Originally published September 2014
Patients have a right to make decisions about their own health and are now more likely than ever to do their own research, ask questions, and at times, seek a second opinion. When a patient receives a second opinion, questions arise around accountabilities, including who is considered the most responsible physician — the first-visit physician or the physician who is providing the alternative viewpoint. What, for example, should the treating physician do if the alternative options of a second physician conflict with the initial treatment plan? And what factors should be considered by the consulting physician?
Why do patients seek a second opinion?
In today's digital world, patients have ready access to a vast array of health information. A recent survey found that 1 in 3 adults in the U.S. has at some time used the Internet to try to diagnose a symptom; 41% of these "online diagnosers" have said that a medical professional confirmed their diagnosis, while 18% said the clinician they consulted either did not agree or offered a different opinion about the condition.1
When patients do consult with a clinician about a health issue, they may choose to seek a second opinion for a variety of reasons: anxiety and fear, skepticism of conventional medicine, lack of understanding or trust, desire to have a "better opinion," or the outcome of online research. Whatever the motivation, in most situations patients simply want to confirm the diagnosis and validate the proposed treatment options.
When you are the treating physician
Diagnosing a condition and choosing a therapeutic treatment are exercises in clinical reasoning and judgment. Physicians should provide information to their patients about treatment options, including significant risks and available alternatives, to allow patients to make informed choices. Further, as the CMA Code of Ethics 2 states, physicians are to respect a patient's reasonable request for a second opinion from a physician of the patient's choice. For physicians who practise in Québec, the province's Code of ethics of physicians is unequivocal: "A physician must acknowledge the patient's right to consult a colleague, another professional, or any other competent person. He must not, by any means, interfere with the patient's freedom of choice."3
When the patient returns after having seen another physician or health practitioner, the patient may have the desired confirmation of the recommended course of action. On the other hand, the patient may have received an alternative diagnosis or treatment options, and consequently request a different therapy. As the treating physician, you are under no obligation to provide treatment that you feel is not medically indicated, or is not supported by scientific evidence, or that is outside your area of competence or experience. Any treatment or therapy you provide must be in accordance with a recognized and accepted standard of practice and should conform to the applicable medical regulatory authority (College) guidelines.
When you, as the treating physician, seek a second opinion from a specialist consultant, you should strongly consider the consultant's advice and incorporate it into the treatment plan if you deem it to be appropriate. If the clinical situation evolves or the advice does not seem appropriate, a follow-up discussion with the consultant may be warranted. It is important to remember that when a second opinion is sought, either independently by the patient or through a referral, responsibility for the care of the patient remains with you, the treating physician. You are expected to make your own assessment and formulate your own treatment plan, and you should discuss the advice received and the final treatment plan with the patient.
When you are asked to give a second opinion
Physicians are sometimes asked to provide their professional opinion in a variety of circumstances. For example, a patient may ask the physician to comment on the care plan being proposed by another physician. Prior to offering a viewpoint and providing a second opinion, you'll want to ensure that you have all necessary background and clinical information (e.g. history, physical examination findings, lab tests, etc.). Keep an open mind and remember there is often more than one way to manage a medical condition. An ill-considered comment on the care provided by others often forms the basis for dissatisfaction and can lead a patient to launch a complaint or lawsuit. Consider having a discussion with the treating physician to obtain their perspective, particularly when the facts and circumstances are not known to you.
An individual could also ask you for a second opinion or seek your medical expertise informally outside your practice such as at a social event. In such a scenario, you could explain to the individual that, given the circumstances, there are both ethical and legal reasons why you are unable to provide medical advice. You could ask the patient whether they are already under the care of a physician and suggest that they contact that physician who would have access to their medical history. Alternatively, you could suggest that the individual make an appointment to see you in your office practice. If you choose to offer advice, you have a duty to provide advice that meets the relevant standard of care, irrespective of the venue. In situations where the individual's symptoms appear urgent, referral to an emergency department or clinic may be appropriate.
The bottom line
Patients have the right to reject their physician's advice and may choose to see a different healthcare provider. The fact that a patient seeks a second opinion should not be interpreted as a breakdown in the doctor-patient relationship. Usually a second doctor's opinion will reinforce that of the first one and satisfy the patient. The patient may very well return, more confident in their ability to make a sound decision about their care.
Of course, there could be serious health consequences when patients do not follow advice regarding their condition. Physicians should strive to help their patients understand the risks, benefits, and reasonable alternatives to the recommended treatment, and should then respect their patients' informed decision. However, if there is a loss of trust in the doctor-patient relationship and this is affecting patient care, it may be appropriate to consider discharging the patient in accordance with College guidelines in your province or territory.
Fox, Susannah, Duggan, Maeve, Pew Research Center, Health Online 2013. Retrieved on April 14 2014 from: http://www.pewinternet.org/2013/01/15/health-online-2013/
Canadian Medical Association, Code of Ethics, 2004 (reviewed March 2014). Retrieved on May 27 2014 from: http://www.cma.ca/code-of-ethics
Collège des médecins du Québec, Code of ethics of physicians (updated June 2014). Retrieved June 3 2014 from: http://www2.publicationsduquebec.gouv.qc.ca