Second Opinions - Online - Worthwhile?

What would you say are the pros and cons of getting a second opinion online through institutions like The Cleveland Clinic and Partners Healthcare (through Harvard)?
Second opinions online or consultations without seeing or examining a patient are probably helpful if someone wants to have the blessing of a major medical institution like Cleveland Clinic. The other advantage is to get advice without traveling to these medical centers. While these second opinions have access to doctors’ notes, lab results, and imaging studies, these institutions don’t usually have their doctors examine the patients. This is the biggest potential problem of these programs.

Let’s for example say you wanted to buy a car. If you wanted to buy a car online, could you make an informed decision whether to purchase it based on its description (doctors’ notes) and pictures (imaging studies)? Would you be able to tell if the engine ran smoothly, the seats were comfortable, or the handling was just right based on the information you received online? For most people, doing the research and having bits of information isn’t a substitute for a test drive.

This is no different than having an online consultation. As doctors, one of the first things we learn is to treat the patient and not test results. People are more complex than simply blood tests, MRIs, and CT scans. Often pathology and radiology reports are qualified with the phrase “clinical correlation recommended”. This is the pathologists’ and radiologists’ way of telling the doctor who ordered the test to realize that the information they provided is only helpful in the context of the patient. Pathologists and radiologists know their limitations. Their expertise provides only a glimpse of the person and his medical condition. This is the main reason that medical students today still spend much of their time learning how to interview and examine a patient before they learn what tests to order.

If the online opinion was used to reaffirm another second opinion, where a patient was examined by a doctor, then this would be reasonable. It would be very concerning if this second opinion overturned or refuted a previous opinion particularly since the patient wasn’t examined. Doctor notes, test results, imaging reports provide only a partial picture of a patient or his condition.

Second Opinions - Blinded and Two Different Options

What is a "blind second opinion"? What are the advantages and disadvantages?
A “blind second opinion” is seeing another doctor, but not providing him any of the other doctor’s notes, lab results, x-ray results, or biopsy results. Advocates feel that by not giving the second opinion doctor any information that it makes him more objective and less likely to be biased by the first doctor’s work-up and assessment. The problem is that since the second doctor is essentially starting from scratch, the patient may need to undergo repeat testing which may be costly. Also, if the second opinion differs from the first, it won’t be clear to the patient why the doctors disagreed with each other since neither one has access to the other’s information.

For a second opinion to be worthwhile, patients should provide the doctor all of the previous doctor notes and results so that he understands what has already been done. What makes it a great second opinion is having the doctor now step back, ask and examine the patient as if it was the first time seeing him, ignore the medical record, reach his own conclusion and then see how his opinion either supports or refutes the diagnosis and plans of the first doctor. If you see a doctor who keeps pushing you to talk about your symptoms and treatments and not what other doctors have said or what the tests showed then you’ve found yourself with a doctor who will give a great second opinion.

If a patient gets two opinions on a condition and they vary greatly, how does one make a decision?
If there is this situation then it means that for that particular condition there is not a general consensus or agreement on what the best treatment is. In this case, there are a few of options. One is to get a third opinion and see if it provides a middle ground between the first two cases. The other option is to get a third opinion, but have it with a guru or nationally renowned expert on the condition. It is possible that with these options that there might be three very different opinions. In this case, the best decision is to find the doctor who suggested a treatment plan the person was most comfortable with. With three opinions for the same condition, it is even more clear that there is no agreement and therefore a person can’t be truly faulted for making a less than ideal choice as three doctors couldn’t agree. What is most important at that point is that the patient makes a choice he is comfortable with.

Second Opinions - How

What is the best way for a patient to approach her doctor about getting a second opinion?
The best way is to tell the doctor that you appreciate their care.  For you to proceed further it would help you to get a second opinion.  You want to know if there are other alternatives or ideas. If you aren’t the one wanting the second opinion, then I would suggest that you tell your doctor that it is your loved one or family member that is requesting it. Reassure the doctor that you wish to continue care with them, but wanted to explore the possibility of other options.

Good doctors shouldn’t be offended. If they are comfortable with their diagnosis and treatment plan, they know that you aren’t likely to find alternative therapies. Good doctors also know that they don’t know it all and they welcome the opportunity to learn something new from a second opinion. Finally doctors are notorious for asking for second opinions when they are patients, as they all understand some of the uncertainly of practicing medicine, and aren’t shy about asking for one. It is your health. Having regret of not asking for a second opinion is worse than having to perhaps bruise an ego. Again, good doctors aren’t offended, often expect to be asked for second opinions, and will suggest a patient get a second opinion in a particularly serious medical condition.


