With Second Opinions, Two Things Invariably Upset Oncologists

Nick Mulcahy

August 31, 2018

Oncologists uniformly cooperate with patients' requests for second opinions — despite frequently doubting their value — and largely manage the process with professional calm and savvy, according to a small study from the Netherlands published online August 23 in JAMA Oncology.

However, two scenarios appear to invariably upset oncologists' equilibrium and create "feelings of insecurity or offense," report lead author Marij Hillen, PhD, a psychologist at the Amsterdam University Medical Center, and colleagues.

With each scenario, the trouble came from patient relations, not the oncologist who provided the second opinion.

The new Dutch study is qualitative research that used in-depth, semistructured interviews with 26 medical oncologists, who had both given second opinions and had had patients request them.

Most second-opinion studies in oncology are quantitative, as this team showed in a systematic review last year (Oncologist. 2017;22:1197-1211). But quantitative studies tend to focus on diagnostic or therapeutic discrepancies between the first and second opinions, which ranged from 2% to 51%.

Using a different approach in the new study, Hillen conducted the physician interviews, which were transcribed, coded by themes, and mined for quotes representative of the group. The interviews stopped at 26 physicians, after no new themes emerged.

The study participants used a variety of strategies to manage second opinions. Oncologists consistently felt insecure or offended when two things occurred.

The first was when the oncologist "had already committed themselves deeply to patient's treatment," Hillen writes.

For this scenario, the representative quote is from a 55-year-old female oncologist: "I can remember people where I was thinking, 'What the heck is this?! I'm doing the impossible.... I've been keeping you on track for years.' "

The second scenario that consistently produced consternation is when patients arranged a second opinion without informing their physician.

According to a 57-year-old male oncologist: "So I said, '....[Y]ou sought, without asking or informing me, a second opinion from someone who passed judgment without even having your medical file.... Now you got confused, and you have yourself to blame for that.' "

"In such cases, these emotions are perfectly normal," Hillen told Medscape Medical News.

She emphasized that, in the study, "many oncologists were well able not to automatically feel offended by patients' second opinion requests."

In the end, the study authors say that seeking another opinion can lead to a firm and positive outcome: "...second opinions can strengthen the physician-patient relationship after back-referral."

The representative quote about this came from a 45-year-old male oncologist: "Any distrust toward me from the patient's side will be gone afterwards. Like, 'Okay, I got it now [said the patient]. The second-opinion consultant told me [that Dr X] knows his stuff and completely agreed with him.' "

Some study interviewees reported that they anticipated second opinion requests, even before they happened.

The representative quote was from a 38-year-old male oncologist: "Sometimes I offer it as an option.... Because I think the act of offering it will get me a little extra trust."

However, many of the study participants think that second opinions are not helpful, and they try to get patients to reconsider. From a 46-year-old male oncologist: "I always tell them that 'yes, I am totally prepared to arrange it.' But I sometimes add that it honestly has zero-point-zero value."

Additionally, second opinions can generate confusion, said Hillen.

In a 2017 study of Dutch men with prostate cancer, she and her team found that men may collect multiple opinions from different specialists (Health Expectations. 2017;20:1264-1274). However, "these multiple (and conflicting) opinions frequently caused uncertainty about which advice to follow," she said.

Applicable to US?

Do these new Dutch findings translate to the United States? Medscape Medical News asked an expert who has studied second opinions in the American setting.

"I do hear some familiar themes in conversations [I've had] with US oncologists. However, I perceive the comments in this study to be somewhat more negative (less collegial) than what I am used to hearing in the US," said Allison W. Kurian, MD, an oncologist and health policy researcher at Stanford University School of Medicine, California.

For example, in the Dutch study, there is a quote from a 57-year-old male oncologist describing his anger over a second opinion. "I called [the second-opinion consultant]. I said, 'How in heaven's name can you provide a second opinion [without a complete medical file]...?!' "

However, this scenario did not consistently produce feelings of insecurity or offense in the Dutch study participants.

When Asked to Provide a Second Opinion

The new study included an analysis of comments from specialists who provided a second opinion. These oncologists often had feelings of "helplessness" toward patients if their opinion was in accordance with the first physician's and "thus took away the patient's hope," explain Hillen and coauthors.

Second-opinion providers also work to help patients regain their trust in their initial oncologist and emphasize their colleague's competence, report the study authors.

None of the study participants relished contradicting another professional, even when they disagreed with his or her assessment. In the words of a 65-year-old male oncologist: "The difficult ones are where I feel that the other doctor is doing something totally wrong and I believe I should intervene.... Because it means I will make that person look like a fool."

In the end, Stanford's Kulian accentuated the positive about second opinions, especially in difficult cases: "A second opinion can contribute usefully to a challenging case, even if there is some difference in opinion from what the first oncologist recommended."

JAMA Oncol. Published online August 23, 2018. Abstract

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