I received a fax recently, from the office of another hematologist-oncologist, at another academic medical center. Attached to the fax cover page, with my name and fax number scribbled in slanted script, was a five-page consultation report on one of my patients. That oncologist — I’ll call him Dr. Z — had seen and evaluated my patient to provide a second opinion on the patient’s diagnosis and treatment.
The lengthy report was thorough and well articulated, representing the Dr. Z’s skill in data gathering and documentation. The other reason the report was so long, though, was because of the templates built into the electronic medical record he used. I know this because my own template-driven consultation notes are exceedingly long, something I struggle with in using our own EMR. The meat of any consultation note, though, is at the end — in the assessment and recommendations section. In Dr. Z’s report, the recommendations took up the entire last page.
When I read that last page, I could feel my anger rising, along with my heart rate.
Dr. Z mostly agreed with my own recommendations to the patient, and while this is always reassuring, I would not have been offended if he disagreed entirely. I refer a lot of patients for second opinions, for a variety of reasons. Second opinions can ease a patient’s mind and provide reassurance, they can open up opportunities for clinical trial participation at other centers, and they can give another outlook on the case from a fresh set of eyes. While I love when someone agrees with my plan of care, I appreciate the art involved in the practice of oncology and that oncologists have different practice styles.
For example, an oncologist with 20 more years of experience than I have can probably teach me something, and I always look forward to learning things that can help me care for my patients better.
This report from Dr. Z, however, was written with a tone that made me want to stop reading immediately. The report made me angry and mistrustful. He mostly agreed with my treatment plan, but he disagreed with some subtleties in the care I provided my patient. In those areas he disagreed, he made it clear in his recommendations that the “local oncologist should be” or “must do” or “should not do” this or that. His use of language was very dogmatic. It was clear in the way Dr. Z had phrased his words that he did not allow for any differing opinions or practice styles than his own. It was clear that he was right, and that I was (obviously) wrong. Unfortunately, this second opinion had not served my patient well and taught me nothing.
Or maybe it did teach me something.
I believe there is an art to writing a good consultation letter to another physician. Heck, it takes skills to write good letters in general. These are skills that we learn first as very young children, when we begin writing thank you letters for birthday presents and letters to pen pals. And, hopefully, we continue to learn these skills throughout the rest of our educational careers.
A good letter to another physician — such as the second opinion letter — should be respectful and polite, and it should convey information in this same respectful and polite tone. The letter should not be overbearing or bullying or inflammatory. It takes skill to write a good second opinion letter when there is agreement with the medical decision-making. It takes a greater level of diligence and finesse to write a respectful letter when there is disagreement.
I perform a lot of second opinion consultations myself, as many of us in academic medicine do. It goes with the territory of being a specialist. In the reports I write to other oncologists, I try to follow my own advice. If I disagree with a treatment plan, or with an aspect of care, or if I have an idea for a treatment that the other oncologist has not mentioned in his notes, I tend to use words like “could consider” or “an alternative could be” or “in my own practice, I sometimes use ___.” I thank the referring physician to allow me to provide this service, and I am polite from beginning to end, even if my opinion on treatment differs.
I write second opinion letters with the full understanding that in medicine in general, and certainly in oncology, there is not always one right answer. In fact, there are usually several accepted, evidence-based treatment options, and there may be many ways to administer and time those different options. I do not judge. Most importantly, perhaps, I realize that my second opinion is formulated at one moment in time, without the benefit of that amazing gift of wisdom: hindsight.