Second Opinions

To celebrate your 50th birthday you head to your doctor’s office to get your yearly exam. He rewards you for your diligence by poking and prodding you, sticking you with needles, and arranging for a colonoscopy (happy birthday!). He also sends you for a stress test out of concern about your strong family history of premature heart disease.

A slightly abnormal treadmill test leads to a slightly abnormal nuclear imaging stress test, and before you know it you’re in with a cardiologist discussing the need for a cardiac catheterization. Your health is otherwise very good and you have absolutely no symptoms that would suggest any significant coronary artery narrowing—in fact, you’ve been vigorously exercising faithfully for several years and feel pretty good about your level of fitness.

You leave the office a little uncomfortable about being told you need an invasive procedure when your health is doing so well, but you let them set a date and time for your study. You relate all this to a friend of yours who suggests that you try to find another doctor for a second opinion.

Do you do it? Do you tell your cardiologist so that he can send his nuclear study results to the new doctor? Do you tell your primary doctor, who, after all, has a good enough relationship with the cardiologist to have sent you to him in the first place? Will your doctors be offended? Will your insurance cover the cost of the second opinion?

Patients don’t ask for second opinions very often. I know of no statistics that can tell us how frequently patients seek the advice of a second physician, but I’d guess it’s pretty uncommon. Most patients are probably pretty satisfied with the care their provider recommends (otherwise they’d have switched to another doctor already) and don’t feel that another opinion is necessary. Of those who feel unease with their doctor’s recommendations, most probably just swallow their personal misgivings and proceed with the suggested therapy.

A select few will seek a second opinion and most of them will likely feel pretty uncomfortable about it. As an example take this article, for example, written by a doctor about other doctors he knows who also happened to be patients:

“When I went for a second opinion, my internist got mad,” a physician with lymphoma recently told me. “As if I were his lover and had cheated on him.”

As a cardiologist, I’ve been the “second opinion” on many occasions (although I can’t know how often my patients leave my office and head elsewhere for another opinion). In most instances, the patient didn’t necessarily feel that the recommended testing or therapy was wrong, they just felt uncomfortable with the entire doctor-patient interaction. Most people don’t come to me saying “My doctor said I needed surgery X, but I know that surgery X is not the right surgery for me.” Rather, it’s more like this: “My doctor said I needed surgery X, but I feel like he didn’t really listen to me when I was telling him about my symptoms and I’m just worried that he’s recommending surgery without hearing the full story.”

My experience is supported by studies on the subject that show that people who seek second opinions do so mainly because of a dissatisfaction with the quality of dialogue they experienced with the primary consultant. In some ways this makes it even harder for patients initiate the move to another doctor, since it signals that the doctor and the patient are not matching up well—kind of like telling your prom date that you had fun but you don’t want to see her again. It would be easier if it were a simple case of suspected incompetence: “Your foot hurts? Nothing that cardiac catheterization can’t cure.” Advice from that type of doctor is easy to abandon.

Will your doctor be offended if you go elsewhere for another consultation? I hope not. He or she should understand that you as a patient must feel comfortable with the care you’re receiving and getting a second opinion may help you achieve that goal. I certainly don’t mind if my patients ask to get input from another doctor; in fact, if I sense that a patient or family member is uncomfortable with the plan I am offering I will suggest that they consider seeking advice from another doctor. There are a couple other cardiologists in town—in other practices—who are regular recipients of my referrals for another opinion. I find it extremely helpful to have a different doctor lay eyes on a patient’s case and offer alternatives.

You may be surprised to learn how often we doctors seek informal second opinions on our own patients. We frequently sideline our partners to have them cast eyes on the chart of a patient with a particularly challenging problem. We have routine conferences where we discuss clinical dilemmas and review study images. Once or twice a week someone in my practice will send out an e-mail asking for others in the group to provide an opinion on a challenging echocardiogram. I think most doctors have a pretty healthy understanding of their own limitations (at least I hope so).

Insurance companies will commonly pay for you to see another specialist. Medicare even mandates that some diagnoses be confirmed with a second opinion. I called an account representative at my insurance company who told me that I can get a second opinion anytime I want and that it would be billed as a standard office visit. “What about a third, fourth, or fifth opinion?” I asked. “Sure,” she said, “as many as you’d like” (although the nice lady on the other end of the phone probably thought that one psychiatric opinion would suffice).

Nowadays you can even get a second opinion without leaving the comfort of your own home. Sites such as the Cleveland Clinic’s MyConsult allow you to tap the brains of their doctors with the ease of the “phone a friend” option on “Who Wants To Be A Millionaire?” The only drawback—as clearly spelled out on the site’s disclaimer page—is that insurance won’t pay a cent of the $565 it costs to initiate the service.

A couple of years ago CNN posted a list of 5 diagnoses that call for a second opinion: “when the diagnosis is tricky, the procedure is risky or has permanent consequences, or when there are less-invasive alternatives.”

1. Heart bypass surgery
2. Hysterectomy
3. Pregnancy termination for fetal abnormality
4. Surgery for varicose veins
5. Treatments for brain tumors

I can’t say that I know much about the manifold treatment options for brain tumors or varicose veins, but I do know something about cardiology. In that light, here’s my list of clinical scenarios where there are many treatment options and for which you should seek a second opinion if you don’t feel comfortable with your doctor’s suggestions:

1. Cardiac catheterization when you have no symptoms (as in the example at the beginning of this post)
2. Surgery for valvular heart disease, especially involving valve leakage (regurgitation)
3. Rhythm control or surgical treatment of atrial fibrillation
4. Hypertension resistant to numerous medications
5. Pacemaker for lightheadedness or fainting in the absence of clear evidence of slow heart rate
6. Pacemaker for slow heart rate in the absence of symptoms of lightheadedness or fainting
7. Any treatment regimen consisting mainly of branded (rather than generic) medications
8. Routine use of expensive “screening” testing in the absence of symptoms

Bear in mind that I’m not recommending that anything on the above list is wrong or inappropriate—there are many situations where such testing or therapy is warranted. It’s just been my experience that overly aggressive therapy occasionally accompanies these particular clinical scenarios.

In summary, you should never hesitate to seek a second medical opinion if you are uncomfortable with the recommendations your doctor makes, particularly when you are being asked to undergo invasive testing or therapy and especially if you feel that you and your doctor haven’t enjoyed a level of communication that satisfies your concerns.