The quantitative analysis of the findings showed that there is a clear positive correlation between the physicians' perceptions regarding the contribution of the medical cannabis reform in Israel to improving and regulating the use of medical cannabis and between their perception regarding the degree of openness among the medical community to the treatment of medical cannabis.
On the other hand, no significant correlation was found between the physicians' perceptions regarding the contribution of the medical cannabis reform in Israel and their perception regarding openness among the medical community to the treatment of medical cannabis and between their perception regarding the priority of medical cannabis treatment compared to other treatments.
In other words, the physicians' perceptions regarding the contribution of the medical cannabis reform and regarding the medical community's perception of medical cannabis treatment are not directly related to their professional perception and their preference for medical cannabis treatment. These findings correspond to the physician conflict that emerged prominently from the interviews and is described in the literature (6,15,16). The physicians believe that the cannabis reform in Israel contributes to regulating the treatment of medical cannabis and that there is indeed an openness in the medical community to the treatment of medical cannabis, but they don't perceive medical cannabis treatment as better than other treatments. The conservative approach of the physicians on the topic of medical cannabis dominates even though there is a perception among the physicians of openness in the medical community to the treatment of medical cannabis. The literature also reports the existing gap between the perceptions of the patients regarding the effectiveness of the treatment, the side- effects and the risk of medical cannabis versus the perceptions of the physicians and nurses on these issues. The physicians held the least positive views regarding medical cannabis treatment compared to the patients who held the most positive views towards medical cannabis (8).
Discussion of physicians' perceptions in relation to the physicians' background characteristics
The analysis of the physicians' perceptions in relation to the gender of the physicians indicates that the perceptions of male physicians in relation to the contribution of the medical cannabis reform in Israel and the openness of the medical community to the treatment of medical cannabis are distinctly higher than those of female physicians. In other words, male physicians believe that the contribution of the cannabis reform in Israel is higher and there is more openness regarding the treatment of medical cannabis among the medical community compared to the perceptions of female physicians.
The analysis of the physicians' perceptions regarding the seniority of the physicians indicates the existence of a significant negative correlation between the seniority of the physicians and their perception regarding the priority of medical cannabis treatment over other treatments. This characteristic is a component of the physicians' conflict regarding the treatment of medical cannabis. Veteran physicians who have been in the system for many years and are well acquainted with conventional treatments find it difficult to accept medical cannabis treatment as equal to other treatments or better than some of them compared to young physicians.
The analysis of the physicians' perceptions in relation to their field of specialization shows that the physicians' perceptions regarding the openness of the medical community to the treatment of medical cannabis are lower among psychiatrists, physicians who deal with anti-inflammatory treatment and physicians who treat pain than among physicians who deal with other fields. Psychiatrists, physicians who deal with anti-inflammatory treatment and pain management believe that there is a lower openness among the medical community in Israel to the treatment of medical cannabis compared to the perceptions of physicians who deal with other fields. It is possible that this difference is due to the fact in these areas the treatment of medical cannabis is more complex and thus problematic or raises more antagonism. For example, in the field of psychiatry, for some psychiatric conditions or diseases, medical cannabis treatment is not approved in terms of indications and sometimes can even worsen the situation, such as worsening anxiety, psychosis, and an increased risk of developing mental disorders, among them schizophrenia and bipolar disorder (2,7,10). Another possibility is that in these fields the physicians are more subject to the pressure of the patients compared to other fields of specialization.
In addition, it was found that family physicians' perceptions regarding the contribution of the medical cannabis reform are lower than among physicians dealing in other fields, and so is their perception regarding treatment using medical cannabis compared to other treatments. In other words, family physicians believe that the contribution of the cannabis reform in Israel is less and less prefer to treat with medical cannabis compared to physicians dealing in other fields. Again, this finding can be explained similarly to the explanation mentioned in the previous section. That is, family physicians are more subject to patient pressure compared to other areas of specialization, and hence the conservative approach has an additional layer in the complexity of the physicians' conflict regarding the treatment of medical cannabis. The general conclusion is that the background characteristic of the physicians' field of expertise affects their perceptions both in relation to the medical cannabis reform and in relation to its treatment and explains the complexity of the physicians' conflict.
The analysis of the physicians' perceptions regarding the extent of their involvement in the medical cannabis reform and in the treatment of medical cannabis shows that physicians who approve the use of medical cannabis (with 'administrator' certification) believe that there is less openness among the medical community to the treatment of medical cannabis than physicians who do not approve the use of medical cannabis. Even this finding links to the previous ones and strengthens the explanation for the physicians' conflict regarding the treatment of medical cannabis. The more a physician is involved in the cannabis reform and in the treatment of medical cannabis, the more he is exposed to these issues, and therefore it is likely that he will be more aware of the conflict between physicians and the lack of openness in the treatment using medical cannabis in the medical community compared to physicians who are less involved in these issues.
In addition to this, personal exposure of the physicians to the issue of medical cannabis treatment affects their support or changes their perception regarding such treatment. Support for treatment using medical cannabis over other treatments was higher among physicians who had one of their family members or a close friend need treatment with medical cannabis. When their family member or close friend needed or needs medical cannabis treatment, they are more supportive of medical cannabis treatment. This finding is interesting due to the physicians' diagnosis between family members or close friends and the rest of the population. Physicians who have one of their family members or a close friend need medical cannabis treatment support medical cannabis treatment over other treatments because they have an emotional and close connection to those people and it is possible that family members or close friends are perceived by them as needing support, protection and assistance.
