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A Shopper’s Guide To Second Opinions
The Advocate
By Herb Denenberg, The Bulletin
The second opinion is one of the great lifesavers in medicine. But it is underused for various reasons.
• First, many people associate it only with surgery. But the second opinion makes sense in many other contexts. For example, when there is a question about a pathology report (Does the biopsy material indicate cancer or no cancer and what kind of cancer does it indicate?), when there is the questions about the radiological interpretation of an X-ray, MRI, CAT scan or other image, when there is a diagnosis of a serious condition with some unanswered questions, or when a course of treatment fails to bring about improvement.
• Second, many people are reluctant to go for second opinions out of fear of offending their doctor, thinking it is a signal that they don’t trust the doctor’s opinion and judgment. Good doctors would encourage a second opinion, and if they discourage one, you should be concerned. At least get the doctor’s reason for not going for a second opinion to see if it makes sense. I suspect you will find it usually doesn’t make sense, and staying with that doctor may not make sense either.
• Third, there is always the question of whether the second opinion will be paid for by an insurance company. It often will be, and in some situations, a second opinion may actually be required by the insurer. If the insurer will not pay for a second opinion, you may have to challenge that denial. Often a persistent patient can reverse a denial. Even without insurance coverage, a second opinion may be a good investment.
• Finally, many patients mistakenly think there is no need for second opinions, and assume a degree of certainty in medicine that simply does not exist.
Second Opinions On Pathology Reports
The need for second opinions can be better understood by considering the case of the pathologist’s report on a biopsy. One of the best discussions of this appears in a book I’ve discussed before, Patrick Malone’s The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.
Mr. Malone discusses the example of surgery to remove a cancer. The issue was whether the surgery was successful. To determine that, the pathologist will look at removed tissue and try to say whether the margins are clean, suggesting that the cancerous cells were removed. The pathologist may also have an opinion on how aggressive the cancer is.
Mr. Malone writes, “What laypeople don’t often know is that these opinions are fraught with possibility for disagreement and outright error, and that’s why getting a second opinion on biopsies — and all other tests, for that matter — is one of the critical nine steps to taking charge of your health care.” Mr. Malone likens it to art critics attempting to decide if a Jackson Pollack painting is genuine. Art critics may debate with passion on that question and their opinions may be all over the lot. By like token, pathologists may also have a range of opinions and demonstrate far less certainty in reaching their conclusions than a casual observer might assume.
Mr. Malone discusses an example, which is loaded with lessons for second opinions. He discusses Sue Carroll (I assume a fictional name used to hide identity), who discovered a lump in her breast. A biopsy showed it was cancer, but a rare one for the breast – a sarcoma. A sarcoma involves less than one percent of all cancers and less than 0.1 percent of all breast cancers.
After receiving the pathology report, her doctor explained it was rare and offered this advice: “The pathologist said it was a very low-grade sarcoma. The margins seem to be clean. There’s not a high likelihood it will pose a problem. Whey don’t we just keep our eye on it, and see what happens?”
One of her friends had advice that may have saved her life. That friend said the pathologist who rendered an opinion probably sees maybe two or three sarcomas a year. So the friend said don’t wait around to see what happens – get an opinion from a pathologists who sees a lot of sarcomas and knows how they should be handled.
The friend helped Sue find a pathologist at the National Institutes of Health who was conducting a study on sarcomas. He agreed to review the slides of the biopsy. The sarcoma expert found:
• It was indeed a sarcoma.
• It was a higher grade – meaning more dangerous – than the [first] pathologist had recognized.
That meant waiting could have been disastrous. Sue had surgery, and after a long course of treatment, fully recovered. Had she not received the second opinion, the cancer most likely would have spread and become untreatable and incurable.
Don’t assume Sue’s case was unusual. Here are the statistics on how often the first pathology opinion is wrong:
• At the University of Michigan, a “tumor board” renders second opinions on pathology reports and found half of patients get a different course of treatment as a result of the second opinion.
• At Johns Hopkins, in one of ten cases, the patients received a major change in the diagnosis and a significant revision in treatment as a result of second opinions on pathology reports.
