Medical Uncertainty and Excessive Testing:

Medical Uncertainty and Excessive Testing:

The Mediating Role of Competence Threat and the Moderating Role of Help-seeking

Silvie H.H. van der Pluijm (s2247291) University of Groningen

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

E-mail: s.h.h.van.der.pluijm@student.rug.nl

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 S.H.H. van der

Pluijm, s.h.h.van.der.pluijm@student.rug.nl.

Abstract

Excessive test ordering unnecessarily inflates healthcare costs and degrades the quality of care. Drawing from compensatory control theory, the present research argued that medical specialists’ test behavior is to compensate for a lack of control due to the medical uncertainty they oftentimes face in their work. More importantly, the present research argued that help-seeking behavior may partly alleviate medical specialists’ lack of control and, therefore, their excessive testing behavior. Consulting colleagues may help to reduce medical uncertainty and, as such, help regain control. Data revealed that medical uncertainty indeed negatively effects a medical specialists perceptions of control. However, it was not validated that help-seeking alleviates this relationship. Furthermore, contrary to the predictions,

medical specialists tend to engage in less instead of more testing when they experience a lack of control due to their perceived medical uncertainty. This means that ordering less tests should be interpreted as a coping mechanism of medical specialists less in control. This also means that the excessive users are those medical specialists high in control. As top-down solutions to the excessive testing behavior fall short of expectations, health care organizations are well advised to involve medical specialists, especially the specialists high in control, to find solutions to their excessive testing behavior. Health care organizations could facilitate meetings in which implications are developed. In those meetings, health care organizations could promote cure alternatives to tests ordering. Such preparation may create a social foundation that will allow patient care to be more comprehensive and subsequently more effective in the future. Data was gathered via a questionnaire distributed amongst 235 Dutch medical specialists.

Keywords: Medical Uncertainty, Competence Threat, Compensatory Control,

Excessive Testing, Help-Seeking, Medical Specialists

Medical Uncertainty and Excessive Testing:

The Mediating Role of Competence Threat and the Moderating Role of Help-seeking Medical specialists often tend to overuse diagnostic tests (Sah, Elias & Ariely, 2013), which unnecessarily inflates healthcare costs and degrades the quality of care (e.g. Knotterus

& VanWeel, 2002; Kwok & Jones, 2005; Moloney & Rogers, 1979; Tierney, Miller &

McDonald, 1990; Winkens & Dinant, 2002). Recent research showed that solutions such as sharpening test guidelines, increasing the monitoring and restricting the use of test does not reduce medical specialists’ excessive testing behavior (Kwok & Jones, 2005; Knotterus &

Van Weel, 2002; Moloney & Rogers, 1979; Tierney, Miller & McDonald, 1990; Winkens &

Dinant, 2002; Zaat, Eijk & Bonte, 1992). Consequently, healthcare costs are still rising and medical specialists’ overreliance on testing ensues. The present research argues that medical specialists experience competence threat – the inability to reach desired outcomes – due to the medical uncertainty in their work, and that they engage in excessive testing as a

compensatory means to regain control. More importantly, the present research puts forward help-seeking behavior as a manner that may help regain control more directly and, therefore, alleviates excessive testing behavior linked to medical specialists’ perceived lack of control.

Indeed, medical specialists are often confronted with medical uncertainty (Fox, 2000) and they often have trouble coping with this uncertainty (Alam et al., 2017). Research on compensatory control theory (Kay, Gaucher, Napier, Callan & Laurin, 2008) showed that uncertainty is accompanied by perceived lack of control which results competence threat (cf.

Ma & Kay, 2017). In line with compensatory control theory (Kay et al., 2008), people will tend to alternative, compensatory, behaviors to experience control when they cannot

experience control directly. Similarly, the present research proposes that the uncertainty that

medical specialists experience in their work regards patient decisions and outcomes instigates

competence threat and that medical specialists try to regain control via testing excessively.

Test ordering provides medical specialists with, at least temporarily, the illusion of control (cf. Kay et al., 2008). Specifically, test ordering may shift away the need to control test outcomes to the control of the process of test ordering.

More importantly, help-seeking may provide an opportunity to positively change the excessive test ordering tendencies of medical specialists. Unfortunately, medical specialists are often hesitant to consult their peers (Gallagher, Waterman, Ebers, Fraser & Levinson, 2003). Involving peers that have complementary competences may provide opportunities to reduce uncertainty and thus regain control on the medical difficulties (cf. Edmonson, 2003).

Asking peers for help may be a better source of regaining control than excessively ordering tests since the first may help regain actual control and the latter only helps to provide the illusion of control. Therefore, using expertise diversity at complex and uncertain cases becomes essential (Edmonson, 2003; Hutchens, 1994; MacKenzie & Shapiro, 1986; Van der Vegt & Bunderson, 2005).

