The sample characteristics are described below and also detailed elsewhere . In total, 20 neurologists and 15 orthopedic surgeons participated in the interviews. Most of the participants were senior specialists (51.4%, 9 neurologists and 9 orthopedic surgeons), or junior specialists (40.0%, 10 neurologists and 4 orthopedic surgeons). We also interviewed 3 senior residents (1 neurologist and 2 orthopedic surgeons). Most of the participants were male (91.4%, 17 neurologists and all the orthopedic surgeons). Most of the participants obtained their medical education in Israel (65.7%, 11 neurologists and 12 orthopedic surgeons). The main setting of practice of most of the participants was a public academic hospital (91.4%, 17 neurologists and all the orthopedic surgeons). We also interviewed two neurologists practicing in a community specialist service and one neurologist in a private clinic. Most of the participants were practicing in the periphery of Israel, i.e., outside the major cities of Tel-Aviv, Jerusalem, and Haifa (65.7%, 15 neurologists and 8 orthopedic surgeons). Most of the participants were providing second opinions in private settings (60.0%, 10 neurologists and 11 orthopedic surgeons) in addition to their public work. In both settings, they invest a different amount of time in giving second opinions; while for some it is a part of their other duties, for others (mainly in the private setting) this is their major work.
Most of the physicians expressed a positive attitude toward the second opinion. Beyond being a patient’s right, they describe it as a legitimate and often justified tool that can improve overall quality of care. They felt that when used properly, the second opinion can benefit everyone involved: the patient (by either ratification of the first opinion or by bringing to the patient’s attention additional options he/she should consider); and the physician (by helping the patient make a decision, discussing the patient’s case with the other physician, and as a source of added income). Some physicians even encourage their patients to seek second opinions.
Through our analysis, we identified the players who participate in second opinion consultations (the patient, the two consultants, the insurer, and non-clinical advisors) and their interactions—the patient interacts first with a primary consultant to get a first opinion and then with another consultant for a second opinion. The second opinion consultation takes place in a particular setting (public hospital, health fund, or private clinic) and in a specific geographical area. These consultations are provided or reimbursed by an insurer or the patient. Sometimes patients seek advice from a rabbinical medical broker outside the healthcare system. Using these definitions and contexts, we arranged the data along several themes: second opinion in public vs. private medicine; second opinion in the center of Israel vs. in the periphery; utilization of second opinion; and medicine between science and religion. We discuss these themes below.
Codes in square brackets (e.g., [N9]) are interviewee identifications, where [N] represents a neurologist, and [O] represents an orthopedic surgeon. Direct quotations from the physicians were translated from Hebrew with particular emphasis on preserving the original meaning and tone of the physicians’ remarks.
Second opinion in public vs. private medicine
The way second opinion is being provided (described above) may create tensions between the settings of public and private medical care. According to the physicians interviewed, patients obtain their second opinions mainly in the private sector [e.g., O3, O4, O6, O7, O9, O11, O15]. According to the physicians, most patients either see a community consultant in their health fund, or get a reimbursement from their health fund via the mechanism described in the Introduction. The latter is more costly to the patient and hence patients expect much more in terms of length of visit and personal attention to their case.
Second opinion has a different meaning in the different settings: The physicians made a strict distinction between an “opinion” provided as an integral part of the diagnosis and consultation during the natural course of being an inpatient. A “second opinion” is another opinion that the patient seeks outside of the hospital. While most of the physicians were supportive of second opinions outside of the hospital, many of them stated that providing a second opinion within the hospital is forbidden, and some even referred to it as a “collegial taboo” or even a “crime” [N2]. The physicians practicing in community consultation care (secondary care) viewed the second opinion of a colleague practicing in the same clinic as a legitimate act, or at least were not affronted by it.
Patients’ reasons for seeking second opinions in the private market
Physicians mentioned several reasons for patient preferences, as the physicians perceived them, for a private physician when seeking a second opinion.
