Second Opinion

Definition
Purpose
Description
Preparation
Normal results

Definition

A second opinion is the result of seeking an evaluation by another doctor or surgeon to confirm the diagnosis and treatment plan of a primary physician, or to offer an alternative diagnosis and/or treatment approach.

Purpose

Getting a second surgical opinion can fill an important emotional need as well as establishing medical needs and treatment goals. When a second opinion confirms initial findings, it can provide reassurance and feelings of acceptance for the patient, and may reduce anxiety and uncertainty.

From a cost-effectiveness point of view, second opinions can save health insurance providers money by establishing the certainty of a clinical need (or lack of need) for surgery, particularly when the diagnosis is life-threatening.

Patients with a diagnosis of cancer may also benefit from a second-opinion pathology review of their biopsy material. A Johns Hopkins study reported that 1.4% of patients scheduled for cancer-related surgery at their facility were found to have been misdiagnosed when their tissue samples were reevaluated by a second pathologist. Similarly, a study published in the Annals of Surgical Oncology in 2002 found that a pathological second opinion of breast cancers changed the initial diagnosis, prognosis, or treatment approach in 80% of the 340 study subjects.

Several clinical research studies, however, have found that patients often seek second opinions not necessarily because they doubt the diagnosis or recommendations of their first provider, but because they were dissatisfied with either the amount of information given to them or the style of communication of their doctor. A 2002 Northwestern University study found that only 46% of patients coming into a breast cancer treatment center for a second opinion had been offered a complete discussion of treatment options during their initial consultation.

Description

Doctors often have differing viewpoints as to how a particular medical problem should be managed, whether through surgery or less-invasive treatment means. One surgeon may prefer to take a “watchful waiting” approach before recommending surgery, while

KEY TERMS

Informed consent— Providing a patient with complete, objective information on the risks, benefits, and potential and probable outcomes of different surgical or therapeutic options so that they may make an informed decision or consent to treatment.

Pathologist— A physician with specialized training in recognizing and identifying diseases through the analysis of abnormal bodily tissues.

Postoperative care— Medical care and support required after surgery to promote healing and recovery.

Watchful waiting— Monitoring a patient’s disease state carefully to see if the condition worsens before trying surgery or another therapy. This term is often associated with prostate cancer.

another may believe in performing surgery as soon as possible to avoid later complications. In some cases, several surgical techniques may be viable options for a patient. Medicine is not as black-and-white as many patients are led to believe, and physicians are not infallible. For these reasons, and because surgery is a major procedure with associated risks that should not be taken lightly, second opinions are an important part of the process of informed consent and decision-making.

Although a physician may strive to be objective, personal views and subjective experiences can influence their treatment recommendations. In addition, both the education and experience of a doctor in a given medical area can also influence the advice they offer a patient. For these reasons, seeking a second opinion from another physician and/or surgeon can be invaluable in making a decision on a course of treatment.

Second opinions are most frequently sought in cases of elective (nonemergency) surgery, when the patient has time to consider options and make a more informed choice about his or her course of treatment. While a second surgical opinion may be requested in some cases of emergency surgery, they are not as common, simply because of the logistical limitations involved with getting a qualified second opinion if a patient requires immediate care.

In some cases, a doctor or surgeon may encourage seeking a second opinion, particularly when the preferred course of treatment is not clear-cut or another surgeon with advanced training or expertise may provide more insights into surgical options. A doctor or surgeon may also recommend seeking a second opinion when the patient is suffering from multiple medical disorders.

Patients should remember that it is their right toseek a second opinion before committing to surgery or another treatment plan. Embarrassment or fear of disapproval from a primary care provider should not be a barrier to getting a second opinion. A competent physician will not consider the decision to seek a second opinion an insult to their ability or experience. Instead, they will consider the patient an informed individual who is proactive and responsible for his or her own health care.

Patients seeking a second-opinion consultation may ask the provider questions similar to those they asked their primary provider. Questions may include:

• Are there other options besides surgery?
• What are the risks and benefits of each treatment option?
• How might each possible treatment impact quality-of-life for the patient?
• What kind of success rate is associated with surgery and other potential therapies?
• How is the surgery performed?
• Is surgery a permanent, long-term, or temporary solution to the condition?
• What type of anesthesia will be used?
• If surgery is chosen by the patient, how soon must it be done?
• What type of aftercare and recovery time is required once the surgery is complete?
• How much pain is to be expected postoperatively, and how is it typically treated?
• What are the costs involved with surgery and other treatment options, including postoperative care?

Providing the second surgeon with appropriate background information is important, but so is refraining from detailed descriptions of what the first provider did or did not recommend before the consultation begins. Patients should allow the surgeon to draw objective conclusions based on the medical history and diagnostic data before them. If the second opinion differs from the first provider’s opinion, and the patient feels comfortable doing so, he or she might then offer information on the first provider’s recommendations to get further feedback and input for a final decision.