All in all, the present research aims to provide a theoretical contribution to our understanding of the effect of medical uncertainty on medical specialists’ use of tests.

Specifically, medical uncertainty is linked to medical specialists’ experience of competence threat which they, in turn, try to compensate for via engaging in excessive testing. More importantly, this research taps into the alleviating role of help-seeking on medical uncertainty and competence threat, and suggests that help-seeking may be a beneficial strategy to deal with uncertainty. From a more practical perspective, the present research may help healthcare organizations to consider to adapt policies that stimulate medical specialists to temper the overreliance on diagnostic tests, arguably via incentivizing the consultation of peers more often.

Medical Uncertainty and Competence Threat

Medical specialists operate in a highly complex environment and oftentimes this involves a great deal of uncertainty (Eddy, 1984; Fox, 2000; Upshur, 2000; Kitto, Chesters, Villanueva & Fox, 2004; O’Riordan et al., 2011). The primary goal of medical specialists is curing patients. In order to attain this goal, medical specialists are tasked with the process of diagnosing. That is, a clear and precise treatment hinges on prior knowledge of what a patient suffers from. Even though textbook examples may be clear and specific, medical practice has shown to be highly complex and ambiguous (Fox, 2000). Frequently, patients’ symptoms are vague and/or patients may suffer from multiple diseases simultaneously. This may lead to inconclusive diagnostic test results and failure of treatment (Fox, 2000; Groopman, 2007). In addition to this, medical specialists’ experience of uncertainty may be further increased by their boundary of knowledge and skills (Eddy, 1984; Evans, David & Trotter, 2009; Fox, 2000), the knowledge gaps in the medical field (Fox, 2000; Ravetz, 1987; Upshur, 2000) and the difficulty of judging between uncertainty as a lack of individual knowledge and skills or as a gap in the field of medicine (Fox, 2000). Recent research seems to suggest that medical specialists suffer from this uncertainty, and that it is associated with a lack of personal control.

Specifically, research on compensatory control theory (Kay et al., 2008) showed that people have a very strong desire to perceive the world as orderly and stable (Brim & Hoff, 1957; Kay et al., 2008; Rothbaum, Weisz & Snyder, 1982; White, 1959). An orderly and stable environment serves a higher purpose of peoples’ inherent need to understand and master their environment (Brim & Hoff, 1957; White, 1959). This desire is closely connected to the ‘need for competence’, which revolves around people’s desire to successfully attain desired outcomes and goals (Deci & Ryan, 2000; White, 1959). Research uncovered that people actively try to experience competence when possible (Byrne & Clore, 1967; Deci &

Ryan, 2000; White, 1957). However, situations are not always orderly and stable, and, hence,

people are oftentimes prevented from experiencing control and mastery over their environment (cf. Deci & Ryan, 2000; Deci, Swartz, Sheinman & Ryan, 1981; Kay et al., 2008). Consequently, people’s control experiences are threatened when the world around them is chaotic and unpredictable, which is referred to as competence threat.

In health care, the chaos and unpredictability of the medical field threatens a medical specialists’ control they wish to experience and maintain and, hence, prevents them from experiencing control (cf. Fox, 2000). Importantly, two inherent aspects of medical

uncertainty seem to reflect the notion that relates to the medical specialists’ lack of control.

First, it is impossible for a medical specialist to cover the entire medical knowledge base (Fox, 2000; Regehr, Geoffrey & Norman, 1996; Verhoeven, Verwijnen, Scherpbier & Van der Vleuten, 2002). Second, since medical progress surely will lead us to identify new gaps, medical specialists will always suffer from knowledge gaps in the medical field (Fox, 2000).

Consequently, the inevitable nature of medical uncertainty makes it impossible to master the medical environment. This implies that medical specialists suffer from chronic competence threat.

Hypothesis 1: Medical uncertainty is positively associated with competence threat.

Competence Threat and Excessive Testing

People have a very strong desire to successfully attain desired outcomes and goals (cf.

Deci&Ryan, 2000). In line with the compensatory control theory (Kay et al., 2008), when people experience a lack of control – competence threat –, they will nevertheless engage in behaviors to increase their control, regardless of whether this actually helps restore control.

That is, when people cannot regain control directly they will compensate for it to maintain at least the illusion of control.

The phenomenon of illusionary control can be further explained by distinguishing

between outcome control (i.e. actual control) and process control (i.e. illusion control).

Similar to the compensatory control theory (Kay t al., 2008), people may shift to process control when they cannot experience outcome control directly (Rothbaum et al., 1982).

