Caring for patients over long periods of time starts out as a romantic courtship. Initially, there is wooing. Both parties can do no wrong. New patients are relatively unknown to clinicians and vice versa. The main difference is that clinicians are expected to catalyze some change in patients for the better. After taking a history, doing a physical exam, perhaps ordering some tests, clinicians are expected to propose a diagnosis and/or prescribe some treatment.
Over a number of effective consultations, the relationship can deepen into a therapeutic marriage. It is a two-way street where both participants listen and learn and change together to achieve an effective result. As in a marriage, however, the doctor-patient relationship can get stuck – especially when the diagnosis is uncertain, the treatment is risky, or the outcome is poor.
At that time about one third of all patients seek a marriage guidance counsellor – in the form of a second opinion. When parties agree to a second opinion, it is in the hope that the opinion can give patients confidence when choosing among treatment options and help them understand their diagnosis. Health insurers in some countries, such as Germany, recognize this opportunity and provide formal second opinions specifically for orthopedic and oncological problems.
Of course, organizations such as the prestigious Mayo Clinic, which tout for second opinion business, have their own evidence to back it up. In one of their studies, only 12% of final diagnoses were the same as the initial diagnosis and 21% had a substantially different diagnosis. Another study reported that 1 in 20 patients were misdiagnosed.
Despite this divergence, there are reasons to distrust second opinions. US-based “Best Doctors” offers second opinion coverage, supposedly by a panel of experts representing the “top 5%” of US physicians. However, the process of selecting these second opinion giver is not clearly defined.
In countries where second opinions which are outside the inpatient setting are acceptable, such as Israel, providers still shy away from giving them, viewing them as a kind of collegial taboo. In the US, litigation is the major roadblock to effective second opinions. Providers have concerns that a change in diagnosis or treatment options could expose the primary provider to a malpractice claim.
Second opinions also are tricky because the lines between a second opinion and transfer of care are not often made clear. One in five patients who get a second opinion expect that the responsibility of their care is going to be transferred to the second opinion doctor.
So, what differentiates a second opinion from a second-hand opinion? Certainly, the focus of both patient and doctor must be aligned and focussed on achieving the optimal outcomes with least risk and minimal harm.
Given that medicine is as much art as science, it is not surprising that in all areas, differences of opinion occur. The unassailable fact, proven over and over again in these pandemic times, is that diagnosis and treatment are a blend of evidence, guidance and individual response. It is only important how these differences are communicated and whether they make a significant change in health outcomes.