Second Opinions

Ok, last time I posted here, I promised I'd write about how to get the most out of a second opinion. To do this, I did something a little novel - and so it took me longer than I expected. While I have pretty strong opinions on how to get the most out of a second opinion, I queried a lot of doctors from around the country to see what they would advise.


I have to say, overall, I was a little disappointed. Most of the responses were some variation of "send the patient to me."


Most advice was also not very helpful. A lot of the advise was almost opposite from the advise of other physicians.


To be fair, not all the people who responded were reproductive endocrinologists, so they may be quite in tune with the issues infertility couples face.


However, of the people I polled, there were some excellent points and issues to consider.


Why Get a Second Opinion?
There are many reason patients consider a second opinion. Frequently, in our field of medicine, it’s because a person did not have success with their previous provider, because they were given difficult news with few acceptable options, or simply because they did not mesh with their first provider. Sometimes, it seems some people get a second opinion because it’s just what they do… they like more than one opinion.


How to prepare for a second opinion:
1) First identify why you are seeking a second opinion (be aware of your agenda).
2) Be aware that your first and your second doctor may have an agenda, too.
3) Gather your records and get them to the physician ahead of time if possible.


Agendas are critical.

Agendas may completely alter the advice you receive.

First, the patient’s agenda: Almost every patient has a reason for getting a second opinion. Nearly every doctor I polled said that patients should know why they want a second opinion. If it’s because they just didn’t get the answer they were looking for from the first doctor, the patient needs to recognize this and keep this in mind when seeking a second opinion.


It has been said that the very poor and the very wealthy are at greatest risk for receiving the worst medical care. The poor have no access. The very rich can doctor shop until they find physicians who will do whatever the patient wants. Michael Jackson could always find yet another surgeon to carve him up or help him sleep. If you're just looking for someone to tell you what you want to hear, you should be aware that this can lead to sub-optimal treatment.

My advice to patients is, to the best of your ability, don’t tell the doctor your agenda until he or she gives his opinion.

Here is why.

There have been many times when patients come to my office for a second opinion and it is very apparent that they simply did not like what they heard from their first physician.

If I realize that the patient is very unhappy with the first doctor because of the opinion, I have a tremendous advantage compared to the first doctor. I already know what information, or what type of information that a patient does not like to hear. Simply agreeing with a patient’s preexisting biases may strongly influence the way the patient feels about my advice.

I would like to think this knowledge does not influence my opinion or how I relay information to a patient. I hope that’s not wishful thinking.

If I don’t know a patient’s agenda, then there is no opportunity for me to be influenced by this.

Knowing which advice is the best is not always easy. These are not fool-proof clues to which advice is best, but here are my suggestions:

*Did each doctor support their opinion, with evidence from the medical literature?
*Did each doctor explain the diagnosis to your understanding?
*Were you given a full range of options and the likelihood of each being successful?
*Does the doctor’s advice make sense?

The Doctors’ Agendas
Dr. Deane Waldman, of the University of New Mexico Health Science Center said that physicians providing a second opinion would ideally just be providing an opinion and not be gaining financially from such an opinion.

I frequently tell patients this, too. If a physician has nothing to gain from giving the opinion, he or she, is less likely to be influenced by his or her own gain. This kind of opinion is least likely to be biased.

So how does the patient learn if the doctor has an agenda?

In general, physicians in our field of medicine should really be providing you with information to help you make the very best choices. If their advice is good, they should not be threatened by the thought of you getting a second opinion.


Red Flags
There are certain circumstances when a first or a second opinion should cause you concern. (Preston Parry, an REI at the University of Wisconsin pointed out some of what follows below.)


1) False choices: I have encountered patients who have been told they either need donor sperm or in vitro fertilization. One couple had actually had two previous pregnancies over the past two years. In this case, the recommendation was made on the strength of a minimally abnormal semen analysis. (Clue 1: this advise didn't make sense, based on the patient history. Clue 2: a minimally abnormal result, even a moderately abnormal does not always mean extreme measures need to be taken.)


2) Only the positives are discussed. Every treatment has advantages and disadvantages. If you are offered only one treatment and the physician does not volunteer the disadvantages and advantages of all the options, then be wary. This is not to say the doctor is incorrect. But unless you really understand the upsides and downsides to all treatments, how can you make an informed choice?


3) It's Natural: the doctor suggests an array of supplements/holistic medicines. (Trying to prove that their practice is more thorough; the reality is if these things had a dramatic effect, everyone would be using them.)

4) It's what we do: the doctor suggests protocol modifications, but can’t say why it is appropriate through evidence-based medicine. (“We do it that way for everyone,” is not science, it’s opinion.)

5) Only We Syndrome: the doctor claims that he or his group has a unique procedure that only he can perform.


6) Cherry picking: This is a common concern among REIs (reproductive endocrinology and infertility specialists). There are some clinics which report extremely high success rates by age group. There is a suspicion among some REIs that some of these clinics are only treating good prognosis patients and trying to funnel poor prognosis patients toward egg donation. Without naming them, I will say this: I have referred some young, fairly poor prognosis patients to certain clinics for a second opinion and they have been told things like, "We wouldn't do a better job than your local docs." This is code for "we don't want you to hurt our statistics." Even if you are poor prognosis, a good clinic will give you realistic odds and should still let you proceed with care as long as you understand the chances and the treatment is not overly dangerous for you.



Conclusion:

Second opinions can be tricky. Ultimately it will come down to a matter of trust. If you get a second opinion, be sure that the physician fully explains why a recommendation is being made. If he or she can't explain it to you so that you understand it, then it likely is not the best choice for you.

If an alternative treatment is suggested, the relative advantages AND disadvantages should have been discussed with you.


You can ask your referring provider what their experience has been with the doctor. Ask your friends. Watch for red flags. And, ultimately, if all else fails, you should trust your instinct.