The Second Opinion

The treating doctor may sense the patient’s anxiety and doubt about their management, and will initiate the second opinion even before the patient requests it. In managing complex medical conditions where the medical practitioner is uncertain as to the diagnosis and best form of management, the practitioner will offer the patient the option of a second opinion from a colleague(s).

In both the above situations, there is usually a very good patient-doctor relationship and open communication as to what is in the patient's best interest.

Treating doctors should always listen to the concerns of their patients and their family. The patient (or their family) may request that the second opinion be sought from a specific doctor of their choice. If the treating doctor feels this would be an inappropriate referral, this should be communicated to the patient and alternative practitioners be suggested for the second opinion.

Medical practitioners should be alert to the concerns of their patients and if they sense the patient's doubt as to diagnosis and management, they should initiate the second opinion. The treating doctor is usually better placed than the patient or family on the choice of the practitioner from whom the second opinion should be sought.

Problems may arise when:

• the patient seeks a second opinion without the knowledge of their treating doctor. In this situation, the doctor giving the second opinion may not be fully aware of the facts relating to the patient's diagnosis and previous management, and should advise the patient that it is in their best interest to request details of previous management from the original treating doctor (consent to seek records must be obtained)
• the doctor whom the patient consults for the second opinion may not be the best qualified person to give the opinion on that specific medical problem
• there may have been previous conflict (unbeknown to the patient) between the doctor consulted for the second opinion and the original treating doctor.

Providing a second opinion

The doctor providing the second opinion needs to respect not only the patient, but also the doctor who was the primary carer, irrespective of whether the patient was referred or not by the primary carer. Disparaging and off-the-cuff comments must be avoided – these may lead to medico-legal action against the primary treating doctor in situations where the care given to the patient was appropriate, and at or above the expected standard of care.

It is also important to bear in mind that where clinical details are not available, the patient may give a history that is not completely accurate and lead to bias in forming the second opinion. Personal conflict between doctors must be put aside in offering the second opinion.

During my career, I have been faced on two occasions with threatened litigation and a report to the Health Care Complaints Commission (HCCC) arising from second opinions sought by parents of patients without my knowledge:

Case 1

A two-year-old girl underwent uncomplicated surgery for left ptosis using fascia lata. Post-operatively she was progressing well with the eyelid in a good position. The child had a fall and subsequently developed preseptal cellulitis. This was managed in hospital with IV antibiotics. The cellulitis was resolving and the child was discharged from hospital on oral antibiotics.

On leaving the hospital, the parents sought a second opinion from another Ophthalmologist who, unaware of all the details of treatment, made a comment: "What butcher did this to your child?" My good relationship with the family allowed me to explain what had transpired. The child had a good outcome from treatment and there was no medico-legal action.

Case 2

I looked after a low birth-weight baby born at 29 weeks for several years. The clinical records were detailed, and at each consultation an attempt was made to record visual acuity using an age-appropriate method. The baby had no signs of retinopathy of prematurity. There were signs of developmental delay and this was being monitored by a Paediatrician.

When the child was aged three years, I received a telephone call from the mother telling me she was going to lodge a complaint with the HCCC and commence medico-legal action as I had missed the child's diagnosis. She agreed to attend another consultation to discuss her concerns. She told me she had seen a very senior Ophthalmologist who found that her child's vision was impaired and had told her: "Your son should have been referred to the Royal Blind Society a long time ago. It would have made a big difference to his visual outcome."

We reviewed my clinical records together. The child's vision at all consultations was found to be age appropriate. The child had not been able to read letters on the Snellen chart due to his age and developmental delay. I also attempted to explain to the mother that an earlier referral to the Royal Blind Society would not have made any difference to her son’s visual outcome. The mother proceeded with the complaint to the HCCC. The case was dismissed and there was no further action.

In both the above clinical situations, comments by the doctor offering the second opinion were inappropriate and unhelpful to the patient's management, as well as being derogatory to the treating doctor. The full clinical details were not known to the doctor offering the second opinion. Better communication would have prevented the families of the children losing confidence in the treating doctor and threatening legal action. Derogatory comments as described above are not in the best interest of the patient.

Professional obligations

The Medical Board’s Good Practice – A Code of Conduct for Doctors in Australia states:¹

4.2 Respect for medical colleagues and other healthcare professionals
Good patient care is enhanced when there is mutual respect and clear communication between all healthcare professionals involved in the care of the patient. Good medical practice involves:

4.2.1 Communicating clearly, effectively, respectfully and promptly with other doctors and healthcare professionals caring for the patient.

4.2.2 Acknowledging and respecting the contribution of all healthcare professionals involved in the care of the patient.

Summary points

• Treating doctors should not hesitate to refer patients for a second opinion. They should try to pre-empt the need for the second opinion, especially if they have concerns as to diagnosis and management, or sense that the patient is losing confidence in their management. 
• If the patient seeks a second opinion, the treating doctor should not feel threatened, but react positively and refer the patient to the most appropriate medical colleague to give a second opinion.
• Doctors seeing patients for a second opinion should have the patient's clinical wellbeing as the first priority. They should try to obtain detailed records of previous treatment before giving the second opinion. Hindsight bias must be avoided. 
• Personal conflict between doctors should be put aside and the doctor giving the second opinion should always avoid disparaging comments about fellow practitioners. 
• The doctor giving the second opinion may have a mandatory requirement to refer the matter to the Australian Health Practitioner Regulation Agency (AHPRA) if he/she believes that the treating doctor's management has been inappropriate.²
• Remember – the second opinion is about the patient, and not about the doctor.

References

1. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Available at: medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
2. Australian Health Practitioner Regulation Agency (AHPRA). Guidelines for Mandatory Notifications. March 2014. Available at: medicalboard.gov.au/Codes-Guidelines-Policies/Guidelines-for-mandatory-notifications.aspx