• A University of Utah Medical School Survey found that there was a significant biopsy diagnostic disagreement in two to five of every 100 cases.
• At another institution, a review of pathology cases found major errors in 12 of every 1,000 cases.
Mr. Malone concludes, “These statistics suggest that many thousands of patients have suffered harm from getting either too little or too much treatment because they relied on the first opinion.”
One institution that gives second opinions on pathology reports is the Armed Forces institute of Pathology. It has 126 pathologists on staff. You can reach it on its Web site at www.afip.org.
Second Opinions On Radiology Reports
Another good example of the need for second opinions involves the whole area of radiology. To get reliable results you need skilled technicians who can run the X-ray or other test correctly; you also need a machine that will give you the fine detail needed for interpretation; and you need radiologists capable of properly interpreting the image.
Mr. Malone gives four red flags suggesting when a second opinion is in order on a radiologist’s opinion:
• The images are read as ‘normal’ but your body is shrieking to the contrary.
• The report shows uncertainty by the radiologists. This can be evident when the report has a lot of ‘on the one hand’ and ‘on the other hand’ with no firm conclusion.
• The report doesn’t address the concerns that led your doctor to ask for the scan.
• The report was issued by a non-subspecialist radiologist.
I ran this column by my brother, Mike, an orthopedic surgeon in California, and he pointed out sometimes the second opinion is built into system. For example, orthopedic surgeons may read the X-rays of their patients, and not simply rely on the conclusions of a radiologist who typically hasn’t seen the patient. He adds that a key precept of medicine is that you don’t treat the X-ray; you treat the patient. In some cases, the X-ray may suggest the possibility of a broken bone, but an orthopedic surgeon who actually sees the patient and examines the patient may be able to rule out a break.
Second Opinions In Surgery
The need for second opinions in surgery should be common knowledge by this point. I started discussing the importance of such second opinions in the early 1970s, when as Pennsylvania Insurance Commissioner, I published a Shopper’s Guide to Surgery. Since then I’ve been writing on the issue. For more detailed discussions of surgical second opinions go to my Web site at www.thedenenbergreport.org. There you will find various guides and columns on surgery.
Mr. Malone summarizes why a second opinion should often be your first choice: “Whenever you stand at a major medical crossroads, you are best off consulting with multiple guides about which way you should travel. Sure, it’s possible that the first person in a white coat who wanders by will know exactly how to guide you to where you need to go. But you will vastly improve your chances of finding the right treatment by seeing what different experts say.”
Conclusions
If in doubt, consider a second opinion. The guidance you get can be of critical importance. In addition, you get educated in the process, and that helps you better ask questions and judge medical alternatives. When you get conflicting second opinions, you might ask the involved doctors to discuss your case and perhaps resolve their differences. You might also ask the doctors whether another opinion or perhaps another line of expertise might help establish what option makes the most sense.
If you need more evidence about the value of second opinions, consider what a famous physician and Harvard Medical School professor went through when he had a severe problem with one of his hands. That physician, Dr. Jerome Groopman, in his book, How Doctors Think, consulted six hand surgeons and got four different opinions. One of the leading hand surgeons, according to Dr. Groopman, didn’t know what the problem was, but instead of admitting that, invented a diagnosis (hyperactive synovium). Dr. Groopman writes, “Dr. A had come to the end of his thinking. But instead of returning to the honesty of ‘I really don’t know,’ he invented something to respond to my plaintive questioning and suggested an operation that could be damaging.” Dr. Groopman finally got the right diagnosis and the right surgical treatment. But his case, described in chapter 7 of his book, shows not only the importance and value of the second opinion (in his case the sixth opinion), but also the complexity and uncertainty that can be generated by multiple opinions. There is no easy answer to medical uncertainty, but one of the best answers is still the second opinion.
Herb Denenberg has served as Pennsylvania Insurance Commission, Pennsylvania Public Utility Commissioner, and the Loman Professor at the Wharton School. Since 1973, he has been a member of the Institute of Medicine of the National Academy of the Sciences, the body that advises Congress on health-care matters. He has frequently testified before Congress on insurance and health care issues.