It can be concluded that the layers that explain the conflict between physicians on the topic of cannabis reform and its treatment are the seniority of the physicians - veterans more conservative, gender - women more conservative, field of specialization - family physicians, psychiatrists, physicians dealing with anti-inflammatory treatment and pain management are more conservative, the involvement of the physicians - physicians who are manager certification holders are more conservative (further detail in the next section).
Discussion of the model: physicians' perceptions in relation to their background characteristics
Examining the connections between the physicians' perceptions and their background characteristics revealed that three background characteristics influence the physicians' perceptions regarding the contribution of the medical cannabis reform. Family physicians, psychiatrists and female physicians believe that the contribution of the cannabis reform is insignificant compared to physicians working in other fields and male physicians. These findings correspond to the findings in the previous section regarding the perceptions of physicians who practice psychiatry, family physicians and female physicians.
The perception of the physicians regarding the degree of openness of the medical community regarding the treatment of medical cannabis is influenced by the characteristics of the background as well as their perceptions regarding the contribution of the medical cannabis reform. The perception of the degree of openness among the medical community to the treatment of medical cannabis is positively influenced by the perceptions of physicians regarding the contribution of the medical cannabis reform. In addition, it was found that the perception of the degree of openness of the medical community to the treatment of medical cannabis is lower among psychiatrists and among family physicians. The explanation for the two background characteristics is given in the previous section and is also valid here.
physicians who treat pain, physicians who deal with anti-inflammatory treatment, family physicians and physicians who approve the use of medical cannabis ('administrator' certification) believe that there is a lower openness among the medical community to the treatment of medical cannabis compared to physicians who deal with other fields and/or who don't approve the use of medical cannabis. This finding corresponds to the previous findings so that the field of specialization of the physicians and/or their certification to approve medical cannabis influence their perception of the degree of openness of the medical community to the treatment of medical cannabis and thus emphasize the complexity of the physicians' conflict which is influenced by different background characteristics.
Three background characteristics influence the extent to which physicians prefer to treat with medical cannabis. physicians working in the field of oncology and physicians whose family members needed treatment with medical cannabis prefer to treat with medical cannabis compared to other treatments. physicians working in the field of oncology are more exposed to medical cannabis patients and are therefore more open to this therapeutic approach, especially in the aspect of terminal patients whose suffering can be alleviated by the treatment. Indeed, about a third of the licenses for the use of medical cannabis are given to oncology patients (12).
In addition, the degree of preference of physicians to treat with medical cannabis is positively influenced by their perception regarding the degree of openness among the medical community to treatment with cannabis. That is, the more the physicians believe that there is an openness among their professional community to treat medical cannabis, the more open they themselves are to treating with medical cannabis. It is not surprising that the medical community to which the physician belongs influences and shapes his personal perception.
Physicians who approve the use of medical cannabis have a higher degree of preference to treat with medical cannabis, but since they believe that the medical community is less open to treating medical cannabis, their preference to treat with medical cannabis moderates. This finding corresponds to the previous one according to which the medical community to which the physician belongs influences and shapes his personal perception. Other studies show that physicians experienced in prescribing medical cannabis are more convinced of its positive effects and less worried about its negative effects compared to less experienced physicians or those who deal with addiction treatment. In general, there is a lack of knowledge among most of medical population regarding the beneficial and negative effects of medical cannabis (14). Therefore, it is reasonable to assume the more physicians there are that approve medical cannabis in Israel, the higher their preference for treating medical cannabis because they will be more experienced in the subject and accordingly their frequency will increase in the medical community that shapes their perception.
The physicians' preference for treatment using medical cannabis over other means of treatment is lower among family physicians, both directly and through the indirect effect of this characteristic on their perception of the contribution of the medical cannabis reform and the degree of openness among the medical community to treatment using medical cannabis. This finding was previously explained in terms of their exposure to the patients' stress on the subject (6,16).
Despite the indirect effect, it is clear from the results of the model that the physicians' preference for treatment using medical cannabis is lower among physicians dealing in the field of psychiatry, among women, among physicians dealing with pain treatment and among physicians dealing with anti-inflammatory treatment. These findings were previously explained in terms of the complexity of medical cannabis treatment in these areas and/or their exposure to the patients' stress on the subject (6,16). In contrast to physicians in the field of oncology, for example who are exposed apparently more to medical cannabis patients and are therefore more open to this therapeutic approach, especially in the aspect of terminally ill patients whose suffering can be alleviated by the treatment.
Background characteristics influence the perceptions of physicians regarding the treatment of medical cannabis such as field of expertise, seniority, gender, and personal involvement. These findings strengthen the conclusion that the physicians' conflict is complex and deep.
Also, the results of the analysis show that the physicians' preference for medical cannabis treatment is positively influenced by their perceptions regarding the contribution of the medical cannabis reform. That is, the more they believe that the contribution of the medical cannabis reform in Israel is greater, the more open they are to treatment using medical cannabis. This makes sense because the purpose of the reform is to regulate medical cannabis. That is, the more the physician believes that there is proper regulation on the subject, the more open he will be to treatment with medical cannabis. Hence, the solution methods for solving problems related to the physicians' conflict regarding the treatment of medical cannabis are important for future dealing with the conflict.