score (M = 3.75, SD = 1.21, α = 0.80).

Results Preliminary Analysis

Preliminary analyses were conducted before testing the main hypotheses. All participants with incomplete or missing responses (N = 191) were excluded from further analysis. Descriptives and correlations are presented in Table 1. Analyses were run with and without controlling for gender, age, and years work experience. The analyses revealed that the control variables did not alter the results. Consequently, all further analyses are reported without control variables. All hypotheses were tested using the mediated moderation

PROCESS macro model of Hayes (2013, model 14). For all analyses, all the variables were mean-centered before executing the PROCESS macro. Medical uncertainty was entered as the independent variable, competence threat was entered as the mediator, patient pressure was entered as the moderator, and excessive testing was entered as the dependent variable.

Hypothesis Testing

The first hypothesis is that medical uncertainty is positively related to competence threat. Analyses revealed a significant link between medical uncertainty and competence threat, b = .33, SE

=.06, t(235) = 5.46, p < .05. Therefore, Hypothesis 1 is supported.

The second hypothesis states that competence threat is positively linked to excessive testing. The analysis revealed a significant link between competence threat and excessive testing. Contrary to expectations, however, the relationship appeared to be negative instead of positive, b = -.34, SE

=.16, t(235) = -2.17, p = .03. Therefore, Hypothesis 2 is not supported.

The third hypothesis states that competence threat mediates the positive relation

between medical uncertainty and excessive testing. Hayes’ (2013) mediation analysis (model

4) was carried out to test this hypothesis. The analysis did not support the idea that competence threat mediates the link between medical uncertainty and excessive testing (estimate: -0.06; Bca CI: [-0.19, 0.04]). There was also no direct effect between medical uncertainty and excessive testing.

Finally, Hypothesis 4 predicted that patient pressure moderates the positive and indirect relationship of medical uncertainty on excessive testing via competence threat. The moderated-mediation analysis (Hayes, 2013; model 14) showed an almost but non-significant interaction effect of competence threat and patient pressure in predicting a medical

specialists’ testing behavior, b = .18, SE

=.11, t(235) = 1.60, p =.11. Exploratively, simple slopes calculations were performed. This revealed that patient pressure moderates the relationship between competence threat and excessive testing for low levels of patient pressure (estimate: -0.18; Bca CI: [-0.43, -0.02]), but not for high levels of patient pressure (estimate: -0.04; Bca CI: [-0.18, 0.07]). In addition, a PROCESS-macro Model 1 was run to test the interaction without the mediator. Competence threat was taken as the independent variable, excessive testing as the dependent variable, and patient pressure as the moderator.

Again, this revealed an almost but non-significant interaction, b = .17, SE

=.11, t(235) = 1.59, p =.11. Again, low levels of patient pressure seemed to moderate the relationship between competence threat and excessive testing, b = -.53 SE

=.22, t(235) = -2.38, p =.02, but high levels of patient pressure did not, b = -.16, SE

=.17, t(235) = -0.60, p =.55.

Therefore, Hypothesis 4 is partially supported.

Discussion

In the present research, it was predicted that medical uncertainty and competence

threat were positively related (Hypothesis 1) and that there is a positive relationship between

competence threat and excessive testing (Hypothesis 2). Furthermore, it was predicted that

competence threat would mediate the positive and indirect relationship between medical

uncertainty and excessive testing (Hypothesis 3). Finally, it was predicted that this mediation was moderated by patient pressure on the relationship between competence threat and

excessive testing (Hypothesis 4). The results of the present study indicate that medical uncertainty is indeed positively related to competence threat. Even though there was a significant relationship between competence threat and excessive testing, this relationship was negative instead of the predicted positive relationship. Therefore, Hypothesis 2 was not supported. The third hypothesis was also not supported. Competence threat did not mediate the relationship between medical uncertainty and excessive testing. Finally, evidence was also found to partially support the fourth hypothesis, namely that this mediation effect was moderated by patient-induced pressure, but only for low values instead of the predicted high values of patient pressure.

