Seeking a second opinion

The family came to see me - without the patient. He was warded in another hospital and apparently too ill to come along.

The patient, who had a liver tumour, had been seen by a senior liver surgeon and was advised to have the cancerous tumour removed.

Unsure if this was the best option, his family sought a second opinion from me. I looked at the stack of reports they brought along.

His bilirubin was raised more than five times above the normal range. Bilirubin is a brownish yellow discharge which is produced when the liver breaks down old red blood cells. An elevated bilirubin raises concern that there is something wrong with the liver.

His liver cancer marker, called alpha-feto protein, was slightly raised, but what was most significant was the fact that the scans had shown a large tumour in his liver with blockage of the biliary ducts.

In many instances, even without seeing the patient, I can give some definite opinion - operate or not, what treatment I would give and so on. But in this instance, I said to the family: 'I am sorry but I can't help you."

I explained: 'It is obvious from the reports that he is very ill. It is going to be a tough judgment call on whether to operate or not."

If I said to operate, I could be putting the patient in the way of unnecessary risks of a major operation. If I were to say not to operate, I could be denying him a chance of a cure.

I advised them to go back and discuss the case further with the surgeon - and to ask him about the likelihood of surgery helping the patient and also the risks involved.

If they felt confident after discussing it with the surgeon, they should go ahead with the operation.

'If there is doubt, please take the patient to see another surgeon or come back to see me, with the patient this time,' I said.

When the family left the consultation room, I felt pleased with myself for helping them understand the situation and guiding them in how to proceed. I did not charge any consultation fee.

As a general rule, I do not charge when I give opinions in the absence of the patient. While some doctors do (nothing wrong with that), I do not because I assume that some would like to check out the doctor before deciding on a formal consultation with the patient present.

I also see it as allowing access to a free consultation for those who may not be able to afford private medical care. As I was basking in the satisfaction of a job well done, my front-counter nurse came in with a look of distress.

'The family is making a lot of noise outside. They are unhappy because they said you did not even look at the reports. They said that if you are not interested in seeing the family without the patient, we should not have given an appointment and wasted their time," she said.

I nearly fell off my chair. How is that possible?

I had reviewed all the laboratory results and radiology reports handed to me. I am sure I acted in the patient's best interest by explaining why I should not make a judgment call on the role of major surgery in a patient who is seriously ill.

Some doctors to whom I related this encounter concluded that the family must have felt that since I did not ask for a fee, I had not put effort into evaluating the case properly. If this were true, then it would devalue all the time and energy that doctors, and indeed all professionals, put into pro bono work.

These days, doctors get many e-mail queries from patients whom they have not met. I do my best to reply expeditiously to all such e-mail.

My comments tend to be rather general, educating the patient about his specific cancer and what is considered standard treatment.

I often refer patients back to the attending doctors to address their specific concerns. I also often direct them to websites where general information on their disease is available.

Second opinions are a good idea for cancer patients. They are especially useful if you don't feel comfortable with the treatment suggested. Hearing it from a second doctor - that the treatment is appropriate - helps to allay the patient's fear and doubts.

Sometimes, the second opinion may be different from the first.

This may cause some confusion to the patient. I feel it is better to be confused and think about the problem, rather than to be ignorant about different options. Knowing the different options helps one make a decision based on one's own interests.

A second opinion may not make that decision any easier, but it does make it more informed. Assuming of course, that doctors giving their opinions are themselves as informed as possible.

angpt@parkwaycancercentre.com

Dr Ang, the medical director of Parkway Cancer Centre, has been treating cancer patients for 23 years. In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to medical research.

This article was first published in Mind Your Body, The Straits Times.