Practice Perfect 972
Second Opinions

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Doctors refer patients for second opinions as part of the regular practice of medicine, and podiatrists are no different. It seems odd to me, then, looking at my own writing patterns, that I’ve addressed this subject so rarely. Perhaps that’s an indicator of my own history, because for several years when I began practice, I was not part of a larger medical community to which I felt comfortable referring patients. I would also wager a bet that most new doctors in practice do not refer patients for second opinions due either to a feeling that they can do it all or a feeling that they must do it all. As the years have progressed, my own views on this topic have changed to the benefit of my patients. I’m much more likely to refer now.

When thinking about second opinions, there are a number of considerations and perspectives that are worthy of discussion, and we can derive a few specific recommendations for both the referring doctor and the receiving doctor.

Second Opinion Considerations

Consideration 1: There’s nothing wrong with obtaining a second opinion. It doesn’t make you less of a doctor.

Consideration 2: Unless you’re contractually obligated with a hospital emergency room, specialists are not required to do what their patients demand. The doctor chooses the treatment along with the patient in a mutually respectful relationship. Doctors aren’t slaves.

Consideration 3: Think of second opinions as another tool in the treatment toolbox with a number of advantages to help patients heal, including a fresh set of eyes with a different perspective.

Consideration 4: Second opinion appointments can sometimes be complicated and may require extra time.

Second Opinion Recommendations

Recommendation 1: When making a referral, know to whom that referral is going. If your community has someone with a specific interest or expertise, then that person will likely provide additional valuable skills or perspective. Take the time to investigate your community and know who the real experts are.

Recommendation 2: Communicate well. When referring a patient for a second opinion, contact that provider and let them know that the patient is coming their way. Explain to them why you’re sending the patient to them, your expectations, and other details that are important to you and the patient. For example, I once made the mistake of referring a patient to a colleague for surgery, but my colleague was not available to do that surgery within the timeframe I wanted. I failed to communicate that to my colleague, which did not help my patient. Do you expect that patient back? A second opinion should be just that: an opinion. It doesn’t necessarily mean you expect the doctor to keep the patient.

If you are the receiving consultant, make sure you understand the reason for the request and the expectations of the referring provider. Ask the same questions mentioned above. I also always ask if the referrer wants the patient back (sometimes the referral is just to get a troublesome patient off one’s hands).

Recommendation 3: If you’re the consultant, be comprehensive. Considering that another provider is sending you a patient, it’s your obligation to give a thorough recommendation properly charted. Perhaps it’s a difficult problem with an unknown diagnosis. Maybe they want you do to a procedure they are unable to perform or that you can perform better. Either way, make sure your work-up and your documentation are thorough, stating clearly the diagnosis (or differential), your thought process, and your recommendations. Be detailed.

Recommendation 4: NEVER bad-mouth another provider. This should be obvious and regular practice, but it’s still a pretty common poor practice. The last thing your referring doctor will want to hear is that their consultant bad mouthed them. Not a good way to maintain a relationship in your community, and this is a good way to generate an unnecessary lawsuit. It’s ok to explain your thinking to a patient who has a question about prior care but remember that you likely were not present during the prior care, and you can’t know the full story. On the other side of this coin, it’s also your responsibility to give patients honest answers. However, this can be accomplished with tact.

Recommendation 5: Always try to send the patient back to the referring provider. Consider this as another tool in your “relationship” toolbox. Second opinions are supposed to be an opinion and not an opportunity to steal a patient from a colleague. There are times when the patient wants to stay with the new doctor, and, assuming the referring doc did not already tell the consultant it was ok to keep the patient, that doctor should send the patient back. When this occurs, I tell my second opinion patients that they were sent to me as a second opinion, and I would like them to return to their original doctor. If they still want to come back to me then I would start seeing them. It’s really about being respectful to both the patient and the referring doctor.

Recommendation 6: Schedule extra clinic time for these patients. Invariably these appointments take a lot more time than a regular patient. They may have a complicated medical or podiatric history, the need for a comprehensive exam, and a review of prior charts and imaging. Try to obtain chart notes and imaging ahead of the actual encounter to review ahead.

During the encounter, some patients may complain about other providers or issues with their prior care, which can drag an appointment out and destroy a carefully designed clinic day. My suggestion is to gently redirect the discussion to the present situation. Also, in highly complex situations, consider asking the patient to return for a second visit so that you can be comprehensive in a reasonable amount of time.

Recommendation 7: Follow up. Whether you’re the referring doc or the consultant, it’s always a good idea to follow up to see how things went. It’s educational for everyone to further discuss the patient’s situation and find out what worked and what didn’t to help everyone improve for future patients.

To wrap up our conversation, one last recommendation, especially to new doctors, is to be cautious with the patient who has seen multiple other providers. If you’re the fifth doctor seeing a patient for a problem, don’t fall into the trap that you’re going to be their savior. There may be a reason that four other doctors were unsuccessful. Don’t let your hubris get in the way of realizing that it’s unlikely four other doctors were incompetent. In that situation, the issue may be the patient, which may lead to a frank and healthy discussion with that patient. Your assessment may be to advise the patient to make certain changes, rather than recommending other actions by their prior caregiver. A respectful approach usually saves the day and provides a quality second opinion.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]