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Acad Med. 2014 Apr;89(4):664-70. doi: 10.1097/ACM.0000000000000163.

Doing what might be "wrong": understanding internists' responses to professional challenges.

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Dr. Ginsburg is professor, Department of Medicine, and scientist, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada. Ms. Bernabeo is a research associate, American Board of Internal Medicine, Philadelphia, Pennsylvania. Dr. Holmboe was chief medical officer and senior vice president, American Board of Internal Medicine, Philadelphia, Pennsylvania, at the time this study was conducted. He is currently senior vice president for Milestones evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois.



To develop a deeper understanding of the complexity of physicians' decision making when faced with professional challenges.


Using constructivist grounded theory, the authors conducted a secondary analysis of transcripts from focus groups with 40 internists in 2011. Participants responded to scripted professional challenge scenarios. The authors analyzed the transcripts for instances in which participants discussed "doing what might be wrong" (i.e., something that goes against their values or others' expectations). They used the theory of planned behavior (TPB), which posits that intention to act is predicted by attitudes, subjective norms, and perceived behavioral control, to understand the findings in a broader context.


The theme of "doing what might be wrong" was pervasive, particularly in response to scenarios involving stewardship, nonpatients' requests for advice or care, or requests for e-mail access. Participants' rationales for suggested behaviors included a desire to keep patients happy and be (or appear) helpful. Modifiers of those responses included type of patient, physician's relationship with the patient, and comfort level with the request. Consistent with the TPB, attitudes or beliefs about the intended behavior, subjective norms, and perceived behavioral control influenced decision making.


Physicians often do what might be wrong when they are asked to do something that goes against their values and beliefs, by patients, others, or as perceived by their organizations. Actions are often rationalized as being done for the right reasons. These findings should inform the development of educational initiatives to support physicians in acting in accordance with their ideals.

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