What should patient and doctor discuss under these circumstances?
Say that you very much appreciate their care and value their advice. You wondered if there were alternative treatment options or therapies that other doctors might be familiar with that he would recommend for a second opinion. Reassure the doctor that you will be coming back to his practice and this request is simply more for your piece of mind, or that of your loved one. Explain that you are very satisfied with his care.

Don’t demand a second opinion. If your doctor won’t help you, you can still get a second opinion. You might also want to consider switching doctors as a doctor who won’t help you get a second opinion, particularly for a potentially serious medical problem, may be more worried about his ego rather than putting you first as a patient.

How can a patient best get his primary care doctor on board if the patient decides to go a route not recommended by his doctor?
Patients need to realize that much the same way doctors can’t force patients to do certain things, like exercise more, lose weight, quit smoking, and take prescription medications, that they also can’t force their primary care doctor, whether an internist or family physician, to get on board to an alternative treatment plan. If their doctor wishes to work with them and both parties can compromise, that would be great. If not, it is best that the patient find another doctor they can work with.

Doctors are available to provide patients their medical expertise. Depending on the doctor, his experience can vary widely. Rather than trying to force a primary care doctor to get on board to a plan he doesn’t agree with, it would be better to find another doctor with the expertise you need.

Second Opinions - Where to Get One

How do patients find doctors to do a second opinion?
Patients should ask their primary care doctor, either an internist or family physician, who to see for a second opinion. Often their doctor refers patients to specialists and will be familiar with different doctor groups in the community.

Another option to find a doctor is by using the physician directory of a professional medical society. For example to find an orthopaedic surgeon, going to the American Academy of Orthopaedic Surgeons website, one can find doctors by zip code, city, or state.

The third option is to find the nearest medical school or university hospital and ask to see a doctor who is staffed there. Through these medical centers' websites you often can get a name and an idea of the individual doctor's background and experience. Because are often teaching hospitals, be sure to clarify if you only want to see that doctor or if it would be ok to be seen by one of the doctors in training. The doctors in training, interns, residents, fellows, are supervised by the doctor.


Is there an advantage of seeking a second opinion at a research and teaching hospital?
Doctors at research and teaching hospitals typically have the latest treatments and technologies available to them. They also have valuable expertise in treating rare medical problems. Patients with especially difficult diseases which has failed conventional therapies or patients with rare illnesses will often seek out these large research and teaching hospitals. Because these doctors see a large number of these uniquely challenging medical cases, their experience is far better than a doctor in the community who may only see one case in an entire career.

Patients who would get the most benefit from a research and teaching hospital are those with medical problems that are rare or that have failed traditional treatments.

Second Opinions - When and Why

When is it a good idea to get a second opinion?

Second opinions should strongly be considered when there is a potentially life threatening medical condition, like cancer, when the proposed treatment options are intensive or demanding, like chemotherapy or major surgery, or when there is a chance for a very bad outcome or complication, i.e. brain surgery. By having a second opinion, particularly in these high stakes situations, patients and their families will have the opportunity to have a second set of eyes double check to see if the original diagnosis and treatment plan are reasonable as well as a chance to hear someone else explain the problem which may be more understandable and enlightening.

With any other big decision — purchasing a new car or deciding to get married, for example — people instinctively seek out multiple opinions. Others voice their unsolicited opinion. When making a decision which could mean the difference between life or death, patients should not be shy about getting a second opinion. Patients should also ask their primary care doctor about their thoughts and understanding of the treatment plan of the first doctor and the need for a second opinion.

Why are patients reluctant to get second opinions?
Patients may be afraid that their doctor won’t take care of them in the future because they are asking for a second opinion. They may not feel the need to get a second opinion since they are comfortable with their doctor. They may not be aware that getting a second opinion is a good idea. They don’t know how to ask for a second opinion.

Do philosophies and treatment options vary among hospitals and medical practices?
Philosophies about treatment options can vary greatly depending on where and who the physician trained with, the physician’s field of practice, when the physician did their training, and the physician’s personal belief. Often for the same medical problem, different doctors, even within the same specialty, will have different recommendations and treatments. This is often a result of who they trained with and their clinical experience. Practice styles and philosophies also differ from the East Coast and West Coast.

For the example of leg pain due to a pinched nerve, some back surgeons will recommend early surgical intervention, while others suggest non-operative conservative therapy. If a doctor trained at a program that advocated watchful waiting, then it is more likely his philosophy is to be conservative. If his mentor, however, always recommended surgery quickly, then it is likely his own belief is that operating is more beneficial. After one year, research has shown that patients do equally well with either option.

