An occasional series of health questions, answered
Q: I've been diagnosed with cancer and hope for a second opinion before I start treatment. I'd like to ask my oncologist for a referral, but that feels like I don't trust her. How do I do this without offending her?
A: How about this: "I love you, but let's both get a second opinion," suggests Jonathan Schaffer, an orthopedic surgeon at the Cleveland Clinic. After all, he reminded me, "it's you and your doctor in this battle, not you against your doctor." In other words, partners, not adversaries.
The number of misdiagnosed cases varies depending on the study or institution but it's worrisome no matter who you ask. Schaffer is also managing director of the hospital's MyConsult service, which has provided tens of thousands of online second opinions; he notes that they disagree with the original diagnosis in more than 11 percent of patients seen. James Naessens, a policy and health services researcher at the Mayo Clinic who led a study on misdiagnoses, told me that 10 to 20 percent of all cases nationwide are misdiagnosed, affecting at least 12 million people and possibly many more.
Given these numbers, it's no wonder that second opinion consultation services are popping up at hospitals and start-ups all over the country. It's no longer necessary to wait weeks to get an appointment with a specialist, and it's no longer required to fly across time zones to get the best medical opinion. All you need is Internet access and the required fee, which usually starts at about $500 per consultation. Second opinions are typically covered by private insurance, Medicare or Medicaid.
I know something about all this myself: In the mid-1980s, I was diagnosed with testicular cancer at a San Francisco hospital. After the surgery to remove my cancerous testicle, the oncologist ordered tests to see whether the cancer had spread. I could not have been more relieved when he told me it had not. My mother, however, insisted I get a second opinion — and, lo and behold, a surgeon at Memorial Sloan Kettering Cancer Center in New York told me I had advanced metastatic disease, for which I then received treatment.
"Every patient has a right to a second opinion," says Joseph Fins, chief of medical ethics at New York-Presbyterian and Weill Cornell Medicine, "and it would worry me if a physician was opposed." Asking for a second opinion doesn't necessarily mean you're questioning a doctor's recommendation. For many, it's seeking the peace of mind that comes with leaving no stone unturned.
Not all second opinions are created equal. Fins says that you want to make sure that person is board-certified in their specialty and that they're affiliated with an academic medical center because they're likely to be "better than average." He cautions against taking recommendations from friends, noting that this is not like choosing a hair stylist, instead suggesting sources such as the annual U.S. News and World Report compilation of hospitals and doctors.
As for asking your doctor for a referral, Fins warns of "an inherent bias effect," meaning your doctor may suggest someone who is "comparably predisposed in the same practice group, in the same institution." Such a physician is also likely to follow the same treatment guidelines, which means you may get a pro forma confirmation of your original diagnosis.
That rang true to me as well. When my mother was diagnosed with lung cancer four years ago, her pulmonologist in New York referred her to an oncologist at the same medical center. Their diagnoses and treatment plans matched up. My indefatigable mother got yet another opinion elsewhere, which confirmed the diagnosis but altered her treatment plan. According to a 2015 study published in the American Journal of Medicine, a change in the treatment plan is recommended as much as 30 percent of the time.
There's almost no excuse for not getting a second opinion today, especially with the prevalence of electronic health records, easy uploading of data and access to video conferencing. All of these technological advances are reducing "the geographic barriers to care," Cleveland Clinic's Schaffer told me.
Whether a patient uses Cleveland Clinic's program, a similar one at Dana-Farber Cancer Center in Boston or a non-hospital online service staffed by board-certified doctors, such as Second Opinion Expert, the basics are pretty much the same: Upload your data. Pay the fee and wait about a week to get the results, which will include a diagnosis and proposed treatment plan. "In a majority of the cases, the physician specialist does not really need to see the patient in person," Ash Davé, president of Second Opinion Expert, explained in an email. Their doctors use the imaging, pathology and lab reports to make the diagnosis.
So what should you do when you want a second opinion?
•Don't be talked out of seeking another opinion by your current doctor or anyone else; this is your decision.
•Be upfront but respectful with your doctor. You are partners in this, and having your doctor on your side makes it easier to transfer your medical records and coordinate care.
•Don't shop for a specialist who will tell you what you want to hear. You need the unvarnished truth.
•Provide the second doctor with all relevant information in your medical record. Fins warns about the "discontinuity of care if all the facts don't follow you."
If the second doctor disagrees with the first, you'll have another decision to make. The doctor who told me I had metastatic disease said, "If you follow my advice and I'm wrong, you'll have had an unnecessary surgery. If you do what the other doctor recommends and I'm right, you'll be dead." I followed his recommendation, and he turned out to be correct: Three decades later, I'm alive, in large part due to that second opinion.
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