The Art of the Second Opinion

Rebecca Bechhold, MD

It is remarkable to me how few cancer patients seek a second opinion. Perhaps this is in part due to the Internet and the extensive information available to them. On their first visit, patients often sound highly educated about their disease and frequently nod their heads in agreement or say out loud, “That is exactly what I read!” And if the oncologist is confirming what they think is correct, I find they are confident to move forward and wave off the suggestion of another consultation. However, I have never shown disdain or hurt feelings when a second opinion is mentioned.

That being said, I was raised in an extremely gracious home that stressed excellent manners. I would never insult another physician to a patient. It is one thing to disagree or have a difference of opinion, but recent experiences opened my eyes to the arrogance of some physicians. Let me relate two vastly different cases. As with all patients discussed in my blogs, details have been changed, but the story is correct in all other aspects.

A patient came to me from a surgeon who knew the diagnosis was bad, but knew that I had an available clinical trial from a leading cancer center that included an investigational agent. We had already seen remarkable clinical response in this neoadjuvant trial. I met with the patient and the family, some on speakerphone, and discussed the trial vs standard therapy in full. The patient and family were all onboard. She had set up an appointment for a second opinion but signed consent and was ready to move on.

The oncologist giving the second opinion discussed the case in front of a tumor board attended by a friend of mine and essentially claimed the patient had seen a second-rate oncologist and told the patient that she would not meet criteria for the study and should just have standard chemotherapy. OK-you may not like me personally, but ASCO’s mantra is that the first choice for a patient is always a clinical trial. And honestly, if you are a patient and your second opinion physician speaks poorly of the first doctor, wouldn’t you be a little taken aback and think twice about what kind of person you were entrusting with your life?

A week later, I happened to give a second opinion to a patient of this physician. I was very careful not to make any indication of ill will toward the oncologist. I completely agreed with the plan of treatment, and I spent a lot of time going over all of the pathology, drugs proposed, and side effects. I never encouraged the patient to switch to my office even though it is 30 minutes closer to her home.

Honestly, what purpose does it serve to speak poorly of another physician? I can express my thoughts independently and make my point if I think another treatment would be better. I have told patients in the past that they should feel free to get a second opinion but not to be surprised if there is minimal variation from one to another, and that in the end it sometimes comes down to logistics-who is closer or more convenient, or maybe it’s based on personality or who doesn’t keep you waiting.

Some of the most brilliant physicians I have known-both surgeons and medical specialists-have impressed me with their personal humility and respect for colleagues. They would never express a difference of opinion by denigrating another practitioner.

Contrast this episode with another patient who had seen me, as well as one of my radiation oncology partners. This patient went for another opinion because she did not want to have radiation. She saw a radiation specialist at another center. That physician agreed completely with the plan of care offered. He could have just told the patient that or offered to treat her at his institution, but he sent her back to our practice and sent a letter reiterating that he had made it clear what excellent care the patient would get from the two of us. All he needed to do was say, “Yes, I agree you need radiation the way it was described to you.” He went out of his way to be complimentary.

A second opinion I saw recently was a delightful couple. We had a wonderful meeting. I agreed with the first doctor. I would have been happy to have her as a patient and they said wistfully, “Oh wow, we really like you!” I warmly replied, “Thank you so much! I enjoyed meeting you and I think you are going to do really well!” I shook hands and left-never would I try to “steal” that patient. If she decides on her own to come back to my office, so be it-but not because I lowered my personal ethics to make a sale.