Theoretical implications

The findings of this research contribute to our knowledge of the extant literature on the effects of medical uncertainty experienced by medical specialists in healthcare

organizations, and its effect on their working behaviors, in this case their testing behaviors, and what kind of influence the patient has on this.

First, analysis of the data revealed that there is no relationship between medical uncertainty and excessive testing behaviors. This is not in line with what research has suggested thus far. For instance, it is claimed that medical specialists tend to exhibit excessive testing behaviors as a result of uncertainty (Bursztajn, Feinbloom, Hamm, &

Brodsky, 1990; Fortess & Kapp, 1985; Sah et. al, 2013). However, the concepts of ambiguity and uncertainty are hard to define and a lot of different conceptualizations have been

introduced over the years (e.g. Birrell, Meares, Wilkinson, & Freeston, 2011; Epstein, 1999;

Frisch & Baron, 1988; Ghirardato, 2004) It might be that Sah and colleagues (2013) used a

different interpretation of the concept, as they do not give a clear definition of how they

interpret or define the concept in their research. This might be a reason for the different observations in recent research on medical uncertainty, and excessive testing behavior in the present research.

Next, in line with existing research (Fox, 2000; Ghosh, 2004) it was shown that medical specialists in fact do experience medical uncertainty. More importantly, it was empirically demonstrated that medical uncertainty is positively associated with competence threat. This resonates with the findings by Ma and Kay (2017) that unclear situations may induce a perceived lack of control, which also seems to translate to a medical context. In other words, medical specialists may experience a lack of control when they experience medical uncertainty. This also shows how fundamental insights from compensatory control theory may translate to practical settings such as, in this particular case, medical specialists (Kay et al., 2015).

Next, the present research showed evidence for the existence of a relationship

between the competence threat experienced by medical specialists and excessive testing

behaviors of these medical specialists. Interestingly, however, this relationship appeared to be

negative instead of positive, such that higher levels of competence threat are linked to less

excessive testing behaviors. Previous research suggested that people have a desire for

certainty and control and, in having so, they want to reduce the competence threat they

experience and show a strong desire to eliminate this uncertainty (Hollway & Jefferson,

1997). Apparently however, even though this might still be true, this research presents

evidence that medical specialists do not compensate for their feeling of lack of control by

ordering additional tests. An explanation could still be found in the compensatory control

theory as explained in the work of Friesen, Kay, Eibach, and Galinsky (2014). Along the

lines of their reasoning, it could be argued that after having ordered a test and having been

confronted with ambiguous test results, medical specialists may experience the feeling that

ordering additional tests is not providing them with a feeling of being in control, since the previous one did not give them a feeling of having control over the situation either. This might fuel their competence threat even more. As a result, they may experience a higher level of competence threat whilst exhibiting less excessive testing behaviors.

Finally, research seems to suggest that as a result of developments in the medical specialist-patient relationship, patients are better able to exert pressure on the medical specialists they are assigned to (Stimson, 1974; Emanuel & Emanuel, 1992; Dickerson, &

Brennan, 2002; Edwards, Kornacki, & Silversin, 2002, Hafemeister & Gulbrandsen, 2009).

Ample research has indicated that there has been a shift in power between patients and medical specialists (Emanuel & Emanuel, 1992; Dickerson, & Brennan, 2002; Edwards, Kornacki, & Silversin, 2002, Hafemeister & Gulbrandsen, 2009). A large part can be

attributed to the fact that information has become more readily available to patients, through, for example, the Internet and advertising (Dickerson & Brennan, 2002; Murray, Lo, Pollack, Donelan, Catania, White, Zapert, & Turner, 2003; Johnson & Ambrose, 2006; Hafemeister &

