Do second opinions truly avert misdiagnosis?

By John Murphy, MDLinx
Published January 17, 2019

Key Takeaways

No one likes to be second guessed. Then again, physicians simply can’t bat a thousand—there’s only so much you can know about medicine, and even experts sometimes make the wrong judgement call.

“Diagnosis is extremely hard,” said Mark L. Graber, MD, researcher and founder of the Society to Improve Diagnosis in Medicine, in a Washington Post article. “There are 10,000 diseases and only 200 to 300 symptoms.”

Consider that about one in five patients who seek a second opinion get a different diagnosis the second time around. Specifically, 21% of patients who sought a second opinion from specialists at an academic medical center (Mayo Clinic, Rochester, MN) had originally received a different diagnosis from their primary care providers, according to results of a 2017 study in the Journal of Evaluation in Clinical Practice.

“Diagnostic error is an area where we need more research, more study and more information,” said lead author of the study James M. Naessens, ScD, professor, Division of Health Care Policy & Research, Mayo Clinic, in the same Washington Post article. “The second opinion is a good approach for certain patients to figure out what’s there and to keep costs down.”

Fresh eyes save lives?

Indeed, Dr. Naessens and coauthors found that original diagnoses were the same as final diagnoses in 12% of cases, and final diagnoses were refined or better defined in 66% of cases. So, even when second opinions come back with the same diagnosis, they can be valuable because they give the patient reassurance.

However, second opinions are sometimes quashed prematurely because health insurers effectively curb referrals by limiting care to within their network. Furthermore, primary care providers may be overconfident in their diagnostic expertise in particular cases, or patients may be too timid or lack the knowledge to request a referral.

“This may prevent identification of diagnostic error, and could lead [to] treatment delays, complications leading to more costly treatments, or even patient harm or death,” Dr. Naessens said. “We want to encourage second opinions when the provider is not certain.”

The main reasons patients seek a second opinion are to confirm a diagnosis or treatment, dissatisfaction with a prior consultation, a desire for more information, or because of persistent symptoms or treatment complications, according to the findings of a 2014 study in Mayo Clinic Proceedings, whose lead co-author was Dr. Graber, then a senior research fellow at RTI International, Research Triangle Park, NC.

“Doctors are humans, and they make the same cognitive mistakes we all make,” Dr. Graber told the Washington Post. “If you are given a serious diagnosis, or you’re not responding the way you should [to medication], a second opinion is a very good idea. Fresh eyes catch mistakes.”

Put your money where your mouse is

In fact, second opinions are becoming a burgeoning business. In the past few years, dozens of remote or online second opinion sites have popped up. Many are based out of existing medical centers. The Cleveland Clinic has an online MyConsult program, the University of Southern California Health has partnered with Grand Rounds to offer a remote second-opinion service, and Dana-Farber Cancer Institute has one for cancer diagnoses. Both Stanford Medicine and Johns Hopkins Medicine have their own programs, while Boston Children’s Hospital has one that offers both online and in-person second opinion consults.

These second opinion services aren’t typically covered by insurance plans. Out-of-pocket costs range in the hundreds of dollars. A second opinion consultation from Cleveland Clinic is $565, for example, while a second opinion with a pathology review is $745.

No guarantees

Surprisingly, even though the practice of second opinions has stood the test of time in medicine, whether they actually improve patient care is still unknown. No one has really studied whether second opinions result in better outcomes for patients who get them.

While patients generally believe that second opinions are valuable, the “literature on patient-initiated second opinions is limited, and the accuracy of the second opinion through follow-up is generally unknown,” wrote Dr. Graber and coauthors in their article. “[T]he potential of second opinions to reduce diagnostic errors merits more rigorous evaluation.”

One thing is certain: The practice of second opinions is here to stay.

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