Outcome control refers to a situation in which people feel themselves able to control their environment. Process control refers to a situation where people come up with explanations that allow them to cognitively accept the objective lack of control over outcomes and research showed that this sense-making process helps people to cognitively experience control (Rothbaum, et al., 1982). For instance, athletes who perceive to have low control over their match (outcome control) sometimes act in superstitious behavior because of their

erroneously belief that this behavior (process control) controls luck or other external factors that determine their desired outcomes (Dömötör, Ruiz-Barquin & Szabo, 2016). Another example is the finding that people with lower levels of personal control (outcome control) are more likely to adhere external systems with clear rules and guidelines (process control). This adherence helps people to feel themselves more able to maintain feelings of control. It should be reminded that, although the perception of control is restored, the process control remains an illusion of actual control.

In a similar vein, it could be assumed that in health care medical specialists who suffer from a competence threat are also motivated to engage in process control when outcome control cannot be obtained. In this study it is argued that the excessive testing in health care is a compensatory mean of medical specialists to restore their lack of control due to the medical uncertainty they experience. Indeed, recent research of Sah and colleagues (2013) showed that medical specialists tend to engage in excessive testing. Excessive testing refers to a situation where ordering more tests does not yield new information to draw

conclusions (Sah et al., 2013). In that sense, the testing is excessive because these tests do not

help to answer a clinical question (Chiffi & Zanotti, 2015; Knotterus & Van Weel, 2002). At

first sight, excessive testing seems irrational. However, seen through the lens of

compensatory control theory (Kay et al., 2008), the ordering of tests may help to experience the illusion of control. Specifically, ordering tests could shift outcome control to process control (Rothbaum et al., 1982). The mere process of ordering tests, waiting for the result, and evaluating the results is orderly and predictable, regardless of the useless outcome. In that sense, excessive testing may help uphold the illusion of control (cf. Kay et al., 2008). In a similar vein, research showed that people in general prefer to take action rather than not acting at all (Litman, 2010; Winkielman & Berridge, 2003). Unquestionably, ordering more tests seems to be the default and even preferred behavior in medicine. Since medical

specialists are tasked with curing patients, it is assumed that to abandon could be detrimental and very unsatisfactory. In that sense, ordering tests is a mean to take action rather than not acting at all. As such, I predict that:

Hypothesis 2a: Medical specialists’ competence threat is positively related to excessive testing

Hypothesis 2b: Competence threat mediates the link between medical uncertainty and excessive testing

The Moderating Role of Help-seeking behavior

Help-seeking refers to actively asking another relevant party to give assistance, providing remedy and or relief (Lee, 1997). The primary aim of help-seeking is to learn and solve problems (Newman & Goldin, 1990) in order to attain goals (DePaulo & Fisher, 1980;

Karabenick & Knapp, 1988). The use of expertise diversity can be stimulated by medical

specialists’ help-seeking behavior (Edmonson, 2003). Consequently, help-seeking behavior

may help medical specialists’ regain control via relying on colleagues’ expertise to reduce

medical uncertainty. In other words, help-seeking behavior may help to become more

adaptive to the environmental demands of the medical enterprise and subsequently may

reduce the lack of control that medical specialists experience. Consequently, because of the

reduced relationship between medical uncertainty and competence threat, help-seeking may reduce medical specialists’ excessive testing behavior.

The potential of reducing perceived uncertainty may be found within the opportunities of extending one’s boundaries of knowledge and skills by consulting other colleagues. When asking others for help one utilizes available resources of new information (Ames & Lau, 1982; Ashford, 1986; Edmonson, 2003; Kitto et al., 2004; Lee, 1997; Newman & Goldin, 1990). Others’ knowledge and skills might complement peoples’ own knowledge and skills and could therefore be an effective way of extending one’s boundaries of knowledge and skills (Edmonson, 2003; Edmonson, Bohmer & Pisano, 2001). If extending boundaries of knowledge and skills helps to master one’s environment and subsequently attain valued goals, medical specialists’ perceptions of uncertainty may be reduced and the help-seeking behavior is considered beneficial (cf. Ashford & Cummings, 1985; DePaulo & Fisher, 1980;

Karabenick & Knapp, 1988; Lee, 1997; Nadler, Ellis & Bar, 2003; Newman & Goldin, 1990). Indeed, help-seeking behavior is found to occur primarily in situations in which there is perceived difficulty to attain valued goals (Butler & Neuman, 1995; Lee, 1997), as no assistance, relief and/or remedy is needed when perceived difficulty is low (Lee, 1997)

In healthcare, help-seeking may aid medical specialists to reduce their perceived medical uncertainty as they can rely on other medical specialists’ experience and expertise.

