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The prevalence, reasons and attitudes for the practice of informal medicine

The prevalence, reasons and attitudes for the practice of informal medicine Background: Informal medicine, entailing undocumented medical advice, has been described in diverse medical disciplines and geographical regions. We assessed the current prevalence and characteristics of informal medical consulting, the reasons physicians provide it, and their attitudes toward it. Methods: We conducted a survey among family physicians in Israel, a country with a national health insurance system. A questionnaire was emailed to all primary care physicians in the two largest HMOs in southern Israel. Fifteen questions addressed the prevalence, practice and attitudes to informal medical consulting. Ten questions assessed demographics and professional experience. Results: Of 143 respondents (mean age 41 years), 55% were women. Ninety-five percent of the respondents reported requesting informal medical consulting from other physicians. Fifty-four percent reported often providing informal consulting to family and friends; and an additional 27% reported doing so under exceptional circumstances. The main reasons given for informal consulting requests were availability and accessibility (81% of respondents), and not financial savings. Only 17.5% stated being in favor of informal consulting for family and friends. Only 11% expressed feeling satisfaction after providing such consultation; 49% expressed discomfort. Sixty- six percent thought a position paper on informal consulting to family and friends is needed. Conclusions: Our survey of primary care physicians shows very frequent informal medical consulting, despite high dissatisfaction with such, and an interest in receiving guidelines on this practice. Keywords: Informal medicine, Informal consulting, Primary care, Family medicine Introduction persons of other relations request and receive informal Informal medical consultation, in contrast to formal medical consultation. Described as “corridor”, “hallway” or medical consultation, is characterized by the provision of “curbside” consultation, such practice has been described undocumented medical advice. This includes any medical in diverse medical disciplines [2, 3] and geographical consultation or treatment provided to colleagues, family regions [1, 4] Self-care and self-prescribing by physicians members or friends. Numerous surveys and editorials have have also been widely described [5–10]. described the intervention of physicians in the health care Israel has a national health insurance system, in which of family members [1]. Thepracticehas persistedoverthe all the residents are insured by one of four health main- years, despite the inherent problems and the recommenda- tenance organizations (HMOs). Family physician visits are tions by such publications and by medical associations at no cost. Small co-payments are charged for visits with against it. In addition to family members, friends and specialists, though low socioeconomic status exempts also from these costs. During 2016, nearly 83% of Israeli * Correspondence: Amran_m@mac.org.il households purchased complementary health insurance Maccabi Health Services, Tel Aviv, Israel 2 from their HMOs [11]. The benefits of such include Ben Gurion University of the Negev, Be’er Sheva, Israel Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Amran et al. BMC Family Practice (2021) 22:30 Page 2 of 8 subsidies for second opinion consultations and scheduling variables. All p-values were two-sided and statistical appointments with shorter waiting periods. significance was set at P ≤ 0.05. In a survey study conducted in Israel over 20 years The protocol was approved by the institutional review ago, 82% of hospital physicians reported having been board of Maccabi Healthcare Services and the ethical asked to provide “hallway medicine”; of them, 91% committees of Maccabi and Clalit Health Services. agreed [12]. However, no position paper has been issued in Israel over the last two decades to guide physicians in Results dealing with this phenomenon. We conducted a survey Study population among family physicians in southern Israel, to assess the The total number of respondents was 143, for a response current prevalence and characteristics of informal med- rate of 24%. Table 1 presents the self-reported demo- ical consulting, the reasons physicians provide it, and graphic characteristics of the respondents. The majority their attitudes toward it. of the respondents were women, 55%. The mean age was 41 years. The majority of respondents work primar- Methods ily in urban clinics, 62%. Half of those who stated their This multicenter survey study is based on questions Table 1 Characteristics of the respondent physicians (N = 143) written by the researchers. The study population is Characteristics Respondent Non-responders primary care physicians (family physicians, general phy- physicians sicians and residents) who are employed in southern Gender, % (n) Israel. In total, 595 physicians were eligible to partici- Men 44.6% (62) 4 pate, from the two largest HMOs in Israel: 356 from Women 55.4% (77) Clalit Healthcare Services and 239 from Maccabi Health Services. Age, mean ± SD 41.3 ± 8.8 14 The questionnaire was designed to access information Familial status, % (n) 4 regarding the prevalence, reasons, means of practice and Single 7.9% (11) attitudes to informal medicine consultation among Married 89.2% (124) primary care physicians. A pilot test was performed on Divorced 2.9% (4) the initial questionnaire, among 10 participants. Follow- Origin, % (n) 13 ing their comments, the questionnaire was revised to the final version (see Additional file 1). The questionnaire Israel 70.8% (92) comprised 15 questions on practice and attitudes; each Elsewhere 29.2% (38) with 2–6 possible responses. One question asked the ex- University, % (n) 15 tent that the physicians consider each of 5 factors when Israel 69.5% (89) approached for informal advice; the responses were on a Elsewhere 30.5% (39) 5-point Likert scale. Ten questions accessed information Workplace, % (n) 4 on demographics and professional experience. The questionnaires were sent by a link to all the email Urban primary care clinic 61.9% (86) addresses of the primary care physicians affiliated with Rural primary care clinic 24.5% (34) Maccabi Healthcare Services and Clalit Health Services Public hospital 5.8% (8) in the southern district of Israel. A request was included Combination 7.9% (11) on the questionnaires, that physicians should not fill the Education level / Specialization % (n) 6 questionnaire more than once. Three reminders were General practitioner without 15.3% (21) sent, at intervals of 3–4 weeks. specialization, % Resident 28.5% (39) Statistical analysis Specialist in family medicine 50.4% (69) Statistical analysis was performed using the IBM SPSS version 25. Data were reported