Belief in the superiority of private consultation
According to the physicians, most patients have a tendency to overestimate the quality of a private consultation and, therefore, they perceive a private medical opinion to be superior to that given in a public setting. Although there is a rationale to support this belief, as physicians practicing in the private market are usually more senior, some physicians mentioned that this perception may mislead the patient. A second opinion from a senior physician in a public setting may be better than that from a less experienced physician in a private setting. Moreover, physicians interviewed mentioned what they perceive as the patients' lack of credible information about the quality of privately practicing physicians.
Personal selection of a consultant
An essential component of the second opinion consultation is the element of patient choice [O4, O9]:
"“… You go to a doctor that YOU choose, unlike the public system where you get the one who was just available … it gives the feeling that they choose one that they really want, after research and recommendations … so they feel more confident and are more inclined to accept the consultant’s opinion …” [O4]."
For example, one physician [O5] recalled a trial program to provide second opinions as a private service within a public hospital by senior physicians practicing in the hospital. This effort failed, however, because patients wanted to choose the second opinion consultant themselves, an option that was not available in this trial.
According to the physicians, many patients are motivated to seek a second opinion for emotional reasons, such as anxiety, and by a desire to get more information and relief. The usual hectic public setting allows very limited time to spend with each patient. But in the private setting, the physician can spend the necessary time with each patient, have a relaxed conversation, and discuss diagnosis, treatment, and prognosis [O15]. The patient effectively “buys the physician’s time” [O2] and the consultant can spend more time evaluating each case, discussing patient preferences, considering further studies, and explaining the diagnosis, treatment, prognosis, etc.
"“… Sometimes a visit in a public setting lasts too long because there are too many questions, and you might become impatient, and the patient also feels that. So the second opinion provides another opportunity to get more information, perhaps about other nuances, I think that is positive …” [O11]."
“I’ve done everything I could”
Obtaining a second opinion is often a part of how the patients cope emotionally with their disease. The high costs of private second opinions may constitute part of the “I’ve done everything I could” feelings of the patient.
Physicians’ attitudes toward the private second opinion
The physicians expressed ambivalent attitudes toward the private second opinion. While some proclaimed it a necessity, others noted what they considered its problematic aspects:
"“… Second opinion, essentially, is an example where private medicine celebrates the current limitations of public medicine, and perhaps, the failure of public medicine. People can’t find satisfactory solutions, so they turn to private medicine …” [O9]."
Several physicians talked about their feelings of unfairness triggered by the huge efforts they often invested in the public settings and the disproportionately small rewards they receive relative to physicians in the private settings [N6, O5]. For example:
"“… In the public sector, it often happens that you are taking care of a patient for two weeks, doing screenings, imaging, weekend duty, etc., and then the patient goes to someone else, who sits with the patient for 30 minutes, reads what you have sweated for, and takes a thousand shekels, and you’ve worked here for free, it’s annoying, it’s frustrating …” [N6]."
Maintaining medical ethics in the private second opinion
The physicians also mentioned the challenge of reconciling the tension between clinical and economic considerations and of maintaining medical ethics regardless of the setting. Some physicians felt that unlike the public setting, in a private setting the physician is driven by a financial motive to satisfy the patient [O6, O15]. However, most physicians said that they maintain the same clinical judgment whether the setting is public or private, and they uphold professional ethics by trying to avoid financial considerations [O1, O2, O4, O5, O13, O15, N7].
"“… The whole idea is to try and stay straight, and not suggest surgery just because of money … “[O15]"
Private second opinion in hospital settings
Several public hospitals provide private services, including second opinions. Hadassah Hospital, for example, is a public not-for-profit hospital, not owned by the government, which provides private consultations. The reimbursement mechanism for getting a second opinion in these services is similar for other consultations with private physicians (i.e., 80% of cost, up to approx. 550 NIS, up to 3 annual consultations). Some physicians (e.g., [O15]) mentioned the prestige of these hospitals relative to “regular” private consultations in a non-institutional setting. Another physician referred to a trial to establish such a service in a peripheral hospital (i.e., private consultation service within a public hospital) that was unsuccessful because the patients realized that the physicians were the same physicians practicing in the public hospital. Hence, we assume that second opinions provided in the private service of the public/private not-for-profit hospitals pose the same kind of issues and problems as second opinions provided outside the confines of these institutions.
