Archive for category Second opinions

Surgical Consultation — when is the right time?

Hhammerwithnailow to make a surgeon cry:  “I don’t want surgery.  What should I do about my hip pain?”  Surgeons are faced with this question every day.  Most of the time the answer is “well, when you are ready you can always come back.”  To be blunt, surgeons are trained to do surgery and surgeons lose money when they spend time doing something else.  In fact, they often don’t have much experience with the “non-operative” management of many conditions.

Think about the problem.   Would you ask a butcher what he would recommend for a vegetarian meal?  Would you ask a home builder about the best apartment to rent?  Would you ask a car mechanic about where to drive your car for a vacation?  It is possible the butcher, home builder or car mechanic will have a good answer but chances are not too great.  So why would this be different with surgeons or other specialists?

The general rule is to ask someone a medical questions who does not have a vested interest in the answer.  Or to do a good job of investigating symptoms on the Internet before getting a consultation so you can ask good questions and be “a little” skeptical.  A primary care doctor’s office is the first place to pose the question.   If the primary care office in uncertain about a diagnosis then a higher level consultation is in order — the question to primary care should be “who would best be able to guide me to the next step?”  Like, “I am having some mild hip pain.  I don’t want to consider surgery yet.  What non-operative treatment is available?”

Recently a friend was having knee pain.  She saw her primary care provider who suggested cutting back on hiking.  That did not seem very high tech so she saw a surgeon who recommended surgery.  Since the knee MRI was normal she was skeptical.  She took some Tylenol and a few weeks later the pain was gone.  The old saying “if you have a hammer then everything looks like a nail” is very true in the procedural world.

Another example comes from gastroenterology.  If a patient has gas and bloating which do you think a gastroenterologist will do first:  a $1000 colonoscopy or trial of a dietary change?  — you guessed it, often the colonoscopy!  Worse,  if the colonoscopy is normal you will likely be sent to primary care to try some dietary changes and some lab tests.  The appropriate route to take is to let primary care suggest the diet changes, get some lab tests and simple x-rays.  Then, if the problem is still not solved go for the colonoscopy.

In health care systems where physicians have a  financial incentive to provide quality and follow evidence-based guidelines the number of unnecessary procedures declines.  Surgical complications are probably higher than you realize.  Taking time to seek answers before getting that surgical consultation is very important.

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DIY Digital Diagnosis — better with some human input

man and algorithm

On 7/23/13 Laura Landro of the Wall Street Journal published an article about “A Better Digital Diagnosis”.  The essence of the story is on-line symptom checkers are available and may be useful to patients.   Just input your symptoms, get your diagnosis, call for an appointment, and get your treatment.  Sounds good; possibly too good.

Below are listed some good sources for information, some symptom checkers and some software to download to a smart phone.  The software is actually intended for health care providers and may have too much jargon for the average person.

However, before you jump in to get a diagnosis for what ails you try a test run.  OK, this is not a double blind experiment but worth your time.  The idea is to look up the details of a known disease then enter the published symptoms in the symptom checker and see what comes out.  You will find a huge variation, often the expected diagnosis does not even show up at all!

For example:  plantar faciitis.  This is a common disease of the foot caused by inflammation of the connective tissue in the sole of the foot especially causing pain just in front of the heel bone.  The striking and often diagnostic symptom is heel pain on first getting out of bed and walking.  The pain gets better after a few minutes of walking.  It is common in runners and people who spend lots of time standing.  Being overweight or wearing hard-sole shoes contributes.  As people get older the natural padding of the sole thins which is probably why the problem is common after age 50.

footpain

The symptoms were entered into several of the symptom checkers.  Esagil seemed to give every diagnosis know to medical science and nothing would narrow down the possibilities — every symptom could be due to syphilis.  The Mayo Clinic site required some human thinking.  Foot pain showed several areas to read about: after reading the material the diagnosis of plantar faciitis seems to fit.

