We own our bodies. Our doctors don't. Yet we tend to forget this once we find ourselves on the hospital carousel. A symptom of the sense of disempowerment many of us feel in our relationships with the medical profession is our reluctance to seek second opinions, not to mention the reluctance of some consultants to accept that their patients have a right to seek second opinions.
One couple told The Irish Times of a disturbing experience they had with a consultant who was looking after their child. He recommended one particular option for treatment. The parents say that when they asked questions about the alternatives and expressed a wish to seek a second opinion in another hospital, the consultant refused to co-operate and threatened to dismiss the child from his caseload. For days, the parents worried and debated, fearful that alienating the first consultant could have disastrous consequences. In the end, however, they decided to go for the second opinion, come what may.
They were glad they did. The second consultant, who had more advanced diagnostic equipment available to him, advised a different approach to treatment, which the parents then agreed to. The child is doing well, but this does not annul the emotional trauma that the parents experienced as a result of the first consultant's negative attitude.
This was not an isolated incident. The Irish Times has been told of other such cases. For example, there is a consultant who is so reluctant to countenance input from his colleagues that, when patients broach the topic of second opinions, he announces that if they seek one he will no longer be able to treat them. The consultant is the only one in his speciality in a wide geographical area. He is effectively putting his patients in a bind, because for them to pursue a second opinion means burning their bridges and sticking with the second consultant, who is likely to be on the other side of the country. This means that their treatment will involve frequent, inconvenient and expensive travel.
More enlightened doctors believe that the inability to deal with having one's authority questioned is an aspect of a paternalistic attitude that is dying out in the medical profession.
"I think it is wrong to be defensive. For a consultant to refuse to countenance a second opinion, I think, shows a weakness or poor attitude," says Dr Jim McShane, a GP in Glasthule, Co Dublin. He belongs to a large practice where doctors seek second opinions from each other as a matter of routine, and where doctors from other practices refer patients for certain procedures.
"The Irish College of General Practitioners has a policy of encouraging inter-referral of patients. We regard inter-referral as a clinical tool, especially in difficult cases," says Dr McShane. There has been a crucial change in attitude among doctors, he believes. "Doctors no longer see themselves as having ownership of the patient."
Even with this in mind, you might feel afraid of insulting your consultant or getting an icy reaction should you seek a second opinion. The key to negotiating this tricky piece of medical etiquette is to maintain a good, working relationship with your GP, who should act as your gatekeeper and advocate throughout your treatment in the hospital consultant system, advises Dr McShane. When a GP refers a patient to a consultant, the consultant should then send a report of all investigations back to the GP. If the patient feels the need for a referral to a second consultant, then the GP can arrange it. "We have difficulty with consultants cross-referring to each other," he says. "You send someone for an opinion on their bottom, and they are referred on to an orthopaedic surgeon, then to a plastic surgeon and so on. But it is better that the GP co-ordinates it," he believes.
Dr Diarmuid O'Donoghue, consultant gastroenterologist at St Vincent's University Hospital in Dublin, supports patients seeking second opinions. "Don't be afraid to offend the consultant. Most consultants will be open and happy to facilitate you," he asserts. "Second opinions are very often sought by consultants themselves. I do it every day of the week with difficult cases. If a patient suggests a second opinion and it proves that you were right, that's reassuring. If the second opinion proves you wrong, then it is better that we know it now, rather than pursuing an ineffective course of treatment," he says. "We often raise the issue of a second opinion with patients. There are people who will not be consoled by a single diagnosis, and that is very reasonable." However, he objects to patients returning to GPs and seeking second opinions behind his back. He prefers to be asked directly for help in arranging a second opinion, rather than to have the patient go back to the GP to ask for another referral.
"I understand that patients do this because they don't want to hurt the feelings of the first consultant, but I think they should be more open. We can suggest who the patient should see, and that could be someone outside the hospital so that the patient can see that the second opinion is not influenced by the first."
TAKING the views of both Dr McShane and Dr O'Donoghue into account, it would make sense to discuss these matters with both your GP and your consultant. If you decide, with your GP, to opt for a second opinion, you or your GP can always give the consultant a call before contacting the second doctor. After all, consultants are human beings too.
"A GP requested a second opinion from one of my more senior colleagues without telling me, and that pissed me off," says another consultant, who preferred not to be named. "I felt like it was pulling rank. I have no problem with my patients getting second opinions, but I would like them to discuss it with me first. I think that it's professional courtesy to let the consultant know," he says.
"It is always painful to have a patient seek a second opinion and to consequently have another consultant going over your notes. It's human nature. But at the same time, I fully support the patient's right to have a second opinion for whatever reason. A good professional will discern from the patient if they require a second opinion and will suggest it themselves, or if they don't suggest it, will be fully supportive."
The Irish Hospital Consultants' Association (IHCA) totally supports the right of patients to a second opinion, according to Donal Duffy, assistant secretary-general of the IHCA. He was surprised to hear that this is not always the case. "Doctors should facilitate a second opinion where required, and it is irrelevant whether the patient is public of private," he says.
For medical card patients, a second referral could mean going to the bottom of a waiting list. However, in urgent cases, such as cancer, no wait should be required. According to Dr McShane, a medical card patient could have a second opinion organised for the following day, with the help of a co-operative GP. "People are treated equally now. There is a two-tier system in terms of access and waiting lists, but if a second opinion is sought for a medical card patient, the patient will get it," he asserts.
Private health insurance should always cover second opinions, but money and time can be saved if the referral is conducted smoothly with the help of the first consultant and/or the GP. If the process of referral is open and above board, the first consultant can give the second all copies of medical reports so that the patient does not have to go through the whole uncomfortable rigmarole of investigations all over again.
The moral of the story is, if a consultant tells you that you have no right to a second a opinion, or that seeking one will disqualify you from his care, tell him he's wrong. And even if your consultant is co-operative, it always helps to have a supportive GP in your corner.