Orthopedic surgeons’ and neurologists’ attitudes towards second opinions in the Israeli healthcare system: a qualitative study

Physicians mentioned several reasons for patient preferences, as the physicians perceived them, for a private physician when seeking a second opinion.

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.

An essential component of the second opinion consultation is the element of patient choice [O4, O9]:

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.

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.

The physicians expressed ambivalent attitudes toward the private second opinion. While some proclaimed it a necessity, others noted what they considered its problematic aspects:

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]."

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].

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:

The tension between public and private medicine is evident in the current struggle over the existence and quality of public health care in Israel as expressed in the recent physicians’ and nurses’ strikes as well as in the Ministry of Health goals to reduce health disparities in Israel. For example, the provision of private medicine in public hospitals in Israel has been a subject of a major debate [31‐33]. According to the physicians interviewed, they think that patients who seek second opinions do so in the private sector. Getting a private second opinion apparently has an element of a premium product, with increased individual attention, shorter waiting time, and greater privacy, that is absent from the public system. The physicians interviewed perceived that patients prefer a private second opinion because they believe that “private” physicians are superior to “public” physicians, and likewise, they prefer to choose a consultant by themselves and to have “personal time” dedicated exclusively to them. This is probably one of the reasons for the tendency of patients to attribute greater value to the second rather than to the first opinion [34‐36]. Getting a second opinion in the private medical sector also allows patient access to high-ranking professors who, although they serve as department chairs in the public health system, are not easily accessible for patients through public health system channels. Finally, paying for a costly private consultation also helps promote the patient’s feeling that “I’ve done everything I could.”

Despite these benefits, such an arrangement has some flaws. First, the private medical sector lacks the same regulatory mechanisms as in the public sector, a situation that may lead to unnecessary and costly second opinions. In a private market, the second opinion becomes a “commodity” that distinguishes between those who can and cannot afford it. Second, the patients’ efforts to choose the “best consultant” under the assumption that “private” physicians are superior to “public” physicians can sometimes be undermined by their lack of valid data on physician quality and performance. Hence, they are prone to rely on the physician’s impression, charisma, and public appeal, and rumors and limited-value data. Surprisingly, although many physicians in Israel work in both the public and private settings, physicians themselves echoed patient assumptions about the professional superiority of private physicians compared to public ones. Yet, one may argue that without current data on the quality of private specialists’ outcomes, the choice of “private” doctors is as informed as a choice of any other physician, including the public sector. However, there are two inherent differences between a choice of a public or private physician. In the public service, patients have less choice of physician, and mostly see an available physician on a first-come, first-served basis. In the private sector, patients proactively seek a physician of their choice. Also, private consultations are costlier than public ones, and hence there is great importance for the patient to choose the best physician they can afford.

What are the implications of publicly employed physicians seeing patients privately for second opinion purposes? First, would the same physician provide a “better” opinion in a private setting? Apparently not. The physicians said that they certainly would not intentionally offer sub-standard care to their public patients. However, the private consultation enables both the patient and the physician more time to discuss the case in a relaxed and informal atmosphere, in which the physician can dedicate adequate time to discuss the history of the case, different diagnoses, and treatment alternatives with the patient. Hence the physician can have a broader view on the case, consider previous diagnoses given to the patient, and hence potentially provide a better decision. But, then, this option is open only to patients who can pay for it. Second, would the same physician provide different opinions in different settings, due to financial interests? The physicians denied such an influence, although some of them mentioned that some cases might fall within a grey area. Some physicians mentioned the challenge of maintaining the same level of professional judgment in the public and private settings. For example, in private settings the physician is usually more interested in satisfying the patient.

While our interviewees argued that the private setting is better suited for second opinion policies, they were concerned about the potential for tension between the public and private settings. For example, several physicians complained about disparate efforts and rewards in the public vs. the private settings. It is important to mention that the physicians did not directly attack patients’ decisions to pursue second opinions from “private” physicians, but the structural issues that cause system failures, such as misinformation about the quality of private physicians, inequality in accessibility, and physicians’ greediness in providing costly second opinions in an unregulated market.

Currently patients have large out-of-pocket costs on second opinions, and the health funds spend very heavily on second opinions through their supplementary health insurance programs. The right to receive a second opinion raises the issue of how a public system should provide at least some of the perceived benefits of the private system, thereby decreasing inequalities for patients and physicians alike. Can the public system provide high-quality, accessible, objective, and affordable second opinions? Can the public system potentially provide the benefits of private consultations, such as adequate doctor-patient time, patient selection of consultants, and patient accessibility to high-ranking professors? If a public system was ideally able to provide conditions similar to those in a private clinic, would that decrease the demand for private second opinions and facilitate equality? While there is currently no clear answer to these questions, the increasing demand described by the physicians for private second opinions reflects the general privatization trend that healthcare services in Israel have been undergoing. Based on a vast body of research that showed how second opinion can change the course of treatment [4‐6], we suggest that the second opinion should be institutionalized and regulated to ensure equality and fairness. A better solution would probably be to provide the public system with mechanisms and resources to provide better care, rather than let the privatization trend reinforce the drawbacks of the public system. One option is to provide second opinion as a public service by a designated “second opinion clinic” or other innovative mechanisms such as polyclinics [39]. A polyclinic is a clinic where key providers such as family practitioners, consultants, social workers, and other allied health professions are located under one roof, enabling enhanced collaboration among services. Policies are required to promote the optimization of treatment and the avoidance of unnecessary risks, and they will help assure the quality of treatment while saving costs by preventing unnecessary treatments.

Both the public and the medical profession should be informed on patients' right to second opinion, and should be directed on how to utilize second opinion to benefit from it as much as possible. Underuse can be treated through education, improved accessibility in peripheral regions, and co-payment reductions. Overuse (i.e., “doctor-shopping”) is sometimes the result of choosing an inappropriate consultant for a second opinion and the lack of a mechanism to help patients reconcile discrepant opinions. Hence, mechanisms for guiding both physicians and patients to an appropriate mechanism to implement the second opinion process, and for making an informed choice between the two opinions, can be implemented in parallel with control over utilization.

There is a need for studies that will examine the prevalence of second opinions overall, as well as by specialty and by various patient characteristics. This has importance for further understanding the overall nature and significance of the second opinion phenomenon, and in particular for exploring the extent of inequalities. In addition, decisions about whether to add second opinions to the national health basket would benefit from the results of cost-effectiveness analyses. Finally, further research is needed to complement physicians' perspectives with a better understanding of how patients perceive second opinions and to learn how significant the gap is between the right and its implementation, so as to inform sound implementation recommendations.