• First, many people associate it only with surgery. But the second opinion makes sense in many other contexts. For example, when there is a question about a pathology report (Does the biopsy material indicate cancer or no cancer and what kind of cancer does it indicate?), when there is the questions about the radiological interpretation of an X-ray, MRI, CAT scan or other image, when there is a diagnosis of a serious condition with some unanswered questions, or when a course of treatment fails to bring about improvement.
• Second, many people are reluctant to go for second opinions out of fear of offending their doctor, thinking it is a signal that they don’t trust the doctor’s opinion and judgment. Good doctors would encourage a second opinion, and if they discourage one, you should be concerned. At least get the doctor’s reason for not going for a second opinion to see if it makes sense. I suspect you will find it usually doesn’t make sense, and staying with that doctor may not make sense either.
• Third, there is always the question of whether the second opinion will be paid for by an insurance company. It often will be, and in some situations, a second opinion may actually be required by the insurer. If the insurer will not pay for a second opinion, you may have to challenge that denial. Often a persistent patient can reverse a denial. Even without insurance coverage, a second opinion may be a good investment.
• Finally, many patients mistakenly think there is no need for second opinions, and assume a degree of certainty in medicine that simply does not exist.
Second Opinions On Pathology Reports
The need for second opinions can be better understood by considering the case of the pathologist’s report on a biopsy. One of the best discussions of this appears in a book I’ve discussed before, Patrick Malone’s The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.
Mr. Malone discusses the example of surgery to remove a cancer. The issue was whether the surgery was successful. To determine that, the pathologist will look at removed tissue and try to say whether the margins are clean, suggesting that the cancerous cells were removed. The pathologist may also have an opinion on how aggressive the cancer is.
Mr. Malone writes, “What laypeople don’t often know is that these opinions are fraught with possibility for disagreement and outright error, and that’s why getting a second opinion on biopsies — and all other tests, for that matter — is one of the critical nine steps to taking charge of your health care.” Mr. Malone likens it to art critics attempting to decide if a Jackson Pollack painting is genuine. Art critics may debate with passion on that question and their opinions may be all over the lot. By like token, pathologists may also have a range of opinions and demonstrate far less certainty in reaching their conclusions than a casual observer might assume.
Mr. Malone discusses an example, which is loaded with lessons for second opinions. He discusses Sue Carroll (I assume a fictional name used to hide identity), who discovered a lump in her breast. A biopsy showed it was cancer, but a rare one for the breast – a sarcoma. A sarcoma involves less than one percent of all cancers and less than 0.1 percent of all breast cancers.
After receiving the pathology report, her doctor explained it was rare and offered this advice: “The pathologist said it was a very low-grade sarcoma. The margins seem to be clean. There’s not a high likelihood it will pose a problem. Whey don’t we just keep our eye on it, and see what happens?”
One of her friends had advice that may have saved her life. That friend said the pathologist who rendered an opinion probably sees maybe two or three sarcomas a year. So the friend said don’t wait around to see what happens – get an opinion from a pathologists who sees a lot of sarcomas and knows how they should be handled.
The friend helped Sue find a pathologist at the National Institutes of Health who was conducting a study on sarcomas. He agreed to review the slides of the biopsy. The sarcoma expert found:
• It was indeed a sarcoma.
• It was a higher grade – meaning more dangerous – than the [first] pathologist had recognized.
That meant waiting could have been disastrous. Sue had surgery, and after a long course of treatment, fully recovered. Had she not received the second opinion, the cancer most likely would have spread and become untreatable and incurable.
Don’t assume Sue’s case was unusual. Here are the statistics on how often the first pathology opinion is wrong:
• At the University of Michigan, a “tumor board” renders second opinions on pathology reports and found half of patients get a different course of treatment as a result of the second opinion.
• At Johns Hopkins, in one of ten cases, the patients received a major change in the diagnosis and a significant revision in treatment as a result of second opinions on pathology reports.
• A University of Utah Medical School Survey found that there was a significant biopsy diagnostic disagreement in two to five of every 100 cases.
• At another institution, a review of pathology cases found major errors in 12 of every 1,000 cases.