Gulbrandsen, 2009; Zhao, Abrahamson, Anderson, Ha, & Widdows, 2013). Instead of just obeying the medical instructions of the medical specialist, the involvement of the patient has grown (Stimson, 1974). However, even though this might still be true, in this research, a high level of patient pressure did not seem to have any effect on the relationship between

experiencing competence threat and exhibiting excessive testing behaviors. Instead, low

levels of patient pressure did seem to have an effect on the positive relationship between

competence threat and excessive testing. This could perhaps be explained through the idea

that when patients exert less pressure, medical specialists might not feel the pressure to come

to quick and conclusive test results as soon as possible, and therefore may order additional

tests just to be sure. In related research, Van Ryn and Burke (2000) present evidence that

patient status and race have an influence on the perceptions medical specialists hold about the

patient. They claim that these perceptions of the patient shape how medical specialists

encounter, diagnose, and treat patients, and what the outcomes for the patients will be. In line with this, research assumes that people of a lower (subjective) status live more unhealthily (Jackson, Twenge, Souza, Chiang, & Goodman, 2011). A possible explanation for the trend found in this work could be that as a result of living more unhealthily, these patients have a bigger chance of actually being sick. Therefore, it is plausible that medical specialists will perform additional tests without the patient demanding it, since the medical specialist will be positive that he or she will find something in the test results, and thus experiencing less competence threat.

What is more, it could be that if medical specialists feel that they are in control, they do not need to execute additional tests to decrease competence threat, since they already feel that they are in control of the situation. Indeed, in the present research, competence threat was negatively related to excessive testing, which seems to suggest that medical specialists test more when they feel in control. Arguably, medical specialists engage in extra testing when they have certain ideas or perceptions about the medical case or the patient (cf.

Jackson, Twenge, Souza, Chiang, & Goodman, 2011; Ryn & Burke, 2000). Medical

specialists may be certain that they expect to find certain things, and when test results come back and appear to be inconclusive or negative, they engage in testing, arguably due to some sort of confirmatory bias.

Practical implications

More practically, the present research showed that medical uncertainty actually exists

among medical specialists and that it has a negative influence on the amount of control

medical specialists experience. The more medical uncertainty medical specialists experience,

the less control they experience. One solution may be to start working at the core of the

problem of uncertainty that medical specialists experience. Hospitals could look into the

possibilities of offering medical specialists specialized training as to how to recognize uncertainty, so that they can deal with it in an early stage or seek help to do so.

Another related answer may lie in the work of Bursztajn, Feinbloom, Hamm, and Brodsky (1990), in which it is suggested that medical specialists simply should not always try to seek absolute certainty (which they label as the ‘mechanistic approach’), but instead, adopt the ‘probabilistic approach’, in which people accept that they cannot know it all and which claims that absolute certainty is neither obtainable and not always objectively identifiable (Fortess & Kapp, 1985). For instance, Fortess and Kapp (1985) argue that this approach proposes that every decision people make, whether this is in general life or in the setting of medical specialists’ working environment, contains some amount of risk and a lack of control over the outcomes. Therefore, they claim that it is best to just acknowledge and accept this risk so that the most rational and reasonable decision can be made in a particular situation.

In addition to this, and in line with other research (cf. Fortess & Kapp, 1985; Sah et.

al 2017), medical specialists in this research actually indicated that they often order an

additional test, whether or not this is as a result of experienced uncertainty. Even though they

may not always have an objective reason for it, most of the respondents indicated that they

would order another test. Therefore, next to simply accepting the experienced uncertainty and

the lack of control, perhaps a second opinion and a discussion with (a) colleague(s) could

provide other insights and a decision as to whether an additional test is really necessary. Also,

ordering (additional) diagnostic tests costs money (Sah et. al, 2013). Therefore, perhaps

training could be offered to medical specialists to show and familiarize them with the general

validity of tests to help them gain knowledge as to whether it actually makes sense to order

the same test and whether it is really necessary to order a different test, especially if the costs

of doing so may not measure up against the potential outcomes. Perhaps this will put a cap on

medical specialists’ general tendency to be generous with their testing.

Strength and limitations

One major strength of the present research is the population from which was sampled.