as means and standard Specialist in internal medicine 5.8% (8) deviations for continuous variables, and as percentages Seniority, median (range) 5 (0.5–45) 15 for categorical variables. We used the Student’s t-test to Less than 5 years, % (n) 41.4% (53) determine statistically significant differences in continu- 6–10 years, % (n) 28.9% (37) ous variables that were normally distributed. For con- More than 10 years, % (n) 29.7% (38) tinuous variables that were not normally distributed or “Specialists” include specialist in family medicine and specialist in ordinal variables, we used the Mann-Whitney test or internal medicine Kruskal–Wallis test, as appropriate. The Chi-square test “Non-specialists” include resident and general practitioner and Fisher’s test were used to compare categorical without specialization Amran et al. BMC Family Practice (2021) 22:30 Page 3 of 8 specialty were family medicine specialists; 28.5% were that reported refusing to provide informal consulting, and residents. Forty-one percent of the respondents had less no association was found between seniority and refusing than 5 years seniority; 30% had more than ten years. to provide consulting. Table 2 presents the responses to the questions regarding informal medical consulting. Attitudes to informal medical consulting Only 27% responded that they were in favor of formal Frequency of informal medical consulting medical consulting for family and friends (Question 4); The vast majority, 95%, of the respondents reported and only 17.5% responded being in favor of informal requesting informal medical consulting from other consulting for family and friends (Question 5). Respon- physicians (Question 1). Thirty percent provided such dents who reported receiving more requests for informal service at least once daily, during the preceding month consults expressed more opposition to this type of con- (Question 2). Only 7% reported not providing any such sulting (p = 0.048). However, those who provided more consulting over the last month. Fifty-four percent of the informal consultations to family and friends expressed respondents reported that they often provide informal their support of doing such (p = 0.012), and their feelings consulting to family and friends, and an additional 27% following these consultations were more positive (p < reported doing so under exceptional circumstances 0.001). (Question 6). Forty-eight percent answered that they Only 11% of the respondents expressed feeling satis- usually accept or never refused a request for informal faction after providing informal consultation; almost medical consulting from family and friends (Question half, 49%, expressed discomfort (Question 8). Differences 10). Seventy-five percent of the respondents stated that were observed between men and women in their feelings they highly or very highly considered their confidence in after providing consultation (Fig. 3). Sixty-one percent of the field, when approached for informal consultation the women compared to 39% of the men expressed feel- (Question 11, Fig. 1). Fifty-six percent responded that ing uncomfortable. Thirty-six percent of the men com- they highly or very highly considered the quality of their pared to 13% of the women felt indifferent (P = 0.002). personal relation with the individual requesting the Of those who reported providing consultation by phone consultation, and 53% reported considering highly or very (96%), almost half (49%) answered that such means highly the consequences of providing incorrect advice. should only be used under emergency situations or should be avoided (Question 15). The main disadvantage Characteristics of informal medical consulting to informal medical consulting according to the respon- Eighty-five percent of the respondents reported provid- dents was the lack of medical documentation, as cited by ing informal consulting face-to-face. In addition, high 85%. Lack of objectivity and the risk of unprofessional- proportions reported also providing consultation by ism or negligence were also cited by the majority of means of phone messages such as WhatsApp Messenger, respondents (Question 13). and by electronic mail. (Question 3). The vast majority, Sixty-six percent of the respondents thought that a 96%, reported providing informal consulting by phone position paper on informal consulting to family and (Question 14). More than half the respondents reported friends is needed (Question 16). Such position paper was providing consultation in non-emergency situations, more often desired among those who expressed having such as interpreting medical tests or providing routine negative rather than positive or indifferent feelings after examinations (Question 7). Only 5% of responders re- providing informal consulting (P = 0.002); and also ported avoiding medical treatment and providing only among those who reported more than one daily request clarification, interpretation or summation of clinical for informal consulting (P = 0.009). information, such as the recommendation of a specialist or the interpretation of medical. Residents and general Discussion practitioners (“non-specialists”) more frequently re- This survey study revealed great dissonance among pri- ported interpreting medical results and recommending mary care physicians, between their behavior and their secondary care physicians than did specialists in internal attitudes, in regard to informal medical consulting. On medicine and family medicine (“specialists”) (Fig. 2). The one hand, an overwhelming proportion reported involve- main reason presumed for the requests for informal con- ment in such consulting, including more than half who sulting were availability and accessibility, as selected by reported frequent rates. Further, almost half reported 81% of the respondents (Question 9). Fifteen percent of that they usually or never refuse a request from family the respondents reported receiving some form of com- or friends for informal consulting. On the other hand, pensation for providing informal medical consulting to more than half the participants in the survey stated family or friends (Question 12). No differences were feeling discomfort or regret after providing informal found between specialists and residents in the proportions consulting. More specific analysis of the data reveals that Amran et al. BMC Family Practice (2021) 22:30 Page 4 of 8 Table 2 Responses to the questionnaire Question Number Percent 1. Did you at any time request informal medical consulting from another doctor? Yes 135 94.4% No 8 5.6% 2. During the last month, how often did people turn to you for informal medical consulting? A number of times a day /Once a day 41 28.9% 2–3 times a week/Once a week or less 91 64.1% Not at all 10 7.0% 142 (mis = 1) 3. By what means were the requests for informal medical consults directed to you (more than one response can be selected)? Face-to-face meeting, planned in advance 121 84.6% Incidental meeting such as a