Should I Seek a Second Opinion?

By Jacob M. Appel, MD, JD

Second opinions in Medicine are nearly as old as illness itself. In Proverbs 11:14, the Bible exhorts that “in multitude of counsellors there is safety.” Wealthy patients in ancient Rome frequently called upon several successive physicians to offer medical advice.

By the mid-20th century, seeking more than one opinion about a serious condition had become common. Some insurers and large employers even started mandating multiple evaluations prior to expensive operations. Yet many patients struggle with whether and how to seek such additional guidance.

For instance, patients may fear they are betraying their first doctor, especially if they are involved in a longstanding care relationship. They may also be concerned that the electronic medical record will reveal the decision to obtain a second opinion to their original provider. As a result, making such a choice can become emotionally trying, especially if one fears subsequent rejection by one’s original provider.

Once a patient decides to seek reassessment, the logistics also raise difficult issues. Is the patient ethically obligated to share that choice with the initial physician? And how should the patient go about securing a second expert? Is it prudent—or tactless—to ask one’s doctor to recommend a trustworthy competitor?

These challenges are compounded for psychiatric patients. Such patients are often highly vulnerable at baseline and likely to seek additional input at times when they are under increased distress because treatment is not fully effective.

Moreover, these patients may develop tight therapeutic bonds with their psychiatrists—attachments that are difficult to sever, even temporarily, or to risk jeopardizing. Some patients describe the act of seeking a second opinion as “cheating” with the same gravity that they might characterize marital infidelity. That attitude may explain why second opinions in psychiatry remain comparatively uncommon.

All these concerns are understandable. They are also unfortunate. Obtaining a second opinion is a fundamental prerogative of every patient—one that can often prove essential in securing optimal care. In many instances, a second set of eyes may recognize a pattern that the first evaluator, no matter how skilled, does not. Different diagnosticians bring different perspectives to bear on any given set of clinical facts.

This is because psychiatric evaluation and treatment is an art as much as a precise science—and different creative insights may prove helpful in different contexts. Moreover, in a field like psychiatry, rapport matters significantly. Even a perfectly competent clinician may not connect with a particular patient in a way likely to produce the optimal outcome. Beneficial results may stem from positive dynamics between doctors and patients as much as from any distinctive, universal talent of the former. Doctors matter. But dyads matter too.

At present, approximately 1 in 5 Americans seek additional opinions after an initial medical evaluation. Although a small number of physicians may react negatively when patients do so, the majority of doctors across fields and countries are supportive.

In Great Britain, for instance, the General Medical Council requires that doctors “respect a patient’s rights to a second opinion” as consistent with “the highest standard of care.” Similarly, the American Medical Association Code of Ethics states, “physicians’ fiduciary obligation to promote patients’ best interests and welfare can include…referring patients to other professionals to provide care. In short, patients frequently overestimate the likelihood of a negative reaction from their doctors.

Several concrete steps may facilitate the process of seeking a second opinion in a manner that reduces patient stress

• Be transparent with your psychiatrist when seeking a second opinion. Most doctors—like most human beings—appreciate candor. One might explain the reason for seeking a second opinion, although no obligation exists to do so. How a patient explains the choice matters. For instance, one might say: “I greatly appreciate the care you provide, and I have confidence in you. At the same time, it will bring me additional peace of mind to obtain a second opinion—just to be certain that I am not leaving any stone unturned….” Similarly, be up front with the second provider about the nature of one’s visit.
• Share the reasons for additional consultation with the new doctor. Do not be afraid to ask questions and express concerns. A second opinion will not be of much use unless the doctors know why a patient wants one.
• Provide the second doctor with complete medical records, lab work, and imaging obtained by the first. Medical records may not be fully interoperable. There is no reason to reinvent the wheel or risk losing crucial information.
• Recognize in advance that diagnosis and treatment are not exact sciences—and that if one psychiatrist proves more helpful in a particular case, that does not mean the other psychiatrist was any less capable as a physician. Even brilliant clinicians are wrong a good portion of the time. Such a generosity of spirit not only prevents resentment against one’s earlier doctors but also the destructive effects of second-guessing one’s own prior medical choices.
• Remain open-minded and prepared to hear unwelcome news. The second consultant, for example, might be no more helpful than the first—and might even confirm a grim prognosis.

Above all else, patients should never forget that they are in charge of their own medical care. A second opinion should not require asking permission; obtaining multiple perspectives should never be a source of shame. In truly extreme cases, seeking numerous opinions (so-called “doctor shopping”) runs the risk of clouding one’s choices unnecessarily. However, for the vast majority of patients, a second opinion—or even a third—can be a lifeline in times of distress. Not obtaining a second opinion, as the expression warns, is often the first mistake.

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Dr. Appel is a member of the GAP Committee on Psychiatry and the Law.