Is second opinion a healthy strategy?
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Seeking a second opinion is currently a cloak and dagger act. Laden with fear and guilt. We take multiple opinions in many aspects of our lives without using this loaded term. It is perfectly understandable in healthcare, which involves life and death
Sanjay Nagral
June 19. 2023, Hindustan Times
It usually unfolds somewhat like this. The patient and family are seated in front of me with a big sheaf of papers. I ask questions about the illness, examine them, go through the investigations including X-ray images. Then give my views on the treatment options. In my area of specialisation, this often involves discussing pros and cons of alternative methods. Of course we also discuss the uncomfortable area of costs. And then I invite questions. When we are about to conclude, someone from the family who is exchanging glances musters courage to say ‘Hope you don’t mind doctor but we have already seen another specialist’. ‘Not a problem,’ I say, ‘Can I see the papers’? These are often in a separate file which has till that moment been hidden away. Slowly these are put in front of me. While I go through them, someone from the family is often saying, ‘Don’t worry doctor we will go by your opinion’, ‘We went to this doctor because a relative forced us to’, ‘You don’t have to take this opinion seriously’. What follows is somewhat variable. Sometimes I agree with my colleague’s opinion, at other times I don’t. Occasionally I offer to talk to the colleague. Often the patient is back for further treatment, other times I don’t hear from them.
Seeking a second opinion is currently a cloak and dagger act. Laden with fear and guilt. I suspect most often, patients and families don’t reveal that they have or are seeking other opinions to their doctor. There is an obvious reason for this. It clearly doesn’t go down well with many doctors. They are offended often to the point of reprimanding the patient. And no patient wants their doctor to be angry. In fact, it’s commonplace for doctors to talk derisively about what’s called ‘doctor shopping’. It’s one of the reasons for the growing distrust . Does it have to be like this? Is second opinion a healthy strategy? Is there a correct way of doing it?
I am acutely aware that this discussion is irrelevant to the large majority of our citizens for whom getting access to decent treatment is the main challenge. Who seek care from their nearest doctor. It also may not be relevant for common, straightforward illnesses. But it is increasingly pertinent to many illnesses. Especially when treatments are becoming complex, invasive and costly. Knee joints needing replacement, stenting for coronary artery disease and the increasingly complex world of cancer care. Or when abnormalities are picked up incidentally. Faced with a difficult choice it is intuitive to seek more than one opinion. We take multiple opinions in many aspects of our lives without using this loaded term. It is perfectly understandable in healthcare, which involves life and death.
Modern medicine is no longer a simple take-a-pill affair. Treatment is increasingly complex and multiple competing therapies with advantages and downsides need consideration. It is possible that a second doctor may pick up a nuance or option which the first may not have. Also the treatment methods may belong to different fields. For example, a surgeon may feel that a cancer is best treated surgically. On the other hand, a radiotherapist may see it differently and may be of the view that it is less damaging to treat with radiation. In several cancers, combining multiple therapies - say chemotherapy and surgery - has been clearly shown to be of long-term benefit. Therefore in modern cancer treatment centres, a multi-disciplinary team approach is the standard way of planning treatment. This is not exactly ‘second’ but ‘combined’ opinion.
Uncomfortable as it sounds, medicine is riveted with inherent conflicts of interest and biases. In private medicine, this mainly involves monetary incentives. A second opinion could reduce this bias. Mechanisms to take an opinion from someone who will not directly benefit from a given treatment are hence gaining popularity across the globe. Online platforms are partly doing this. Tata Memorial Hospital has an online second opinion service called Navya for cancer. It is now possible to seek opinions from institutions abroad though these are expensive. In an area where information asymmetry is severe, it’s not easy to distinguish between bias and unbiased opinions. Accessing reliable information on the internet from validated sites is one option.
What is to be done if multiple opinions don’t match? Can the two doctors confer and come to a collective decision. This is difficult in a hyper competitive environment. It is unlikely to happen. How does an ordinary patient then decide which pathway to follow? Will it confuse them more? Will it delay treatment? These are all possibilities. Moving towards opinions which are transparent and free of incentivisation is a major challenge. But we have no choice but to seek strategies to do this for what is at stake is the well-being of patients. Our own.
Second opinion is a personalised response of those who can afford to do it. And often with a backlash from the medical establishment. Collective actions towards rational unbiased care may be better. Citizens need to demand and create access to impartial information. The internet and even artificial intelligence are full of possibilities.
Across the world, more and more patient groups are beginning to address this area. Fellow sufferers are empowering each other. By creating support groups. Sharing experiences. Spreading reliable information. Engaging with the medical profession and the state to demand appropriate care. Those who have skin in the game are likely the least biased. Everyone else is compromised in greater or lesser measure. Remember Covid?
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