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Dr Larry Creswell

Dr. Larry Creswell on athletes and heart health.
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Getting a Second Opinion

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There can be tremendous value in getting a second opinion.  I’m certain about that.  At times, though, the process of getting a second opinion can cause unnecessary angst for patients and doctors, alike.  It shouldn’t.  Here’s my take.

 

What do we mean by a second opinion?

We’re talking about an additional opinion from a doctor who has not already been a part of things–somebody who did not offer the first opinion.  Perhaps that’s obvious.  Ordinarily, the process of getting a second opinion involves:

  1. Gathering information (eg, records, test results) that formed the basis for the first opinion for some new doctor to review.
  2. An in-person visit with the second doctor for the purpose of an interview and physical examination.
  3. A discussion with this doctor, where the second opinion is shared with the patient, highlighting the similarities and differences from the first opinion.

Most commonly, we’re talking about second opinions from medical specialists or subspecialists rather than primary care physicians (PCPs).

 

When is a second opinion helpful?

Here are some situations where second opinions can be helpful.  For each situation, I’ve included an example of an athlete-related heart problem.

  1. When the diagnosis is uncertain. Not everything in medicine is black and white.  As they say, the practice of medicine is both an art and a science.  Sometimes, even when all of the relevant information has been gathered, it’s still not possible to decide with certainty as to a diagnosis.  In this situation, a second opinion may help to sort out the diagnosis by bringing additional experience as well as a fresh set of eyes and ears to the problem.

An example.  The condition known as hypertrophic cardiomyopathy (HCM) can be a difficult diagnosis to establish.  There are known genetic mutations associated with this condition, but only a small percentage of cases can be diagnosed that way.  In many cases, the diagnosis depends on the findings from echocardiography, magnetic resonance imaging (MRI), clinical features, and family history.  In some athletes, there can be particular difficulty in distinguishing between an athletic heart, simply the result of exercise, and HCM.  It’s easy for this diagnosis to be uncertain.  In this situation, a second opinion may help to gather consensus about the diagnosis or suggest additional diagnostic testing that might be helpful.

  1. When the treatment carries high risk, is expensive, or is logistically difficult. The diagnosis is settled and the conventional treatment involves a fair bit of risk.  Often, we’re talking about a surgical procedure.  In this situation, a second opinion may bring clarity to the need for treatment and confirmation that the planned treatment is appropriate.

An example.  The condition known as bicuspid aortic valve (BAV) can involve regurgitation (leaking) of the aortic valve as well as enlargement of the nearby aorta to form an aortic aneurysm.  When this diagnosis is established in a non-emergency setting and the patient requires replacement of the aortic valve and the nearby aorta, there are often several related, but technically different, surgical options.  There are different types of prosthetic heart valves and different types of substitutes to take the place of the aorta.  In each of these variations, though, the operation carries a fair bit of risk, is expensive, and can be logistically difficult, especially if operation must be pursued some distance from home.  Here, a second opinion can be helpful to be certain about the diagnosis and the need for operation; provide clarity about how soon an operation should be performed; provide additional discussion about the various surgical options, with the advantages and disadvantages of each; afford an opportunity to re-address the amount of risk that comes with operation; and offer thoughts about the expected recovery timeline and return to exercise.

  1. When there are several treatment options to choose between. After a diagnosis is established, the usual next step is to settle on a treatment.  For many conditions, however, there can be several treatment options.  Ordinarily, doctors like to share these possibilities with a patient and then decide together which treatment is best.  This choice might depend not only on the medical specifics, but also the patient’s social, work, family, financial, cultural, or religious situation.  But sometimes, even after discussion, it may not be easy to choose the best treatment.  In this situation, a second opinion can sometimes be helpful to explain, from another doctor’s perspective, the treatment possibilities along with the advantages or disadvantages of each option.  This doctor might well include additional or different possibilities or share the opinion that some of the previously considered possibilities may not be appropriate.

