Twenty-one students participated in four focus group discussions. Each focus group lasted approximately 60 min. Participants were representative of their year groups in respect of gender and age (participant demographics can be found in Additional file 2).
Five main themes relevant to the integrative model of behavioural prediction [36] were identified from the focus group data. These were: attitudes towards incorporating cost into clinical decision making; normative beliefs and motivation to comply; self-efficacy beliefs; skills and knowledge, and environmental constraints.
Attitudes and beliefs towards incorporating cost into clinical decision making
This theme refers to beliefs which link incorporating cost into clinical decision making to expected outcomes and the degree to which this is positively or negatively valued by the student. This includes the consequences of considering cost for both the student and the patient. It encompasses the student’s personal emotions and their belief in terms of the general value of considering cost, as well as their attitudes towards the usefulness of specific items which come with a cost.
Participants focused overwhelmingly on negative expected outcomes. They considered, for example, that not doing a particular investigation was an unnecessary risk that might lead to negative outcomes for the patient. They expressed their primary focus as the best interests of the patient and their job to rule out life-threatening causes of illness. Their overwhelming concern was patient safety and outcomes.
I think I mean it’s a bit expensive, yeah, but if you miss an injury then it can be life threatening or like mobility threatening when it’s quite, uh, you know, quite unreasonable also. (P7)
I think it’s like, kind of like, better to be safe than sorry kind of mentality, for me. Yeah. I would rather do it and make sure the patient is okay than not do it and then like, um, if in the unfortunate event that the patient deteriorates. (P6)
While participants were able to discuss cost and sustainability this seemed more on an abstract level: it was not part of their clinical decision-making process and instead was an administrative matter.
We’re also quite detached from the cost, like we are not the ones handling the transactions. (P8)
Um, but I think in a public setting, I think our main, I think our main goal is just to work the patient up and see what we can do best for them. (P15)
Rather their attitude was one of “better safe than sorry” (P6).
Normative beliefs
Normative beliefs refer to the pressure to avoid not doing something (e.g., ordering a test) in terms of the student’s perceptions of what others think they should do, as well as the student’s perceptions of what other students are doing (see later). The most common reference group was that of consultants and other medical staff. Participants talked about following what they see others do, rather than making a cost–benefit evaluation. For example, if others typically order a certain test, so too will the students. For example,
Can I just ask, why are we not setting a plug? Cause at the ED they set up plug for everyone. (P14)
Every patient comes in and gets the FBC and renal panel. I didn’t know why. (P1)
Students also highlighted the role of patients in shaping their attitudes towards costs. They felt they should inform patients about the costs and let them decide whether or not to go ahead with treatment or investigations.
I think we need to meet his expectation first like. He could well be like coming because he has some concerns and worries and he might expect investigation of us. (P18)
Their perception of an individual patient’s financial situation, such as whether they could afford treatment or had sufficient insurance coverage, was discussed (e.g., I think it will only matter to me if there’s like very extraordinarily expensive things or the patient needs to consistently follow up with like very expensive scans and all that. Or if the patient has financial difficulties (P16)) but seemed to come secondary to a perception that if patients presented at the ED, these patients probably wished to receive treatment and investigations.
He’s already at the emergency department and he’s probably worried about um, I mean he probably wants to get some answers and some treatment. So uh, would it be better to do some investigations to uh, like, uh, like put his mind at ease and then like, direct the management or so. (P6)
Efficacy beliefs (self-efficacy)
Self-efficacy refers to the belief, or confidence, that one can carry out a behaviour (in this case, cost conscious care) even under difficult circumstances. Low self-efficacy is related to doubting one’s own judgement or ability to carry out cost conscious care (or that one has the skills to do so [see Skills and knowledge]). Issues related to self-efficacy included participants feeling they had little authority in the ED and needed to clear their decisions with seniors.
Number one, you’ll probably get screamed at by a consultant. Number two, the family will be super pissed at you, and number three, to top it off you probably won’t be able to forgive yourself or you’ll be very down after that, because you sort of like, you contributed to that. On the other hand, if you do it like pre-emptively in a sense, it’s not the most efficient use of resources, yes, unfortunately, but at the end of the day, you know, your salary is fixed and it’s okay, you’re covering your own ass. (P5)
Self-efficacy is linked to attribution, and students did not want to be the cause of adverse outcomes. They had a strong tendency to over-investigate for fear of missing something that could cause harm to the patient (see also Beliefs and Attitudes), rather than basing their decisions on clinical probability. Participants discussed how they would order tests even where they were not fully certain such tests were needed to minimise the change of adverse clinical outcomes (e.g., I would want to cover all my bases, just in case anything happens (P19). They assumed that ED patients were serious cases, and this appeared to contribute to their arguably overly cautious approach.
Skills and knowledge
This theme refers to participants feeling they have the necessary skills and knowledge to take cost into account in their clinical decision making. In terms of knowledge, they had very limited awareness of the cost of ED equipment (e.g., intravenous cannula, blood tube, syringes) or common laboratory and radiological investigations (e.g., liver function tests, chest X-ray, CT [Computed Tomography] scans).
It is probably very expensive, I don’t know how expensive. (P3)
When asked how much they thought these might be, they either could not estimate cost or their estimates were very inaccurate, usually much less than the actual cost.
It sounds a bit stupid but I thought that most blood tests would be like around the same price but I see there’s like a big difference between like c-reactive protein vs procal, even though they kind of test for similar things. (P21)
When accurate costs were shared in the second part of the vignette discussion, participants were very surprised. Participants reported that they were not taught the prices of equipment or investigations in the classroom or in the workplace.
e.g., I feel like, uh, we’ve never really been, uh, educated on the prices of the tubes itself. And like, frankly speaking, it’s, it’s actually more expensive than what I expected it to be. (P11)
In terms of skills, participants reported that their focus was on learning to successfully use equipment (e.g., successfully inserting an intravenous (IV) cannula into a patient’s vein for medication or fluids administration), rather than thinking beyond skills development to consider if the task was necessary.
Environmental constraints
Environmental constraints refer to barriers to cost conscious clinical decision making or cost-conscious care. The themes were mostly associated with students being aware that they are training in a public hospital setting which has constrained resources (e.g., limited bed spaces). However, they argued that, since patients pay a standard price in a public hospital ED setting, they didn’t need to pay attention to the costs of the equipment or tests because these items are already included in the ED bill (e.g., And I think since bedside ultrasound is also included in the ED bill already, we will just do it. (P18)). They indicated that they might approach costs differently if they were practicing in a private hospital.