Posts Tagged biopsy

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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False Positive — what’s not there can kill you.

An x-ray, biopsy or other medical test can have a number of possible results.  The uninformed patient or the unwary doctor can be fooled by some of the possibilities.  How could a little test hurt you — it’s just a harmless x-ray or small biopsy or just a few drops of blood?  There is some underlying truth about a condition we want to know.  Do we have a problem or not, yes or no, cancer or no cancer, pregnant or not pregnant, AIDS or no AIDS and many other questions.

Most people understand if the weatherman predicts rain tomorrow, but no rain comes, we laugh because we know prediction of weather is not always accurate.  Yet we don’t apply the same common sense to medical tests.  If a test predicts a person has cancer we believe it — the sad fact is medical tests are not always accurate.  A test can predict a condition when none is present which is called a false positive.  A test can predict a condition is absent when it really is present which is called a false negative.  A test can predict a condition which turns out to be correct which is a true positive.

So how can a little test hurt?  If the test is a false positive which leads to surgery which has a complication then a person could die.  This is not just theoretical, it happens.  The problem is made worse by a tendency of health care professionals to over-diagnose disease.  For example, if a pathologist is not certain if a biopsy shows cancer the safe thing to say is “possibly cancer” rather than “I don’t know”.  The surgeon says if it is “possibly cancer” the best thing is to “take it out”.  Later, when the patient is missing some body part and no cancer is found the surgeon says “you were lucky”.  Really?  Perhaps the patient should not have had the test in the first place.

In certain circumstances the chance of getting a false positive is higher than the chance of a true positive.  A good example is finding a small spot on a chest x-ray.  Most spots on chest x-rays are not cancers.  Because of the unreliable nature of the chest  x-ray for cancer screening, routine chest x-rays are not advised.

People who study the statistics of medical testing can figure out which tests have the best chances of true results.  This is important information for patients and doctors.  Recently, the PSA test has come under criticism.  It seems the test has a high rate of false positive results and to make it worse, positive results may lead to unnecessary surgery.  In view of the statistics, experts now do not recommend PSA tests for routine screening for prostate cancer.  Hopefully, this will lead to better tests while the old PSA test heads to the history books.

Another important question is whether the result of a test will change treatment.  If not, then don’t do the test.  For example, surgery in the very elderly is dangerous.  So if no surgery would be recommended for a 100 year old person then don’t do a CT scan of the brain.  Is that mean and uncaring?  No, it is taking care not to do tests that lead to harmful procedures.

So, more information is not always better.  It is smart to avoid tests with a high false positive rate.  National guidelines do exist for many tests so search for them on the Internet and as they say “ask your doctor”.

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