Doctors' Love/Hate Relationship With Second Opinions

Neil Chesanow


June 18, 2015

In This Article

"Preference-Sensitive" Treatments

A key reason for seeking a second opinion is when more than one treatment for a given condition is endorsed in the clinical literature, and even though the patient's doctor may favor one over another, the buck ultimately stops—or should stop—with the patient.

"I see a lot of second opinions in atrial fibrillation," says Dr Mandrola. "Treatment is 'preference-sensitive.' You can live with the disease, take a drug, or have a procedure. It's a very common disease to get second opinions on."

In orthopedic surgery, when outcomes are often unpredictable, second opinions are also common.

"In spinal stenosis," says Dr Kirschenbaum, "you could have a situation where, when you ask surgeon one, 'What about a pain clinic?,' he'll say, 'You can do pain clinic for as long as you want, as long as your spine is not at risk. But in my opinion and in my experience, this will eventually need surgery, and you probably need it now, whether or not you want pain management.' Another surgeon might say, 'You may indeed go on for surgery. I just want to try one more trial of pain management.'"

"But if you're going to a pain management doctor vs a surgeon for spinal stenosis, a pain management person will probably not recommend surgery," Dr Kirschenbaum says. "When your only tool is a hammer, everything looks like a nail. A surgeon technically may be more likely to recommend surgery. However, the surgeon has two hammers in his toolbox. He can treat you operatively or nonoperatively. My advice: Ask doctor one about what doctor two is going to do and hear his opinion, and vice-versa. You may find that the two opinions are not so far apart. The two doctors may just be timing things differently."

"Preference-sensitive conditions are more common than most people would think," says Dr Eid, the vascular surgeon. "In the US, if you have prostate cancer, how you start treatment depends on what kind of doctor you visit. If you visit an oncologist, you start with chemotherapy. If you visit a urologist, you get the tumor removed. If you see a radiation guy, you get it radiated."

"Another example is treatment for breast cancer: lumpectomy vs mastectomy," Dr Eid continues. "A lumpectomy followed by radiation is medically equivalent to a mastectomy followed by breast reconstruction. If I am a surgeon in a setting where I have a clinic with myself and a plastic surgeon, I would remove the breast and refer the patient to my friend, who would reconstruct the breast. In a different community, I could do the lumpectomy, but since my hospital has a nice radiation department, they would do the radiation."

"A large percentage of second opinions result in a different opinion," Dr Eid observes. "This is normal, but it also does not mean that the first opinion was wrong. It simply means that each doctor is presenting his take on it. The second opinion where we catch a mistake is in the minority. Most of the time there is more than one acceptable choice, but doctors typically are not really telling the patient, 'Let's see what works for you.' Each one is saying what works for him."


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