social event 99 69.2% Phone messages (such as Whatsapp) 103 72.0% Electronical mail 114 79.7% Other 11 7.7% 4. To what degree are you in favor of formal medical consulting for family members and friends? Strongly in favor/In favor 38 26.6% Neutral reaction 41 28.7% Not in favor/Strongly opposed 64 44.8% 5. To what degree are you in favor of informal medical consulting for family members and friends? Strongly in favor/In favor 25 17.7% Neutral reaction 51 36.2% Not in favor/Strongly opposed 65 46.1% 141 (mis = 2) 6. Do you give informal consulting to family and friends? Yes, often 77 53.8% Yes, under exceptional circumstances 39 27.3% I try to avoid it/Never 27 18.9% 7. If you answered yes on the previous question, what type of consulting to you provide to family members and friends (more than one response can be selected)? Referrals to the emergency room 66 46.5% Recommendation to medical specialists 96 67.6% Prescriptions for drugs 98 69.0% Interpretation of results of medical testing (blood tests, imaging, etc) 115 81.0% Routine examinations 31 21.8% Treatment in emergency situations 72 50.7% Requests for a second opinion 62 43.7% 142 (mis = 1) 8. How would you describe your feeling after providing such consultation? Satisfaction 16 11.3% Indifference 34 23.9% Amran et al. BMC Family Practice (2021) 22:30 Page 5 of 8 Table 2 Responses to the questionnaire (Continued) Question Number Percent Discomfort 70 49.3% Regret 12 8.5% Other 10 7.0% 142 (mis = 1) 9. What do you think are the main reasons that people turn to you informally rather than to their family physician? Savings in treatment costs 3 2.2% Accessibility and availability 116 83.5% Lack of trust in the public healthcare system 16 11.5% Confidentiality 4 2.9% 139 (mis = 4) 10. Did you ever refuse a request for informal consulting from a family member or a friend? Yes, always/Yes, most often 10 7.0% Sometimes 65 45.5% Usually not/ Never 68 47.6% 12. Did you every receive compensation (financial or other benefits) for medical treatment or from preferring informal medicine for a family member or friend? Yes 22 15.4% No 121 84.6% 13. What do you think is the disadvantage of informal medicine (more than one response can be selected)? A lack of medical documentation 121 85.2% Lack of the patient’s full consent 30 21.1% Lack of objectivity 88 62.0% The risk of unprofessionalism or negligence 85 59.9% There are no particular disadvantages 5 3.5% 142 (mis = 1) 14. Have you provided informal medicine by telephone or by text messaging? Yes 137 95.8% No 6 4.2% 15. If you answered yes on the last question, what is your opinion regarding such? It’s legitimate/It’s not ideal, but adequate in certain situations 72 51.1% It’s only suitable for emergency situations 31 22.0% It’s problematic and best to avoid 38 27.0% 141 (mis = 2) 16. No position paper exists at this time of an ethical committee regarding the provision of informal medicine to family members and friends. Do you think such position paper is needed? Yes 94 66.2% No 48 33.8% 142 (mis = 1) Amran et al. BMC Family Practice (2021) 22:30 Page 6 of 8 Fig. 1 Physicians’ considerations when approached to informal consultation (Question 11). The numbers represent percentages as follows: the green colour represents the percentage of physicians who graded the specific consideration as ‘very high level’, the yellow colour represents ‘high level’, grey colour ‘medium level’, orange colour ‘low level’ and red colour ‘not at all’. Total N = 142 some respondents may resolve the dissonance integral to The high proportion of physicians reporting informal their provision of informal medical consulting. Specific- consulting concurs with other studies, most of which fo- ally, those who reported more frequently providing cused on consulting to family members [1]. Nonetheless, informal consulting, expressed greater support of such, the report by 30% of family physicians in the current and their feelings following informal consultations were survey, of providing informal consulting on a daily basis more positive than were those who less frequently is remarkable. A particularly high prevalence of informal provided such consultations. medicine in Israel may be related to cultural factors. Fig. 2 Type of informal consultation among study physicians (Question 7). The orange bar represents the percentages of residents and general practitioners without specialization (“non-specialists”) who reported providing each type of informal consultation. The blue bar represents the corresponding percentages among specialists (Include family medicine and internal medicine specialists). Differences were statistically significant regarding “medical results interpretation” (P = 0.037) and “secondary care physician recommendation” (P = 0.025). P-value was calculated using Chi-square test. ER: emergency room Amran et al. BMC Family Practice (2021) 22:30 Page 7 of 8 may reflect a pervasive impact of the national health insurance system in Israel, despite the heavy reliance of the health care system on private financing [11]. In contrast, among 41 studies, financial savings was cited as a main reason for the intervention of physicians in the health care of family members [1]. In the current investigation of informal consultation, the high use reported of electronic mail and phone mes- sages, including WhatsApp Messenger, is in agreement with the currently high use of these means of communica- tion in formal medical consultation. WhatsApp Messenger has become a common telemedicine tool in conventional, as well as in informal medicine [14]. In a study conducted among primary care physicians in Switzerland, 82% reported communicating with their patients by email [15]. The authors emphasized confidentiality issues as a prime disadvantage to such. Ninety-five percent of our respondents reported request- ing informal consultation from other physicians for their personal health issues. This corroborates the documenta- tions of this phenomenon around the world, as mentioned above. Notably, a recently published cross-sectional study showed that two-thirds of hospital-based physicians in Israel do not have a regular personal physician [16]. Almost two-thirds of the respondents to our survey answered that a position paper on informal medical con- sulting could be beneficial. The proportion holding this attitude was particularly high among physicians who had more negative feelings after providing informal consult- ation and among those who reported receiving more than one daily request for informal consulting. The Fig. 3 Physicians’ feelings regarding informal consultation (Question seventh edition of the American College of Physicians 8). Pie A demonstrates feelings among men while pie B Ethics Manual, issued in 2019, [17] expanded the topic demonstrates feelings among women. Male physicians expressed of informal medical consulting, as well as the topics on more indifference regarding informal consultation compared to electronic communication