Posts Tagged care coordination

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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Poor Coordination of Care – Who is in charge?

23% of sick Americans felt  “no one doctor understood or kept track of all the different aspects of their medical issues.”  At present there is only one solution.  The patient needs to keep a notebook of information about their health.  This should include an up to date health history, medications, allergies,copies of significant tests, x-ray reports and lab tests.  After office visits ask for copies of results and after hospitalizations ask for copies of the discharge summary for the notebook.  The impediments to sharing of information are tremendous:

  • No nation-wide patient identification number
  • No common way to store health information
  • No way to search all sources of health data
  • Patients moving or changing doctors or changing health systems
  • Name changes, identity theft, undocumented aliens
  • Poor communication to and from a primary care providers
  • Lack of pharmacy integration into databases
  • Strict privacy rules
  • Separation of outpatient and inpatient providers

Nobody knows who to trust with their health information.  If such a trusted place for information could be found then American’s health information could be electronically stored there with access controlled by the patient.  This probably will not happen soon so patients should:

  • keep a health information notebook
  • get a primary care provider
  • try to stay in a health system that has a good information system
  • support the idea of trusted regional or statewide health information systems

Health care mergers and acquisitions are increasing but the merging of information systems sometimes does not follow.  Perhaps such joining of health care systems should have legal requirements to merge the patient data systems as well.

Despite the dim hope of information sharing on a large scale there are things providers can do.

  • Give patients copies of important medical information either on paper or electronically
  • Always send information to the patient’s designated primary care provider.
  • Always give the patient an updated list of medications they should be taking, not just the medications prescribed that day.
  • Encourage the patient to bring the medication list to every health care encounter.
  • Make it clear to the patient who is in charge at all times.  Hand-off of care means a positive, certain, provider to provider communication and not just a whisper in the wind.
  • Make it easy for other providers to contact you.

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