Second opinions: Agendas and ego

To the Editor

When we see a new patient we usually assume that we know why they presented. A standard consultation is focused on making a diagnosis or recommending a treatment. However patients presenting for a second opinion may have a broad variety of agendas. Enquiring explicitly what the initiator of the referral wishes to get out of the visit can be very informative. This article explores approaches to some common agendas, with suggestions for making these consultations beneficial for all concerned.

Ego is a particular issue with second opinions. Medicine is a competitive profession, and many practitioners have healthy egos and strong sense of competitiveness. This may create a situation where the doctor's agenda may be swayed by the need to boost their standing by lowering those of their peers, negatively impacting collegiality. The distortion to the consultation process also potentially creates a problem for patients. We all like to be the hero who makes a brilliant diagnosis or treatment recommendation, but it is important that this does not overshadow the needs of the patient.

There is surprisingly little literature to guide physicians in their approach to patients seeking a second opinion. In one US survey, 56% of cancer survivors had sought a second opinion [1]. In an environment where information is expanding rapidly, the number of patients searching the internet and seeking second opinions are increasing [2], [3]. The benefit of this to patients is uncertain and duplicative consultations are a significant strain on the health care system [4].

The experience of a surgical oncology clinic with second opinions in the Netherlands has been reported [5]. The authors emphasised the variety of motivations for seeking a second opinion. Two-thirds of patients were seeking reassurance, yet two-thirds also hoped the recommendation would change. A significant proportion of patients (one-third) was motivated by dissatisfaction with the original oncologist.

Other studies in the non-oncology patient population have shown that the decision of a patient in seeking a second opinion is influenced by several other factors. These include culture and tradition [6]; health policy; social trends and fashion [7], [8]; gender [5]; socioeconomic status and educational level [7], [8]. Concern over the competence of the treating specialist is usually not the reason for seeking a second opinion. One study has indicated that the best predictor for a patient seeking a second opinion lies in the patient's relationship with their first-opinion consultant [9]. First-opinion consultants are often not aware of communication issues [9]. Other studies have addressed the legal and ethical issues involved [7], [10].

Sikora has suggested some situations where a second opinion is likely to be helpful and should be considered by the treating oncologist. These include: rare cancers; availability of super-specialist teams with unusual expertise; recommendation of radical therapeutic options of uncertain benefit; unresolved conflict within the treating institution over treatment; patient non-acceptance that active treatment should stop; and the availability of clinical trials [8].

However, what is missing in the literature is lack of guidance related to managing a patient seeking a second-opinion. When a second opinion is sought, the importance of ensuring that all information is available and that the patient's primary care practitioner is involved has been highlighted. There is, however, no study focusing on the practical points of how to deal appropriately with these patients. This paper outlines practical guidelines and simple suggestions on how to approach a patient presenting for a second opinion according to the agenda.

Patient-initiated referrals

A) “I just want to make sure my doctor is giving me good advice”

This common statement is an explicit request for reassurance. The first issue, of course, is to ensure that the patient has been given good advice. Inappropriate treatment recommendations should be rare. In the majority of cases, recommendations will be reasonably consistent [11]. The risk is that recommending minor variations in treatment (e.g. interchanging two equivalent drugs) can erode confidence and not provide the reassurance that the patient is seeking.

In this situation, it pays to reaffirm previously given reasonable recommendations, affirm the expertise of the first-opinion consultant, and to use multidisciplinary-team recommendations and/or guidelines or references to published data to reassure the strength of the recommendation given. Taking over care is clearly inappropriate.

B) “I wasn't happy with the advice I have been given”

This statement is helpful because it focuses the discussion on potential alternatives. The issues are what treatment options there are and what has been discussed. Time spent exploring the reasons for unhappiness with the recommendation is particularly useful.

