The Operating System of Clinical Decision-Making: Why Context Matters More Than We Think

Early in my career, I was conducting a qualitative one-on-one with an infectious disease specialist based in an academic medical center who treated people living with HIV. I had done dozens of interviews like it before, but something about this conversation stayed with me. It revealed a deeper truth—one that would shape how I’ve approached customer behavior and habit formation ever since.

We were discussing treatment preferences—how he chooses among antiretroviral (ARV) regimens, what matters most in therapy selection, and how he might react to a potential new ARV candidate. His reactions to the TPP were thoughtful, evidence-based, and seemed to be consistent with the DHHS clinical guidelines.

Yet as the interview progressed, it became increasingly clear that his decisions weren’t driven solely by product attributes on the page like virologic efficacy, side effect profile, or convenience. Instead, they were shaped—often decisively—by the setting in which he practiced and the medical environment he navigated every day: a hospital-based clinic serving a largely underinsured population, where many patients faced housing instability, co-morbid conditions, and systemic barriers to consistent care.

What I gleaned, under the surface, is that many of his patients are at risk for non-compliance with their ARV therapies and that this was a dominant consideration in terms of whether or not he would prescribe a given medication. His prescribing behavior and preferences for a new product weren't just a reflection of his clinical judgment—they represented a rational adaptation to the realities and real-world conditions surrounding him.

That interview, and many others since, have taught me something critical: context isn’t a backdrop. It’s the operating system. And unless we take the time to understand it, we risk misinterpreting everything else an HCP tells us in an interview.

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Context: The Most Important Variable We Rarely Probe

In healthcare marketing research—especially qualitative—we’re often focused on surface-level responses: how an HCP says they feel about a product profile, what they say drives their treatment decisions, and/or how they react to messaging or other promotional stimuli. But too often, we skip over—or give short shrift to—the structural realities shaping those responses. Context includes all the background conditions that frame an HCP’s clinical behavior. It’s the reason why two physicians with similar training and values might make entirely different decisions.

Several years ago, when we developed our Habit Lens methodology, one of the key departures from traditional behavioral models (like those proposed by Nir Eyal or Charles Duhigg) was this recognition: behavior doesn’t just follow a cue–action–reward loop. It’s shaped—sometimes constrained—by the context in which that loop runs. Eyal and Duhigg focus on the stimulus that prompts action and the feedback that reinforces it. But we argue that the environment—the system around the habit—is just as critical.

If Eyal gives us the wiring diagram, context gives us the voltage. It determines what’s possible, what’s practical, and what’s simply out of the question.

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What Does Context Actually Include?

Context in healthcare is multifaceted and complex, and understanding it requires going well beyond superficial profiling of the HCP, practice type, or patient mix. It’s about uncovering the systems, constraints, and practical realities that truly shape clinical behavior—and that are often so ingrained they go unspoken. As part of our Habit Lens methodology, we place strong emphasis on these environmental dimensions, because they influence what an HCP can do as much as what they want to do.

Below are some of the contextual factors we consider essential:

• Practice Setting Is the HCP in a private office, group practice, hospital clinic, HMO, or IDN? Autonomy, access, and administrative complexity vary widely. In highly structured settings, practical realities—protocols, formularies, EMRs, staffing—can outweigh personal clinical preference. In many cases, institutional constraints may slow or even prevent the adoption of a new therapy, regardless of clinical enthusiasm.
• Patient Demographics Age, income, education, comorbidities, and geography all shape how treatment decisions are made and implemented. A rural patient who drives hours for care may be less suitable for therapies requiring frequent in-office administration or intensive monitoring. A low-literacy population may require simplified regimens to ensure adherence.
• Volume and Experience When an HCP sees only a handful of patients with a given condition, familiarity is often limited. That can reduce confidence, increase perceived risk, and reinforce reliance on habitual prescribing. From a Habit Lens perspective, low patient volume means fewer “cues” to act differently—fewer decision points where behavior change can take root.
• Time and Capacity Time is a scarce resource. Most HCPs have only minutes with each patient, and under that pressure, they often revert to streamlined routines or cognitive shortcuts. Capacity limitations—whether due to staffing shortages, scheduling bottlenecks, or administrative overload—also impact whether a new medication, device, or diagnostic can be integrated into practice. Even clinically sound innovations may face friction if they require more time, training, or follow-up than the system can realistically support.
• Insurance Mix and Access Is the practice serving mostly Medicaid patients? Is it in a commercial-heavy suburban area? Are prior authorizations routine or rare? Is the clinic subject to step therapy mandates? These nuances matter—and they often make or break a product’s viability in real-world usage. Access challenges can be decisive, even when clinical intent is aligned.
• Organizational and Economic Structure Is the HCP an employee or a practice owner? Is the group physician-owned, PE-backed, or part of an academic center? Who controls purchasing decisions, treatment protocols, or preferred formularies? These internal business dynamics shape not only prescribing behavior but openness to innovation.
• Adoption of Technology and AI As artificial intelligence becomes increasingly integrated into clinical workflows, it’s becoming part of the operating system that influences HCP behavior. From decision-support tools to automated prior authorization prompts, AI may eventually guide—or constrain—how care is delivered. While still emerging, understanding an HCP’s relationship with new technology, and how it fits into their day-to-day practice, will be an increasingly relevant contextual factor in years to come.

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Context Shapes Habits—and Understanding It Reveals the Real Barriers

When we think about understanding customer habits, context is not just helpful—it’s essential. It’s like the envelope that surrounds decision-making. And yet, it’s often overlooked.

This becomes particularly relevant in rare disease treatment. We often zero in on the physician’s perspective around a specific condition without recognizing that this condition may account for less than one percent of their total patient load. That low frequency translates into lower exposure, fewer opportunities to build confidence, and less habitual fluency in prescribing or managing care. In these cases, context isn't just influential—it may be the dominant factor in whether new therapies are adopted or ignored.

Think about that: ultra low volume may be the real reason why a doctor is reticent to change behavior.

This is where Habit Lens truly differentiates itself. Unlike traditional methods that look at drivers and barriers at the surface level, we look beneath—at the systemic, environmental, and organizational dynamics that shape those behaviors. Without accounting for context, we risk misunderstanding the source of friction. We miss the organizational bottlenecks, the subtle pressures, the unspoken limitations that HCPs navigate daily.

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In Research, Context Must Come First

If context is the operating system, then our job as researchers is to understand the "system specs" before interpreting the software behavior. That means:

• Starting with context, not tacking it on. Build it into the screener. Explore it up front in interviews. Treat it as foundational, not ancillary.
• Probing for unspoken systems. Ask about formulary dynamics. Explore EMR prompts, care pathways, and staff roles. Listen for passive signals—like “we usually” or “we’re required to”—which often indicate structural influence.
• Synthesizing with a systems lens. Don’t just analyze the “what”—analyze the why behind the what. Often, what seems like inertia or resistance is actually a rational adaptation to a complex care environment.

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Conclusion: Without Context, Insight Falls Flat

Clinical decision-making doesn’t happen in a vacuum. It takes place within a dense landscape of constraints, incentives, and institutional realities that HCPs navigate every day. If we want to truly understand their behavior, we must begin with the systems and structures that shape it.

But here’s the challenge: these contextual factors often go unspoken—not because they’re unimportant, but because they’re so fundamental and ingrained. To the physician, their environment can feel as invisible and ever-present as the air they breathe. That’s why moderators must be intentional in surfacing it. We can’t rely on it to emerge naturally. We have to probe for it—delicately, consistently, and early—if we want to understand not just what HCPs do, but why they do it.

Context may not show up in a topline quote or a single data point, but it's the gravitational force around everything else. It's not the background—it’s the foundation. So next time you're designing a qualitative study or interpreting its results, ask yourself: Have we truly accounted for context? Because without it, we’re not just missing nuance—we’re missing the truth.