Preparation

Before seeking a second opinion, patients should contact their health insurance provider to find out if the service is covered. Some insurance companies may request that a second opinion be sought before major elective surgery, and may reserve the right to designate a physician or surgeon to provide the patient evaluation. As of early 2008, Medicare Part B covered 80% of costs for surgical second opinions after deductible, and 80% for a third opinion if the first two opinions are contradictory. Other Medicare programs may cover second opinions as well; patients should check with their Medicare carrier for details.

There are several ways to find an appropriate health care professional to provide a second opinion. Patients can:

• Ask friends and family for references.
• Ask their primary care physician or another trusted health care provider for a referral.
• Contact an appropriate specialty medical organization (e.g., American College of Surgeons) for a referral.
• Call their local medical licensing board.
• Check with their insurance provider or Medicare carrier.
• Cancer patients can consult a list of multidisciplinary institutions that will provide a second opinion on request. The list is available at < http://www.blochcancer.org/>.

When seeking a second surgical opinion, patients should find a surgeon who is board certified in the appropriate specialty by an organization that is part of the American Board of Medical Specialties (ABMS). For example, surgery of the urinary tract may be performed by a provider who is board certified by the American Board of Urology and/or the American Board of Surgery (ABS), two member organizations of the ABMS. Diplomates of ABMS member boards are surgeons who have passed rigorous written and oral testing on these specialties and have met specific accredited educational and residency requirements. In some cases, surgeons may also be certified in subspecialties within a discipline (for example, a vascular surgeon may be board certified by the vascular surgery board of the ABS). The ABMS provides a verification service for patients to check on the certification status of their provider.

In addition, the surgeon may also be a Fellow of the American College of Surgery (ACS), as indicated by the designation F.A.C.S. after their name. This indicates that he or she has met standards of clinical experience, education, ethical conduct, and professional expertise as prescribed by the ACS.

Once a second health care provider is selected, patients should speak with their primary doctor about providing the appropriate medical history, test results, and other pertinent information to the physician who will give the second opinion. The patient may have to sign an information release form to allow the files to be sent. If x rays, magnetic resonance imaging (MRI), or other radiological testing was performed, the second physician may request to see the original films, rather than the radiologist’s report of the results, in order to interpret them objectively. In some cases, the office of the surgeon giving the second opinion canarrange to have these materials transferred with a patients written approval. Patients should call ahead to ensure that all needed materials arrive at the second provider’s office before the appointment, to give that physician adequate time to review them and to avoid potentially costly repeat testing.

Normal results

Second opinions that agree with the first provider’s conclusions may help ease the patient’s mind and provide a clearer picture of the necessary course of treatment or surgery. However, if a patient still feels uncomfortable with the treatment plan outlined by the first and second physicians, or strongly disagrees with their conclusions, a third opinion from another provider is an option.

In cases in which the second provider disagrees with the first provider on diagnosis and/or treatment, the patient has harder choices to face. Again, a third evaluation may be in order from yet another physician, and some insurance companies may actually require this step in cases of conflicting opinions. If a patient is very comfortable with and confident in their primary care provider, they may wish to revisit them to review the second opinion.

In all cases, a patient should remember that their personal preferences, beliefs, and lifestyle considerations must also be considered in their final decision on surgery or treatment, as they are the ones who will live with the results.

Resources

BOOKS

Horton, Richard C. Second Opinion: Doctors, Diseases, and Decisions in Modern Medicine. London: Granta Books, 2003.

Rose, Eric. Second Opinion: The Columbia Presbyterian Guide to Surgery. New York: St. Martin’s Press, 2000.

PERIODICALS

Reichman, M. “Optimizing Referrals and Consults with a Standardized Process.” Family Practice Management 14 (November-December 2007): 38–42.

Staradub, V. L., et al. “Changes in Breast Cancer Therapy Because of Pathology Second Opinions.” Annals of Surgical Oncology 9, no.10 (December 2002): 982–7.

ORGANIZATIONS

American Board of Medical Specialties (ABMS). 1007 Church St., Suite 404, Evanston, IL 60201. (866) ASK-ABMS. http://www.abms.org.

American College of Surgeons (ACS). 63 N. St. Clair Drive, Chicago, IL 60611. (312) 202-5000. E-mail: postmaster@facs.org. http://www.facs.org.

OTHER

Center for Medicare and Medicaid Services (CMS). Getting a Second Opinion Before Surgery. Publication CMS-02173. Revised November 2007. http://www.medicare.gov/Publications/Pubs/pdf/02173.pdf. A Spanish version of this document is available at <http://www.medicare.gov/publications/pubs/pdf/02173_s.pdf>

Yale-New Haven Hospital. Getting a Good Second Opinion. < http://www.ynhh.org/choice/secondopinion.html>. [cited January 12, 2008].

Paula Ford-Martin

Rebecca Frey, Ph.D.