health

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:

Gathering information (eg, records, test results) that formed the basis for the first opinion for some new doctor to review.
An in-person visit with the second doctor for the purpose of an interview and physical examination.
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.

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.

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.

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.

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?

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.
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.
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?

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.
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.
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.
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:

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

Related Posts:

Have you wondered about the “medical toll” at endurance sports events? By that, I mean the sum of all the medical problems that occur to atletes during their participation (and perhaps shortly afterwards as well).

It’s an interesting issue, with many practical implications. If you’re organizing a swim meet, you’d be interested in the likelihood of drowning. If you’re participating in a bicycle race, you’d be interested in the frequency of crash-related traumatic injuries. If you’re the spouse of a long-distance runner, you’d be interested in the likelihood of heart-problems for the participants of a marathon. Should your event have a “medical tent” to handle anticipated injuries or medical problems? Where should the medical tent be located and how should it be staffed? How should your local EMS system or hospital prepare to handle athlete-patients? You get the idea.

Yet surprisingly little has been written in the medical and scientific literature about the medical toll of endurance events. There’s probably a bunch of reasons, including the fact that nobody in particular’s keeping track.

This past week there was an interesting report in the British Medical Journal from a group of investigators in Cape Town, South Africa, and headed by Martin Schwellnus. The report, “Medical complications and deaths in 21 and 56 km road race runners: a 4-year prospective study in 65,865 runners–SAFER study I,” describes the “medical toll” at recent editions of the Two Oceans Marathon races. The report and the findings caught my eye.

The Study

The participants in the study were the 65,865 runners who took part in either the 21 km half marathon or 56 km ultra marathon, the premier events at the Two Oceans Marathon races that are held each year in Cape Town, South Africa. They focused on the 2008 through 2011 editions. The weather conditions for these races was generally favorable, with temperatures ranging from 11.5 to 18.2 degress C and relative humidity ranging from 77% to 93%.

Like many long distance running events, these races had an elaborate set-up for provision of medical care on race day, including on-route medical stations, a dedicated medical facility at the finish, and designated hospitals where athlete-patients would be transferred should they need emergency care. Because the system for medical care was so well proscribed, the investigators were able to compile a list of all “medical complications” that occured in the race participants.

The investigators did not consider the most minor of medical complications, such as seeking medical attention at various first-aid stations for minor injuries or requiring physical therapy attention at the finish line. For simplicity, “medical complication” was defined as an episode that required the attention of a doctor. Exercise-associated muscle cramps alone were not considered a “medical complication” unless there were additional symptoms such as confusion, dizziness, nausea, or vomiting. A serious medical complication was defined as a “medical complication that could result in death unless urgently diagnoses and treated.” And finally, deaths were recorded as well.

The Results

Of the 65,865 participants, 64,420 (97.8%) finished their race(s). The finishing rate was 99% for the 21 km races and 97% for the 56 km races.

Two deaths were documented, each in a 21 km race. The fatality rate, then, was approximately 1 per 20,000 participants in the 21 km races. There were no deaths in the 56 km races.

Overall, there were 545 medical complications among the 65,865 participants, a rate of approximately 0.8% (8.27 per 1000 participants). The rate was approximately 0.5% for participants in the 21 km races and 1.3% for participants in the 56 km races.

Included in the 545 total medical complications were 37 that were designated as serious medical complications. This is a rate of approximately 0.06% (0.56 per 1000 participants). There was no significant difference in the overall rate of serious medical complications based on the distance of the race. The serious life-threatening medical complications included:

Ischemic heart disease (including successful resuscitation from cardiac arrest), in 3 runners
Myocarditis, in 2 runners
Serious cardiac arrhythmias, in 2 runners
Symptomatic hyponatremia (low sodium), in 9 runners
Serious metabolic complications, in 5 runners
Serious heat-related disorders in 7 runners (1 with hypothermia, 6 with hyperthermia)
Pulmonary edema, in 2 runners
Serious fluid, electrolyte, or acid-base abnormalities, in 4 runners
Bronchospasm, in 2 runners
Convulsions, in 1 runner

Further statistical analysis was used to evaluate groups of medical complications, depending upon the body’s organ system that was involved. In this analysis, the frequency of complications involving the cardiovascular, musculoskeletal, metabolic, gastrointestinal, and respiratory systems was greater among the 56 km runners than for the 21 km runners.

The Takehome Messages

The chances of a medical complication or serious medical complication were small, for both of the race distances. Athletes should know, then, that these risks are small as they consider participation in an event.

Information like this should inform safety planning on the part of event directors, event medical directors, and events’ local medical communities.

I suspect that the results are generalizable to races outside of South Africa and also to the real-world question of half marathon vs. marathon races which would be typical distances in the United States.

It is a somewhat surprising finding that the only 2 deaths occurred in the shorter, 21 km races. We know from recent detailed studies involving millions of runners that the risk of sudden cardiac arrest at long-distance running events is almost 3 times higher for marathon runners than for half marathon runners. In this study, it’s a statistical oddity–that not enough years were considered to evaluate such a rare end point.

Intuitively, it is not surprising that there would be more medical complications in the longer events. If nothing else, there is more “time exposure”–more athlete-hours spent in strenuous exercise.

I am surprised, though, that the frequency of serious, life-threatening, medical complications was similar for the 2 race distances, I would have guessed that these, too, would be more common in the longer distance races. Perhaps the take home message is the converse–that a shorter race is not necessarily safer when it comes to life-threatening medical complications. And the real world consequence would be that half marathoners not give short shrift to their health before participating.

Lastly, I’ll continue to hope that national governing bodies and large event organizers (eg, World Triathlon Corporation [WTC[) might collect and disseminate information about the “medical toll” at their races. As a sporting community, we would all benefit.

Writing on…

Getting a Second Opinion

The Medical Toll at Endurance Events