Mr. Malone concludes, “These statistics suggest that many thousands of patients have suffered harm from getting either too little or too much treatment because they relied on the first opinion.”
One institution that gives second opinions on pathology reports is the Armed Forces institute of Pathology. It has 126 pathologists on staff. You can reach it on its Web site at www.afip.org.
Second Opinions On Radiology Reports
Another good example of the need for second opinions involves the whole area of radiology. To get reliable results you need skilled technicians who can run the X-ray or other test correctly; you also need a machine that will give you the fine detail needed for interpretation; and you need radiologists capable of properly interpreting the image.
Mr. Malone gives four red flags suggesting when a second opinion is in order on a radiologist’s opinion:
• The images are read as ‘normal’ but your body is shrieking to the contrary.
• The report shows uncertainty by the radiologists. This can be evident when the report has a lot of ‘on the one hand’ and ‘on the other hand’ with no firm conclusion.
• The report doesn’t address the concerns that led your doctor to ask for the scan.
• The report was issued by a non-subspecialist radiologist.
I ran this column by my brother, Mike, an orthopedic surgeon in California, and he pointed out sometimes the second opinion is built into system. For example, orthopedic surgeons may read the X-rays of their patients, and not simply rely on the conclusions of a radiologist who typically hasn’t seen the patient. He adds that a key precept of medicine is that you don’t treat the X-ray; you treat the patient. In some cases, the X-ray may suggest the possibility of a broken bone, but an orthopedic surgeon who actually sees the patient and examines the patient may be able to rule out a break.
Second Opinions In Surgery
The need for second opinions in surgery should be common knowledge by this point. I started discussing the importance of such second opinions in the early 1970s, when as Pennsylvania Insurance Commissioner, I published a Shopper’s Guide to Surgery. Since then I’ve been writing on the issue. For more detailed discussions of surgical second opinions go to my Web site at www.thedenenbergreport.org. There you will find various guides and columns on surgery.
Mr. Malone summarizes why a second opinion should often be your first choice: “Whenever you stand at a major medical crossroads, you are best off consulting with multiple guides about which way you should travel. Sure, it’s possible that the first person in a white coat who wanders by will know exactly how to guide you to where you need to go. But you will vastly improve your chances of finding the right treatment by seeing what different experts say.”
Conclusions
If in doubt, consider a second opinion. The guidance you get can be of critical importance. In addition, you get educated in the process, and that helps you better ask questions and judge medical alternatives. When you get conflicting second opinions, you might ask the involved doctors to discuss your case and perhaps resolve their differences. You might also ask the doctors whether another opinion or perhaps another line of expertise might help establish what option makes the most sense.
If you need more evidence about the value of second opinions, consider what a famous physician and Harvard Medical School professor went through when he had a severe problem with one of his hands. That physician, Dr. Jerome Groopman, in his book, How Doctors Think, consulted six hand surgeons and got four different opinions. One of the leading hand surgeons, according to Dr. Groopman, didn’t know what the problem was, but instead of admitting that, invented a diagnosis (hyperactive synovium). Dr. Groopman writes, “Dr. A had come to the end of his thinking. But instead of returning to the honesty of ‘I really don’t know,’ he invented something to respond to my plaintive questioning and suggested an operation that could be damaging.” Dr. Groopman finally got the right diagnosis and the right surgical treatment. But his case, described in chapter 7 of his book, shows not only the importance and value of the second opinion (in his case the sixth opinion), but also the complexity and uncertainty that can be generated by multiple opinions. There is no easy answer to medical uncertainty, but one of the best answers is still the second opinion.
Herb Denenberg has served as Pennsylvania Insurance Commission, Pennsylvania Public Utility Commissioner, and the Loman Professor at the Wharton School. Since 1973, he has been a member of the Institute of Medicine of the National Academy of the Sciences, the body that advises Congress on health-care matters. He has frequently testified before Congress on insurance and health care issues.
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Bruce_S wrote on Jan 6, 2010 7:09 AM:
1. The Importance of Second Opinions for Sarcoma http://is.gd/sDrU
2. The Importance of Treatment at a Specialty Center for Sarcomas http://is.gd/ldGd
Bruce "