Among medicine’s most enduring myths

Abstract

There are any number of valid reasons why a patient might want to seek a second medical opinion. He may want reassurance before embarking on a treatment plan or undergoing invasive surgery. He may have felt that he was rushed out the doctor’s door without having had the opportunity to obtain answers to all his questions. Or he may have felt the physician overlooked some information in his diagnosis One of the precepts of Canada’s health care system is that aggrieved or confused patients always have the option of seeking a proverbial second medical opinion. But is that more than an enduring, and perhaps reassuring, but entirely meaningless myth? Is it really feasible or even possible to get a second medical opinion? Possibly, although observers note that the wait for a second opinion can be even longer than the wait for the first opinion, particularly when it comes to getting the second opinion of a medical specialist. Not that getting a medical opinion from a second family physician is necessarily any easier than getting one from a specialist. Already, Canadians are on long waiting lists just to obtain a family doctor. It almost makes the notion of finding a family physician who’d be willing to provide a second opinion entirely comical. Given the lengthy wait times, the majority of patients balk at getting a second medical opinion, notes Sholom Glouberman, president of the Patients’ Association of Canada. De facto, wait times have turned getting a second medical opinion into “one of those things that’s available in principle but unavailable in practice in Canada.” Others fear that getting a second opinion will compromise their treatment, and ultimately, their health, says Heather Chapman, founder of the Saskatoon, Saskatchewan-based Patient Factor, an advocacy group and “an independent online source” for news and opinions about health care (http://thepatientfactor.com). Patients less than impressed with a doctor’s diagnosis can seek second opinions but may have to wait even longer than for first opinions, particularly if seeking them from a specialist. Image courtesy of © 2012 Thinkstock Compounding the situation, particularly when it comes to obtaining an opinion from a second specialist, is the fact that patients are already being prioritized on wait lists, she adds. Those seeking second opinions typically get pushed to the bottom of the roster. But there are other barriers, including the not entirely unjustified concern that patients will offend the delicate sensibilities or egos of their physicians by seeking second opinions, Glouberman notes. Such physician resistance to second medical opinions isn’t appropriate, says Dr. Ruth Wilson, a professor of family medicine in the Department of Medicine at Queen’s University in Kingston, Ontario, and past president of the College of Family Physicians of Canada. “We’re not perfect and thinking about things from a different point of view or through a second set of eyes can sometimes turn up a different diagnosis or a different approach that’s more helpful to the patient.” What research is available certainly supports the proposition that there is value in obtaining a second opinion. A study of 466 surgical oncological patients concluded that “one third of patient-initiated second opinion consultations resulted in a discrepancy with the first opinion” and that half resulted in “major changes in therapy or prognosis” (EJSO 2006; 32:108–12). Another study of 814 cases of patients facing head and neck surgery found that a second review of the pathology “resulted in 54 (7%) changed diagnoses. Of the changed diagnosis, 13 (24%) involved a change from a benign to a malignant diagnosis; 8 (15%) involved a change from a malignant to a benign diagnosis; and 33 (61%) involved a change in tumor classification” (Head Neck 2002; 24:684–93). Similarly, a review of the pathologic material of 213 patients suspected of having a urologic malignancy found that there was a difference of opinion in 10% of cases, leading to the conclusion that “a second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes” (Urol Oncol 2011; 29:194–8). By international standards, Canada appears to be one of the worst performing nations when it comes to second medical opinions, according to reports issued by the Health Consumer Power-house, a private company based in Danderyd, Sweden, and the Frontier Centre for Public Policy, an independent think tank with offices in Winnipeg, Manitoba; Regina, Saskatchewan; and Calgary, Alberta. In all three reports, Canada received the lowest grade in the “right to a second opinion” performance indicator, a mark reserved for those countries that don’t ensure the right to a second opinion or those with “severe obstacles that very often cause difficulties accessing a formal right” to a second opinion.” The most recent iteration, Euro-Canadian Health Consumer Index 2010 (www.fcpp.org/files/1/ECHCI2010%20Final.pdf) states that “many of the provincial bodies that license doctors do explicitly note that patients have a right to a second opinion. But since a second opinion from a specialist requires a referral and often a lengthy wait, even those regions that seek to provide second opinions have great difficulty in translating this into reality. … (Further) the literature indicates that the accessibility of second opinions remains much worse than that of specialist referrals in general.” But patients who’d like second medical opinions, particuarly those with deep pockets, aren’t entirely without options. There’s always the option of seeking a second opinion from a private clinic, Chapman notes. There are also online services, based in the United States, that allow patients to submit their medical records and obtain second opinions remotely for a fee, typically on the order of US$500–US$1500. As well, there are services such as Best Doctors Canada and WorldCare, which collect a patient’s medical records, test results and other pertinent data for review by physicians. But membership is required to access these services, which are provided strictly within the parameters of employee benefit packages or private insurance plans. When it comes to obtaining a second opinion from a second specialist, some physicians say the hurdle isn’t as high as many believe, and generally doesn’t involve marathon wait times. It depends in large part on “the acuity of the patient’s situation,” says Dr. Danielle Martin, chair of Canadian Doctors for Medicare and a practising family physician in Toronto, Ontario. “If the reason for the second opinion is because it appears the person is really ill, they’ll get their second opinion very quickly. If the reason that they want a second opinion is because they want another discussion of the pros and cons of a treatment they’re already taking, they may wait a very long time and I actually don’t think that’s necessarily inappropriate.” Moreover, Martin argues, triaging such patients according to the urgency of their condition promotes good use of specialists’ time, even if it means that a lower priority patient has to wait longer for that second opinion. As well, patients who want a second specialist’s opinion can always consult their family doctor, Martin adds. “You serve a translation function as a family physician. We tend to have more time to spend with our patients, we have that longitudinal relationship... We know a lot more about them because we’ve known them for a long time. So we can provide that context that the specialist who is seeing a patient for the first time may not have.”