Sometimes options are not discussed (e.g. expensive drugs, experimental options, and supportive care alone). More commonly, the issue is either the patient has not understood the reasoning behind a recommendation, or does not agree with the values behind the recommendation. An important example is where a 5% response rate is valued differently between the clinician and the patient. This difference in treatment philosophy/values is particularly difficult. There may be differences in opinion as to what is reasonable between clinicians. A conservative clinician will not be a good match for a patient preferring aggressive treatment. A good approach is to clarify the issue and encourage the clinician with the better “match” in philosophy to continue care.

C) “I wanted more explanation about my diagnosis, treatment, and prognosis”

The best approach in this scenario is to first determine that the recommendation is reasonable, then to focus on the communication issues. Asking what the patient has understood about the previous consultation is a good place to start. It is critical that enough time is allowed for the consultation. Providing written information may also be particularly helpful. The issue of ego, in this instance, is that it is tempting to believe that clinicians are always the better communicator. In truth, clinicians often underestimate the time required to answer questions. Having answered the questions and encouraging the patient to go back to their usual doctor for more information is useful for reinforcing, rather than undermining, the first opinion.

D) “I didn't like my doctor”

This is a difficult situation, as genuine personality mismatches occur. The problem is that patients with borderline personalities and a tendency for “splitting” are over-represented in these types of referrals. Sometimes the problem is prejudice in regards to the doctor's race, age, gender, dress sense, etc. Often the doctor concerned is a colleague and you may be predisposed to agree or disagree with the patient's impression. It is important to understand what the problems were. If the patient denigrates someone you regard highly and excessively praises your reputation, be wary that you may be next.

E) “I wanted to talk about a specific treatment/trial you offer”

These are relatively easy referrals as the agenda is clear and the focus can be directed toward the specific treatment.

Doctor-initiated referrals

A) “I am not sure what to do”

These are particularly rewarding referrals, as the patient presumably comes to you because of your particular expertise. Such requests can also come from a clinician who is emotionally attached to the patient, or has looked after the patient for a long period of time and would value a “fresh opinion”. In this situation, a comprehensive review of the diagnosis, previous treatment, reasons for stopping treatment, and prior toxicities or other relevant information is helpful. The patient may be concerned or confused as to why (if you have particular expertise) you had not been involved sooner. Addressing this concern may be helpful. Endorsing the skills of the referring clinician and stating that doctors often request a fresh set of eyes on a problem can be reassuring. Endorsing previous treatment recommendations, when appropriate, can also be helpful. It is useful to close these consultations by saying that you will have a discussion with the referring doctor and that the two of you will collaborate with the next step.

B) When a patient needs to hear the advice (usually to stop treatment) from someone else

This reason for seeking a second opinion can be quite powerful, when used wisely, but requires a different approach. Patients may be more accepting of difficult advice if they hear it “independently”. This, however, creates a problem for the clinician giving the opinion, as they need to be independent and not simply “rubber-stamping” a recommendation.

The challenge in this situation is that the normal processes of history-taking and relationship-building have been short-cut. It is worthwhile making a special effort to focus on the personal aspects of the history, hobbies interests, aspirations, and concerns, before dealing with the difficult aspect of a recommendation. Finding out how the patient feels about the advice given by the referring doctor is particularly useful. Emphasising that you have looked over the medical record and previous investigations is important for the patient to know.

Other issues

In many situations, the outcome of a second consultation is a recommendation much like the first and provides reassurance that they are in “good hands”. It is infrequent that a major difference in outcome can be achieved. However, there are a number of “side issues” that would be rewarded by particular attention. Issues that are not the reason for referral, but are often overlooked, benefit from closer attention. Such issues include family history, symptoms of anxiety or depression, timeliness of palliative care referral, adequacy of symptom control, social or family concerns, and sexuality. Attention to issues that are frequently missed helps ensure that each patient who comes to you for a second opinion leaves with some added value.

Key Points

1. Determine the patient's or referring doctor‘s agenda.

2. Adapt your approach to the consultation agenda.

3. Build confidence in previous care wherever appropriate.

4. Avoid minor variations that do not influence outcome.

5. Be aware of temptations to boost your ego.

6. Pay extra attention to communication.

7. Try to find some added value, by paying attention to issues that are often overlooked.