The art of the second opinion

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Second opinions are tricky. Patients who seek them often have complex conditions, and physicians must exercise caution when delivering them to avoid further confusing patients who are already conflicted. 

And while it may seem self-evident to say that patients have a right to seek a second opinion regarding their medical care, it's often important for physicians to remind them of this right, as fear of offending their original provider makes some patients reluctant to ask for a referral. 

But "patients owe it to themselves to get the most up-to-date and consistent information possible to provide themselves with the best options for treatment," said Jeff Bahr, MD, chief medical group officer of Downers Grove, Ill., and Milwaukee-based Advocate Aurora Health. 

"As physicians, we expect our patients to seek second opinions, especially for nonemergent illnesses such as rare diseases, cancer, heart conditions and neurological conditions," Dr. Bahr told Becker's.

Moreover, research has shown second opinions lead to some level of change for the majority of patients who seek them. A Rochester, Minn.-based Mayo Clinic study from 2017 found as many as 88 percent of patients who sought out a second opinion at the health system left with a new or refined diagnosis that changed their care plan. 

Since second opinions have high-stakes potential to change patient outcomes, Becker's spoke to four physicians about best practices for navigating them. 

Emphasize the patient's right to seek a second opinion

Some patients are hesitant to seek a second opinion, making it imperative for physicians to support their right to do so, said Neveen El-Farra, MD, a professor of clinical medicine at the University of California Los Angeles and medical director for international services at UCLA Health. 

"Physicians will not be offended. We have to do a better job ensuring we are supportive of their choices," she said. "Physicians must emphasize the fact that this is your health, your body." 

For patients who seem to have lingering doubts or concerns, an added boost of encouragement can be helpful and make them feel more comfortable initiating the second-opinion process. 

"When there's not a clearly superior treatment option or when I sense hesitancy from the patient, I try to remind them that they are welcome to seek another opinion," said Eileen Crawford, MD, associate director of the orthopedic surgery residency program at Michigan Medicine in Ann Arbor. "I think it means a lot to hear that from the physician, and in many cases that gesture alone alleviates their doubts," she said. 

Physicians must be keenly aware of their demeanor when responding to patient hesitancy to ensure they don't inadvertently add stress to an already delicate situation. 

"There's so much fear," Dr. El-Farra said. "Our role is to alleviate fear, make it less overwhelming and give patients options, peace of mind." 

Helping patients understand the complex nature of medicine 

"Patients who seek second opinions usually have complex issues that don't have clear-cut solutions, so being conflicted is expected to some degree," Dr. Crawford said. 

In medicine, there's often more than one interpretation of a problem, and it's part of a physician's job to help patients understand this to avoid confusing them, Dr. Crawford explained. Thus, physicians delivering second opinions should overtly communicate the dynamic nature of medicine and focus on why they believe their diagnosis or treatment plan is in the patient's best interest, and explain the evidence behind it. 

"Comparing it to other [diagnoses] and treatment options is helpful for the patient as well," Dr. Crawford said. 

When delivering a second opinion, it's critical to describe the circumstances surrounding the diagnosis and the evidence available at the time.

"It's important to recognize that medical opinions are based on all the information available at a given time and that we are able to affirm a prior opinion, augment it or even disagree with it in the most professional of ways," Dr. Bahr said, noting that physicians must acknowledge that the same resources or experiences may be viewed differently by the clinician providing a second opinion.

And while physicians who deliver second opinions frequently agree with the initial opinion of another provider, "we try to walk the patient through the risks and benefits of each of the opinions offered" in the case of disagreement, Dr. Bahr said. 

"Every option is carefully considered, and we focus on personalizing the medical options provided. Ultimately, we want the patient to make a decision that is best suited for him or her and collaborate to guide individuals toward the most suitable option," he said. 

A physician's word choice is especially key at this time and can help maintain the integrity of the first physician. 

"You don't want to offend or put down any other specialist," Dr. El-Farra said. "I would never use the language that they were wrong." 

Dr. El-Farra uses language that doesn't dismiss what the other physician said, but emphasizes that it was their opinion, and she has a different opinion. She tends to use phrases such as, "In my opinion, after reviewing all the records," "Yes, but from my standpoint," and, "Based on the information I have, this is what I recommend."  

Focus on the path forward 

Sometimes, to move forward, things in the past must be minimized. 

Subtle differences between physicians should be de-emphasized, according to Jenny Chang, MD, director of the Houston Methodist Cancer Center and Emily Herrmann Chair in Cancer Research in Houston. It's rare that a patient treatment plan is just plainly incorrect. Remembering the patient comes first will help the second physician realign the treatment plan accordingly, Dr. Chang said.

Dr. El-Farra underscored the need for constant assurance from both herself and other members of the medical team. Sometimes she calls in additional specialists to boost patient confidence. She also highlighted the importance of physician-patient communication and picking up on patient body language and facial expressions. 

"If they look conflicted, I just take more time to go through everything with them and give reassurance, whether it's data, answering questions or bringing in another specialist," Dr. El-Farra said.

"These discussions with the patient need to be thoughtful and mindful of these long relationships that he or she may have had with their initial physician," Dr. Chang advised. She noted that while it is very rare that a previous treatment was harmful to the patient, it does happen, and such situations require additional skills to navigate. In that situation, physicians should establish a treatment path forward without embellishing past missteps. 

"It is more important to look forward in the treatment plan and not backward," the physician said.

"I welcome patients who want a second opinion for me so that we can evaluate the different strategies that may be available," Dr. Chang said. "Additionally, in some academic centers, the availability of clinical trials which may further the understanding of the biology of the disease and hopefully, better the outcomes for patients is critical for patients seeking a second opinion."

Patient-centered care — always

"A physician's ego shouldn't be a main determinant in treatment decisions for patients," Dr. Crawford said. "I truly believe that patients do best when they're comfortable with the treatment plan and don't have lingering doubts or questions."

Physicians should always ask each patient about their goals and priorities, rather than making assumptions, to help guide them to the path that's best for them.  

The bottom line is simple — the most important part of care is the patient. Focusing on the patient, not another physician, will help physicians give the best diagnosis and care.

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