Second opinions

Spine surgeons facing second opinions: a qualitative study

BACKGROUND CONTEXT

The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients.

PURPOSE

The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view.

STUDY DESIGN/SETTING

This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions.

PATIENT SAMPLE

We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared).

OUTCOME MEASURES

Themes and subthemes were analyzed using semistructured interviews until saturation was reached.

METHODS

Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon).

RESULTS

Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations).

CONCLUSIONS

The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel

Background

Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO.

Methods

A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one.

Results

Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%).

Conclusions

Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions.

Electronic supplementary material

The online version of this article (10.1186/s13584-017-0191-y) contains supplementary material, which is available to authorized users.

Second opinion in medical encounters - A study among breast cancer patients

OBJECTIVE

To examine the association between whether physicians discuss the possibility of seeking a second opinion (SO) with patients and the patients' decision to seek an SO. We also investigated the impact of seeking such an opinion on patients' trust in physicians.

METHODS

Newly diagnosed breast cancer patients were surveyed postoperatively with a mail survey. A patient survey is carried out annually to evaluate the breast cancer centers in North Rhine-Westphalia, Germany. In 2016, survey data from 4517 patients in 87 hospitals were analyzed.

RESULTS

Physicians were more likely to inform patients under the age of 75 years with higher education levels about the possibility of seeking an SO. Our results indicate that requesting another opinion is associated with less trust in the physician.

CONCLUSION

Our results indicate that physicians may selectively inform only a subset of patients about the possibility of seeking an SO. Patients who were informed about such a possibility are more likely to do so.

PRACTICE IMPLICATIONS

Physicians may need to be careful to avoid inequalities based on the age and education of patients regarding giving information about the possibility of an SO. Moreover, breast cancer centers could provide material to patients regarding seeking an SO.

Association of treatment and outcomes of doctor-shopping behavior in patients with hepatocellular carcinoma

BACKGROUND

A variety of unfulfilled needs may trigger doctor-shopping behavior (DSB) in patients. In oncology, treatment results usually cause patients the most concern. This study investigated the association of DSB with active treatments received by patients with hepatocellular carcinoma (HCC) and outcomes.

METHODS

With approval from the institutional review board, all patients registered in the cancer database of a teaching hospital and diagnosed as having HCC by self-referral from outside hospitals or by in-house diagnosis were retrospectively identified. Patient data were then reviewed and analyzed via electronic medical records.

RESULTS

Hepatitis B carriers were significantly more likely than noncarriers to show first-time DSB. Recurrent disease was less likely to result in DSB than predicted. Patients from outside hospitals not receiving upfront first treatment after diagnosis were significantly more likely to show more frequent DSB than those receiving it. Male patients eligible for salvage treatment were less likely to have frequent occurrences of DSB than their female counterparts. Receiving first salvage treatment was not associated with more frequent DSB. Treatment recommendations offered in the study hospital did not influence patients' decisions to leave or stay. Only elderly patients (>70 years) were less likely to show DSB.

CONCLUSION

DSB can occur throughout the entire course of treatment for HCC for a variety of reasons. Active treatments, disease status, and patient characteristics all exerted an influence on DSB.

Heterogeneity of Cancer Patient Information-Seeking Behaviors

Objectives. This study aimed to determine whether cancer patients report different information-seeking behaviors (ISBs), investigate why they searched for information, and determine the relationship between their ISBs and their socioeconomic and behavioral characteristics. The authors also explored the relationship between ISB and participation in the medical decision-making process as well as the patients’ health state. Methods. A sample of 4270 French cancer survivors aged 18 or older was interviewed at 2 years following diagnosis. Rather than deciding a priori who should be considered an information seeker, the authors chose to statistically define the different ISBs using cluster analysis. Results. The authors identified 4 distinct profiles: Stereotypical high-information seekers and acquainted seekers are generally highly educated. They search for information due to their own motivation or because they are close to the medical profession. Constrained information seekers are characterized by a low socioeconomic status. They perceive themselves as “dropouts” of the health care system. Finally, the general information seekers did not systematically resort to any specific ISB. The authors show that after adjustment, belonging to a specific ISB was associated with the likelihood of participating in the medical decision-making process and, more surprisingly, with health state. Conclusions. A key finding of this study is that social disparities are significantly associated with the different ISBs. If these relationships are found in other samples, it would further support the need for medical teams to pay more attention to patients with lower levels of education, particularly in health care systems that have acknowledged equality as a founding principle. The clusters determined in this study offer a potential theoretical framework that can be used in future studies.

Seeking a second opinion: Do patients need a second opinion when practice guidelines exist?

INTRODUCTION

Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons?

METHODS

We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion.

RESULTS

We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case.

SUMMARY AND CONCLUSION

We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.