NEWS: NYTimes: Ask Another Doctor? Expect a Chill in the Exam Room

[janet paterson <janet313@xxxxxxxxxxx>]

Ask Another Doctor? Expect a Chill in the Exam Room

April 4, 2000 - Almost anyone who has ever been part of a couple has 
experienced that moment of sudden disorientation when one looks at a partner 
and sees only a stranger -- and an unreliable, possibly deranged stranger at 
that.

The thought hits: "I must get out of this right now before I am damaged 
forever," and life suddenly becomes more complicated than it was an instant 
before.

For romantic couples the impulse may pass, or it may escalate into therapy, 
separation or divorce.

The options are more limited when the couple consists of patient and doctor.

Some patients jarred by that sudden glimpse of Mr. Hyde across the desk do 
nothing; for others (about one in five, according to a Commonwealth Fund survey 
reported in the policy journal Health Affairs last fall), the moment leads 
directly into the awkward and disorienting no man's land of the second opinion.

If medical practice were the science it is sometimes said to be, even the word 
opinion would be obsolescing fast.

But medical opinions are everywhere, and second opinions are tricky business 
for doctors and patients alike -- superb evidence, as if anyone really needed 
it, that patients may be somewhat less empowered than the gurus of the medical 
consumers movement like to maintain.

Shopping around for a doctor is one thing, but for a patient to ignore a 
familiar voice to consult a stranger still takes real courage -- courage to 
head out into the unknown and also, as Dr. Jerome Groopman points out in his 
new book "Second Opinions," (Viking, 2000) courage to risk leaving ill will 
behind. "Often a patient and his family hesitate to ask if a second opinion 
would be beneficial," Dr. Groopman writes, "because they fear they will 
'insult' the doctor, that the question will be misconstrued as a threat and 
alienate their caregiver."

It would a pleasure to pooh-pooh those common fears as groundless, but actually 
they are not entirely off the mark. "Alienate" puts it a little strongly, but 
only doctors heading for sainthood usually weather the experience of a 
long-term patient's heading elsewhere without flinching just a bit.

No matter how justified the doctor knows the decision may be, it is still a 
poke in the viscera.

Every weird harmonic overtone in the doctor-patient relationship begins to 
resonate, from the military ("I'                                                
                                                                  
minchargehere!totheprofessionaltothecollegialtotheparental.

Even when the second and third opinions concur entirely with the first one, 
there's still something hanging in the air that wasn't there before: not a 
distrust, precisely, but perhaps just a sudden awareness of the wide windy 
world outside the examining room and the fragility of the arrangement within.

Pity your doctors for their human frailties, but be aware of their 
inconsistencies, because in fact they are out getting exactly the same second 
opinions on your case all the time.

These opinions simply fly by another name, that of "consultations," and they 
are the scaffolding on which the highly fragmented structure of medical care 
rests these days.

It is for formal consultations that I cheerfully ship patients off to 
specialists, and for informal ones that I waylay colleagues in the hall.

When Mr. P. got that pain back in his tuberculous hip a few years ago, I 
contacted every authority in the city I could think of, friend and stranger 
alike, just to gather opinions of my treatment plan.

And here's the unvarnished, sorry truth: had Mr. P. been the one who decided to 
make all those phone calls, I would have applauded his industry and heeded his 
suggestions, but that same chilly little wind would have blown through the 
examining room nonetheless.

Science or no science, the balance of power is as much of a complicated reality 
in medicine as it is in the marble halls of government. And so it has always 
been.

In fact, among the first tasks medical ethicists took upon themselves centuries 
ago was to think through the perplexing diplomatic issues posed by second 
opinions and consultations.

The British physician Sir Thomas Percival devoted large sections of his 
pioneering 1803 textbook of medical ethics to the subject.

Consultations are necessary in "difficult or protracted cases," Sir Thomas 
wrote, and "no important operation should be determined upon" without them.

He also knew, however, that consultations could provoke serious internecine 
conflict, and he devoted pages to protocols for minimizing it: who should speak 
first at the meeting of doctors (the most junior), who should actually 
administer treatment (the primary physician), what to do in case of 
disagreement (find yet another doctor). And, he advised, be sure never to 
breathe a word about the disagreement to the patient (lest the entire medical 
profession start to look foolish).

Larger subjects compete for medical ethicists' attention these days, and the 
etiquette of second opinions goes largely unsupervised. Perhaps it is just as 
well that, as Dr. Groopman points out, most medical decisions do not require 
them. If they did, heaven preserve us from the tangled emotions and power 
struggles that would begin to s   trangulateroutinehealthcare.

The doctor in me knows that Dr. Groopman is entirely right: most medical 
conditions are so clear-cut and so routine that seeking out a second opinion is 
just looking for trouble.

Unfortunately, the patient in me, at the moment, knows no such thing.

My left upper wisdom tooth may be just a tooth, but it is my own, and when my 
dentist sympathetically announced a few weeks ago that it was time to bid it 
goodbye, suddenly there was Sir Thomas whispering in my ear that old line of 
his about operations and second opinions.

And now I am in a sad pickle indeed.

I love my dentist, my friend for 15 years, but I also love my wisdom tooth, and 
I love the second opinion that stated there seemed to be no urgent reason for 
its removal.

Sir Thomas thinks I need a third dentist.

I think that what I need is simply to talk to my first one and outline in 
straightforward fashion what I have done, and what the other dentist said, and 
proceed from there.

The problem is that I know perfectly well that as soon as I start to talk, a 
cool little wind is going to blow through the examining room and ruffle my 
dentist's hair, and nothing is ever going to be quite the same again.


By ABIGAIL ZUGER, M.D.
Copyright 2000 The New York Times Company
<>
janet paterson
53 now / 41 dx / 37 onset
a new voice: 
613 256 8340 PO Box 171 Almonte Ontario Canada K0A 1A0