An example.  One common arrhythmia problem in athletes is atrial fibrillation, or “Afib.” This is a problem that can be nagging or persistent over months or even years.  Once an athlete patient has had this diagnosis established, there are often many options regarding treatment:  lifestyle changes like losing weight, stopping tobacco or alcohol use, or moderating extreme exercise; medicines like aspirin, anticoagulants, or anti-arrhythmics; and procedural treatments such as arrhythmia ablation or left atrial occlusion.  Moreover, a patient will find that his primary care provider (PCP) and perhaps even his cardiologist may not actually perform such ablation or left atrial occlusion procedures.  In this situation, a second opinion might help to review the various treatment possibilities from another doctor’s perspective, and get another take on the advantages and disadvantages of the various treatment possibilities.

  1. When it’s mandatory. Because of various regulatory frameworks, it’s sometimes necessary to get a second opinion before a patient can receive a particular treatment.  Regulations at the local hospital level, from insurance providers, or from the federal programs like Medicare and Medicaid may all come into play in this regard.

An example.  For patients with severe, symptomatic narrowing of the aortic valve (aortic stenosis), we often recommend aortic valve replacement (AVR).  In recent years, a new approach for AVR, trans-catheter aortic valve replacement (TAVR), has become available for select patients.  To satisfy requirements of the FDA and the Medicare program, patients must get opinions from two heart surgeons before they qualify for the TAVR procedure.  In this situation, the second opinion is essentially mandatory.

 

When is a second opinion not helpful?

  1. In an emergency situation. Second opinions are usually not logistically possible in an emergency situation.  Here, patients must usually rely on the doctors that are tending to their emergency condition, even in the situations I’ve outlined above.
  2. When the patient is already in the hospital. Once admitted to the hospital under the care of one or more doctors, it can be difficult to pursue a second opinion, at least in the common sense.  If the condition or situation is not an emergency, sometimes it’s possible for partners of specialists to add their opinion, less formally, about a particular issue.
  3. When two or more previous opinions are already similar. There is a diminishing return with multiple second opinions.  When there is already a chorus of similar opinions, it’s likely the next opinion will also be similar.  In general, it’s probably not wise to chase after the opinion you want.  If you search long enough, you might find that opinion, but remember that there is usually value to consensus among the opinions you’ve received.  Outlying opinions should be treated cautiously.

 

How to find a second opinion?

  1. Ask your primary care provider (PCP). For patients who are fortunate to have a PCP, this may be the best source of a recommendation about how and where to seek a second opinion.  Your PCP will know the local medical landscape.  In many cases, he may have referred you to the specialist for your first opinion.  But he will also know which doctor to suggest next, whether that’s another doctor in your community or one that’s farther away.
  2. Ask your specialist. You can certainly ask the specialist who provided your first opinion.  Some specialists will be more helpful than others when it comes to identifying a good choice for a second opinion.  You may find that it’s easiest for your current specialist to suggest a partner who might also take a look at your situation.
  3. Do some (online) research. There’s a lot of information online about specialists who you might visit for a second opinion.  Perhaps there’s too much information.  It can sometimes be challenging to sift through all of this information and make judgements about its quality.  You may find that you will need to travel some distance to see a particular specialist.  The danger here, though, is in not understanding the medical details sufficiently to select just the right doctor.  And sadly, sometimes if you choose the wrong type of specialist, this may not become obvious until after you’ve invested in a visit.  Another approach may be to select a large medical institution and have that institution help with finding just the right doctor to see you after they get some information from you and perhaps gather some medical records.
  4. Word of mouth. At first, word of mouth may sound like a great way to find a doctor for a second opinion.  Indeed, you may have friends or family that could suggest a doctor that they’ve seen and liked.  The challenge here is that it can be difficult to find just the right doctor unless your family or friends have the exact same medical problem that you do.

 

Doctors get second opinions, too

Sometimes doctors obtain second opinions without their patients even knowing.  This is just good practice.  In this situation, the process may happen behind the scenes.  Your doctor may share your particulars with a colleague to ask for help in settling on a diagnosis or settling on the best treatment.  Your surgeon may ask a colleague to join him in the operating room to help decide what to do with an unexpected finding.  Your pathologist may “send out” your biopsy specimen to get an additional opinion from a center of expertise.  These sorts of second opinions are everyday occurrences.

