Showing posts with label second opinions. Show all posts
Showing posts with label second opinions. Show all posts

Tuesday, December 12, 2017

Second opinions

When should I get a second opinion?

In our era of increasing medical specialization, it is sometimes a good idea to get additional medical opinions from experts in specific fields. It is unreasonable to expect any single doctor to know everything. There may be several reasons for seeking a second opinion.

Here are some situations that may lead you to get a second opinion:

• Just a feeling that something doesn’t seem right to you.
• The response to treatment isn’t what you’ve been led to expect
• Your doctor has told you something (or you think he has) that conflicts with information from another doctor or study you’ve read
• You want another opinion regarding a controversial issue (e.g., adjuvant vs salvage radiation, intermittent vs continuous hormone therapy)
• You want to explore a specific new or experimental diagnostic technique or treatment (e.g., CDUS, mpMRI, focal ablation, hyperthermia, etc.)
• You want a more aggressive protocol – something beyond the standard of care.
• You have a rare type of cancer (e.g., neuroendocrine) and want advice from an experienced specialist.
• You want another set of eyes or a confirmation on your biopsy slides, pathology, or radiology results.

The first second opinion we should all get is an expert opinion on our biopsy slides. The pathologist at most hospitals must be a jack of all trades. He has to be able to assess all kinds of tissue samples from cancers as well as all other diseases. Consequently, it would be unreasonable to expect them to be expert at reading a prostate biopsy. It is as much an art as a science, and even practiced pathologists looking at the same slide may differ. Unlike pathology labs in most hospitals, Jonathan Epstein's lab at Johns Hopkins has pathologists who specialize in reading prostate tissue samples. Their opinions are widely held to be definitive. The out-of-pocket cost may be in the $300 range (insurance may not cover it), and it is a simple matter to call your urologist to forward the slides to them. Here is the link.

The other diagnostic technique where a second opinion may change your treatment is multiparametric MRI (mpMRI). There has been a surge in popularity of mpMRIs and they seem to be offered by new facilities every day. The downside is that these are notoriously difficult to read. Experienced “rockstar” radiologists may score them differently from neophytes, and there is considerable inter-observer variability. If you are confident that a “rockstar” read yours, all well and good. If you got yours at a facility that recently began offering them, you may want the DVD sent to a rockstar for a second opinion.

Color Doppler Ultrasound (CDUS) is another imaging technique where years of training make a difference. There is a dynasty of CDUS readers who have mentored pupils starting with Dr. Lee. He taught Dr. Bahn, who taught Dr. Ukimura. I’ve had the opportunity to watch Dr. Bahn in action, and can attest to the artistry involved.

Who do I get second opinions from?

Many of the same techniques mentioned in the blog  “Finding the right doctor,” may be useful in finding the right doctor for a second opinion. 

One aspect to consider is whether you want an opinion from an unrelated doctor at an unrelated institution. If you are suspicious of something your doctor has told you, you may not want him to recommend the doctor for the second opinion. For example, I spoke to a man who had detectable yet stable PSA after his RP. His pathology Gleason score was 6, negative margins, no EPE or SVI. His urologist recommended salvage radiation, and a second urologist at the same practice who took an MRI concurred. He then went to a large tertiary care facility, and an MRI there revealed a “huge” chunk of prostate tissue left behind – something his first urologist failed to mention on the surgery report, and the second urologist did not mention on the MRI report, only noting a small amount of residual tissue. I don’t mean to imply that most urologists are like those two, but I’m only suggesting that an unrelated second opinion has the imprimatur of impartiality.

I think many tertiary care facilities have “tumor boards” that meet periodically to discuss difficult cases. You may be getting the benefit of some of the great practitioners in the field, and also some “out-of-the-box” thinking from experts in related disciplines. This is one of the advantages to treatment at large tertiary care facilities.

How do I tell my doctor?

Doctor’s are professionals. Approach them with the respect they deserve, and most will respond in kind. I’ve never heard of a doctor objecting to getting a second opinion – they are trained to value them. As long as you don’t take a confrontational stance, he will probably be fine with it. Also, avoid “shopping” until you get the opinion you decided in advance you wanted to hear. Doctors have been known to drop patients for doing that. Just as you expect your doctor to keep an open mind, he has a right to expect the same from you.

Other second opinion issues

• How do I resolve two conflicting opinions from equal experts? 
• Will my insurance cover it?
• What if my doctor won’t follow the second opinion?
• What if I don’t like the second opinion?