and telemedicine ethics. Accord- female physicians (P = 0.002), as calculated using the Chi-square test ingly, physicians are encouraged to avoid treating them- selves and family members except in emergency situations. Along this line, the practice in Israel of informal pay- Among the reasons cited earlier by the American Medical ments for health care has been explained in the context Association for such recommendation are difficulties in ob- of a specific type of political culture, called “alternative jectivity, in accessing full information and in professional- politics” [13]. This is characterized by a “do-it-yourself” ism that arise in the context of informal medical consulting approach, which bypasses formal rules and relies on [18]. Our study considered informal medicine in a broader personal and reciprocal relations. The scope of this ap- sense than in the American College of Physicians Ethics proach is broad, and may contribute to understanding Manual. Remarkably, 95% of our responders reported the atmosphere that makes it difficult for physicians to providing informal medicine in the form of treatment and refuse requests for informal consulting [12]. health care management, and not only clarification and The negative attitude toward informal medical consult- interpretation of clinical information. More detailed guide- ing expressed by the respondents of the current survey lines may be beneficial to physicians, with a broader scope corroborates other publications [1]. Problems related to in regard to the nature of informal consulting, and includ- the lack in medical documentation, objectivity, and profes- ing consulting of persons who are not family members. sionalism were the main disadvantages cited for informal No differences were found between specialists and res- medical consultation, concurring with the literature [1]. idents in the responses to any of the items of the survey. Only 2% of the respondents presumed that financial This contrasts with the findings of a qualitative study savings was the motivation for informal consulting. This conducted in the Netherlands, which showed more Amran et al. BMC Family Practice (2021) 22:30 Page 8 of 8 difficulties among junior than senior physicians in deal- Consent for publication Not applicable. ing with requests for informal consulting [19]. A main limitation of this survey study is selection bias, Competing interests arising from the possibility that the respondents to the The authors declare that they have no competing interests. survey may not have been representative of the family Author details physicians in the region examined. The questionnaire 1 2 Maccabi Health Services, Tel Aviv, Israel. Ben Gurion University of the was kept short, so as to encourage respondents to fill it Negev, Be’er Sheva, Israel. Clalit Health Services, Tel Aviv, Israel. completely. Accordingly, very few responses were left Received: 19 October 2020 Accepted: 10 December 2020 blank. Nonetheless, the brief and structured questionnaire is limited by the information it was able to assess, com- References pared to a more in-depth questionnaire or an interview. 1. Scarff JR, Lippmann S. When physicians intervene in their relatives' health care. HEC Forum. 2012;24:127–37. 2. Ashique KT. Curbside (corridor to the E-corridor) consultations and the Conclusions dermatologists. Indian Dermatol Online J. 2017;8:211–4. According to a survey of family care physicians in Israel, 3. Lowe S. The corridor consult. Obstet Med. 2017;10:155–6. the vast majority provide informal medical consulting to 4. Bird S. The pitfalls of prescribing for family and friends. Aust Prescr. 2016;39:11–3. family and friends, a high proportion of them do so fre- 5. Chambers R, Belcher J. Self-reported care over the past 10 years: a survey of quently. Discomfort and regret following such consulta- general practitioners. Br J Gen Pract. 1992;42:153–6. tions were reported among many. Interest was expressed 6. Wachtel TJ, Wilcox VL, Moulton AW, et al. Physicians’ utilization of health care. J Gen Intern Med. 1995;10:261–5. in receiving guiding principles on the matter. Due to the 7. Christie JD, Rosen IM, Bellini LM, et al. Prescription drug use and self- cultural influences inherent to informal medical consult- prescription among resident physicians. JAMA. 1998;280:1253–5. ing, more studies and specific guidelines in different geo- 8. Hem E, Stokke G, Tyssen R, et al. Self-prescribing among young Norwegian doctors: a nine-year follow-up study of a nationwide sample. BMC Med. graphical regions may help elucidate the problem and its 2005;3:16. consequences in various contexts. Overall, physicians 9. Roberts LW, Kim JP. Informal health care practices of residents: seem to need more guidance and tools to help them say "curbside" consultation and self-diagnosis and treatment. Acad Psychiatry. 2015;39:22–30. “No” when this is the ethical and professional response. 10. Fekadu G, Dugassa D, Negera GZ, et al. Self-medication practices and associated factors among health-care professionals in selected hospitals of Supplementary Information Western Ethiopia. Patient Prefer Adherence. 2020;14:353–61. The online version contains supplementary material available at https://doi. 11. Achdut L. Private expenditures on healthcare: determinants, patterns and org/10.1186/s12875-020-01362-z. progressivity aspects. Isr J Health Policy Res. 2019;8:87. 12. Peleg A, Peleg R, Porath A, et al. Hallway medicine: prevalence, characteristics and attitudes of hospital physicians. Isr Med Assoc J. 1999;1:241–4. Additional file 1. 13. Cohen N. Informal payments for health care--the phenomenon and its context. Health Econ Policy Law. 2012;7:285–308. 14. Giordano V, Koch H, Godoy-Santos A, et al. WhatsApp messenger as Acknowledgements an adjunctive tool for telemedicine: an overview. Interact J Med Res. Not applicable. 2017;6(2):e11. 15. Dash J, Haller DM, Sommer J, et al. Use of email, cell phone and text Authors’ contributions message between patients and primary-care physicians: cross-sectional MMA was responsible for the conception of the study, for collection of the study in a French-speaking part of Switzerland. BMC Health Serv Res. 2016; data and for preparing the first draft of the manuscript. ABK analysed the 16:549. data. HAK interpreted the data and revised the manuscript. RP was involved 16. Wilf Miron R, Malatskey L, Rosen LJ. Health-related behaviours and in the design of the work and the interpretation of the data. All the authors perceptions among physicians: results from a cross-sectional study in Israel. read and approved the final manuscript. BMJ Open. 2019;9:e031353. 17. Sulmasy LS, Bledsoe TA. ACP Ethics, Professionalism and Human Rights Funding Committee. American College of Physicians Ethics Manual: Seventh Edition. This study was funded by Marom, a research program for physicians and Ann Intern Med. 2019;170(2_Suppl):S1–32. residents in Maccabi Healthcare Services, and by a grant from the Israeli 18. Code of Medical Ethics of the American Medical Association. Chicago: Association of Family Physicians. American Medical Association Press, 1847.22. The AMA Code of Medical Ethics' opinion on physicians treating family members. Virtual Mentor. 