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October 10, 2011

Second Opinions In Modern Medicine: A Twenty-First Century Imperative
M.J. McKeown, MD, FACOG, FACS, Alexandra Andrews

Need For Second Opinions - The Patient's Advice
Need For Second Opinions - The Doctor's Advice

Need For Second Opinions - The Patient's Advice
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Because of terrific pain and three conflicting scan results - bone scan read bone metastasis; PET/CT read clear; plain film xray read fractured hip - I was referred to an orthopedic institute at a large teaching hospital. There was no diagnosis before my visit.

Imagine my surprise, when without a diagnosis, I was asked to take part in a study to prepare for hip replacement surgery. Previous to the consultation there were emails and phone calls. I made it clear that the purpose of the appointment was to answer the cause of the pain.

First I saw one of the doctor's students. Her diagnosis - I had osteoarthritis in a deformed hip which was frozen. Enter Doctor God with satellites. Now four white coats filled the very narrow consultation room. The pressure was on for me to agree to surgery -- still no concordant diagnosis.

It was very strange to feel like a living down payment for a new BMW. When it became obvious that I would not agree to surgery without some thought, the surgeon walked out in a huff. His attitude was, Why are you bothering me?

Lesson Learned
Medical professionals are human. There are the dedicated, the greedy, the mediocre, the incompetent, and the capable. Unless it is an emergency, take the time. Get a second opinion.

Should medicine ever fulfill its great ends it must enter into the larger political and social life of the time
Virchow 1849

Need For Second Opinions - The Doctor's Advice
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Medicine began with Shamanism, and, as society became more educated and coordinated, so did medicine become more structured and guided by experimental science. The greats of these developments are known to students of this history: Avicenna, Galen, William Hunter, Ehrlich, Cushing, Charcot and many others. Virchow again spoke of medical developments, "Through the ages an increasing purpose runs."

This country of ours, this United States of North America, is undergoing increasing social and political pressure to extend the preventive and healing hand of medicine to all its population in some equitable and financially attainable manner. Inevitably this means judgments must be made on which therapies are applicable in any given instance of care. The political side of this problem is fond of committees determining these answers. However, the committee is subject to using economics as the primary tool of judgment. England with its National Health Service is one of the most comprehensive of the current systems, and it has its NICE. This committee always seems to lean on the economics of the usefulness and the cost of any treatment. This tends to affect the long-term survival of certain diseases and, in particular, breast cancer and prostate cancer.

Medicine has another time-honored tradition, the second opinion. Since medicine is not an exact mathematical science like physics frequently there can be another opinion of how to proceed in any given problem. However, there is no organized, formalized system to obtain such opinions.

A useful solution to both would be an organized system of reviewers who would perform both functions. A company, Second Opinion, LLC, could be formed. It seems that many of the coming changes in the delivery of health care have brought many physicians to early retirement. These retired physicians could be utilized in performing reviews of the necessity of a particular therapy and to render second opinions. Using skilled, experienced physicians in these situations would employ this valuable resource and likely lessen the economics of a decision being the major factor.

There has been for some time the development of Evidence Based Medicine. Many systems are available. The Cochrane system, is one and an extremely well developed one is that of the Dartmouth Medical System. Systems such as these would be the basis for evaluating second opinions and the efficacy and necessity of any given treatment.

An initial suggestion for these panels would be that they be:

- Comprise a panel of experts with experience from all the major medical specialties.
- Include experienced experts in the recognized fields of alternative medicine.
- Develop guidelines applicable to each state based on Cochrane and Dartmouth.

It is critically important that alternative therapies be included, since in some instances they work better than traditional therapies. However, these alternative therapies should have standards of training. It would be hoped that having alternative therapies in the decision matrix being viewed by traditional and alternative practitioners, there would be an exchange of ideas, and perhaps some application of evidence-based studies would be developed in these alternative disciplines.

A comprehensive, harmonizing system such as this would likely foster great increases in the general knowledge of health care, and it is likely the recipients of that health care would have a greater understanding of their care. The providers of all levels of health care have an obligation to have the most up to-date knowledge possible. This requirement to be knowledgeable is discussed in Knowledge Is Me: Medicine And The Internet, found at

When a man falls ill he does not forfeit his rights to be treated as a sentient human being or as an individual.
Joseph Collins, MD, Harper's, Sept. 1929

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