Guiding Patients to and Through Second Opinions

Advice From Medical Oncologists

Debra A. Patt, MD, MPH, MBA; Bradford R. Hirsch, MD, MBA


July 23, 2019

This transcript has been edited for clarity.

Debra A. Patt, MD, MPH, MBA: I'm Debra Patt, a medical oncologist and executive vice president of Texas Oncology in Austin, Texas. Welcome to Medscape Oncology Insights. Joining me today is Dr Brad Hirsch, a medical oncologist at Texas Oncology, to talk about second opinions.

Have you ever incurred a second opinion where you disagreed with the medical recommendation of another doctor?

Challenges With Second (and Third) Opinions

Bradford R. Hirsch, MD, MBA: Absolutely. As a matter of fact, a few weeks ago I saw a patient who had had three opinions. He had gone to California, another center in Texas, and then he came to me. He was incredibly confused. I think that the best thing you can do under these circumstances is to just sit down with the patient, work through the logic of it, and try to show where the evidence exists. Help the patient understand how to reconcile all of the different things they have heard. Listen to what they found previously and what they feel to be the right path, and try to support them through that.

Patt: I often see my major role as an educator to our patients, and educating them on reasonable medical decisions is really important in sorting through disparate recommendations. It's important, too, because sometimes they may receive recommendations that you feel are not appropriate for them. We have obligations to patients—of course, first to do no harm, and then help as we can. But it's important to know that we are not obligated to follow someone else's recipe of treatment if we feel like it's not appropriate for the patient.

Hirsch: I agree. It puts the patient in an incredibly difficult circumstance if one of the doctors says they are not going to treat them unless their specific recommendations are followed. So it's about reconciling it all and landing in a good place.

Tips for a Smooth Second Opinion

Patt: Do you have any pearls of wisdom when guiding patients through a second opinion discussion?

Hirsch: Sure. I always try to figure out what their goal is and understand why they want a second opinion. I think that guides where they go. Maybe they are looking for a clinical trial opportunity that is not available in other places or maybe they are looking for more advice about what opportunities are out there. We help to guide them about what we can do as a practice and what I can do as a physician versus making sure they get to the right place. I also try to guide them on places where they are not going to have to go through another 100 tests unless they are important to do, and where I really believe there is expertise and where we can all work together to improve their care.

Patt: I couldn't agree with you more. I talk with patients very openly about seeking a second opinion, and while I think that it's not necessary, it can sometimes be helpful. It's important to have those discussions transparently with your patients because it does build trust, and we have the opportunity to guide our patients around second opinions by giving them some advice.

People seek second opinions for a couple of clear reasons. Sometimes there are deficiencies in health literacy. Sometimes there are questions about medical decision-making or access to clinical trials. And sometimes there may not be an optimal fit with the person who has told them they have cancer for the first time that leads them to seek another opinion to make sure that they are on the right track.

It's useful to understand what patients seek from a second opinion so you as their doctor can help guide them in the right way. I read a study regarding health literacy, showing that patients leave the room with about 20% of what their doctors tell them, and I certainly feel that.[1] When I tell patients they have a new cancer diagnosis, they leave the room like a deer in headlights. We try to do things to make that better by giving patients treatment care plans. I often invite patients to have a spouse or other caregiver in the room with them. I give them something written when they leave the room. I let them record me if they want to so they can hear that again. I also have my nurse call them the next day. I try to improve their health literacy.

But still, sometimes hearing it from another doctor can improve their health literacy and let them make more logic-based treatment decisions, which I find helpful.

Hirsch: I totally agree. There is a misconception that if you are going to get a second opinion, it means you are going to travel to an academic medical center in another part of your state or even a different state. Often, it's just a second opinion where they can go down the road to another doc within community medicine or academic medicine, who can give them a new insight and a new opportunity. It's really about understanding what they are looking for in that process.

Patt: I think that's true. Sometimes people seek a second opinion in distant locations. They might travel to a major cancer center or somewhere else because of a clinical trial we don't happen to have open at our site or because they want to see someone in particular. When we can guide them around that, it's helpful because, to your point, there are some keys that they need to understand. The first is that they don't need to repeat expensive testing. It's completely unnecessary to have a CT scan, labs, or a biopsy repeated. That is an unnecessary spend of money.

It's also important to have transparency with your patients. When they have a treatment plan recommended to them, they can come back. Most patients prefer to have treatment and cancer care close to their home where they can have dinner with their family, where they can sleep in the same bed as their spouse. That way, it gives you an opportunity to address the treatment plan and to look to see if there is any discordance and manage some of that.

Sometimes a Second Opinion Is Necessary

Hirsch: There are times when you actually need a second opinion and when they need to go somewhere else.

I had a patient with a malignant metastatic pheochromocytoma, of which there are 100 or 200 a year in the country, and there was one trial of a new drug that was only at two centers in the country. I tried to get them a second opinion and their insurance company would not let them be seen, so I spent a month battling to get them the second opinion. So there are times when it's actually wrong not to send them to those organizations as well.

Patt: I, too, have seen utility in facilitating second opinions for many of my patients. I'm fortunate to have great clinical trials at my center, but we don't have everything. Frequently, if they have intractable cancers where I don't have a good clinical trial fit for them, and I know nationally that somewhere else they would have a clinical trial fit, getting them to those right places can be really helpful. But I think if doctors approach this transparently with their patients, encourage them to do what is going to make them feel comfortable, and have open and honest discussion with them, they can navigate the environment better.

I often manage that referral, so patients tell me who they would like to see and I make sure they get all of the appropriate information. It makes that second opinion process much better for them.

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