May 15, 2000 -- In an interview with WebMD, Jerome Groopman, MD, author of Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine, summarizes valuable lessons from seven life-and-death stories.
WebMD: What situations demand a second opinion?
Groopman: Any time you have a very serious or life-threatening disease:
- Where the treatment is very risky or toxic
- Where the diagnosis is not clear, the treatment is experimental, or there is no established consensus or Food and Drug Administration-approved treatment
- If you're considering participating in a trial for a new drug
- If you're considering some new experimental approach or a procedure that involves using experimental instruments or devices.
WebMD: We all fear being the "demanding" patient. How should you ask for a second opinion?
Groopman: I think we all want to be polite and civil and don't want to spark an adversarial relationship. Yet, I feel very strongly that any time a patient raises the issue of a second opinion, a physician should welcome and endorse it.
WebMD: Should you always tell your doctor if you're seeking a second opinion?
Groopman: Absolutely. One, you need all the medical records and any pathology slides or other test results to give to whoever is giving the second opinion. Two, you want the experts to discuss in an open way what the areas of agreement and disagreement are. If you don't tell your doctor because you're afraid you're going to insult him, it's hard to get the records together and communicate.
WebMD: Should you ask your doctor to recommend someone for a second opinion?
Groopman: You can, but it's important to see someone at a different institution. Institutional cultures are real, and often an opinion leader at one hospital will do things a certain way and others at that institution will conform to that viewpoint. But at another hospital, even across town, there may be a very different philosophy.
WebMD: What if your health plan doesn't say anything about how it covers second opinions?
Groopman: This is one of the major flash points for a patients' bill of rights and the whole issue of managed care. Each plan differs as to the level of choice and freedom you might have to see someone inside and outside the network. If you're restricted, or in a situation where the diagnosis is not clear, or you feel the best treatment exists at another institution, then you need to advocate for yourself quite loudly.
WebMD: A recent study of biopsy slides at Johns Hopkins published in the December 1999 issue of the journal Cancer showed a surprising rate of misdiagnoses. Is it realistic to ask for a second medical and lab or pathologist opinion?
Groopman: Always. Absolutely. I saw a woman recently who had sought three "second" opinions in Boston. She had been diagnosed with a breast cancer that was characterized by the genetic marker HER2, a marker for a very aggressive breast cancer. If staining of the tissue by a pathologist shows this, it means that you're eligible to be treated with a new medication called Herceptin. It also means you have a much more aggressive form of cancer and need chemotherapy immediately.
As part of my assessment, I sent the slides to our pathologist and he said, "I just don't think this is HER2. I think there may have been a technical error in the staining." We repeated the lab test and it was negative. She's done extremely well on hormones, which are not toxic, in contrast to a course of intensive chemotherapy -- without probable benefit -- and Herceptin, which wouldn't have worked for her.
WebMD: What if you are convinced that your opinion is correct and the patient wants to do something you feel won't work?
Groopman: I try to present my advice in as compelling a way as possible. I suggest that they see other specialists because sometimes the weight of more than one opinion helps. But the ultimate choice is the patient's. No one's going to shackle him and take him to the operating room in the middle of the night.
Alice Kahn, RN, NP, spent eight years as a reporter and columnist for The San Francisco Chronicle. She currently works as a clinician in the Chemical Dependency Recovery Program and as a research nurse-practitioner in the Women's Health Initiative Hormone Study at Kaiser Permanente in Oakland. She is the author of five books, including Your Joke Is in the E-mail.