For patients to see what the varying philosophies are, they will need to seek out different hospitals and practices. Even within a group practice, the doctors may have different approaches for the same problem.

Diabetes - What You Need to Do to Stay Well

This past year the New York Times printed a series about the six killers in America which included cancer, diabetes, heart disease, emphysema, stroke, and Alzheimer's. The article on diabetes shows how much more our healthcare system needs to improve to basics and fundamentals of preventive care to keep people healthy and productive. Highlights from the article include:

• Most [diabetic] patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.
• The fault for the missed opportunities to prevent complications and deaths lies with the medical system.
• A recent survey by the American Diabetes Association conducted by RoperASW found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.
• Yet, said Dr. David Nathan, director of the Diabetes Center at Massachusetts General Hospital, “when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.”"
• “Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.”
• “We already have the miracle pills” — statins and blood pressure medications, he said. And they are available for pennies a day, as generics.
• “We need patient education and physician training that this stuff is out there and this is what we should be focusing on to make a difference in lives.”

Without a doubt, the United States does deliver the most sophisticated and technologically advanced medical care in the world. This is why patients come here to get care that they can't get anywhere else.

That doesn't mean that we do a great job with simple things like vaccination rates, cancer screening, and control of high blood pressure, cholesterol, and diabetes, to levels recommended by expert committees. Although the level of care has improved over the past decade as evidenced by reports from the National Committee for Quality Assurance, there is more we need to do.

Vaccine against "infant killer"

Doctors in Macau, which is near Hong Kong, want the government to pay for the pneumococcal vaccine to protect against Streptococcus pneumoniae. The bacterium dubbed "infant killer" claims nearly 50 children per hour in Asia. The bacterium is already resistant to many antibiotics. Unfortunately the cost of the vaccine is out of reach for many in Asia.

Lui Kin Man, president of the Macau Paediatric Society, said childhood vaccination against the bacteria was important in southern China because treatment was especially difficult.

"In our region, like Hong Kong, Macau and Taiwan, bacterial drug resistance is very high, and pneumococcal (bacteria) is resistant to drugs like penicillin and erythromycin," Lui said in a telephone interview.

"Mortalities (caused by the pneumococcal bacteria) are higher in developing countries and mostly from pneumonia. Of all pneumonia deaths, 40 percent of them are caused by this bacteria," Lui said.

In the United States, prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

In America, children are routinely offered this vaccine. Recommendations by the Centers for Disease Control suggest that for children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

With immunization, parents don't need to worry that there children will contract the illness or a bacterium that is resistant to many antibiotics. Yet, in this country many parents question the importance of vaccinations as doctors and parents a world away wish they had the opportunity to immunize.

War on Obesity - at the Workplace and School

A report in the journal Circulation found that around the world, except for East Asia, the majority of individuals are overweight or obese. The study looked at nearly 170,000 patients across 63 countries, but excluding the United States, to see if their body mass index was in the overweight or obesity range. The report was somewhat skewed as the researchers look that those individuals who were seeing their primary care doctor.

Researchers found that of men 24 percent of men were obese and 30 percent were overweight. For women the numbers were higher at 27 percent of women were obese and another 40 percent were overweight.

These results are not surprising as many countries are opting the Western lifestyle of fast food and inactivity. It is unfortunate that one of our country's major export is to make people fatter.

Perhaps stemming the tide of this international epidemic of obesity will rely on innovative programs that are occurring in the workplace and at schools in the United States. Increasingly employers are trying to slow their health care costs by encouraging employees to quit smoking or lose weight. A few have actually terminated individuals who were found smoking. More Americans feel that those who adopt unhealthy habits should pay more for health insurance than those who are healthy.

The other area of opportunity is changes in food options available to school children. A CDC report found that the number of schools that offered french fries as their only vegetable fell by half from 40% in 2001 to under 20% in 2006. Schools are removing sodas and other junk food from their vending machines and cafeterias. Physical education programs, once cut because of inadequate funding or time due to additional academic requirements, are being re-introduced to get students more active.

Providing environments that are supportive of healthy choices and lifestyles may help current and future generations avoid the overweight and obesity problems currently plaguing too many individuals.

America's Lagging Health Care System

An editorial from the New York Times reiterates what has been known for quite sometime which is that the American health care system trails that of other industrialized countries. More individuals are becoming dissatisfied with a system that does not support quality, leaves too many without insurance, and continues to increase costs.

The editorial correctly points out that for the system to improve it will require that patients have easy access to primary care doctors. It is the robust primary care doctor network that other countries have that help improve the health of their citizens while keeping costs manageable.