Similarly, in healthcare help-seeking can promote master of new knowledge (Butler &

Neuman, 1995; Morrison, 1993), improves problem solving (Hoffman & Maier, 1961) and serve better responses to environmental demands (Hutchens, 1994; Bantel & Jackson, 1989;

Eisenhardt & Schoonhoven, 1990). Subsequently, the present research argues that help-

seeking can be seen as a critical coping mechanism to overcome uncertainty (Edmonson,

2003; Edmonson et al., 2001; Lee, 1997; Villavicencio, 2011) and a way to remain adaptive

in an uncertain environment (Ames & Lau, 1982; Ashford, 1986; Ashford, 1991; Kitto et al.,

2004; Lee, 2002; Villavicencio, 2011). Consequently, by reducing the feeling of medical uncertainty, medical specialists may regain perceptions of control. As such, I predict that:

Hypothesis 3: help-seeking behavior moderates the positive and indirect effect of medical uncertainty on excessive testing behavior via competence threat, such that the positive indirect link between competence threat and excessive testing behavior is weaker when help-seeking behavior is stronger.

Method Respondents and Procedure

426 medical specialists participated this study but 191 were removed from further analyses due to missing data, resulting in a final sample of 235 medical specialists. From the final sample, 56.6% were male, and age ranged from 20 to 67 (M = 42.94, SD = 11.98). The native language of all participants was Dutch. All medical specialists were employed in Dutch healthcare and executed tasks such as diagnosing and/or had the responsibility of determining medical treatment of patients: physiotherapist (26.4%), surgeon (22.1%), nurse (10.6%), general practitioner (6.4%), anesthetist (5.1%), doctor assistant (3.8%), and internist (2.6%). Their work experience in their current profession ranged from 0 to 42 years (M = 13.64, SD = 10.53) and they worked on average 41.71 hours a week, ranging from 12 to 80 hours a week (SD = 13.73). Their education level varied from university education (57%), higher vocational education (34%), intermediate vocational education (4.3%), pre-university education (3.0%), elementary school (0.4%), and higher general secondary education (1.3%).

The participants were recruited via e-mail, LinkedIn, via the researcher’s personal

network, as well as face-to-face by approaching medical specialists in their own work

environment, clinics, and practices. Respondents were asked to fill in a paper-and-pencil

questionnaire or an online survey via a web link. It was ensured that both formats followed

the same layout. Full anonymity was guaranteed and participants were asked to sign an

informed consent before participation. Participants then proceeded to the main part of the questionnaire where they completed questions about the main constructs in this research.

Participants were also asked to fill in demographic information. The questionnaire ended with asking participants to participate in a follow-up research and by thanking them for their participation.

Measures

Medical Uncertainty. Based on Fox’s (2000) conceptualization of medical

uncertainty, we constructed a self-report scale that consists of 7 items. Example items were:

‘In my interaction with patients, I often have to deal with vague patient complaints’ and ‘In my interaction with patients, it is difficult to make a diagnosis’. For all items, see Appendix A. The participants responded on a 7-point Likert-type rating scale (1 = strongly disagree, 7 = strongly agree). The items were averaged into a single medical uncertainty score (M = 3.37, SD = 1.16, α = .86).

Competence Threat. The perception of competence threat was measured using the Competence Frustration subscale of Chen and colleagues (2015). Example items are: ‘In my current job, I feel insecure about my skills’ and ‘In my current job, I have serious doubts about whether I can do things right’. For all items, see Appendix B. The participants responded on a 7-point Likert-type rating scale (1 = strongly disagree, 7 = strongly agree).

The items were averaged into a single competence threat score (M = 2.15, SD = 1.14, α = .87).

Excessive Testing. In order to assess people’s tendency to test excessively, we used the critical incident technique (Flanagan, 1954). Particularly, we asked participants to remember a situation in which it was unclear what the patient suffered from. We then connected our excessive testing follow-up questions to the story that people self-reported.

Excessive testing, then, was measured using two items: ‘How likely is it that you will

perform an additional test or diagnostics for the purpose of diagnostics and a potential treatment?’ and ‘If test results are unreliable or unclear, how likely is it that you would use a different test or diagnostic instrument?’ ¹ The participants responded on a 10-point rating scale (1 = very unlikely, 10 = very likely). A higher score indicated a higher propensity to engage in excessive testing. For the complete questionnaire, see Appendix C. We averaged these two items into an average excessive testing score (M = 7.51, SD = 2.50, α = .81).

