Originally created 02/18/99

Getting a second opinion



Your car's making ominous groaning noises. So you drive it to the repair shop, and soon enough the mechanic emerges from its underbelly to give you the depressing diagnosis: "Transmission's shot. We'll have to replace it."

But a little bell goes off in your head: Maybe the transmission can be repaired! Maybe I should see another mechanic? So if you'd get a second opinion for your car, then why not for your body?

When it comes to our bodies, even when the stakes are high -- when major surgery or a potent drug is recommended, or a doctor's not sure what ails us -- some of us are reluctant to get another physician's opinion.

There are many reasons why. Maybe we're nervous about challenging his or her authority -- especially if we're timid to begin with or raised in certain times or cultures that place physicians on a pedestal. We may not want to do anything that could potentially harm our relationship with our doc. And, after all, doesn't the doctor know best?

All that aside, there are often good reasons for consulting another doctor, say physicians and other health care experts. Medicine has never been the precise, scientific endeavor we'd like to imagine. And the growth of managed care, with its emphasis on cost-saving and its restrictions on which doctors we can see, has left some patients concerned about whether they are being offered the best treatment.

"Whenever you have doubts about your care, you should at least think about getting a second opinion," says Peter Lee, director of consumer protection programs at the Center for Health Care Rights, a Los Angeles-based consumer advocacy group. "Patients aren't shackled to their doctors. They need to be assertive. They need to be in control of deciding what their care should be."

Of course, no one's recommending we seek second opinions for every last sniffle and sneeze. So when should we seek one? How do we find the right doctor? And what do we do with that opinion once we've got it?

Second opinions, experts say, are worth seeking when you're considering major surgery for a nonemergency condition. Study after study has shown that many surgeries, from C-sections to coronary bypasses, are sometimes performed unnecessarily. And every time you go under the knife, there's a risk.

If you've got a serious or life-threatening condition, second opinions can also be critical. Has the full range of treatment options been offered? Is your doctor sufficiently specialized in your kind of case?

If you or your doctor is uncomfortable with a recommended treatment, if your doctor can't figure out what's wrong with you, if you're not getting better or you can't get your questions answered -- all can be reasons to seek second opinions.

Remember: Many medical conditions can be treated in more than one way.

"There are very few conditions for which there is a gold standard treatment," says Peter Clarke, professor of preventive medicine at the University of Southern California and co-author of "Surviving Modern Medicine" (Rutgers University Press, 1998), a consumer health care guide. "The variation in treatment modalities is immense, simply immense."

In fact, this variation in medical treatments is what leads some experts to question whether more opinions lead to more confusion.

It would be one thing, says Dr. Robert Brook, a health policy researcher at the University of California, Los Angeles, if second opinions were scientifically built into medical practice -- with well-qualified physicians independently reviewing treatment decisions. That would help standardize medicine.

One area in which second opinions may be valuable is gynecology, where treatment recommendations can differ greatly, says Dr. William Parker, chairman of the department of obstetrics and gynecology at Santa Monica-UCLA Medical Center and author of "A Gynecologist's Second Opinion" (Plume/Penguin, 1996).

Take fibroids, growths in the uterus that often cause bleeding. Women with heavy bleeding from fibroids are commonly advised to have an abdominal hysterectomy, which is the removal of the womb through an incision in the belly, Parker notes. But there are other less-invasive ways for dealing with the problem that may be easier on the patient.

"Bonnie," a Los Angeles woman who asked that her real name not be used, was advised to get a hysterectomy for her fibroids. When she told her gynecologist she wanted a second opinion, the doctor agreed.

"She said, `Of course you do,' and gave me my most important medical records on the spot." When Bonnie met with Parker, he suggested doing nothing. Bonnie was close to menopause, a time when fibroids tend to shrink anyway. For now, she has decided to wait.

Specialized knowledge can be crucial, says Dr. Beth Karlan, director of gynecologic oncology at Cedars-Sinai Medical Center in Los Angeles. A less specialized doctor may not know about the newest treatments or may have seen fewer cases of, say, your particular type of cancer.

But even if a second opinion doesn't differ from the first, it doesn't mean that seeking it has been a waste of time.

"Even if the patient's diagnosis and treatment is unchanged by the second opinion, it is a small price to pay for the reassurance and confidence it brings," says Dr. William Norcross, professor of clinical family medicine at the University of California, San Diego.

Which isn't to say that broaching the subject with your doctor will be easy, or that a doctor will always be receptive. Going about it the right way should help.

"Be candid, but polite," Clarke recommends. "A lot of people think that `patient empowerment' means you have to be confrontational -- and that's going to destroy a healing relationship.

"Instead, say something like, `You know, this is a complicated and important decision for me, and I think I'd like to talk to another physician about my options as well. Perhaps you have a recommendation?' That helps preserve the bond."

But how do you know whether that recommended doctor will give you a truly independent second opinion? With managed care, doctors are often required to recommend physicians in the same medical group or plan. Very likely that's fine. But if you're worried that you aren't being told about the full range of treatments available because the group or plan favors a certain approach, you may need to find another, independent doctor.

Who's going to pay for your second opinion? Again, there's no blanket answer. It depends on your health plan and medical condition. Study your health insurance contract to understand your rights.

In general, a managed care plan is much more likely to pay for a second opinion with a doctor who belongs to your plan. If you want to go to someone outside your plan, be prepared to pay roughly $100 for the consultation alone.

Once you've forked over the cash and consulted with doctor No. 2, what next? If your first and second doctor agree with each other, well and good. If they don't, whom do you believe? Patient, beware: There are pitfalls everywhere.

For example, Clarke says, it's very tempting to weigh the second opinion more favorably than the first, for a reason our parents used to lecture us about: The harder you work for something, the more you value it.

It's tempting, too -- silly as it sounds -- to favor the doctor who's more charismatic or better fits the Marcus Welby image.

Also, ask yourself if you are leaning toward one opinion because that doctor gave you the news you wanted.

Weighing two opinions won't be easy. If there really is an impasse, and you don't know what to do, you may need a third opinion. But getting the two doctors to talk with each other could help. Perhaps one of them isn't considering some vital piece of information. Or perhaps both treatments are fine: The difference may be more one of medical approach, such as "to cut or not to cut." Your philosophy may jell more with one doctor's than the other's.

But what if your plan denies treatment because it considers the second doctor's recommendation unnecessary, experimental or too costly? If you can't wait, you may have to choose the treatment the plan will pay for, or consider fronting the money yourself. You can appeal the denial -- all health plans have an appeals process.

Remember -- it's your body. You owe it to yourself to know as much as you can to keep it well.

"Education is empowerment," Cedars-Sinai's Karlan says. "It's a sound bite, but it's true. It's really important that you view yourself as a consumer of the most important thing in the world -- your own life."