by Wendy S. Harpham, MD, FACP
Here are words any patient awaiting cancer surgery would be thrilled to hear: “We are canceling your upcoming operation! It turns out that the suspicious changes we saw on your recent biopsy are completely benign.”
This happy turn of events happened in my life recently, thanks to a second opinion from a type of physician few patients realize plays a critical role in their care: the pathologist.
Pathologists are medical doctors who look through microscopes and use a variety of lab techniques to determine what disease(s), if any, are present in blood or tissue obtained with a biopsy. Their task is not as straightforward as putting a key in a lock and turning. (”Aha. The key turns, so this is cancer.”) Pathology is an art that depends on sleuthing skills and judgment calls.
When talking about cancer, some biopsies are straightforward because all the changes are obvious and typical for one specific type of cancer. Even a medical student could make the correct diagnosis. Other biopsies, like my most recent one, are difficult to interpret. In these cases, a second opinion from another pathologist helps both the patient and the patient’s physicians.
Considering how much rests on the pathology, it is surprising more patients and physicians don’t take the “second opinion” path at the time of diagnosis. After all, a wrong diagnosis leads physicians to prescribe the wrong therapy—garbage in, garbage out.
When the original diagnosis is confirmed by a second opinion, everyone feels confident they know what is wrong. This confidence makes it a bit easier to accept the risks of recommended treatment than if there were any uncertainty about the diagnosis.
When a second pathology opinion yields a different diagnosis, the stress level may rise in the short run. “Which opinion is right? What should I do now?” But with everyone working together to get the patient the best care, further discussion and, maybe, a third or fourth opinion eventually leads to the most likely diagnosis. Then, no matter what happens with the patient thereafter, everyone takes comfort in knowing they did the best they could.
Three reasons to think about getting a second opinion from another pathologist, preferably one who specializes in the disease that is suspected, are (1) if the biopsy tissue shows only subtle changes, (2) if the diagnosis is notoriously tricky and difficult to make, or (3) if the proposed treatment is especially risky.
It is important to discuss the patient’s medical condition and how much time is safe to take for additional pathology readings, so the added time does not compromise the patient’s chance for improvement.
Until sophisticated tests are developed that make pathology an exact science, a second opinion from a pathologist may play an important role in getting good care.
As a Healthy Survivor (namely, a survivor who gets good care and lives as fully as possible), I hope and pray for accurate news. And if the accurate news is also good news, that’s even better.
Wendy S. Harpham is an internal medicine physician who blogs at Dr. Wendy Harpham on Health Survivorship.
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{ 6 comments }
As a pathologist, I concur with your post, with a few caveats.
First, most pathologists practice in a group, and it is very common to obtain a second, third or fourth opinion from others in their group. This is free to the patient, and is usually recorded on the pathology report as “this case was reviewed by Dr. X who concurs with the diagnosis.” Second, how is the patient to tell if his/her biopsy changes are obvious or subtle? This is where his physician comes in. If the language of the pathology report is ambiguous (such as saying “consistent with breast cancer”, rather than just “breast cancer”, or “suspicious for breast cancer”), the physician needs to call the pathologist and really ascertain the pathologist’s level of confidence in the diagnosis. I have seen clinical physicians act on a diagnosis of “suspicious for” as if it were a definitely positive diagnosis.
To keep this short, the first question a patient in the above situation should ask of their physician is, “have you talked to the pathologist by phone?”
If so, you can be more confident that the case has been thoroughly discussed. If not, either ask them to call or ask for another opinion.
Ditto with radiology reports.
Dear Bev MD,
Thanks for your helpful comment.
With respect, Wendy
One of the great economic failures (and that’s saying something) in medicine is patient’s inability in most settings to choose radiologists or pathologists. People are often just stuck–as in the hospital environment.
In an economically rational world, pathologist/ radiologist error rates would be public, and patients would pay variable rates depending on the degree of reliability they need.
Instead, you have a kabuki dance in which the healthcare consumer (who pays for the show) begs her almighty doctor to make a call. Kinda makes me sick.
btw bev M.D. made me laugh. Ever hear of confirmation bias, interest bias . . . . all the other well proven cognitive biases that infect our reasoning that the social psychologists have discovered? Given these biases, I’m not sure what an intragroup second opinion is worth. A tabula rasa when looking at a film might be invaluable . . . (oh , even better, how bout a computerized expert system_
To alban berg;
Of course all the biases also infect the original pathologist, so you are not really saying anything new. That is why the new advances in molecular medicine will eventually turn pathology into just another lab test, instead of the subjective judgments that go on now. This is a good thing, although it will take awhile. Another advance is telepathology so that expert opinions can be obtained remotely, especially valuable in rural areas.
As for those biases, however, do not assume that the pathologist’s partners agree with him/her just to be nice. On the contrary, at times!!!
I also wonder how this works in practice, especially in the UK. My feeling would be that second opinions are unusual events requested by very few patients – or possibly demanded by their family members. How would a patient who is not medically trained know that there is any room for doubt? Perhaps this is a time for an accompanying family member to innocently ask ‘What is the degree of confidence in these results?’ Perhaps if this was a standard question second opinions from unrelated pathologists would become more common (though I cannot imagine how the NHS would manage this in practice).
Thanks for raising this topic, it is very enlightening.
Anne Orchard
Author ‘Their Cancer – Your Journey’
http://www.familiesfacingcancer.org
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