235 actual medical specialists participated in the present study, which boosts confidence in the findings. The sample size is also relatively large, especially considering that medical specialists are notoriously difficult to recruit for participation in research studies. However, these strengths are offset by some limitations, and the present findings should be seen in the light of these limitations. Participants complained that the questionnaire was perceived to be relatively long, which may have influenced the seriousness of their answers. Unfortunately, we did not include attention check questions. We thus have no way of knowing whether questionnaire length was a real issue in the present study. Furthermore, the effects on excessive testing may be understated, because we relied on a self-report measure and admitting potentially unaccepted or undesired behaviors may be associated with low admission rates (Sacket, 2002). Finally, even though the present study may generalize to other medical specialists, we cannot claim causality, as the present study was cross-sectional.

Directions for Future Research

First, future research could focus on providing causal evidence in a more isolated environment to rule out alternative influences on medical specialists’ behavior. For example, an experiment would be ideal to explore the idea that competence threat leads to more excessive testing. The notoriously complex work of medical specialists may have obfuscated this link, making it difficult to draw clear inferences from the current data.

Second, the findings of the present research seem to suggest that excessive testing is

not a compensatory means by which medical specialists try to boost feelings of personal

control. Future research is needed to elucidate alternative compensatory means that medical

specialists may turn to in their quest to deal with their competence threat.

Finally, I still believe that when patients exert more pressure on their medical

specialists, this has an influence on the decisions medical specialists make in response to the lack of control they experience and the forth-flowing behaviors that follow from it. As indicated earlier, it may have been that the measure of patient induced pressure was not accurate. Future research might try to find new and other ways of measuring patient induced pressure, which may shed more insight into the role that patient pressure has on medical specialists’ decision-making

Conclusion

All in all, the present research has shown that medical uncertainty is positively related to competence threat and that there exists a negative relationship between competence threat and excessive testing behaviors. This study implies that when medical specialists experience a lack of control, they do not compensate this feeling of lack of control by exhibiting

excessive testing behavior. It was further shown that there is no direct link between medical uncertainty and excessive testing and that competence threat does not mediate this

relationship. Future research could look at what causes exist for the observed phenomenon

that medical specialists excessively order tests and how medical specialists deal with the

uncertainty they experience in their daily working lives.

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Table 1

Means, standard deviations, reliabilities, and intercorrelations of the constructs

M SD (1) (2) (3) (4) (5) (6) (7) (1) Medical uncertainty 3.37 1.16 (.86)

(2) Competence threat 2.15 1.14 .34** (.87)

(3) Excessive testing 7.51 2.50 .04 -.09 (.81)

(4) Patient pressure 3.75 1.21 .45** .22** .09 (.80)

(5) Gender 1.43 .50 .01 .12+ -.08 -.04 1

(6) Age 42.94 11.98 -.16* -.19** -.18** -.13* -.17* 1

(7) Years of Working Experience 13.64 10.53 -.07 -.08 -.14* -.11 -.15* .80** 1 Notes. 232<N<235;

p < .10,

p < .05,

p < .01. For gender 1 = male and 2 =

female. Cronbach’s alphas are displayed on the diagonal.

Appendix A – Measures Medical Uncertainty

Response scale: 1 = Strongly Disagree; 7 = Strongly Agree

In my contact with patients…

1. …I often have to deal with vague ailments of patients.

2. …it is often unclear what is the matter with the patient.

3. …it is hard to form a diagnosis.

4. …it is hard to choose a treatment based on unclear or vague ailments.

5. …it is hard to predict the results of a treatment based on test results.

6. …test results are often unclear.

7. … test results are often unreliable.

Appendix B – Measures Patient Pressure

Response scale: 1 = Not at all; 7 = Very much

To what extent do you experience pressure of patients whom you encounter?

1. I often experience pressure from patients to do something.

2. I often experience pressure from patients to use a specific diagnostic tool.

3. I often experience pressure from patients to prescribe a certain medicine or start a certain treatment.

4. Patients often expect from me that I take action.

5. It is hard to do nothing, even when there are solid medical reasons to do so.