Monday, June 29, 2015

Second opinions

Many if not most doctors would probably agree with Melissa Walton-Shirley, MD, a clinical cardiologist at Cardiology Associates in Glasgow, Kentucky, when she insists that "patients absolutely have a right to a second opinion." Dr Shirley did not qualify when a second opinion might or might not be justified.

But while many physicians say they agree with Dr Shirley, not all of them do.

"If a doctor is upset that a patient got a second opinion, I would consider that a knock," says John Mandrola, MD, a cardiac electrophysiologist at the Louisville Cardiology Group in Louisville, Kentucky. Dr Mandrola specializes in treating patients with atrial fibrillation, a condition for which patients commonly seek a second opinion regarding treatment. "I think it's a mark of a good physician that they don't get upset if a patient wants a second or third or even a fourth opinion."

But some physicians do get upset.

Even Dr Mandrola sometimes does.

"It would be a little overconfident to say that I don't ever get emotionally attached to my recommendations," he admits. "But I am actively mindful of not being attached to what the patient chooses to do."

Not every doctor is always so mindful, however...

"There's certainly an ego component for some physicians," says emergency physician Miles Varn, MD, medical director of PinnacleCare, a health advisory firm in Baltimore, Maryland, "although what I tell the patients is: 'If a physician is really resisting a second opinion, there has be a reason for that,' and it's not necessarily a reason that's in the best interest of the patient. In our experience, we see very little resistance to second opinions."...

"I make no pretense of omniscience," wrote oncologist Jerome Groopman, MD, also a professor at Harvard Medical School, in his 2000 collection of clinical tales, Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine. "Decisions about diagnosis and treatment are complex. There are dark corners to every clinical situation. Knowledge in medicine is imperfect. No diagnostic test is flawless. No drug is without side effects, expected or idiosyncratic. No prognosis is fully predictable."

Nevertheless, when Dr Groopman was asked by a former college classmate to render a second opinion on her ailing father, who turned out to have a rare form of leukemia, and he discovered that the father's physician had misdiagnosed his patient and as a result had proposed a treatment plan that was downright "dangerous," he walked on eggshells when breaking the news.

Physicians, even those of Dr Groopman's reputation, may be loath to criticize other physicians. A second opinion that not just differs from but invalidates the first opinion may not go over well.
"Interesting," the patient's doctor muttered, after Dr Groopman had bent over backward to be diplomatic in conveying the correct diagnosis.  It did no good. "His tone sharpened," Dr Groopman recalled. After that, "A heavy silence hung between us." And later, as the physician stubbornly defended to his treatment plan: "It was no longer a skirmish. It was war."..

Another study, published this year, examined the impact of an expert second opinion on medical outcomes. The researchers collected data on over 1000 cases over a 3-year period. They found that almost 77% of medical interventions led to changes in diagnosis, treatment, and/or the treating physician.

"There's a diversity of opinion on the subject, which shouldn't surprise us," Dr Miller says. "I have patients who have been told that there was no need to get a second opinion. From my perspective, if a physician tells someone there's no need for a second opinion, it's a good indication that you need a different doctor."

In Dr Miller's experience, misdiagnosis or mistreatment accounts for a minority of second opinion requests. "I see a lot of patients for second opinions," she says. "Only about 20%-25% of the time would I recommend a treatment different in some way than what they've had before."

Most patients who come to Dr Miller seeking a second opinion do so for two reasons: "They didn't feel like their doctors were listening to them and hearing their concerns, and I gave them a better, more complete explanation of their situation and treatment options. I hear that a lot from people for whom I did not recommend any different treatment. They were getting exactly the right therapy. But they didn't feel like they got a thorough discussion or a good education about their situation and their options. They were told: 'This is what you have, and this is the treatment. You'll come in on Monday and do this, and then on Friday you'll do that.' There was no sense that anything else was considered. They wanted to know: 'Why is this the best treatment for me?'"


1 comment:

  1. PinnacleCare, a leading health advisory firm, studied the impact of an expert second opinion on medical outcomes. Researchers collected data on 1,000 cases over a three-year period and found that almost 77 percent of medical interventions led to changes in diagnosis, treatment, and/or treating physician.

    With more health care decisions increasingly in the hands of consumers who are busy and ill-equipped to make important medical decisions, the potential for misdiagnosis or improper course of treatment will most certainly increase.

    "With all of the inherent complexities in the healthcare system, it's imperative that people actively do everything they can to ensure they're getting the very best care possible," said Dr. Miles Varn, chief medical officer of PinnacleCare. "Medicine is still an art subject to human error or interpretation. You owe it to yourself to see the physician with the expertise, skill and experience for your specific condition."

    PinnacleCare gathered data on patient outcomes from their interventions over a three-year period. In a sampling of 1,000 cases with known outcomes from 2012-2014, 41% resulted in transfer of care to a COE or expert provider with 34% resulting in a change in diagnosis, treatment, and/or course of care. A total of 18 patients were able to avoid unnecessary surgery as a result of a PinnacleCare intervention.