Table 4:

Individual Clinician Factors Sub-themes and Illustrative Quotes

CLINICIAN
Implicit Bias	“I think that there is a lot of bias with the Muslim community even more so than some of the other religious communities .And so I think that from a provider’s standpoint, they may be less inclined to delve into some of those issues and to ask some of the questions that are pertinent because… they have that negative connotation of Muslims … they don’t ask as many things.” (FG10) “and the patient gets labeled [by prejudiced provider]as whatever, whether it’s like somebody with fibromyalgia who is seeking pain medicine or like sickle cell or something and has that true need but gets labeled a complainer or crazy or just looking for medicine, and so then nobody like really investigates what’s this underlying thing that’s actually bothering this person.” (FG10)
Fatigue/Exhaustion	“Like last night, I was just done at the end of my shift and really had to force myself to slow down and make sure I was looking at all my results and all my imaging to ensure that I wouldn’t miss something. But I can, very easily, see how things would slide under your radar when you’re tired…” (FG5)
Cognitive Bias –anchoring, general	“I think, with some of the diagnostic stuff, just getting the history from a patient can take you down a rabbit hole, it can be hard …to not have tunnel vision and just go along with what the patient says, and then each person kind of keeps going along with like- it went from the patient’s opinion to, this is the diagnosis, and these other things haven’t even been considered…” (FG10)
Training/Background/Experience	“But then you compare that to a nurse who’s six months in or fresh off of orientation who feels that they haven’t listened to enough normals to really identify the abnormal. And so are they crying wolf, themselves? Are they overreacting?… I’ve had nurses who have less than six months of experience on our unit say to me, Oh I’m not worried about that A-fib RVR cause it’s only 120. I’m not gonna bother the provider with that 3:00 a.m. Well, 120 RVR can quickly go to SVT.” (FG4) “We have significant concerns about the safety of our patients after midnight with a single resident reading. They’re slow and they make mistakes, and the over-reads coming in the morning and calling patients back.” (FG9)
Ego	“if your ego gets to where you’re trying to handle problems that really would be best handled by a specialist that, in general, is a possible area for diagnostic error or delay.” (FG11) “I would say sometimes ego can affect our provider even accept what you’re telling them. Sometimes, nurses are the ones sitting by the bedside, or probably worked with this patient maybe 4 days in a row for 12 hours, so you know your patient. But you’re trying to communicate with the doctors, and you’re saying, With their vital signs the way they’re doing, I think this is what is going on. But it just sound like[the provider thinks], You can’t tell me what to do, but you’re like, I think this patient is- has been here for five days- is constipated,… he’s been having nausea, and maybe we need to check something. But they’re[providers] like…they’re kind of pushing you backwards, so you can tell that it’s like ego and like, I know more than you do…” (FG4)
Work Ethic/Responsibility	“We have proceduralists that don’t show up on time. …for example, we’re gonna do… some type of neuroradiology procedure, like … check and see if somebody’s aneurysm could be clipped instead of coiled, and your radiologist doesn’t show up until 8:15. I mean the whole team has been sitting there. The patient’s been waiting since 7:45, and people just kind of stroll in when they feel like it…”(FG6) “One of our older doctors, like he sees about 34 patients a shift [in ED] compared to like the younger ones [doctors] that see maybe 12 to 14… he’s amazing. But if they[younger physicians] modeled after this guy [There would not be any waiting for a diagnosis in ED] Where the other ones[doctors], if- we feel like they sit on ‘em intentionally[and slow down diagnosis in ED” (FG6)
Multiple factors	“the provider’s historical perspective on how they’ve done it, So this has always been that way, or like you’re talking about the behavioral patterns of these patients and like they- they stereotype them, or the person who’s giving the information, how much do they trust that person who’s delivering it? What do they- how- what are their thoughts on, Oh this person has been here a while. I trust them. I’m just gonna listen, do what they wanna do because they’ve been right before. So it’s the perceptions of the patient from the provider’s point of view, the perceptions of the information deliverer, from the provider point of view, and then the pressures that they’re getting from outside sources. If it’s a resident, are they getting pressures from the consultant? Are they on the night shift and they’ve been in surgery for ten hours that day and they’re tired? Or are they- this is their tenth admit in the past seven hours, and they’ve been hit by a patient? So it’s the external variables…”(FG2)