Ask Another Doctor? Expect a Chill in the Exam Room
April 4, 2000 - Almost anyone who has ever been part of a couple has experienced that moment of sudden disorientation when one looks at a partner and sees only a stranger -- and an unreliable, possibly deranged stranger at that.
The thought hits: "I must get out of this right now before I am damaged forever," and life suddenly becomes more complicated than it was an instant before.
For romantic couples the impulse may pass, or it may escalate into therapy, separation or divorce.
The options are more limited when the couple consists of patient and doctor.
Some patients jarred by that sudden glimpse of Mr. Hyde across the desk do nothing; for others (about one in five, according to a Commonwealth Fund survey reported in the policy journal Health Affairs last fall), the moment leads directly into the awkward and disorienting no man's land of the second opinion.
If medical practice were the science it is sometimes said to be, even the word opinion would be obsolescing fast.
But medical opinions are everywhere, and second opinions are tricky business for doctors and patients alike -- superb evidence, as if anyone really needed it, that patients may be somewhat less empowered than the gurus of the medical consumers movement like to maintain.
Shopping around for a doctor is one thing, but for a patient to ignore a familiar voice to consult a stranger still takes real courage -- courage to head out into the unknown and also, as Dr. Jerome Groopman points out in his new book "Second Opinions," (Viking, 2000) courage to risk leaving ill will behind. "Often a patient and his family hesitate to ask if a second opinion would be beneficial," Dr. Groopman writes, "because they fear they will 'insult' the doctor, that the question will be misconstrued as a threat and alienate their caregiver."
It would a pleasure to pooh-pooh those common fears as groundless, but actually they are not entirely off the mark. "Alienate" puts it a little strongly, but only doctors heading for sainthood usually weather the experience of a long-term patient's heading elsewhere without flinching just a bit.
No matter how justified the doctor knows the decision may be, it is still a poke in the viscera.
Every weird harmonic overtone in the doctor-patient relationship begins to resonate, from the military ("I'm in charge here!") to the professional ("I certainly do know what I'm doing!") to the collegial ("Anyway, we're in this together!") to the parental ("But you're MY baby!").
Even when the second and third opinions concur entirely with the first one, there's still something hanging in the air that wasn't there before: not a distrust, precisely, but perhaps just a sudden awareness of the wide windy world outside the examining room and the fragility of the arrangement within.
Pity your doctors for their human frailties, but be aware of their inconsistencies, because in fact they are out getting exactly the same second opinions on your case all the time.
These opinions simply fly by another name, that of "consultations," and they are the scaffolding on which the highly fragmented structure of medical care rests these days.
It is for formal consultations that I cheerfully ship patients off to specialists, and for informal ones that I waylay colleagues in the hall.
When Mr. P. got that pain back in his tuberculous hip a few years ago, I contacted every authority in the city I could think of, friend and stranger alike, just to gather opinions of my treatment plan.
And here's the unvarnished, sorry truth: had Mr. P. been the one who decided to make all those phone calls, I would have applauded his industry and heeded his suggestions, but that same chilly little wind would have blown through the examining room nonetheless.
Science or no science, the balance of power is as much of a complicated reality in medicine as it is in the marble halls of government. And so it has always been.
In fact, among the first tasks medical ethicists took upon themselves centuries ago was to think through the perplexing diplomatic issues posed by second opinions and consultations.
The British physician Sir Thomas Percival devoted large sections of his pioneering 1803 textbook of medical ethics to the subject.
Consultations are necessary in "difficult or protracted cases," Sir Thomas wrote, and "no important operation should be determined upon" without them.
He also knew, however, that consultations could provoke serious internecine conflict, and he devoted pages to protocols for minimizing it: who should speak first at the meeting of doctors (the most junior), who should actually administer treatment (the primary physician), what to do in case of disagreement (find yet another doctor). And, he advised, be sure never to breathe a word about the disagreement to the patient (lest the entire medical profession start to look foolish).
Larger subjects compete for medical ethicists' attention these days, and the etiquette of second opinions goes largely unsupervised. Perhaps it is just as well that, as Dr. Groopman points out, most medical decisions do not require them. If they did, heaven preserve us from the tangled emotions and power struggles that would begin to strangulate routine health care.
The doctor in me knows that Dr. Groopman is entirely right: most medical conditions are so clear-cut and so routine that seeking out a second opinion is just looking for trouble.
Unfortunately, the patient in me, at the moment, knows no such thing.
My left upper wisdom tooth may be just a tooth, but it is my own, and when my dentist sympathetically announced a few weeks ago that it was time to bid it goodbye, suddenly there was Sir Thomas whispering in my ear that old line of his about operations and second opinions.
And now I am in a sad pickle indeed.
I love my dentist, my friend for 15 years, but I also love my wisdom tooth, and I love the second opinion that stated there seemed to be no urgent reason for its removal.
Sir Thomas thinks I need a third dentist.
I think that what I need is simply to talk to my first one and outline in straightforward fashion what I have done, and what the other dentist said, and proceed from there.
The problem is that I know perfectly well that as soon as I start to talk, a cool little wind is going to blow through the examining room and ruffle my dentist's hair, and nothing is ever going to be quite the same again.
By ABIGAIL ZUGER, M.D.
Copyright 2000 The New York Times Company
<http://www.nytimes.com/library/national/science/health/040400hth-essay.html>
janet paterson
53 now / 41 dx / 37 onset
a new voice: http://www.geocities.com/janet313/
613 256 8340 PO Box 171 Almonte Ontario Canada K0A 1A0
