Medical Consultation Additional Opinion

     

    For many patients, and most acutely among those with rare / complex / interactive conditions, there arise difficulties in the diagnosis, treatment and management of such health concerns. In some instances, multiple subspecialists may be involved and – through no fault of their own – may be unaware of what other experts are considering and recommending. It is for this reason that many patients may seek an additional individual to ‘quarterback’ their care or provide an additional (“second”) consultative opinion.

    Personally, I seek to avoid the use of both the ‘quarterback’ and the ‘second opinion’ terms. Having a quarterback implies one individual in charge of clinical planning and decision making. A more constructive term would be ‘advocate.’ Further, a ‘second opinion’ implies a lesser weight than a ‘first opinion.’ So a more constructive term would be ‘additional opinion.’ All of these efforts do fall under the general rubric of Consultative Medicine.

    Internists are often asked to provide an independent evaluation of a patient in several different contexts – perhaps the most common ones being prior to surgery – but also in the consideration of chemotherapy, biologics or other treatments that could have significant side effects.

    Patient Advocacy (‘Quarterback’ of Care)

    For those patients feeling overwhelmed with the volume or complexity of information being presented to them, an independent advocate (‘quarterback’) might be of significant clinical and emotional benefit. A recent summary paper by Drs. Delbanco and Gerteis identify seven broad dimensions of care of most concern to patients. These are:

    • Respect for patients’ values, preferences, and expressed needs
    • Coordination of care and integration of services within the clinical setting
    • Transparent communication among patient and clinicians: dissemination of accurate, timely, and appropriate information, and education about the long-term implications of disease and illness
    • Enhancing physical comfort
    • Emotional support and alleviation of fears and anxiety
    • Involvement of family and friends
    • Transition and continuity from one locus of care to another

    Four of these seven areas of concern all involve communication and dissemination of information. Commonly referred to as the ‘voltage drop’, information is most often lost in moments of transition of care or between care providers. Having one core professional able to receive, review and update a patient’s health records with new information is critical to the coordination of are. Ranging from allergy testing, to a screening colonoscopy or a new cancer diagnosis, these reports are examined and incorporated into a comprehensive plan. With electronic records, technology can give us almost immediate access to overwhelming amounts of information. Yet communication entails more than access to information. It encompasses the transmission of information, thought, and feeling, such that it is satisfactorily received and understood in context. In these instances, we will proactively reach out to patients to review results and arrange for any needed follow-up.

    Family members, close friends, and significant others can have far greater impact upon patients’ experience of illness and on their long-term health and happiness than can any health care professional. It is for this reason that we welcome family members to attend patient visits, or will provide updates (with the patient’s permission of course!). 

    Additional (‘Second’) Opinion

    When dealing with a complex medical condition, the diagnosis, treatment and management can be complicated, and making decisions about your health care is important. Getting an additional opinion can help you feel more confident about your diagnosis and treatment plan. In my primary care practice, I welcome the input of an additional opinion, both from a generalist approach as well as from a subspecialist. With any case that has nuance, there may be some disagreement across the treatment team but, without question, that process of debate and consideration will lead to an enhanced treatment plan for the patient.

    There are many reasons why you want to seek another opinion during the course of your care. Maybe you don’t feel confident in your doctor’s ability to treat your condition, or you have a rare or unusual condition. Or your condition isn’t responding to the current treatment. Taking the time to learn about your condition, and getting a second or third or fourth opinion is a reasonable approach. Proactive decision-making will give you a greater degree of control over your treatment. It also permits you to make decisions regarding your health after you have been thoroughly informed about your diagnosis, prognosis and available treatment options.