What's Up, Docs?

By R.J. Ignelzi
17 aug 2008--When you need answers to serious medical questions, seeking second opinions can be real lifesavers
Dave Duval might have died had he waited for either his HMO or a famous medical center to accurately diagnose his symptoms. Fran Vigil would have had to endure significantly more discomfort and pain if she'd agreed to her first oncologist's treatment recommendations.
However, today both of them are active, healthy and happy that they took the time, trouble, and sometimes added expense, to get more than one medical opinion.
“It's your health. You have to be assertive. You have to take charge,” says Duval, a 68-year-old investment banker from Del Mar, who had to be seen by three doctors before his serious staph infection was discovered. “Nobody should ever have any reservations about getting a second or even a third opinion.”
But according to a 2005 Gallup poll, only 20 percent of Americans whose medical condition or diagnosis warrants a second opinion get one.
With the recent increase in medical knowledge and new treatments, it's difficult for any one physician to be aware of all the latest data. Studies show that getting another doctor's point of view results in a new diagnosis in as many as 30 percent of cases. Second opinions can provide a fresh perspective and new information so better medical decisions can be made.
“I always advise my patients to get a second opinion,” says Dr. Ewa Carrier with the Moores UCSD Cancer Center. “Patients need to feel comfortable with their treatment and should be part of the discussion. They must have options and be informed. And to be informed, they're entitled to a second opinion.”
Sometimes a second opinion just confirms the original diagnosis, providing peace of mind for the patient. Other times it may offer alternatives which can lead to an enlightened discussion with the doctor and a better understanding of the pros and cons of a proposed treatment.
What happens when two opinions are conflicting or contradictory? Do you need a third? Sometimes, say patient advocates, but two points of view usually give you enough information to make an informed decision.
“I recommend sitting down and looking at the (reports of possible) outcomes from each physician and then evaluate how you relate to each physician,” says Cindy Murphy, director of customer operations at Sharp Metropolitan Medical Campus. “Communication between the doctor and patient is the most important aspect of care.”
Although some patients think they're insulting their physician by seeking another's advice, second opinions are often expected by doctors and even required by some insurance companies before certain procedures.
“When a patient wants a second opinion, it's best to be direct, honest and upfront. Most physicians welcome that,” says Dr. Dana Launer, colorectal surgeon and former chief of staff at Scripps Memorial Hospital La Jolla.
If the physician's response to a patient getting a second opinion is negative, “that's a tip-off that something may be wrong from the get-go. That's a sign that a second opinion is more important than ever,” Launer says.
When 71-year-old Vigil was told by her Riverside County oncologist that she needed radiation and both intravenous and oral chemotherapy as part of her treatment for colon cancer, she was skeptical.
“I read the operative report and the pathology report and I didn't agree,” says Vigil, a registered nurse in San Jacinto.
For a second opinion, she returned to Scripps Memorial Hospital in La Jolla, where she'd had her cancer surgery. The oncologist there recommended oral chemo only.
“When I went back (to Riverside County) and told the first oncologist I had gotten a second opinion, he was very upset. His attitude convinced me to drive the extra distance (for treatment) in La Jolla rather than close to home,” Vigil says.
Here are some things to do or consider when getting a second medical opinion.
Check your insurance.
Most insurance plans allow second opinions. Health maintenance organizations (HMOs) in California must offer patients a second opinion, but it often must come from within the group's physician network. This can be a problem if you need to see a trained specialist and there are no others in that group or if the organization's specialists all follow a particular medical philosophy or treatment plan.
“Sometimes you have to spend the money and go outside the system,” Launer says. “It's worth it to get the opinion of a real expert. You're dealing with your life.”
After Duval's HMO spent months unsuccessfully trying to figure out what was causing his fever, night sweats and fatigue, he left the security of his insurance coverage and headed to Mayo Clinic for more extensive tests and an out-of-pocket bill of more than $10,000. Although it took yet a third doctor to discover his staph infection, he has no regrets.
“Thanks to getting other opinions, I'm alive and kicking and back to competitive rowing,” says Duval, a longtime competitor in the sport.
Find a doctor through physician referral services, such as the one offered by the American Medical Association, ama-assn.org (click on Doctor Finder). You can also ask organizations that deal with your condition, such as the National Kidney Foundation or the American Cancer Society for specialists near you. Friends and family who have had or know someone who had a similar condition and were satisfied with their doctor, may also be of help.
Make sure your doctor is a board-certified specialist in the area of medicine that's important to you. To verify board certification, call the American Board of Medical Specialties at (866) 275-2267 or abms.org.
Consider using your primary-care physician as a gatekeeper of care and treatment options.
“If one of my patients has questions after seeing a specialist, I can ask the specialist, get an explanation and then call the patient back,” says Dr. Gene Kallenberg, family medicine physician and chief of staff at UCSD Medical Center. “If the direction to the specialist came through me, it should come back to me. I want to follow it through.”
Even though the primary doctor may agree with the first specialist's diagnosis or treatment, “if the patient is still skeptical, I have to work to get him a second opinion,” Kallenberg says. “As the primary physician, you always need to find specialists who are credible and communicate well with patients.”
Consider getting a second opinion via the Internet. Top medical centers such as the Cleveland Clinic and Partner's Center for Connected Health, which is affiliated with Harvard Medical School, offer electronic second opinions.
Within a few days after receiving the patient's history and pathology reports, a second opinion is rendered electronically to the primary physician and patient. Not usually covered by insurance, a second opinion costs between $500 and $1,000, depending on the complexity of the case.
“If there are any follow-up questions, suggestions or different treatment plans, this is usually an online discussion between the Partners physician and the primary physician,” says Doug McClure, manager of operations at the Center for Connected Health, which offers Partners Online Specialty Consultations. “The patient is allowed to funnel questions and comments through his primary, but can't communicate directly with the Partners specialist.”
While electronic medical advice may be a reasonable option for expatriates or people living in remote rural areas, some physicians don't recommend it.
“There's no substitute for seeing a patient in person. You lose a tremendous amount by not seeing the patient face to face,” Launer says. “Just sitting across from somebody and eyeballing them. Seeing where they are psychologically and what effect their (medical condition) has on them and their family. That can only be done in person.”
Request your medical records. Get copies of all relevant medical tests, reports and X-rays from your doctor's office. Don't wait until the last minute to request records since the process often takes a while. You can have the records sent to your second-opinion doctor or deliver them yourself. It's a good idea to make sure the information arrives some time before your appointment so the second physician has time to review the records. This can eliminate delays, duplication of tests and additional costs.
Get it in writing. Don't just trust the second doctor to send your first doctor a report. Request a written report of the second opinion for your own records.
Take someone with you to your second-opinion appointment. Serious illnesses and doctor discussions can be emotional for the patient. Have a friend or relative join you to listen, take notes and ask questions.
Approach getting a second opinion objectively. You're not trying to have your first doctor's work checked. You need another physician to approach your case completely fresh, without any preconceived notions.