2012; Availability of data and materials 14:396–7. The datasets used and/or analysed during the current study are available 19. Giroldi E, Freeth R, Hanssen M, et al. Family physicians managing medical from the corresponding author on reasonable request. requests from family and friends. Ann Fam Med. 2018;16:45–51. Ethics approval and consent to participate The protocol was approved by the institutional review board of Maccabi Publisher’sNote Healthcare Services and the ethical committees of Maccabi and Clalit Health Springer Nature remains neutral with regard to jurisdictional claims in Services. published maps and institutional affiliations. No patients were involved in this research. Informed consent was waived by the ethics committees of Clalit Health Services and Maccabi Health Services, because filling the questionnaires by the physicians was considered an indication of their agreement to participate. We confirm that all the methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

The prevalence, reasons and attitudes for the practice of informal medicine

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Abstract

Background: Informal medicine, entailing undocumented medical advice, has been described in diverse medical disciplines and geographical regions. We assessed the current prevalence and characteristics of informal medical consulting, the reasons physicians provide it, and their attitudes toward it. Methods: We conducted a survey among family physicians in Israel, a country with a national health insurance system. A questionnaire was emailed to all primary care physicians in the two largest HMOs in southern Israel. Fifteen questions addressed the prevalence, practice and attitudes to informal medical consulting. Ten questions assessed demographics and professional experience. Results: Of 143 respondents (mean age 41 years), 55% were women. Ninety-five percent of the respondents reported requesting informal medical consulting from other physicians. Fifty-four percent reported often providing informal consulting to family and friends; and an additional 27% reported doing so under exceptional circumstances. The main reasons given for informal consulting requests were availability and accessibility (81% of respondents), and not financial savings. Only 17.5% stated being in favor of informal consulting for family and friends. Only 11% expressed feeling satisfaction after providing such consultation; 49% expressed discomfort. Sixty- six percent thought a position paper on informal consulting to family and friends is needed. Conclusions: Our survey of primary care physicians shows very frequent informal medical consulting, despite high dissatisfaction with such, and an interest in receiving guidelines on this practice. Keywords: Informal medicine, Informal consulting, Primary care, Family medicine Introduction persons of other relations request and receive informal Informal medical consultation, in contrast to formal medical consultation. Described as “corridor”, “hallway” or medical consultation, is characterized by the provision of “curbside” consultation, such practice has been described undocumented medical advice. This includes any medical in diverse medical disciplines [2, 3] and geographical consultation or treatment provided to colleagues, family regions [1, 4] Self-care and self-prescribing by physicians members or friends. Numerous surveys and editorials have have also been widely described [5–10]. described the intervention of physicians in the health care Israel has a national health insurance system, in which of family members [1]. Thepracticehas persistedoverthe all the residents are insured by one of four health main- years, despite the inherent problems and the recommenda- tenance organizations (HMOs). Family physician visits are tions by such publications and by medical associations at no cost. Small co-payments are charged for visits with against it. In addition to family members, friends and specialists, though low socioeconomic status exempts also from these costs. During 2016, nearly 83% of Israeli * Correspondence: Amran_m@mac.org.il households purchased complementary health insurance Maccabi Health Services, Tel Aviv, Israel 2 from their HMOs [11]. The benefits of such include Ben Gurion University of the Negev, Be’er Sheva, Israel Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Amran et al. BMC Family Practice (2021) 22:30 Page 2 of 8 subsidies for second opinion consultations and scheduling variables. All p-values were two-sided and statistical appointments with shorter waiting periods. significance was set at P ≤ 0.05. In a survey study conducted in Israel over 20 years The protocol was approved by the institutional review ago, 82% of hospital physicians reported having been board of Maccabi Healthcare Services and the ethical asked to provide “hallway medicine”; of them, 91% committees of Maccabi and Clalit Health Services. agreed [12]. However, no position paper has been issued in Israel over the last two decades to guide physicians in Results dealing with this phenomenon. We conducted a survey Study population among family physicians in southern Israel, to assess the The total number of respondents was 143, for a response current prevalence and characteristics of informal med- rate of 24%. Table 1 presents the self-reported demo- ical consulting, the reasons physicians provide it, and graphic characteristics of the respondents. The majority their attitudes toward it. of the respondents were women, 55%. The mean age was 41 years. The majority of respondents work primar- Methods ily in urban clinics, 62%. Half of those who stated their This multicenter survey study is based on questions Table 1 Characteristics of the respondent physicians (N = 143) written by the researchers. The study population is Characteristics Respondent Non-responders primary care physicians (family physicians, general phy- physicians sicians and residents) who are employed in southern Gender, % (n) Israel. In total, 595 physicians were eligible to partici- Men 44.6% (62) 4 pate, from the two largest HMOs in Israel: 356 from Women 55.4% (77) Clalit Healthcare Services and 239 from Maccabi Health Services. Age, mean ± SD 41.3 ± 8.8 14 The questionnaire was designed to access information Familial status, % (n) 4 regarding the prevalence, reasons, means of practice and Single 7.9% (11) attitudes to informal medicine consultation among Married 89.2% (124) primary care physicians. A pilot test was performed on Divorced 2.9% (4) the initial questionnaire, among 10 participants. Follow- Origin, % (n) 13 ing their comments, the questionnaire was revised to the final version (see Additional file 1). The questionnaire Israel 