Approaches to a Second Opinion in Dermatology
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
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.
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
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
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
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
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.
- Failure of communication between the provider, patient, and
- 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
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.
- 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]
- 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]
- 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.
- Underhill C, Mckeown L. Getting a second opinion: health
information and the Internet.Health Rep. 2008;19(1):65-9.
- Kimball AB, Resneck JS Jr. The US dermatology workforce: a
specialty remains in shortage. J Am Acad Dermatol.