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It’s urban legend that the second opinion is the correct one. We’ve all given second opinions and had patients who seek them. Yet, if the first and second opinions don’t align, how does the patient know which one to take?
Patients seek second opinions for a variety of reasons. One of the most common is a breakdown in communication. Patients report that the doctor didn’t listen to their concerns, didn’t explain the procedure, or was rushed. Sometimes patients don’t want to accept the initial recommendation and are looking for alternative advice. I recently saw a patient for a third opinion who simply did not want to have glaucoma surgery despite high pressures and a deteriorating visual field. She was looking for someone to agree with her plan.
Often, the second or third physician seems better informed or a better communicator, but this characterization can be unfair. As patients process information and hear things again, they gradually accept the advice and understand the disease and its treatment. A good tactic is to ask patients why they are seeking a second opinion and then to clarify exactly what they hope to achieve during the consultation. A well-known customer service strategy is to ask, “Were all your concerns addressed?” It’s common that patients feel more comfortable with the second physician because they have the chance to articulate their concerns, not necessarily because the care is better. However, some physicians are simply better communicators—and, sometimes, a different physician is a better personality fit for a patient.
While the second opinion is often an exercise in reassurance, it may well reveal a diagnostic error. Mayo Clinic researchers reviewed 286 charts of patients referred to their Internal Medicine Division and found that the original diagnosis differed significantly from the final diagnosis in 21% of cases.1 More often, however, there are multiple treatment options for a chronic and complex disease. This is especially true during times of innovation. For example, there are many new surgical options for glaucoma treatment. One surgeon might recommend traditional filtering surgery, while another recommends a MIGS procedure combined with cataract surgery. The palette of glaucoma surgical options is dizzying for the patient—and even for the ophthalmologist. One choice isn’t necessarily right or wrong, and this can be confusing for the patient. It’s important to explain the rationale for the recommended treatment and to support the rationale for the original recommendation (unless it is frankly wrong). Part of educating patients is helping them understand that disease is complex and that there are nuances to treatment choices.
It’s difficult to determine the value of second and third opinions. If the consultation corrects a misdiagnosis or recommends an evidence-based strategy for treatment, then it improves patient care. If the second opinion results in a less costly treatment or averts inappropriate surgery or medicine, then it is cost-effective. While second opinions might help an individual patient, we don’t yet know if they lead to better health outcomes.
A number of hospitals and digital health companies offer online second opinion services. Cleveland Clinic’s MyConsult online offers review and recommendations for $565-$745. Although Medicare and most insurances don’t reimburse for online consultations, some employers offer the service as an employee benefit.
Second opinions—whether in person or online—will continue. Excellent medical decision-making will continue to require wise, thoughtful, experienced advice from the physician. Most of the time, this occurs face-to-face between a patient and an ophthalmologist. Occasionally, consultation with another ophthalmologist is helpful. Ophthalmologists must be open to accepting or suggesting a second opinion when our patient needs another approach or another viewpoint. Likewise, we help the patient make a good decision when we are respectful and supportive while providing the second opinion. It’s still a very human process.
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1 Van Such M et al. J Eval Clin Pract. 2017;23(4):870-874.