70.8% (92) comprised 15 questions on practice and attitudes; each Elsewhere 29.2% (38) with 2–6 possible responses. One question asked the ex- University, % (n) 15 tent that the physicians consider each of 5 factors when Israel 69.5% (89) approached for informal advice; the responses were on a Elsewhere 30.5% (39) 5-point Likert scale. Ten questions accessed information Workplace, % (n) 4 on demographics and professional experience. The questionnaires were sent by a link to all the email Urban primary care clinic 61.9% (86) addresses of the primary care physicians affiliated with Rural primary care clinic 24.5% (34) Maccabi Healthcare Services and Clalit Health Services Public hospital 5.8% (8) in the southern district of Israel. A request was included Combination 7.9% (11) on the questionnaires, that physicians should not fill the Education level / Specialization % (n) 6 questionnaire more than once. Three reminders were General practitioner without 15.3% (21) sent, at intervals of 3–4 weeks. specialization, % Resident 28.5% (39) Statistical analysis Specialist in family medicine 50.4% (69) Statistical analysis was performed using the IBM SPSS version 25. Data were reported as means and standard Specialist in internal medicine 5.8% (8) deviations for continuous variables, and as percentages Seniority, median (range) 5 (0.5–45) 15 for categorical variables. We used the Student’s t-test to Less than 5 years, % (n) 41.4% (53) determine statistically significant differences in continu- 6–10 years, % (n) 28.9% (37) ous variables that were normally distributed. For con- More than 10 years, % (n) 29.7% (38) tinuous variables that were not normally distributed or “Specialists” include specialist in family medicine and specialist in ordinal variables, we used the Mann-Whitney test or internal medicine Kruskal–Wallis test, as appropriate. The Chi-square test “Non-specialists” include resident and general practitioner and Fisher’s test were used to compare categorical without specialization Amran et al. BMC Family Practice (2021) 22:30 Page 3 of 8 specialty were family medicine specialists; 28.5% were that reported refusing to provide informal consulting, and residents. Forty-one percent of the respondents had less no association was found between seniority and refusing than 5 years seniority; 30% had more than ten years. to provide consulting. Table 2 presents the responses to the questions regarding informal medical consulting. Attitudes to informal medical consulting Only 27% responded that they were in favor of formal Frequency of informal medical consulting medical consulting for family and friends (Question 4); The vast majority, 95%, of the respondents reported and only 17.5% responded being in favor of informal requesting informal medical consulting from other consulting for family and friends (Question 5). Respon- physicians (Question 1). Thirty percent provided such dents who reported receiving more requests for informal service at least once daily, during the preceding month consults expressed more opposition to this type of con- (Question 2). Only 7% reported not providing any such sulting (p = 0.048). However, those who provided more consulting over the last month. Fifty-four percent of the informal consultations to family and friends expressed respondents reported that they often provide informal their support of doing such (p = 0.012), and their feelings consulting to family and friends, and an additional 27% following these consultations were more positive (p < reported doing so under exceptional circumstances 0.001). (Question 6). Forty-eight percent answered that they Only 11% of the respondents expressed feeling satis- usually accept or never refused a request for informal faction after providing informal consultation; almost medical consulting from family and friends (Question half, 49%, expressed discomfort (Question 8). Differences 10). Seventy-five percent of the respondents stated that were observed between men and women in their feelings they highly or very highly considered their confidence in after providing consultation (Fig. 3). Sixty-one percent of the field, when approached for informal consultation the women compared to 39% of the men expressed feel- (Question 11, Fig. 1). Fifty-six percent responded that ing uncomfortable. Thirty-six percent of the men com- they highly or very highly considered the quality of their pared to 13% of the women felt indifferent (P = 0.002). personal relation with the individual requesting the Of those who reported providing consultation by phone consultation, and 53% reported considering highly or very (96%), almost half (49%) answered that such means highly the consequences of providing incorrect advice. should only be used under emergency situations or should be avoided (Question 15). The main disadvantage Characteristics of informal medical consulting to informal medical consulting according to the respon- Eighty-five percent of the respondents reported provid- dents was the lack of medical documentation, as cited by ing informal consulting face-to-face. In addition, high 85%. Lack of objectivity and the risk of unprofessional- proportions reported also providing consultation by ism or negligence were also cited by the majority of means of phone messages such as WhatsApp Messenger, respondents (Question 13). and by electronic mail. (Question 3). The vast majority, Sixty-six percent of the respondents thought that a 96%, reported providing informal consulting by phone position paper on informal consulting to family and (Question 14). More than half the respondents reported friends is needed (Question 16). Such position paper was providing consultation in non-emergency situations, more often desired among those who expressed having such as interpreting medical tests or providing routine negative rather than positive or indifferent feelings after examinations (Question 7). Only 5% of responders re- providing informal consulting (P = 0.002); and also ported avoiding medical treatment and providing only among those who reported more than one daily request clarification, interpretation or summation of clinical for informal consulting (P = 0.009). information, such as the recommendation of a specialist or the interpretation of medical. Residents and general Discussion practitioners (“non-specialists”) more frequently re- This survey study revealed great dissonance among pri- ported interpreting medical results and recommending mary care physicians, between their behavior and their secondary care physicians than did specialists in internal attitudes, in regard to informal medical consulting. On medicine and family medicine (“specialists”) (Fig. 2). The one hand, an overwhelming proportion reported involve- main reason presumed for the requests for informal con- ment in such consulting, including more than half who sulting were availability and accessibility, as selected by reported frequent rates. Further, almost half reported 81% of the