"Doctor, I’m here for a second opinion"
Thursday, 17 September 2020
Patients commonly present to doctors seeking ‘second opinions,’ but the term is often misunderstood and can lead to medico-legal consequences if the consultation is not managed appropriately.
In a previously published article, a surgeon member faced a complaint for allegedly damaging the relationship between the patient and their usual treating surgeon.
The patient consulted the member and stated that they were there for a ‘second opinion’. However, the patient omitted some important information and pushed hard for a surgical solution the member did not recommend and thought was dangerous.
The member had valid concerns the patient would inaccurately report the consultation to their treating surgeon and believed it was necessary to share the advice they had provided with the patient’s treating surgeon and referring GP. Given that the patient was there for a ‘second opinion,’ there seemed to be no impediment to doing so.
Shortly after, the patient filed a complaint against the member for breach of privacy. Fortunately, the member was found to have shared the health information in the patient’s best interests and not to have breached privacy laws.
By Dr Sean Mackay, MBBS, MD, FRACS, Upper GIT, HPB and Bariatric Surgeon, Senior Lecturer, Eastern Health Clinical School
A ‘second opinion’ is a medical term that is often misused by patients and sometimes even by doctors, leading to misunderstandings which can significantly impact the doctor-patient relationship.
There are two scenarios to consider: when the original treating doctor is seeking a ‘second opinion’ from a colleague to help them in the assessment of that patient, and when the patient is concerned or disagrees with the diagnosis and seeks ‘another opinion’.
Reasons doctors seek ‘second opinions’
Historically, the term ‘second opinion’ describes a situation in which a treating doctor asks a patient to see a colleague so that the two doctors can discuss the case with the aim of allowing the treating doctor to better understand the case and its significant aspects. Therefore, a second opinion is provided to and for the treating doctor, to help their assessment and formulation of a treatment plan.
This would usually occur in the context of a difficult or complex clinical case. The doctor providing the second opinion would see the patient, perform an examination, review any test results, and then contact the treating doctor to discuss. The considered opinion of the two doctors would subsequently be explained to the patient by the treating doctor.
Another reason doctors may obtain a second opinion is when there are concerns the patient may present a medico-legal risk. For example, a ‘difficult’ patient who seems likely to become dissatisfied and potentially litigious if an outcome is anything less than perfect. A broadly similar situation may also arise when the clinical decision is clear, but it is difficult for the patient to accept.
In these cases, requesting a second opinion can bolster the treating doctor’s position that they took every reasonable step to arrive at a consensus on the most appropriate treatment for the patient and ensured that the patient had every opportunity to understand the treatment plan and the material risks and benefits.
The true meaning of a ‘second opinion’
It is worth keeping in mind that when a patient comes to your consulting rooms and breezily announces they want a second opinion, it is usually the patient and not the treating doctor, who has initiated the consultation, and the patient is actually looking for an opinion that they prefer to the first one obtained.
In the case under discussion, the patient came to see a second doctor and stated they were there for a second opinion. As it transpired the patient was not actually seeking a second opinion in line with the term’s accepted medical meaning. Of course, the statement, “I am here for a second opinion” infers, “I want you to discuss my case with my initial treating doctor” and our colleague saw this as entirely appropriate and, indeed, necessary.
Although our colleague acted in good faith, the complaint was based on the fact the patient did not want the treating doctor to know they had sought another opinion and they alleged this breached their confidentiality. The whole unfortunate situation arose from the patient’s misuse of the term second opinion.
The ‘take-home’ message for doctors is that the term second opinion is often used inappropriately. It is incumbent upon doctors who hear the term from a new patient to determine whether they are requesting a second opinion in the traditional sense, or simply doctor-shopping.
In the latter scenario, it is reasonable to presume the patient does not want you to communicate with their initial treating doctor, although it is sensible to ask the patient this explicitly. If the patient requests that you take over their care and you are concerned they may present a medico-legal risk, it would be wise to decline the patient’s request.
In the less common scenario where the patient does seem to be there for a second opinion in the traditional sense, it is prudent to establish this by direct questioning and to inform the patient you will be calling or writing to their initial treating doctor. If the patient then requests you take over their care, you should state that it is considered unethical for a doctor to subsume the care of a patient sent for a second opinion, and if they are unhappy with the treating doctor’s management, they should ask their GP to refer them to another doctor.
In a difficult clinical case, obtaining a second opinion is similar to having a Multidisciplinary Team (MDT) review the case. If the treating doctor is concerned a second opinion is required in that situation, then they should also consider whether discussion at an MDT could contribute to the doctor’s understanding of the case.