Despite mandated reporting laws that require physicians to report elder abuse, physicians have low rates of reporting. The purpose of this study was to identify physician's perspectives on mandated reporting of elder abuse.Individual, semistructured interviews were conducted with 20 primary care physicians practicing in a variety of settings and caring for a diverse patient population in the Los Angeles area. Interviewers collected information on physicians' perspectives about factors that may influence physicians' likelihood to report elder abuse. The interviews were recorded and transcribed verbatim. Transcripts were analyzed using a grounded theory approach based on the constant comparative method and the emergence of the core category of paradox to best account for the most problematic elder abuse situations faced by physicians.During the interviews 3 paradoxes were expressed by physicians about the mandatory reporting of elder abuse. Specifically, mandatory reporting was related to both perceptions of increases and decreases in physician-patient rapport, patient quality of life, and physician control or ability to decide what is in the best interest of the patient. These paradoxes appear to be primarily hidden or unconscious, yet they influence the conscious decision process of whether to report.Primary care physicians appear to be subject to paradoxes of reporting that contribute to the underreporting of elder abuse. These paradoxes and alternative modes of managing paradoxes are important and should be addressed in educational and training programs for physicians, and systematic evaluation of these issues may help to inform future legislation in this area. Further studies are needed to assess the generalizability of these findings to other groups of clinicians.