The diagnosis of plantar faciitis can usually be made by a primary care provider in a flash — it is a common problem.  Worrying about whether you have syphilis is a waste of time and a real source of anxiety — if you ask the primary care provider whether you could have syphilis, you can almost count on some testing.

Once you have tested any symptom-checker and understand the limitations they can be helpful.  It’s almost like a second opinion about a problem.  Discuss the findings with the health care provider early in an office visitdon’t spring the information after the provider makes a plan.  Be a team player to prevent being at odds with the provider.


Good sources for medical information:

Evaluate symptoms / differential diagnosis

Smart Phone Apps

  • Android
    • Differential Daignosis by mHealth Labs, LLC
    • Differential Diagmosis by  Borm Bruckmeier Publishing LLC
    • Your Rapid Diagnosis for Android by  WWW Machealth
  • iPhone
    • Differential Diagnosis from the BMJ Group
    • Your Rapid Diagnosis by  WWW Machealth
    • VisualDx by Logical Images
    • Common Symptom Guide by Mobile Systems:

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Second Opinion — really?

marcus welby 2nd opinion

Dr. Kiley asks Dr. Welby for a second opinion (circa 1970).  What was the story?  A crusty patient does not believe Dr. Kiley’s diagnosis and demands a second opinion from Dr. Welby.  Oh, the drama, the crushed feelings of Dr. Kiley, the wisdom of Dr. Welby, and the horror that neither knows how to use a microscope!

Holly Finn wrote an article today in the Wall Street Journal “First of All, Get a Second Opinion” (WSJ March 23, 2013).  She is strongly in favor of second opinions for two basic reasons:  there are now more successful companies that specialize in second opinions and 60% of people who seek a second opinion obtain recommendations which are less invasive and less costly.  But, she is taking the statistics out of context.  99% of people do not get a second opinion but the 1% who find a problem with the first opinion are often correct another solution is better.  The take-home lesson, like many things in life,  if something does not sound right,  it’s probably not.

Contrary to popular belief most physicians are very happy to help a patient get a second opinion.  Why?  Because a patient who feels uneasy with a situation will not follow directions, will not take prescribed medications, and will be hyper-critical if the outcome of treatment or surgery does not meet their expectations.  So, all a patient has to do to get a second opinion is to ask the provider (“do you think a second opinion would help us?”).

It is important to keep the primary care provider “in the loop”.  The best consultations or second opinions happen when there is a good exchange of information — what has been done, what tests show and what medications have been tried.

When should a person ask for a second opinion?

  • When a provider is unable or unwilling to discuss your questions or the information you have found in books or the Internet.  An unending barrage of questions is counterproductive — be prepared by doing your homework and ask a few good questions.
  • When you simply do not understand the diagnosis.
  • Give your provider an opportunity to adjust medications if side effects happen or if medications are not working as expected.  A second opinion is a good idea if the treatments and modifications are not working.
  • When the provider is unable to make a diagnosis of a problem.
  • When you have been diagnosed with a life threatening condition — you may not get a second chance for a second opinion so don’t wait.  Sometimes a bad situation can not be cured — at least you will have some comfort that what can be done is being done.
  • When your doctor is not giving you more than one option for treatment — there is always an option (perhaps not a good one, but there is always a choice)
  • When you are uneasy about the need for any surgery.  A CNN report  lists 5 surgeries that should trigger a second opinion:
    • Heart bypass surgery (get a second cardiologist opinion)
    • Hysterectomy (often not needed)
    • Pregnancy termination for fetal abnormality (because the diagnosis can be difficult)
    • Surgery for varicose veins (often not needed)
    • Treatments for brain tumors (a really big step)
  •  Sometimes insurance companies require a second opinion for certain problems.  Listen carefully to that second opinion even if you were happy with the first opinion.  There is indeed a lot of unnecessary testing and surgery which can be  dangerous for you and expensive for the insurance company.

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