respondents (Question 9). Fifteen percent of that they usually or never refuse a request from family the respondents reported receiving some form of com- or friends for informal consulting. On the other hand, pensation for providing informal medical consulting to more than half the participants in the survey stated family or friends (Question 12). No differences were feeling discomfort or regret after providing informal found between specialists and residents in the proportions consulting. More specific analysis of the data reveals that Amran et al. BMC Family Practice (2021) 22:30 Page 4 of 8 Table 2 Responses to the questionnaire Question Number Percent 1. Did you at any time request informal medical consulting from another doctor? Yes 135 94.4% No 8 5.6% 2. During the last month, how often did people turn to you for informal medical consulting? A number of times a day /Once a day 41 28.9% 2–3 times a week/Once a week or less 91 64.1% Not at all 10 7.0% 142 (mis = 1) 3. By what means were the requests for informal medical consults directed to you (more than one response can be selected)? Face-to-face meeting, planned in advance 121 84.6% Incidental meeting such as a social event 99 69.2% Phone messages (such as Whatsapp) 103 72.0% Electronical mail 114 79.7% Other 11 7.7% 4. To what degree are you in favor of formal medical consulting for family members and friends? Strongly in favor/In favor 38 26.6% Neutral reaction 41 28.7% Not in favor/Strongly opposed 64 44.8% 5. To what degree are you in favor of informal medical consulting for family members and friends? Strongly in favor/In favor 25 17.7% Neutral reaction 51 36.2% Not in favor/Strongly opposed 65 46.1% 141 (mis = 2) 6. Do you give informal consulting to family and friends? Yes, often 77 53.8% Yes, under exceptional circumstances 39 27.3% I try to avoid it/Never 27 18.9% 7. If you answered yes on the previous question, what type of consulting to you provide to family members and friends (more than one response can be selected)? Referrals to the emergency room 66 46.5% Recommendation to medical specialists 96 67.6% Prescriptions for drugs 98 69.0% Interpretation of results of medical testing (blood tests, imaging, etc) 115 81.0% Routine examinations 31 21.8% Treatment in emergency situations 72 50.7% Requests for a second opinion 62 43.7% 142 (mis = 1) 8. How would you describe your feeling after providing such consultation? Satisfaction 16 11.3% Indifference 34 23.9% Amran et al. BMC Family Practice (2021) 22:30 Page 5 of 8 Table 2 Responses to the questionnaire (Continued) Question Number Percent Discomfort 70 49.3% Regret 12 8.5% Other 10 7.0% 142 (mis = 1) 9. What do you think are the main reasons that people turn to you informally rather than to their family physician? Savings in treatment costs 3 2.2% Accessibility and availability 116 83.5% Lack of trust in the public healthcare system 16 11.5% Confidentiality 4 2.9% 139 (mis = 4) 10. Did you ever refuse a request for informal consulting from a family member or a friend? Yes, always/Yes, most often 10 7.0% Sometimes 65 45.5% Usually not/ Never 68 47.6% 12. Did you every receive compensation (financial or other benefits) for medical treatment or from preferring informal medicine for a family member or friend? Yes 22 15.4% No 121 84.6% 13. What do you think is the disadvantage of informal medicine (more than one response can be selected)? A lack of medical documentation 121 85.2% Lack of the patient’s full consent 30 21.1% Lack of objectivity 88 62.0% The risk of unprofessionalism or negligence 85 59.9% There are no particular disadvantages 5 3.5% 142 (mis = 1) 14. Have you provided informal medicine by telephone or by text messaging? Yes 137 95.8% No 6 4.2% 15. If you answered yes on the last question, what is your opinion regarding such? It’s legitimate/It’s not ideal, but adequate in certain situations 72 51.1% It’s only suitable for emergency situations 31 22.0% It’s problematic and best to avoid 38 27.0% 141 (mis = 2) 16. No position paper exists at this time of an ethical committee regarding the provision of informal medicine to family members and friends. Do you think such position paper is needed? Yes 94 66.2% No 48 33.8% 142 (mis = 1) Amran et al. BMC Family Practice (2021) 22:30 Page 6 of 8 Fig. 1 Physicians’ considerations when approached to informal consultation (Question 11). The numbers represent percentages as follows: the green colour represents the percentage of physicians who graded the specific consideration as ‘very high level’, the yellow colour represents ‘high level’, grey colour ‘medium level’, orange colour ‘low level’ and red colour ‘not at all’. Total N = 142 some respondents may resolve the dissonance integral to The high proportion of physicians reporting informal their provision of informal medical consulting. Specific- consulting concurs with other studies, most of which fo- ally, those who reported more frequently providing cused on consulting to family members [1]. Nonetheless, informal consulting, expressed greater support of such, the report by 30% of family physicians in the current and their feelings following informal consultations were survey, of providing informal consulting on a daily basis more positive than were those who less frequently is remarkable. A particularly high prevalence of informal provided such consultations. medicine in Israel may be related to cultural factors. Fig. 2 Type of informal consultation among study physicians (Question 7). The orange bar represents the percentages of residents and general practitioners without specialization (“non-specialists”) who reported providing each type of informal consultation. The blue bar represents the corresponding percentages among specialists (Include family medicine and internal medicine specialists). Differences were statistically significant regarding “medical results interpretation” (P = 0.037) and “secondary care physician recommendation” (P = 0.025). P-value was calculated using Chi-square test. ER: emergency room Amran et al. BMC Family Practice (2021) 22:30 Page 7 of 8 may reflect a pervasive impact of the national health insurance system in Israel, despite the heavy reliance of the health care system on private financing [11]. In contrast, among 41 studies, financial savings was cited as a main reason for the intervention of physicians in the health care of family members [1]. In the current investigation of informal consultation, the high use reported of electronic mail and phone mes- sages, including WhatsApp Messenger, is in agreement with the currently high use of these means of communica- tion in formal medical consultation. WhatsApp Messenger has become a common telemedicine tool in conventional, as well as in informal medicine [14]. In a study conducted among primary care physicians in Switzerland, 82% reported communicating with their patients by email [15]. The authors emphasized confidentiality issues as a prime disadvantage to such. Ninety-five percent