Help-seeking. A specialist’s help-seeking behavior was assessed using a self-report scale adapted from Odgen and colleagues (2002). Medical specialists were asked to what extent three statements were applicable to them ² . Example items are: ‘I ask my supervisor for clarification of things that I do not understand correctly’ and ‘I ask other medical specialists/

colleagues for help if I do not understand the patient’s file correctly’. For all items, see Appendix D. The participants responded on a 7-point Likert-type rating scale (1 = not applicable at all, 7 = fully applicable). The items were averaged into a single help-seeking score (M = 5.50, SD = 1.18, α = .65).

Results Preliminary Analyses

Before testing the actual hypothesis, preliminary analyses were conducted.

Participants with missing or incomplete responses (N=191) were excluded from further analyses. Descriptives and correlations are presented in Table 1. Next, analyses were performed with and without controlling for the covariates age, gender and tenure. Only the analyses with controlling for age revealed results different to those without controlling for

1

There was another item to measure excessive testing: “If test results are unreliable or unclear, how likely is it that you will perform the same test or use the same diagnostic tool again?”. We have excluded this item from further analyses as the present two items represent the notion of excessive testing better (cf. Sah, Elias, & Ariely, 2013).

2

There was another item to measure help seeking: “I ask my supervisor for clarification of things that I

do not understand correctly”. We have excluded this item from further analyses as the present tree items

represent the notion of help seeking better (cf. Odgen et al., 2002).

age. When controlling for age, the relationship between competence threat and excessive testing becomes significant, which is not the case when age is not included as a covariate.

Also, the mediation effect of medical uncertainty and excessive testing via competence threat became significant when age was included as a covariate. Therefore, the main analyses were run including the control variable age. Implications, strengths, and limitations are discussed later on.

Hypothesis Testing

The first three hypotheses were tested with the PROCESS macro mediation analysis model 4 of Hayes (2013), see Table 2. The last hypothesis was tested with PROCESS macro mediation-moderation analysis model 7 (Hayes, 2013), see Table 3. The interaction variables were mean-centered. The first hypothesis (H1) states that medical uncertainty is positively associated with competence threat. In line with this hypothesis, the regression analysis showed a significant proportion of variance (∆R² = .36, ∆F(2,229) = 16.97, p < .001) and medical uncertainty was positively associated with competence threat (B = .30, SEb = .06, t(229) = 4.95, p < .001).

The second hypothesis (H2a) states that medical specialists’ competence threat is positively related to excessive testing. The regression analysis showed a significant proportion of variance (∆R² = .23, ∆F (3,228) = 4.18, p <.01), however, in contrast to hypothesis 2a, competence threat was negatively associated with excessive testing (B = -.33, SEb = .15, t(228) = -2.21, p < .05). This means that although competence threat and excessive testing are significantly related, it was in the direction contrary to what was hypothesized.

Next, hypothesis 2b states that competence threat mediates the link between medical

uncertainty and excessive testing. The mediation analysis showed a significant albeit weak

indirect effect of medical uncertainty on excessive testing (B = -.10, SEb = .06, LLCI = -.23,

ULCI = -.01). There was no significant direct effect between medical uncertainty and

excessive testing (B = .13, SEb = .15, t(228) = .89, p = .38). Thus, there was a mediation effect but in the opposite direction of what was hypothesized. Specifically, medical

uncertainty is significantly related to excessive testing via competence threat, but the indirect effect is negative as opposed to positive. As such, hypothesis 2b is not supported.

Finally, hypothesis 3 stated that help-seeking behavior moderates the positive link between competence threat and excessive testing. The moderated-mediation analysis showed a non-significant interaction effect of medical uncertainty and help-seeking in predicting a medical specialists’ competence threat, B = .01, SEb = .01, t(227) = 15, p = .88, and thus no moderated-mediation relation (estimate = -.0037, LLCI = -.06, ULCI = .04). In other words, the present data does not support the idea that help-seeking behavior moderates the link between perceived medical uncertainty and competence threat.

Discussion

In the present research, it was predicted that medical specialists experience increased levels of competence threat due to the medical uncertainty they experience in their work.

Next, it was argued that medical specialists engage in excessive testing to boost their feelings of control that are undermined due to the uncertainty they face in their work. Finally, it was predicted that medical specialists’ feelings of competence threat and their excessive testing, could be decreased when medical specialists use their colleagues to ask for help. This, eventually, should withhold specialists from excessive testing behavior.

First, the present data support the idea that medical uncertainty is positively related to competence threat. Indeed, medical specialists experience a general lack of control due to the uncertainty regarding diagnoses and treatment they experience in their work (Hypothesis 1).

Interestingly, competence threat was related to excessive testing but in the opposite direction.

