Why patients seek a second opinion

This has been a very busy week already.  I have seen many second opinons and I am always very interested in the reason why the patient initiated the second opinion.

In many situations it was simply to see if I would perform the surgery.   After I spent a while listening to the patient, examining them and coming up with an appropriate treatment plan, more than 50% of the patients I had seen elected not to have the surgery at this time.  They weren’t ready, or their symptoms didn’t warrant it.  Worse, the information they received prior to our interaction was misleading or wrong.

Here’s a transcript of the video.

Good morning. Forgive the little bit of haze you may find in my presentation, that’s a residue of some Benadryl I took. It ripped myself of these Northeastern virus that’s been on misery especially in my family in the last week. And I have something to do with 30 inches of snow that we’ve dumped on us that everyone enjoyed yesterday. Anyway, that’s not what we’re here to talk to you about today. What I wanted to talk to you was about a short week of second opinions. Typically I see a number of people each week where I tend to see them as a second opinion —simply because I’m situated in a tertiary care or advanced level care institution and we are an academic center, so which means we train, that we train the next generation of surgeons and we tend to be a referral base for a very large catchment area.

Anyway there were some second opinions this week regarding the treatment of people with a history of osteoarthritis of the knees. Some of these people were here to discuss whether or not I would do their replacement or whether or not they should go back to their previous surgeon and have them perform a knee replacement.

But I was surprised how very few of the discussions that the patients initiated began with the idea of do I need a knee replacement? It seems that they were simply shopping around for where their knee replacement should be done.

Now, let’s say there were 10 of these patients. In the end only five patients decided to have the surgery done, why? Realistic expectations. We went through a relatively crude but useful shared decision-making process. We went through the facts that this truly is a quality of life decision and it’s not the doctor who makes the decision when you’re thinking about a procedure that’s here strictly to improve your quality of life and alleviate pain. So, when the question was posed to the patient, do you feel that it’s time to have a knee replacement? Do you feel that the pain that you are experiencing is significantly interfering in your quality of life and you feel that you are willing to assume the risks of knee replacement in order to obtain that relief?

When that question was posed to those 10 theoretical patients — and they weren’t theoretical, the patients  are real — the number is theoretical, half of them said no, half of them said, I’m fine, you know, I’ll take my time or I’ll use my cane and I’ll come back when my symptoms are very severe.

That’s the power of shared decision-making and it has very broad implications for healthcare as a whole. A lot of these patients were told they’ll be up and around in a week or that there are really aren’t any significant complications associated with the knee replacement.

And I’m not going to critique other physicians work, however it’s all in the presentation.  It really is incumbent upon us as physicians to let people know exactly what it is they are in for, as best as we can. We need to describe reasonably foreseeable risks. If there is a risk that occurs, one in one million or risks that we cannot, yet even conceive of, we are not held responsible for that. But things like infections and blood clots and the fact that it can take 6 weeks to drive in some situations or that 5 percent get stiff or one percent become infected. Those are very important things to discuss with patients.

I saw a number of  patients this week with ACL deficient knees, that means that the ACL of the anterior cruciate ligament was torn.

They were coming again to see whether I would do the surgery or to see whether or not they should go back and have the surgery with their previous surgeon. The same questions were proposed to all of them. Do you feel that the surgery is necessary?  Sometimes it was met with a blank face (and some of you people out there have certainly shouted out at me and said it’s your decision, you are the doctor). No, it’s not necessarily true, I’m here to provide you with the facts. If your knee is buckling, unstable or you’re suffering from instability at the knee is giving away, you can’t go up and down the stairs, you can’t turn pivot or twist.  And braces and therapy and everything else did not improve your symptoms, then you can consider yourself a good candidate for an ACL reconstruction. If you work on the roofs, or if you are a tree climber, if you’re a mountain climber or a rock climber, then in those situations I would suggest an immediate reconstruction simply because the first time your knee buckles it may in fact cause significant injuries, harm or even death. However, for the vast majority of you, you have an ACL tear yet you do not have any issues with your quality of life, you do not have any buckling instability or giving away, the knee may feel a little unusual but yet it doesn’t give out.

