Response to the second opinion

I read with interest the article on the ‘second opinion’. Unfortunately I am at a disadvantage in that I am not aware of the questions presented to various doctors, on whose responses this article has been based. Even so, I would like to express my views on the subject.

In my opinion, the problem should be examined under the following heads: (1) the patient’s right to a second opinion; (2) a second opinion requested by the family physician; (3) a second opinion requested by a consultant; (4) a second opinion sought by the doctor or the patient, in a public hospital; (5) a second opinion sought by the doctor or the patient, in a private hospital; (6) doctors wishing to establish themselves as ‘second opinion’ consultants.

1. In the first instance, one must state in no uncertain terms that it is the patient’s right to consult whomsoever he pleases. No one can deny him that right. How he goes about it is another question, as in whether he will derive full benefit by receiving various opinions regarding the nature of his complaint and his treatment.

In such cases it is usual for such a patient not to tell the doctor that he has visited other doctors previously. If he does inform the last doctor of his previous visits to other doctors, the doctor is now placed in a difficult position. What should be his line of action? Should he contact each of the previous doctors consulted? What if the patient does not want him to do so? What about maintaining patient confidentiality which prevents a doctor from discussing his condition with others without the patient’s permission?

On this respect, some guidelines from the Medical Council would be helpful. Failing that, I think that the best and easiest way out is to advise the patient according to what one feels is in his best interests even if it differs from the opinion of the doctors previously consulted.

2. The next situation is when the family physician seeks a second opinion either as confirmation or because of genuine doubt regarding the advice of the first consultant, or at the insistence of the patient.

If the second consultant is not aware of the first consultation, he will automatically examine the patient and give his advice accordingly. However, what should be his stance if he has been made aware of the fact that the patient has already been examined by a consultant and that his opinions either the same or contradictory?

In this case, the second consultant is placed in a quandary, because it is natural that he would not like to spoil his relationship both with the family physician as well as his consultant colleague.

If the opinion he has formed of the case is the same as that of the previous consultant there is no problem, unless the family physician or the patient insists that the second consultant carries out the treatment, particularly if an operation has been indicated. In this case, the second consultant should tell the family physician that he will conduct the operation only after discussing the case with the first consultant. Unfortunately, in this case, he will have placed himself in a position of spoiling his relationship with both the family physician as well as his consultant colleague.

Again, suppose his opinion differs from that of the first consultant. He has no option but to tactfully suggest to the family physician that removesemicolon; they all discuss the problem with the first consultant. But this can only be done if the family physician agrees. If the latter refuses the end of the matter is that the second consultant gives his opinion and lets the matter rest. Of course, he will be more careful the next time the family physician wishes to bring a patient to him for consultation.

3. The situation is much more straightforward when a consultant requests a second opinion. In this case the second consultant examines the patient and gives his opinion in writing and perhaps also on the telephone to the first consultant.

However, he must under no circumstances proceed to treat or operate upon the patient unless the first consultant specifically requests him to do so, even if the patient desires that he do so. In fact, the second consultant should make it clear to the patient at the outset that he is carrying out this examination at his colleague’s request and therefore he will send his findings and opinion to the first consultant who will then discuss the same with the patient.

Here again, the question arises as to whether the second consultant should reveal his findings and opinion to the patient, particularly if the patient desires that he do so. In my opinion, he should tactfully explain to the patient that the first consultant will reveal the same and if necessary the possibility of a joint meeting of both consultants with the patient and family physician may be considered.

4. A patient admitted into a public hospital is in the unique position of being under the care not only of a junior doctor and registrar but also two specialists in the field (honorary, and honorary assistant of the unit). It is unusual for the patient or his family physician to ask for a second opinion. However it is possible that in a problematical case, the specialist himself may request a second opinion (usually informally) from a colleague in another unit or at times get the opinion of others when the case is presented at a clinical conference in or out of the hospital.

But suppose that the patient or family physician wishes to have a second opinion from a specialist in the same hospital, or from one not attached to the hospital. This again creates a problem.

In my opinion if the case is really problematical, the consultant-in-charge of the patient may well be advised to allow this second opinion even from one outside the institution. If the hospital rules do not permit outside consultation the patient and family physician can be informed politely of the fact and asked to decide if they wish to continue the treatment in the same hospital or take a discharge from the hospital. However, if the case is really problematical the institution should see its way to bend the rules even to allow outside consultation.

5. With regard to a patient admitted in a private hospital the situation is somewhat different. Here one does not usually have a team of doctors treating the patient, but only a junior resident of experience, and as a senior specialist (the situation may well have changed since I left Bombay in 1969).

In this case, I only partly agree with Dr Desai as regards the procedure to be performed when the patient or his family physician requests a second opinion. In this case, only a consultant of the same speciality should be called in (unless the patient has developed a complication which requires a doctor specialised in that condition). In my opinion, this examination should not be taken independently but preferably in the presence of the treating docor unless it is not convenient. In any case the findings and opinions of the second consultant should first be made known to the treating doctor and after mutual discussion both doctors should present their findings and opinions to the patient and family physician.

6. About the advisability and utility of a second-opinion clinic: If one has considered the various conditions under which a second opinion is sought, one may well come to the conclusion that a special second-opinion clinic is superfluous. To start with, doctors working in such a clinic will be laying themselves open to the charge of arrogating to themselves superior knowledge. Again, their field will be limited because as special second-opinion consultants they are now confined only to giving their opinions and suggesting treatment.

Further, such doctors will only be able to examine patients referred to them by a family physician or specialist colleague and that too with all detailed notes regarding the patient, and with the consent of the first consultant who examined the patient. No individual patient will be able to approach them directly. Lastly, the doctor will have to forgo the right to carry on the treatment or operate on such patients. Under such circumstances, the second-opinion doctor may find his practice becoming smaller as days pass by and thus not economically practicable.