Contrary to the predictions, medical specialists tend to engage in less instead of more testing

when they experience a lack of control due to their perceived medical uncertainty

(Hypothesis 2a and 2b). Furthermore, the present data did not support the idea that help- seeking weakens the effect of medical uncertainty on competence threat. It therefore could not be argued that help-seeking is an effective coping mechanism for medical specialists to regain perceptions of control (Hypothesis 3).

Theoretical Implications

In the light of the results, the present research contributes to our knowledge of the extant literature of medical uncertainty in healthcare organizations and its effect on work behavior, specifically diagnostic test behavior and help-seeking behavior. First, it was empirically demonstrated that medical specialists indeed do experience medical uncertainty (cf. Fox, 2000) and that their perceived uncertainty is associated with a lack of control. This contributes to the literature of uncertainty on competence threat (cf. Deci & Ryan, 2000;

Deci, Swartz, Sheinman & Ryan, 1981; Kay et al., 2008).

Second, the present research extends the findings of Sah and colleagues (2013), who were first to test the notion that medical specialists engage in excessive testing. The present research further adds that competence threat is a precursor of excessive testing. However, in contrast to what was predicted, the present research showed that medical specialists engage in less excessive testing when they experience competence threat. This finding is different from the findings of Sah and colleagues (2013). Based on the findings of this study, it cannot be argued that ordering extra tests is a coping mechanism for medical specialists to regain perceptions of control. Instead, when still following the compensatory control theory (cf. Ma

& Kay, 2017), it should be interpreted that ordering less tests is a compensatory control

mechanism of specialists less in control. One explanation could be that people that generally

perceive less control, are perhaps more inclined to avoid additional inconclusiveness than

confident people that are not afraid of any further uncertainty. Thus, when medical specialists

with a low perception of control receive inconclusive tests results, they probably feel not

stimulated to order any additional tests as these tests may symbolize additional uncertainty.

At first sight, not ordering additional tests seems passive behavior. However, according to Rothbaum and colleagues (1982) passive and withdrawn behaviors reflect the attempt to inhibit unfulfillable expectations, which they see as an active choice. This is the essence of the two-process model of perceived control of Rothbaum and colleagues (1982): “when people cannot bring their environment into line with their wishes, they bring themselves into line with the environmental forces” (p.5).

Finally, the present data showed no relationship between help-seeking and the level of competence threat. This is contradictory to the existing research on help-seeking and the perceptions of competence (e.g. Nadler et al., 2003). One explanation for the missing effect of help-seeking on level of competence could be that, in this research it was assumed that help-seeking and its effectiveness is a positive and linear relationship. However, previous research showed that help-seeking and its effectiveness are not necessarily linearly related but can oftentimes be interpreted as a curvilinear relationship. Specifically, seeking help as opposed to not seeking help could be an effective strategy to boost feelings of control.

However, excessively seeking help could become ineffective as it withholds people to master a task independently (e.g. Karabenick & Knapp, 1998; Nadler et al., 2003).

Practical Implications

There are some interesting implications for practice following from the present research. First, this research shows that medical uncertainty, which is inherent to the medical field, has negative implications for a medical specialists’ perceptions of control. Since it is known that perceptions of control are important for high motivation, performance, and general well-being (cf. Landau, Kay & Whitson, 2015), it is important for healthcare organizations to find ways to deal with insurmountable uncertainty of the medical field.

Specifically, healthcare organizations could support training sessions in which effective

clinical decision-making skills is learned, which is nowadays a more and more acknowledge training for medical students (Kitto et al., 2004).

Second, in line with previous research of Sah and colleagues (2013), results of this study revealed that excessive testing is an actual phenomenon in healthcare organizations.

Particularly, excessive testing might unnecessarily inflate healthcare costs and degrades the quality of care. This research uncovered that competence threat is negatively linked to excessive testing. This implies that perceptions of control are positively related to excessive testing. That is, medical specialists may engage in more testing when they feel in control.

Under the assumption that – generally – medical specialists feel in control, excessive testing seems a very real phenomenon and an important issue. Since restricting the use of test, increasing monitoring and rules do not prevent medical specialists from ordering tests excessively (e.g. Kwok & Jones, 2005). Therefore, solutions to excessive testing should be initiated bottom up instead of top down. Health care organizations could organize evaluation moments in which teams discuss their points of improvement. One agenda item could be the use of tests, in which excessiveness is addressed. The excessiveness of ordering tests should be explained as a phenomenon in which patients will not recover sooner and budgets for patient care are wrongly spent. Since one of the primary aims of a medical specialists is to cure their patients (Becker et al., 2015), this will hopefully contribute towards this salutary realization. However, since the realization of ineffectiveness of ordering any additional tests is still not satisfying a medical specialists’ primary aim of curing patients, health care

organizations should help medical specialists to find alternatives to test ordering. Health care organizations could help to overcome barriers such as professional silos or geographically distributed teams (Weller, Boyd, Cumin, 2014), so that patients could be easier referred to alternative medical disciplines.