In addition, the setting may affect the way second opinion is practiced. Hospitalized patients are less inclined to seek a second opinion because they feel that within the framework of normal hospital procedures, several physicians discuss their case [O11]. Some hospitalized patients invite physicians from outside the hospital to give them second opinions in the ward, but this is relatively rare [O5, O15]. It may also affect the patient-physician relationship:
"Interviewer: “Is it common that patients hear your opinion and then seek a second opinion from someone else?”"
"Interviewee: “Frankly, in all of those cases I initiated the second opinion; I cannot recall anyone who heard my opinion, and went to someone else and then came back to me, or that I heard they went to someone else. I work in a private, very exclusive milieu. I guess that the setting plays an important role” [O14]."
Second opinion in the center of Israel vs. the periphery
One of the most common expressions, made mainly by physicians practicing in the periphery, is the patient perception that “the phenomenon of the second opinion is routine in the ‘center’” (i.e., Tel-Aviv metropolitan area and hospitals in Jerusalem) and that “the best physicians are in the center” [N2]. According to this perspective, patients consider physicians practicing in central regions of Israel as more knowledgeable and of greater expertise than those in the periphery, and, therefore, it is important for patients to meet “the expert from the center”, even when such physicians possess the same training and experience as a physician practicing in the periphery. Going to “the doctor from the center” instills in patients the confidence and the feeling that they did everything they could to find the best treatment [O6]. Patients from the periphery come to the center for a second opinion, but seldom the other way around. A common feeling expressed by physicians practicing in the periphery is that patients devalue their expertise and perceive them as inherently under-qualified compared to the physicians practicing in the center. One physician described an ironic situation, in which physicians who work in the periphery are more highly esteemed by their patients if they also have private clinics in the center [N2]. The following is another anecdotal example of patient over-evaluation of physicians who practice in the center:
"“… I had a patient whom I advised that she needed surgery, but then she was gone and returned after a month. Apparently she waited for a whole month for a very famous doctor in the center, just to hear him say that I’m right, and that I’m the best surgeon for it. That’s fine, but she waited a whole month, and meanwhile the fracture deteriorated, the risk increased and eventually she was not operated. She spent a month which was very, very critical, and screwed her chances, only to hear a very famous person …” [O15]."
According to the physicians, several structural reasons can be cited for the low utilization of the second opinion by patients in the periphery. For example, in the periphery 1) there are fewer experts and hence, less choice for patients; 2) private medical care is less developed, especially for private surgery; and 3) supply of and demand for private medicine are much lower and fewer people have adopted the mentality that accepts and promotes using private medicine [N2]. Patients living in the center are usually more aware of the option of getting a second opinion, and even those from the low-medium socioeconomic classes in central Israel obtain second opinions. Moreover, they are often more aware of why the second opinion is important [N2, O2]. Although such inequalities exist throughout Israel, they are more prominent in the peripheral regions where patients of limited means can be found in greater numbers, and therefore, many physicians prefer to work in the central regions of Israel. Physicians who practice in the periphery are often frustrated by their perception of being under-valued by patients and generally unappreciated merely because they practice in the periphery:
"“… The assumption of most patients is that when working in the periphery, you are professionally inferior to doctors doing the same work in the center. It is annoying, because it’s the premise of most of the patients, and if it is their reason to hear a second opinion, it’s annoying … I mainly face it with patients whom I offer something and they turn to doctors in the center, because they think they are better, because they are ‘doctors in the center’ … I say this with sad cynicism” [O15]."
According to the physicians interviewed, there are legitimate reasons to consult physicians practicing in the center: because some services are supplied better by central hospitals than by those in the periphery [O15] and because different hospitals also have different approaches to the same treatment [N2]; the second opinion consultation is legitimate and even useful. However, the physicians have expressed frustration from being automatically devalued relative to the physicians practicing in the center of the country.