 

When to change doctors

We should wrap up with talking about when to change doctors.  So far we’ve been talking about getting additional, or second opinions.  Most often, this is done with the intention of continuing to receive care from your first doctor.  But what if you’d like to change doctors?  There’s nothing wrong with wanting to receive your ongoing care from the doctor who gave your second opinion.  That’s your decision and your doctors should understand making a change like that.  I suggest that straightforward discussion with your doctors is the best way to make such a change.

Finally, let me mention two particular situations where you should consider finding a new doctor:

  1. When you are concerned about honesty, transparency, or communication with your current doctor.
  2. When you have reasonable concern about experience on the part of your doctor, clinic, or hospital.

 

Related Posts:

  1. How to Find a Doctor (For Athletes)
  2. Five Questions for Your Doctor
  3. Who Needs a Doctor?

 

In the Medical News: Your Heart Rate Monitor May Help Your Doctor!

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Arrhythmias–abnormal heart rhythms–are one of the most common heart-related problems for athletes.  Sometimes an athlete may notice nothing more than a “skipped heartbeat.”  At other times, there can be palpitations, lightheadedness, or even unconsciousness associated with a sustained arrhythmia.

By their very nature, many types of arrhythmias are transient or paroxysmal–that is, they are fleeting.  And often, they can be provoked by exercise.  Because these arrhythmias can be transient and exercise-related, it can often be challenging for the doctor to sort things out.  The athlete-patient arrives at the office with a normal heart rhythm and only a story of a problem that happened during a workout 2 weeks ago.  There’s no lasting “evidence” of the episode.

For diagnostic purposes, we typically use a Holter monitor–an EKG “tape recorder” of sorts–for periods of 24 to 72 hours to make recordings of the heart rhythm for extended periods of time.  The patient, or athlete, wears a set of skin electrodes that attach to a recording device.  The set-up would be something like wearing a bulky iPod.  And although longer time-frame devices are increasingly available, it’s often challenging for an athlete to capture his/her arrhythmia on such a recording.

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Published last week in the medical journal, Medicine and Science in Sports and Exercise, a group of investigators from Leipzig Germany issued a report entitled “Diagnosis of arrhythmias in athletes using leadless, ambulatory heart rate monitors.” [1]  They call our attention to 3 case reports of athletes in whom a standard exercise heart rate monitor provided useful clues to the diagnosis of their arrhythmias.

In Case #1, a 32-year-old cyclist with palpitations was found during an ER visit to have a brief episode of paroxysmal atrial fibrillation.  Review of stored heart rate tracings from his heart rate monitor revealed evidence of heart rate (and cycle length variability) suggestive of atrial fibrillation that correlated temporally with his reported symptoms.

In Case #2, a 36-year-old cross country skier with palpitations during exercise presented for evaluation.  The resting EKG, echocardiogram, and stress testing could not reproduce the arrhythmia.  Subsequently, the arrhythmia recurred during exercise and the skier’s heart rate monitor captured the event, with a heart rate of 230+.  With specialized invasive electrophysiologic testing, the diagnosis of atrioventricular nodal re-entrant tachycardia (AVNRT) was made.  The athlete underwent a successful ablation procedure.

In Case #3, a 28-year-old triathlete experienced episodes of tachycardia during exercise.  Efforts at recording the arrhythmia on a typical Holter monitor were unsuccessful.  His exercise heart rate monitor recording showed clear evidence of episodes of tachycardia, with heart rates of 170-200.  He underwent invasive electrophysiologic testing and was found to have an ectopic atrial tachycardia and underwent a successful ablation procedure.

The authors report that different brands and/or models of heart rate monitors (Polar, Garmin) were used for each of these three patients.  They noted that the important features were the ability to use vendor-supplied software to retrieve tracings of the heart rate information during periods of exercise.

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The report isn’t surprising and I don’t doubt that there are many athletes who’ve already thought to take their heart rate monitor tracings to their doctor or cardiologist.  In a previous column at Endurance Corner, I shared a heart rate monitor strip from an athlete who was bothered with paroxysmal atrial fibrillation.  The new report reminds us, though, to take advantage of ALL of the information that’s available to us as we sort out arrhythmia problems in athletes.

Reference

1.  Mussigbrodt A, et al. Diagnosis of arrhythmias in athletes using leadless, ambulatory heart rate monitors.  Med Sci Sports Exercise 2013; epub ahead of print.