Strength and Limitations

A strength of the study is its strong external validity. Actual healthcare professionals working in actual healthcare organizations participated. This boosts confidence in that the findings of this study actual occur in the population that we sought to study.

However, like most studies, the present study is not without its limitations and the findings should be interpreted in the light of these limitations. First, the internal validity of this study is low. No variables in this study were manipulated which means that causal inferences cannot be made. Second, it should be noted that the relationships that has been found between help-seeking and excessive testing, and help-seeking and competence threat, should be interpreted with caution. The present data showed on average a very high result for medical specialists’ help-seeking behavior. In other words, medical specialists in general often ask their colleagues for help. Because medical specialists ask each other a lot for help, the present study possibly does not allow medical specialist to differentiate their help-seeking behavior in different sets of conditions. This effect is called the restriction of range (Salkind, 2010). A restriction of range could lead to a limited range of covariance in the data. This in turn could cause difficulties when analyzing relationships between these constructs. Third, no attention checks were included in the analyses. Having healthcare professionals partake in the questionnaire was notoriously difficult because of their busy time schedule. Therefore, the extent to which the medical specialists filled in the questionnaire seriously and

concentrated should had been tested. Last, this study may have suffered from common method bias as all measures were self-report measures (cf. Podsakoff, MacKenzie, Lee &

Podsakoff, 2003). Respondents who give high ratings in a questionnaire oftentimes also give

themselves high ratings in the following questionnaires and vice versa. This tendency could

account for systematic covariance between two or more constructs that is different from the

covariance that probably will be found when the constructs are measured separately.

Consequently, the effects sizes that have been found in this study could be inflated because of this tendency.

Directions for Future Research

Future research should explain the underlying mechanism of the excessive test behavior of medical specialists that do perceive themselves in control. It is known that increasing monitoring and restricting the use of test do not prevent them from ordering extra tests (e.g. Kwok & Jones, 2005). It therefore would be interesting to examine whether medical specialists that perceive themselves high in control tend to undermine these rules more than their colleagues that do perceive themselves low in control. Previous research already revealed interaction between (non)conformity and perceived competence. In these studies it is argued that people confer competence to nonconforming rather than conforming individuals (Bellezza, Gino, Keinan, 2013; Ridgeway, 1981). It would be interesting to examine whether indeed the people that are seen as competent are also the persons that perceive themselves competent. It is then interesting to examine whether the relationship between perceived competence and nonconformity still exists. The studies of Bellezza and colleagues (2013) and Ridgeway (1981) both argue that status is also an important condition for nonconformity behavior. They argue that the higher status of people alleviate the social costs to behave not conform standards and rules. Since status is often attributed to medical specialists, this would be an important variable to take part in the research.

Also, if we can assume that this research revealed that not ordering tests is a coping mechanism for medical specialists to restore their control, it would be interesting to further examine the explanatory mechanism. Rothbaum and colleagues (1982) argue that inward behavior (e.g. not ordering tests) can be further explained by attributions to powerful others.

It is imaginable that the medical specialists that perceive their competence threatened, tend to

adhere more to the rules of the hospital and restrict their test ordering behavior. Future

research could further investigate whether this is the explanatory mechanisms that is applicable to the medical specialists.

Furthermore, help-seeking did not attenuate the excessive testing behavior via reducing the competence threat of medical specialists. Instead, this research revealed a positive significant relationship between help-seeking behavior and excessive testing behavior. One explanation for this effect could be that both the behaviors help-seeking and excessive testing do have the same beneficial result of partly transferring responsibility to an external actor. It should be further investigated whether this overlapping effect is the

explanatory mechanism of both behaviors.

Finally, in contrast to previous research (e.g. Nadler et al., 2003), this study revealed no interaction between help-seeking and level of competence. However, this study did reveal a positive relationship between help-seeking and excessive testing. Therefore, it would be interesting to develop a research paradigm in which the relationships between help-seeking, competence threat and excessive testing are more thoroughly investigated in, for example, an experiment.

Conclusion

In sum, the present study showed that medical uncertainty is positively related to

competence threat. Also, it has been shown that competence threat is negatively related to

excessive test ordering behavior and that competence threat mediates the negative relation

between medical uncertainty and excessive testing. Medical specialists with low perceptions

of control, compensate their competence threat with the inward behavior of less ordering

tests. Since the excessive testers are medical specialists that are convinced about their test

behavior, medical organizations may try to counter this by increasing awareness among

medical specialists about their excessiveness use of test and its detrimental consequences.

