A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a “second opinion.” This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.
Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.
On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.
Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.
What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.
Examining a “top doctors list” can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.
The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a “physician-trustee” can be a primary care physician with whom the patient has a solid relationship.
Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.
Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.
Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.
Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.
This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.
Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.
The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.