Doctors' Love/Hate Relationship With Second Opinions

Neil Chesanow

Disclosures

June 18, 2015

In This Article

A Sensitive Subject?

Second opinions can be a touchy subject. Physicians are typically independent and authoritative decision-makers. They undergo the most arduous training of any profession to develop this ability. Having graduated from medical school and residency, they are supposed to know what they are doing. Having another doctor sit in judgment of their diagnosis or treatment of a patient can cause some doctors to feel annoyed.

"I'm ostensibly an expert," surgeon Atul Gawande, MD, MPH, a professor at Harvard Medical School in Boston, Massachusetts, wrote in The New Yorker about hiring a physician coach to improve his clinical acumen.[1] "I'd finished long ago with the days of being tested and observed. I'm supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding?"

It's not hard to understand how some physicians might feel something similar when their patients seek a second opinion.

"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.[2] "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.[2]

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.[2] 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."

High Rates of Misdiagnosis

Is it unusual for a physician offering a second opinion to consider the first opinion flat-out wrong? In the experience of many doctors, the answer is yes: It happens, but it's not the norm. But researchers have found that rates of misdiagnosis and mistreatment by physicians are disconcertingly high.

To take one of many examples, a 2014 study in the journal BMJ Quality & Safety found that approximately 12 million adults who seek outpatient treatment in the United States are misdiagnosed, or 1 in 20 adult patients.[3] In half of those cases, the investigators found, the misdiagnosis had the potential to result in severe harm. Nearly 100,000 US hospital deaths a year are due to medical error, although these include errors by nonphysicians as well as physicians.[4]

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.[5] They found that almost 77% of medical interventions led to changes in diagnosis, treatment, and/or the treating physician.

"Physicians are human, and medicine is still an art as well as a science," says Dr Varn, whose firm sponsored the study.

Sensitivity about territorial encroachment among some doctors is underscored by the many articles offering advice to patients on how to broach the subject with their physicians. It's no doubt true, as Dr Mintz says about this advice: "The patient often has a concern about upsetting their physician, not the other way around."

But sometimes it is the other way around.

Breast cancer expert Kathy D. Miller, MD, associate professor of medicine at Indiana University School of Medicine in Indianapolis, insists that getting a second opinion is a patient's right—and, with a breast cancer diagnosis, a good idea. Yet she concedes that not every oncologist agrees.

"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."

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