Health care organizations should help their specialists to offer patients alternative cure treatments.

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Appendices 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) Help-seeking 5.50 1.18 .07 .03 .13* (.65) (5) Gender 1.43 .50 .01 .12+ -.08 .23** 1

(6) Age 42.94 11.98 -.16* -.19** -.18** -.12+ -.17* 1

(7) Years of Working Exp. 13.64 10.53 -.07 -.08 -.14* -.10 -.15* .80** 1 Note. N=232; ⁺ p < .10, ^* p < .05, ^** p < .01, ^*** p < .001. ; Gender: 1 = male and 2 = female.

Cronbach’s alphas are displayed on the diagonal

Table 2

Regression Results for Mediation

b (SE) t p

Medical uncertainty to competence threat

.30 (.06) 4.95 .000

Competence threat to excessive testing

-.33 (.15) -2.21 .03

Direct effect (c’) .13 (.15) .89 .38

Indirect effect -.10 (.06) (-.23, -.01)

Notes. N=228; ⁺ p < .10, ^* p < .05, ^** p < .01, ^*** p < .001. Coefficients are non-standardized.

All variables were mean-centered prior to analysis.

Table 3

Assessing Moderated Mediation Wherein the Positive Indirect Effect of Medical Uncertainty on Excessive Testing Behavior via Competence Threat is Conditional on Help-seeking

DV Competence threat

Variable b SE t(227)

Constant 2.72 .32 8.63***

Medical Uncertainty .31 .08 3.88***

DV Excessive Testing

Variable b SE t(228)

Constant 9.95 .79 12.66***

Competence threat -.33 .20 -1.70+

Medical Uncertainty .13 .17 .77

Conditional indirect effect

Variable Boot effect Boot SE LLCI ULCI

Weak Help-Seeking -.10 .06 -.24 -.01

Average Help-Seeking -.10 .06 -.24 -.00

Strong Help-Seeking -.11 .07 -.30 -.01

Moderator mediation

Mediator Idex Boot SE LLCI ULCI

Competence threat -.0037 .02 -.06 .04

Notes. N= 235. Standard Errors between parentheses; ⁺ p < .10, ^* p < .05, ^** p < .01, ^*** p < .001.

Coefficients are non-standardized. All variables were mean-centered prior to analysis.

Appendix A: Questionnaire Medical uncertainty

Response range:

0 1 2 3 4 5 6 7

Strongly disagree Strongly agree

In my interaction with patients, (e.g. in the infirmary, clinic, OR, IC, or emergency)…

1. …I often have to deal with vague patient complaints.

2. …it is often unclear what is going on with the patient.

3. …it is difficult to make a diagnosis.

4. …it is difficult to choose a treatment due to unclear or vague complaints.

5. …it is difficult to predict the outcomes of a treatment based on test results (e.g. blood, radiology, etc.).

6. …test results are often unclear (e.g. blood, radiology, etc.).

7. …tests results are often unreliable (e.g. blood, radiology, etc.);

Appendix B: Questionnaire Competence Threat

Response range:

0 1 2 3 4 5 6 7

Strongly disagree Strongly agree

In my current job,…

1. …I have serious doubts about whether I can do things right.

2. …I am disappointed with my work performance.

3. …I feel insecure about my skills.

4. …I feel incompetent because of the mistakes I make;

Appendix C: Questionnaire Excessive Testing

Describe shortly the situation: what was going on with the patient? Give a few examples of which you thought was vague or unclear.

---

Response range:

0 1 2 3 4 5 6 7 8 9 10

Very unlikely Very likely

1. How likely is it that you will perform an additional test or diagnostics for the purpose of diagnostics and a potential treatment?

2. If test results are unreliable or unclear, how likely is it that you will perform the same test or use the same diagnostic tool again? (Deleted item)

3. If test results are unreliable or unclear, how likely is it that you would use a different test or diagnostic instrument?

In your profession as a medical specialists, you will be confronted with patients who are

vague about what exactly is going on with them. This can be due to vague symptoms,

vague explanations and/or unreliable, very variable or vague diagnostics or test results

(e.g. blood, radiology). Try to remember a case in which you had to deal with such a

situation. Then continue to the following questions.

Appendix D: Questionnaire Help-seeking

Response range:

0 1 2 3 4 5 6 7

Not applicable at all Very applicable

To what extent do the following statements apply to you?

1. I try to work independently, without the help of others, even when I have difficulty in making a diagnosis.

2. I ask my supervisor for clarification of things that I do not understand correctly.

(Deleted item)

3. I ask other medical specialists/ colleagues for help if I do not understand the patient’s file correctly.

4. I look for professionals in my work, which I can ask for help if necessary.