of our respondents reported request- ing informal consultation from other physicians for their personal health issues. This corroborates the documenta- tions of this phenomenon around the world, as mentioned above. Notably, a recently published cross-sectional study showed that two-thirds of hospital-based physicians in Israel do not have a regular personal physician [16]. Almost two-thirds of the respondents to our survey answered that a position paper on informal medical con- sulting could be beneficial. The proportion holding this attitude was particularly high among physicians who had more negative feelings after providing informal consult- ation and among those who reported receiving more than one daily request for informal consulting. The Fig. 3 Physicians’ feelings regarding informal consultation (Question seventh edition of the American College of Physicians 8). Pie A demonstrates feelings among men while pie B Ethics Manual, issued in 2019, [17] expanded the topic demonstrates feelings among women. Male physicians expressed of informal medical consulting, as well as the topics on more indifference regarding informal consultation compared to electronic communication and telemedicine ethics. Accord- female physicians (P = 0.002), as calculated using the Chi-square test ingly, physicians are encouraged to avoid treating them- selves and family members except in emergency situations. Along this line, the practice in Israel of informal pay- Among the reasons cited earlier by the American Medical ments for health care has been explained in the context Association for such recommendation are difficulties in ob- of a specific type of political culture, called “alternative jectivity, in accessing full information and in professional- politics” [13]. This is characterized by a “do-it-yourself” ism that arise in the context of informal medical consulting approach, which bypasses formal rules and relies on [18]. Our study considered informal medicine in a broader personal and reciprocal relations. The scope of this ap- sense than in the American College of Physicians Ethics proach is broad, and may contribute to understanding Manual. Remarkably, 95% of our responders reported the atmosphere that makes it difficult for physicians to providing informal medicine in the form of treatment and refuse requests for informal consulting [12]. health care management, and not only clarification and The negative attitude toward informal medical consult- interpretation of clinical information. More detailed guide- ing expressed by the respondents of the current survey lines may be beneficial to physicians, with a broader scope corroborates other publications [1]. Problems related to in regard to the nature of informal consulting, and includ- the lack in medical documentation, objectivity, and profes- ing consulting of persons who are not family members. sionalism were the main disadvantages cited for informal No differences were found between specialists and res- medical consultation, concurring with the literature [1]. idents in the responses to any of the items of the survey. Only 2% of the respondents presumed that financial This contrasts with the findings of a qualitative study savings was the motivation for informal consulting. This conducted in the Netherlands, which showed more Amran et al. BMC Family Practice (2021) 22:30 Page 8 of 8 difficulties among junior than senior physicians in deal- Consent for publication Not applicable. ing with requests for informal consulting [19]. A main limitation of this survey study is selection bias, Competing interests arising from the possibility that the respondents to the The authors declare that they have no competing interests. survey may not have been representative of the family Author details physicians in the region examined. The questionnaire 1 2 Maccabi Health Services, Tel Aviv, Israel. Ben Gurion University of the was kept short, so as to encourage respondents to fill it Negev, Be’er Sheva, Israel. Clalit Health Services, Tel Aviv, Israel. completely. Accordingly, very few responses were left Received: 19 October 2020 Accepted: 10 December 2020 blank. Nonetheless, the brief and structured questionnaire is limited by the information it was able to assess, com- References pared to a more in-depth questionnaire or an interview. 1. Scarff JR, Lippmann S. When physicians intervene in their relatives' health care. HEC Forum. 2012;24:127–37. 2. Ashique KT. 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Use of email, cell phone and text Authors’ contributions message between patients and primary-care physicians: cross-sectional MMA was responsible for the conception of the study, for collection of the study in a French-speaking part of Switzerland. BMC Health Serv Res. 2016; data and for preparing the first draft of the manuscript. ABK analysed the 16:549. data. HAK interpreted the data and revised the manuscript. RP was involved 16. Wilf Miron R, Malatskey L, Rosen LJ. Health-related behaviours and in the design of the work and the interpretation of the data. All the authors perceptions among physicians: results from a cross-sectional study in Israel. read and approved the final manuscript. BMJ Open. 2019;9:e031353. 17. Sulmasy LS, Bledsoe TA. ACP Ethics, Professionalism and Human Rights Funding Committee. American College of Physicians Ethics Manual: Seventh Edition. This study was funded by Marom, a research program for physicians and Ann Intern Med. 2019;170(2_Suppl):S1–32. residents in Maccabi Healthcare Services, and by a grant from the Israeli 18. Code of Medical Ethics of the American Medical Association. Chicago: Association of Family Physicians. American Medical Association Press, 1847.22. The AMA Code of Medical Ethics' opinion on physicians treating family members. Virtual Mentor. 2012; Availability of data and materials 14:396–7. The datasets used and/or analysed during the current study are available 19. Giroldi E, Freeth R, Hanssen M, et al. Family physicians managing medical from the corresponding author on reasonable request. requests from family and friends. Ann Fam Med. 2018;16:45–51. Ethics approval and consent to participate The protocol was approved by the institutional review board of Maccabi Publisher’sNote Healthcare Services and the ethical committees of Maccabi and Clalit Health Springer Nature remains neutral with regard to jurisdictional claims in Services. published maps and institutional affiliations. No patients were involved in this research. Informed consent was waived by the ethics committees of Clalit Health Services and Maccabi Health Services, because filling the questionnaires by the physicians was considered an indication of their agreement to participate. We confirm that all the methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

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BMC Family PracticeSpringer Journals

Published: Feb 3, 2021

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