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Opinions on Practice Management

William Huang

Approaches to a Second Opinion in Dermatology

William Huang

Thursday, January 17, 2013

Working at an academic medical center, one of the more common reasons I see patients in my dermatology practice is for a second opinion. Whether the patient presents because of an unclear diagnosis, a therapeutic challenge, or a broken relationship with their original provider (Figure 1), this type of encounter can be difficult for both the patient and the consultant. For providers who refer a patient to a consultant within their own specialty, the reason for the consultation should be specified and communication should be maintained. For patients who seek out another opinion regarding their care, there can be a lot of frustration, confusion, and sense of despair.

Figure 1. Reasons for seeking a second opinion

Huangfig1

Referring a Patient for a Second Opinion

Despite all best efforts, a patient will occasionally require a referral to a consultant within the provider's own specialty. Knowing one's own limitations and when to refer a patient can be a humbling experience, but a necessary step to provide the patient with the best care possible. Patients will usually appreciate a provider's healthy sense of self-doubt and will initiate the referral on behalf of the patient, especially when the patient fails to improve.

Communication before, during, and after the referral-consultation process is critical for optimal patient outcomes. The referring provider should relay a summary of the patient's condition, work-up, and therapeutic interventions thus far, as well as provide any critical documentation prior to the patient's consultation appointment. In addition, whether the referring doctor would like an opinion only or for the consultant provider to take over the care of the patient should be discussed. Finally, the consultant provider should communicate their independent findings and plan for the patient.

Unclear Diagnosis

Seeing a patient for the first time to provide a second opinion can be a real challenge. Often, the patient has had multiple visits, laboratory studies, biopsies, etc., and yet does not have a clear diagnosis, leading to significant frustration. Although this may be their initial visit with you, the patient is likely to have seen a number of primary care and specialty providers and travelled a significant distance for their appointment.

Having prior records available before the time of the patient's visit is critical so that repeat testing is not necessary and to understand the patient's work-up thus far. By reviewing the patient's own records with them and highlighting key components, the patient gains a better understanding of why they might not yet have a diagnosis. Too often, medical testing is not explained well enough to the patient who may state "the doctor just said everything was fine" or "the biopsy did not show anything".

If a patient has had a biopsy previously performed, those results can be requested so that a second opinion on their pathology can be formed. A study from the University of Pittsburgh Medical Center examined the discrepancy rate between the preliminary diagnosis and final diagnosis given for dermatopathology referral cases. The authors found that, in 56% (226/405) of cases, the referral diagnosis and the outside diagnosis differed; in 22% (91/405) of cases, there was a major discrepancy (Figure 2).1

Figure 2. Discrepancies between preliminary diagnosis and final diagnosis given for dermatopathology referral cases

Huangfig2

Although a patient may have already had an extensive work-up, they should be approached in the same way as for any new patient. Time should be taken with the patient, and the patient's history and treatment course should be comprehensively reviewed, along with a thorough examination. If no biopsy has been performed or if there is a clinicopathologic mismatch, a biopsy should be performed if clinically indicated. A patient deserves a fresh perspective on their case.

Therapeutic Challenge

Often, a patient has had an adequate work-up for their skin condition and their diagnosis has been defined, but they are not responding to prescribed treatment. The patient is left to wonder why they are not getting better. Whether this represents poor patient adherence or a true failure of therapy can often be difficult to determine. Reviewing, in detail, the past treatments that the patient has used, the duration of each treatment, the patient's perceived compliance, and the side effects of each treatment can help to understand the patient's experience thus far.

Every patient will have a certain preference for treatment (topical, systemic, holistic, etc.) and level of risk tolerance for treatment. A patient may not be using their topical medication because they prefer a cream over an ointment vehicle or may not be taking their methotrexate because they are fearful of immunosuppression. By presenting available options to the patient and having the patient actively participate in their medical decision-making, patient adherence and patient satisfaction with treatment can be improved.2

Broken Relationships

Physicians receive similar training in medical school and residency, yet have their own opinions on how to apply this knowledge to the practice of medicine. Often, patients and their providers do not see eye-to-eye on their condition, leading to feelings of mistrust or lack of confidence in a provider. A patient may feel that the provider is either too aggressive or too conservative in their approach, or feel that there are barriers in communication with their provider. In these and other situations, a patient will either ask for a referral to another provider or seek out another on their own.

Indeed, the patient-physician relationship in a second-opinion encounter balances a complex framework between the patient, the initial provider, and the consultant provider, leading to unstated challenges in communication, trust, and loyalty.3 In situations where patients have been dissatisfied with the medical care provided elsewhere, it is best not to place blame or fault on other providers. However, a discussion of unmet needs should occur to establish goals for each visit.   

The doctor-patient relationship is complex yet a fundamental element in the delivery of medical care. Establishing rapport and trust can be difficult in a patient who may have had previous negative experiences thus far in their care. Sitting down with the patient and actively listening to their concerns, fears, and frustrations can go a long way in building a strong relationship with them. Patients often come for a second opinion with a well-organized summary of their course and have expectations that should be negotiated with them regarding their visit.

Patients are becoming increasingly more involved in their healthcare decisions and more educated, with the availability of an infinite number of online resources, blogs, websites, and social media. A survey from Canada noted that about 60% of internet users searched for specific health information online and almost 40% of these users discussed their findings with the doctor.4 Every effort should be made to address the inevitable questions that a patient may have after acquiring such information.

Common Pitfalls

  • Failure of communication between the provider, patient, and consultant
  • Patient not improving due to incorrect diagnosis, poor compliance, or true failure of therapy
  • Breakdown of the doctor-patient relationship
  • Missing documentation (clinical notes, pathology reports, labs) prior to consultation can lead to unnecessary repeat testing
  • Not addressing the patient's true concerns about their condition


Conclusions

Second opinions are an important tool in the delivery of medical care, especially in dermatology where the workforce is relatively limited.5 Although resources such as teledermatology and remote second-opinion programs are becoming more available, the most common form of consultation is in person. Inherent to the interaction, there can be varying levels of frustration, confusion, and feelings of despair that a provider may encounter in addition to the diagnostic and therapeutic aspects of the visit. Understanding the patient's perspective, providing the patient with education, and involving them in the medical decision-making helps to establish a trustworthy doctor-patient relationship.

References

  1. Gaudi S, Zarandona JM, Raab SS, et al. Discrepancies in dermatopathology diagnoses: The role of second review policies and dermatopathology fellowship training. J Am Acad Dermatol. 2012 Aug 11; [Epub ahead of print]
  2. Umar N, Schaarschmidt M, Schmieder A, et al. Matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction.  J Eur Acad Dermatol Venereol. 2012; May 28. [Epub ahead of print]
  3. Greenfield G, Pliskin JS, Feder-Bubis P, et al. Patient-physician relationships in second opinion encounters - the physicians' perspective. Soc Sci Med. 2012;75(7):1202-12.
  4. Underhill C, Mckeown L. Getting a second opinion: health information and the Internet.Health Rep. 2008;19(1):65-9.
  5. Kimball AB, Resneck JS Jr. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol. 2008;59(5):741-5.
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