Seeking a second opinion

Seeking a second opinion

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

The patient had been seen by a senior liver surgeon and advised to have surgery to remove the liver tumour.

Uncertain whether this was the best option, his family came to see me for a second opinion.

I looked at the stack of reports provided. His bilirubin was raised more than five times above the normal range, his liver cancer marker, called alpha-fetoprotein, 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.

Now 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 to operate.”

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

I advised them to go back and discuss the case further with the surgeon – asking him what is the likelihood of surgery helping the patient and also the risks involved. If they felt confident after discussing with the surgeon, they should go ahead with the operation.

“If there is doubt, please bring the patient to either 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 on 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 size the doctor up before deciding whether they would like 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 nurse from the front counter came in with a look of distress.

“The family was making a lot of noise outside. They are unhappy because they said you did not even look at the reports.

"They scolded us for making an appointment. They said that if you are not interested in seeing family without the patient, we should not have given an appointment and wasted their time!”

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

The nurse who assists me in the consultation room quickly defended me as she had witnessed the entire discussion.

I reviewed every sheet of 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 on a patient who is seriously ill.

Some doctors whom I relayed this encounter to concluded that the family must have felt that since I did not charge, I did 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 email consultations from patients whom they have never seen before. I do my best to answer all the email and expeditiously.

My comments tend to be rather general about that particular cancer and what is considered standard treatment. I often refer them back to the attending doctors to address their specific concerns.

I also like to direct them to websites where general information on the 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 that there are different options. Knowing the different options helps you make a decision based on your own interests.

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

This article was contributed by Dr Ang Peng Tiam, Medical Director and Senior Medical Oncology Consultant at the Parkway Cancer Centre, located at Mount Elizabeth Hospital.

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