After reading yet another post extolling the virtues of pooled referrals, an anonymous reader asked: “If all the urologists in Saskatoon work in a group practice in one clinic, how can a patient get a second opinion, without causing any unintended displeasure to the first physician?”
Great question! Plenty of meat on that bone.
There’s a simple answer for our group, a longer discussion about physician attitudes toward second opinions, and a dilemma around consolidating medical (or any service, for that matter) into one source.
First, let me address the reader’s actual question. In our group, patients are welcome to seek a second opinion from another member of the group. As the reader points out, we’re the only urology group in Saskatoon and, other than one urologist in Prince Albert, the only ones in the “north” of the province. While patients are free to travel anywhere in the province (or out of the province, or country) to obtain a second opinion, we recognize that this may be a significant burden for some and so provide the option inside our group. (Some may prefer not to seek second opinion within the same group, for fear that our practices may be too homogeneous. Or, they may worry that we don’t want to contradict one another.)
That’s the quick answer, but I’d like to turn the question back to the reader and ask this: “Why do you assume that a physician would be displeased if a patient sought a second opinion?” It’s disingenuous to ask, because I know that some docs do get bent out of shape if someone asks to consult another specialist.
Patient care may suffer when patients fear that a request for second opinion may displease their doctor. Most obviously, the first physician’s diagnosis and/or recommended treatment may be incorrect. A fresh evaluation may reveal the true problem.
Even when the first physician’s assessment is correct, patient and physician may not have an established a relationship of trust and respect. This can be particularly important if treatment involves something as dramatic as surgery, where stakes are higher. If a patient is uncomfortable with the physician’s manner or demeanor, they may have a good technical result from treatment, but their overall experience of care will suffer.
It’s not unusual for patients to see me for a “stealth” second opinion, that is, they will be referred for assessment and not reveal that they’ve previously seen another urologist. (As our group shares an electronic medical record, they would have seen a urologist in another centre.) Their motivation is that they want a fresh viewpoint, and worry that I’ll take the shortcut of accepting the other urologist’s opinion if I have access to his/her notes. The problem with that approach is that there may be clinical information, test results or xray findings not made available to me. That results in unnecessary repeat testing, or incorrect assessment because of incomplete data.
So, if some physicians balking at requests for second opinions can harm patients, why would docs behave that way? Apart from the very rare case of Munchausen’s syndrome, where people feign illness to gain attention, or doctor-shoppers seeking prescriptions for narcotics, its hard to posit a logical argument against a second opinion.
However, logic doesn’t necessarily get in the way of behaviour.
Physicians may feel slighted by the request. We take pride in our professional ability and may be upset at the thought that someone has questioned our diagnostic acumen. The message here: I get it right every time.
Perhaps a physician is insecure about his ability. This may be subconscious, or a conscious realization of inadequate skills and/or knowledge that could be revealed under scrutiny by another physician.
Some docs may have financial motivations. If being paid fee-for-service, there is an incentive (particularly for surgeons) to keep patients in their practice. If a surgeon is flush with referrals, and has a long wait list for surgery, he has enough “inventory” to maintain his income. If not, he may be tempted to “maintain control” of patients.
Physician paternalism is another factor. Docs pride themselves on having their patient’s best interest at heart, even to the point of making decisions on behalf of the patient. They may see the request for a second opinion as a rejection of their caring.
As physicians, we need to remind ourselves that we don’t own our patients - they choose to consult us. The therapeutic relationship can be strengthened by our openness to seeking a second opinion, as it demonstrates our humility and willingness to learn, as well as our true concern for the well-being of our patients, rather than our egos.
The other issue this reader’s question raises is that of detrimental effects of consolidating medical services in one place. I’ve already flogged the benefits including efficiency, improved access and standardization of procedures. But, there is a dark side.
There have been practical problems for our patients, stemming from our practice structure. While we are open to patients seeking second opinions from within our group, there are circumstances where we have to end a relationship with a patient. This is rare, but there have been instances of personality conflicts between a patient and one of our docs that make it impossible for them to continue in a physician-patient relationship. Because our partnerships shares call and patient care responsibilities, our policy in those rare cases is that we decline to provide any care for that patient. They would then need to travel outside Saskatoon to obtain urologic care. Because of the significant burden that may place on a patient, we haven’t made that decision lightly and without considerable discussion.
Our group (and others like ours) is essentially a monopoly. Take it or leave it. Drive 3 hours to see another urologist. If you can get an appointment, that is.
Well, that’s not our attitude, but what if it were? What’s to stop any monopoly from doing exactly as it pleases for its own benefit? Customer be damned! And when I say monopoly, that could be our group, the entire medical profession, or the government-administered health care system.
In the case of medical groups, there are internal and external checks against degradation of service.
Internally, we rely on a culture of professionalism and altruism. This stems from our perception of our roles in society, and from behaviour we’ve internalized throughout our training and practice. In our group, peer expectations drive a desire to provide current and competent care. We (both physicians and office staff) pride ourselves on considering our patients’ needs and convenience. But, it’s also possible that a different culture could prevail, and lead to very different behaviour.
Externally, there are implicit expectations from peers, patients and society. Explicit expectations come from regulatory/licensing bodies that produce and enforce practice standards.
If internal influences weren’t working to maintain excellent standards of care, how would the external checks become involved? For example, what if we decided to “coast” on our knowledge and skills, and not offer the most current surgical techniques (and not inform our patients of the more up-to-date options)?
First, someone would need to recognize the problem. That may be our patients, but there is a significant inequality of access to information between patients and physicians (pace Internet), and I think it would be years before any but the most discriminating and über-informed patient would realize anything was amiss.
Peer-review programs conducted by regulatory bodies would pick up some problems, such as gross misdiagnosis or out-of-date treatment. But, peer reviewers would be unlikely to identify quality problems such as poor access, as some are so pervasive that they are accepted as inevitable!
Patients may be reluctant to report a perceived problem for fear of being ostracized, tied up in red tape, or jeopardizing the sole source of medical care (no matter how inadequate) in their community.
When a monopoly’s internal culture fails to ensure appropriate service (or whatever its stated purpose may be), it falls to external influences to apply incentives. In the case of our practice, that would mean the health region, College of Physicians of Surgeons, or the courts. In the case of the entire country’s health care system, well, maybe someone needs to go all 1789 on it.
Thanks for the question!
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