Wednesday, September 18, 2013

Second Opinions

Paul Levy has another interesting post on the value of second opinions.  He says:

Simon Schurr at Collaborative Medical Technology Corporation suggests in this blog post that current levels of overtreatment and inappropriate care could be reduced by more widespread and judicious use of second opinions.  He points to unnecessary surgeries, overtreatment of back pain, mistreating ovarian cancer, and outdated procedures.

His diagnosis: "The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment."

His solution:  "The best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions."

My response:

Here, here!
Years ago I advocated (in the first ever Sounding Board section in the NEJM) for patient access to medical records, partly reasoning that if medical records got a wider circulation, their quality would improve, because clinicians would know that what they wrote could be seen by others.  Now, EMR serves the same purpose, as does the growth of group practices generally, where you know that your colleagues will sometimes see your patients and read your notes and judge.
Likewise, it's possible that even the knowledge that your patient would likely be seeking a second opinion would be very bracing.  When our pediatric practice seemed to have an excessive number of referrals to specialists for one HMO. I announced that I would be reviewing all referral requests from our group before they went out.  Instantly, the number of requests dropped, just from the knowledge that they would be reviewed.  I then had to send back the referral request for reconsideration by the clinician only rarely; just the existence of the review process did the job -- as expected.
Moreover, if you consider Groopman's How Doctors Think, you immediately are impressed with the desirability of second opinions,  to avoid the cognitive error of anchoring, if nothing else.
Here's another example.  A doctor friend of mine had a father-in-law, I think it was, who was sick for years and years without a diagnosis.  By chance, my friend and his father-in-law were walking around the halls of Dartmouth Medical Center and a doctor friend of my friend saw them, walked up to them, and said to the father-in-law, "You have hemochromatosis!"  He could just tell by the look.  After years without a diagnosis.  A single doctor just can't know everything.
Or, consider this.  Just two days ago I was at our health club and a 76 year old friend came up to me.  He had pneumonia almost a year ago and has never really recovered, he thinks.  For the last few weeks he has felt really, really tired.  He's worried -- as he should be.  He asked me about a second opinion -- from an internist, he specified -- because his regular doctor (who is in fact an internist), who he likes, hasn't pinned down anything.  Is his doctor saying subconsciously to himself that my friend Arthur has just run out his string?  Is he out of ideas?  What?  I don't know.  But I urged Arther to in fact get a set of fresh eyes on him -- take up the case from the beginning!  Why not?  Visits are cheap.
Finally, while we have many specialists in many fields, what we really don't have is a super specialist in internal medicine.  When I did my medical school internal medicine rotation at the Beth Israel we had an attending who was revered for his differential diagnosis acumen (Manny something).  His visits were prized, as various residents sought help, and to stump him.  The Chief Residents sought to emulate him.  But what happened to these Chief Residents when they moved on out of training?  Chief Residency was the best training possible for a job that didn't, and doesn't, exist.  You either go to a recognized specialty, or you go into primary care, which really presents a different set of circumstances than Chief Residency.  (For one thing, primary care puts a premium on prevention, which internists generally do not excel at, nor are they well trained for, etc.)
What we need is an institutional setting for the master internist, someone to turn to, or a set of doctors to turn to, who are really smart.  They wouldn't have to give primary care, and their field would feature breadth, rather than the depth of the recognized specialties.  These would be great for second opinions.
I guess you could do the same thing for surgery, but that's a more complicated issue.

And to reiterate: visits are cheap - it's the procedures that are expensive.

Budd Shenkin

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