Doctors' Love/Hate Relationship With Second Opinions

Neil Chesanow

Disclosures

June 18, 2015

In This Article

When Doctor and Patient Disagree

A common reason to seek another doctor's advice is when the patient disagrees with the recommended treatment.

"I'm most mindful of making sure that I've removed fear and ignorance from the decision and that I've helped the patient make the best decision for them," says Dr Mandrola of patients with atrial fibrillation. "It does get tricky when I think that a patient is choosing to do something that's not what I think is best."

He offers this example: "If I think an atrial fibrillation patient should take a drug I think is beneficial, but then they see the statistics, and they see that the drug reduces the risk for stroke by 3%, which means they have a 97% chance of not having a stroke, they may decide to go with the 97% and not take the drug. Then I struggle with myself: 'Okay, maybe I am biased because I want them to make the best choice.' If they disagree, that's often when I say, 'You should go and get another opinion. Go talk to somebody else.'"

Other disagreements may hinge on which tests patients want performed. Many patients, for example, want an expensive MRI—often at the urging of friends and family—when their conditions don't warrant one. Not long ago, a physician may have acquiesced. But today, as insurers seek to rein in costs, this may result in a warning letter or even deselection from a health plan if the physician is singled out as a high utilizer of tests or procedures that are deemed unnecessary.

"If a patient is requesting an unnecessary test or procedure that a physician is uncomfortable with, a second opinion will either strengthen the patient's confidence in the first physician's opinion or place a problem in someone else's willing hands," Dr Mintz points out.

A surgeon should refer a patient to another surgeon if two procedures are equally efficacious, but the patient's surgeon has more experience with performing procedure A, and the patient wants option B. However, Ibrahim Eid, MD, chief of vascular surgery at PrimaCare, a multispecialty group in Fall River, Massachusetts, asserts that such referrals may not always occur.

"Many physicians will try to hide option two if they are not comfortable with it and take care of the patient themselves because they are comfortable with option one," he contends. "The patient may not even know that there was a second option. The physician may not disclose it or elaborate on it much because he doesn't want to lose the patient."

Medicine is too physician-centric, Dr Eid insists. He is hopeful that the Affordable Care Act will provide the impetus to make medicine more patient-centric.

"As a doctor, I should be able to tell my patient, 'These are the options that are okay for you. This is the one I am comfortable doing. Let's talk about your choice. If you elect the second one, which I am not comfortable doing, I will refer you to a doctor who does it.'"

PinnacleCare, which helps patients obtain second opinions from specialists at leading medical centers nationwide, advises them of five situations in which they should always seek a second physician's advice: when the diagnosis is cancer; when surgery is recommended; when the diagnosis or course of treatment is unclear; when the patient's current treatment isn't working; and when a rare disease or condition has been diagnosed.

"Technologies and thought leader-based approaches may not be available in community settings that are available elsewhere," Dr Varn says. "Without a second opinion at a center of excellence, the patient might not understand that there are unique opportunities for either a clinical trial or care, but it could be an opportunity for them to take advantage of and possibly lead to a better outcome."

Recognizing that you aren't a good fit with the patient or the best doctor to treat the patient's condition are also reasons to refer the patient out, Dr Eid maintains.

"It's my duty as a physician to detect that the patient is not easy with me, or doesn't feel totally comfortable, and make it easy for them to talk about getting a second opinion," he says. "I live in the backyard of Massachusetts General, Brigham & Women's, and other hospitals. All of the patients who see us have a chance to go to these institutions. When I talk to my patients, I tell them, 'We're going to look at your CAT scan, and on the basis of that, I will tell you what kind of surgery you need.' But sometimes it looks so complicated, I will refer them to Mass General. Patients don't have to do the homework themselves. I will tell them, 'This aneurism is too difficult for me. I'm going to refer you out.'"

Kathy Miller also frets that she may not be the best oncologist for all of the breast cancer patients who come to see her. "I worry about what the outcome might be for aggressive treatment," she says. "I worry about patients being exposed to toxicities I don't think they need. I spend time reflecting on my interactions with them. Did they really get me at my best? We all have good days and bad days—days where it's crazy and distracted, with lots going on. Sometimes it's just that I'm not the best person for a patient. My approach isn't the best for them. The best solution for them is to see someone else."

However, Dr Miller also believes that a second opinion is justified even if it does no more than help to reassure the patient.

"Most of the time, it's more common that the second opinion confirms that medically you're on the right path," she says. "Even if that's all it does, sometimes a different explanation, different analogies, or simply explaining something the same way a second or third time in a more removed setting can give patients a lot more confidence and comfort that they really are on the right path and doing the right thing."

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