Utilization of second opinion
Opinions among physicians were mixed about the level of second opinion utilization. Several neurologists stated that there has been an increase in its use but that many patients are still unaware of the existence and/or importance of this tool, which is sometimes used inappropriately [N4, N5, N6, N8, N9]. Others stated that many patients seek second opinions [N14, N15], and some orthopedic surgeons pointed to an overuse of second opinion consultations due both to patient anxiety and to such consultations being too accessible, thus leading to many unnecessary consultations for relatively simple problems [O2, O10, O11, O12]. Some physicians mentioned the need to increase awareness and to reduce co-payments to encourage second opinion utilization [O5, O7, O8].
Most physicians agreed that the second opinion has been increasingly utilized in recent years due to the reimbursement that patients now receive from their health funds. The health funds’ policy regarding second opinions has increased the legitimacy of such consultations and made them more accessible. The physicians also mentioned that the increased availability of medical information on the Internet and in the media has made patients more knowledgeable about their diseases and more skeptical of their physicians. Some physicians referred to the trend of legal claims against physicians as contributing to the increase in second opinion utilization, ultimately leading to unnecessary and redundant second opinion consultations and the phenomenon of “doctor-shopping” (i.e., getting many opinions for the same episode), which may be the result of the lack of a mechanism that helps patients to reconcile discrepant opinions [O1, N10].
Although physicians mentioned that it is difficult to characterize the patients who seek second opinions, some mentioned anxious patients as those with the greatest tendency to request additional consultations about their health. Moreover, the patient asking for a second opinion is typically from among the more educated sector of the population, of high socio-economic standing, with access to sources of information, and the ability to pay for a second opinion [O2, O4, O13, O14].
Medicine between science and religion
According to the physicians, many patients in Israel get rabbinical consultations, in parallel with their clinical consultations, about surgery or treatment regarding selection of the hospital or physician [O2, O3, O4, O11, O14, O15, N1, N6, N8]. This practice is used mostly by ultra-orthodox Jewish people, but for different reasons some members of the secular public also consult Rabbis about medical treatment. In the ultra-orthodox community, the rabbinical consultation is an integral part of getting a Rabbi’s blessing (i.e., approval) for a medical procedure. The Rabbi usually directs the patient to a specific specialist or hospital. Secular patients, on the other hand, seek advice from rabbinical medical brokers to get additional opinions based on their sources and contacts.
But physicians are not wholly satisfied with rabbinical involvement, as it casts doubt on their professional judgment, and it creates tension between “faith” and “science”. The physicians were also uncomfortable with the patients’ need to receive approval from a Rabbi after the physician recommended a decision and being “dictated” to by a Rabbi, which contradicts the perception of the professional authority and clinical autonomy of the physicians. Some physicians expressed some distrust of Rabbis as a source of clinical judgment, because they rely on faith rather than on medicine as a scientific profession [N6, O2, O4, O11, O14, O15]. The fact that Rabbis advise patients to be treated in certain hospitals or by certain physicians arouses resentment among physicians [O15]. They also mentioned that ultra-orthodox patients tend to express their desire for a second opinion more blatantly than secular patients, probably due to their perception of the physician as inferior to the Rabbi.
"“… We have quite a bit of experience here with orthodox people. The decision may be easier for them because they do not decide, but the Rabbi, so it is a kind of a second opinion. Rabbis have their knowledge, but if the patient delivers incorrect information, then their decision may be wrong, but it is sacred. Sometimes the Rabbi objects to surgery although I recommend one. So sometimes it can be problematic in terms of the therapeutic approach” [O11]."
"“… In the orthodox sector it is sometimes an integral part of getting the blessing of the Rabbi, and to go to whom the Rabbi ordered you to go. They come from relatively lower socioeconomic levels, but yet they are willing to pay to consult with the physicians to whom the Rabbi sent them” [O14]."