February 12, 2008
New York Times

Second Opinions, Through a Patient’s Eyes.

By ROBERT KLITZMAN, M.D.

"When I went for a second opinion, my internist got mad,” a physician with lymphoma recently told me. "As if I were his lover and had cheated on him."

The reaction may be extreme, but it is far from uncommon. Second opinions have undoubtedly saved many lives and are likely to gain in importance with the growing public focus on medical errors. But they can be awkward for doctor and patient, and surprisingly little is known about them.

Some studies have examined the frequency and efficacy of second opinions related to invasive procedures like biopsy and cancer surgery. Rates of discrepancies between doctors vary, and for the most part they do not lead to changes in treatment. For 30 percent of patients who voluntarily seek second opinions for elective surgery and 18 percent of those whose insurance companies require it, the second doctors disagree with the first.

Little research has been done on how often second opinions occur in more routine practice — how, when and why patients decide to obtain them, the obstacles and how they overcome the obstacles.

Although insurers require the consultations for certain procedures, they refuse to pay for them in many other cases. Cost cutting may make such consultations even rarer, while patients surfing the Web may find information that leads them to question their doctors more.

Recently, I have been interviewing physicians who themselves were patients with serious illnesses and who saw both sides of the issue. Repeatedly, they said professional etiquette often operated against second opinions, standing in the way of optimal treatment.

Even so, many of these ill physicians sought such second, third, fourth and even fifth opinions, consulting experts nationally, even if they had previously been wary of their patients’ pursuing such consultations.

They became more aware, too, of the complexities. When a patient obtains multiple opinions, confusion can arise over who is responsible in the end. Several of these physicians had treated other ill doctors and at times asked: “Am I still your doctor? Or are you now seeing them over there? Or just talking to them?”

Some wanted to self-doctor, and did not really want a doctor but were just “doing serial consultations” hoping to find a colleague who would agree with their judgments.

Many of these physicians had felt it was important to respect authority, that they should simply choose a physician they trusted and abide by that doctor’s decisions. But when they became patients, they realized that this taboo on questioning colleagues could undermine responsibility to help patients as much as possible. At times, they made nuanced decisions based on the magnitude of the problem, obtaining a second opinion just for truly major procedures.

Even when second opinions were deemed acceptable, third opinions were generally not. The disease and proposed treatment mattered; some involved increased risks.

These doctors also had to decide whether to provide second opinions for friends, family members, patients and others. Some felt that they would not pursue second opinions themselves, but that others had a right to do so.

When insurers do not cover a second opinion, patients usually cannot afford to pay for them. That is unfortunate, because the results may be worse care and unnecessary procedures — prospects that highlight the need for more research in this area. At times, when patients have told me they want another opinion, I have felt a twinge of defensiveness. But I always went along. After all, as patients have said to me, “If I hadn’t seen another doctor, I would have died.”

I hope more doctors and policy makers don’t first need to become patients themselves to have the profession and the insurance industry take a second look at second opinions.

Dr. Robert Klitzman is a psychiatrist at the Columbia University Medical Center and the author, most recently, of "When Doctors Become Patients"