Sunday, July 21, 2013

Asking For Help

Primary care physicians often refer their patients to specialists, say a cardiologist,  for what is simply known as a consultation.  If the doctor or patient is unsatisfied with the consultation, a second consultant might be  brought in for what is called a second opinion.  On rare occasions,  an internist might refer a patient to another internist for advice and consultation.

While the primary doctor usually orchestrates the referral, patients sometimes do it themselves.

A second opinion might be invoked when someone has been advised to have a major operation.  Or, it might be invoked in an unusually complicated case where the primary physician and his/her consultants are out of ideas.

The selection of the doctor to give a second opinion can be fraught with biases.

Consider the following.  If the patient makes the choice, it is often influenced by family and friends who can be easily moved by the celebrity of a consultant, or their personal experience with him/her,  rather than objective performance measurements such as post operative complication rates.  

When the primary doctor picks the consultant, it is often someone in their own group.  This introduces a financial bias where keeping the fees in house might trump inviting a consultant from another organization, who might be more qualified to weigh in on the case.   

If the ordering doctor picks a colleague from their own group, there are at least two more important concerns. The doctor giving the second opinion might be reluctant to disagree with care rendered by someone who is in their personal, clinical and financial orbits.  Additionally,  there is the matter of herd mentality (common in groups and hospitals) where physicians, with social and clinical ties, tend to manage certain problems uniformly, making it less likely that alternative approaches will be considered.

Surprisingly, internists almost never ask internal medicine colleagues for formal consultation.  This is unfortunate since another internist, with a panoramic view of medicine, might be of much greater service in mysterious or complicated cases than a squadron of sub-specialists who tend to look at cases through a single lens. 

My years in medicine have shown me that a consultation or second opinion, centered in knowledge and a wide ranging experience, is often, in tough cases, more valuable than endless testing, which tends to get more and more  incoherent as time goes on. 

Sound judgement is vastly superior to rampant testing, which once unleashed,  tends to generate more smoke than light.

In good hands the second opinion (a third opinion is almost never a good idea) is often clarifying and reassuring for both patients and doctors.  Bias should be kept to a minimum and doctors and patients should work together in picking a consultant.


  1. A second opinion from a respected physician can have a healing effect. This is even more the case when the referring physician is supportive of the patient's request to seek a second opinion.

    1. Yes, I agree with Cha Sen. it's important to give the patient unambiguous support in getting a second opinion as it leaps over the trust issue and paves the way for good communication between the primary care doctor, patient and consultant.