Do you need an ACL reconstruction? I don’t think so. But really, that is up to you. The indication for an ACL reconstruction is simply not its absence. It is the fact that it is causing an issue with your quality of life, with your ability to participate in activities that you would otherwise enjoy. There were other second opinions that I did this week are the lesser procedures such as meniscus tears etc., but it was the same story. These patients were being indicated for surgery by the presence of a finding on an x-ray or the presence of a finding on an MRI. Not necessarily a custom-designed treatment plan based on how that injury was behaving in them.

I put a blog post up on this a while ago. I call it the personality of an injury. It’s simply because the same injury will not show itself or behave in the same way in many individuals. Some will be symptomatic, some will not be symptomatic, some will have problems, some will not. I have also talked about shared decision-making before. This is a process where we sit, we go through your quality of life. There are a number of scores that we can utilize, we go through a list of the reasonably foreseeable risks, your expected goals, your outcomes, and the time that you can expect to be in rehabilitation before you will be  “normal,” if that in fact, it ever occurs.

And once we go through all this processes, you know, then people start to understand why I’m not as aggressive as others in recommending surgery only because it doesn’t seem to suit your injury properly. So, take home message, pay attention to shared decision-making principles. It’s going to be a very prominent area in medicine soon. Seek out a second opinion, they are worthwhile, if necessary seek out a third opinion, they are very worthwhile. And just because something shows up on an x-ray or an MRI doesn’t mean it always needs to be treated surgically. You do have options, find someone who is willing to explain those options to you and respond accordingly.

Howard Luks is an orthopedic surgeon who blogs at his self-titled site, Howard J. Luks, MD.

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  • dspacl

    Bravo Dr Luks! Shared decision-making, how novel! The irony being that it is NOT how most of us are taught. We are taught to “give” informed consent. We are not taught how to “arrive” at a shared decision based on the personal context of the patient. You have palliative care skills, humanity and empathy, which (in my opinion) defines a master clinician. I’m sure your residents will be the better for it. Thanks for the post.

    • http://www.dialdoctors.com Dial Doctors

      I agree with you that shared decision-making is not how we are taught. I know doctors who cringe whenever a patient asks for a second opinion for no reason at all. When a doctor presents a course of treatment it’s almost always already been discussed with at least someone else.

  • ninguem

    I was doing a rectal exam on a guy one time.

    He told me to use two fingers.

    He wanted a second opinion.

    badda-bing

  • http://www.drmartinyoung.com Martin Young

    Howard, let’s be real!

    There’s no such thing as an ‘unnecessary’ operation. Someone, or more correctly, several people either need the operation or would like to see it happen. The patient need not be among them.

    It is a perversity of the fee for service model. I prefer the term ‘unwarranted’ surgery because it points the blame for the decision in a clear direction.

    Great post – it makes all the right points.

  • http://www.womeninpainawareness.ning.com carol

    I had a doctor tell me a surgery was appropriate but I should contact another surgeon to see what he thought. I talked to the other man as well as a third surgeon. The second and third said “absolutely not”. To my surprise the first had put through the insurance forms for pre certification. He offered to do the appeal when the insurance turned him down. I said “No” to the operation after talking with #’s 2 and 3 and still found #1 raring to go.
    The problem of getting a second opinion is often the opposite of Martin Young’s post (although for sure fee for service can be an inducement). Insurance may well refuse to cover the cost of opinion #2 causing some to have procedures they might not had they been able to get a second opinion.
    Carol
    http://apainedlife.blogspot.com/

  • http://www.howardluksmd.com Howard Luks

    Thanks for the comments…. and thanks for posting this Kevin.

  • http://secondbasedispatch.com Jackie Fox

    This is a great post, thank you.
    My introduction to shared decision making came from my oncology second opinion. My first oncology consult made it sound like a mastectomy for DCIS was my only option. As I kept bringing up alternatives that were summarily shot down, I felt like door after door was slamming shut. While he also recommended a mastectomy based on my risk factors and DCIS type/volume, my second consult told me he’d respect my choice if I opted for radiation and surveillance. Guess which one I asked to take me on as a patient.

    Jackie Fox
    Author, “From Zero to Mastectomy: What I Learned And You Need to Know About Stage 0 Breast Cancer”

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