Friday, 14 September 2012

Second opinions

"Ok, I hear what you're saying.  But I'd like a second opinion."

As a patient, if you aren't comfortable with what I tell you, getting confirmation from a second doctor is definitely a good idea.  Even still, these are words that no doctor wants to hear.  Whenever patients say this to me, I always say that I'm not offended, and that a second opinion is their right.  I know this is true.  I really do.  But on the inside, I'm fuming.  I'm very good at what I do, but it's as if you're telling me that you don't believe me, don't trust me, or just don't like me.

My patient was a relatively young pediatrician who had severe acute-onset abdominal pain, and her internist thought she may need emergent surgery.  I examined her thoroughly and reviewed her CT scan, but it looked to me like she had an acute flare of Crohn's disease.  This is NOT a diagnosis I like to make, because it's a terrible, incurable, lifelong disease with potentially horrible complications.  After my examination, I excused myself to chat with her internist and gastroenterologist who had been seeing her.  I discussed the case with them, and they both agreed that this was the most likely diagnosis.  Surgery during an acute flare of Crohn's disease is a terrible idea and is almost never necessary.  A course of steroids usually calms the flare.  I went back and sat with the patient to discuss the situation.  She listened intently, thought for a moment, and said that she wanted a second opinion from another surgeon.

This was a particularly difficult case, and I explained that if she wasn't completely comfortable with my plan of care a second opinion is always fine.  Oh no, she said, it wasn't the plan that she wasn't ok with.  She just thought I looked young and wanted someone a bit older.

Really?  REALLY?  She's also a doctor, and she knew that my assessment was correct.  I wanted to yell at her and tell her I've been a doctor for over a decade and I know exactly what the fuck I'm talking about.  But fortunately I kept my composure and told her that was no problem.  I know I have a young face and I get this sort of thing a lot, I told her with an apparently-boyish smile.  A colorectal surgeon was called in as the second opinion.

He's two years younger than I am, but thankfully his hair is starting to grey.

The colorectal consultant completely agreed with my assessment, and the steroids were started.  The next morning she felt 90% better.  Surgery was avoided, and I felt completely vindicated.

I love being right, especially in situations like this.  Maybe I should dye my hair grey so I look more venerable and believable.

EDIT: The patient sent me an email last night with an update:

I just write to thank you for your care. You were the only doctor, in my honest opinion, who truly cared and helped me during my stay. I underwent extensive diagnostics, and the biopsies are still pending. I went home off steroids which were stopped after 48 hrs. 
Thank you for your care and excellent bedside manners.
There is something very satisfying about getting a "thank you" from a patient.  It somehow makes the world seem brighter.


  1. As a 18-year-old often mistaken for a 16-year-old, I know what you're saying.

    The common thought is that young people know nothing and should always relie on their elders. Sometimes true, but always insulting all the same.

  2. I'd check with the wife before reaching for the grey dye....

  3. Go with a salt and pepper look doc.

  4. If I would be able to choose doctors by age, I'd probably go for mid thirties to late fourties. I think in that age range they already have enough experience to know what they are doing and are out of med school long enough to not follow the possibility of what each symptom could imply to certain death, but they are more likely to take me as a patient and my concerns seriously and take the time to talk to me than older doctors.

    I've repeatedly been under the impression that older doctors often come in to see me, fly over the page with all my test results of tests taken by nurses or young assistent doctors, brabble out some diagnosis in latin and shortcuts, and leave again within three minutes, leaving me confused and uncertain of the validity of their diagnosis. Surely a quick glance at some numbers is hardly enough to judge what exactly is wrong with me? Or maybe it is, but I'd like to be explained why it is enough and what they did see.

    That being said, if a diagnosis I get from a doctor of any age, experience level or demographic, is very exotic, different from anything I'd have expected, very devastating or their course of action to treat it is very invasive (removing organs, other severe surgery, strong medications,...), I would always go for a second opinion. It doesn't mean I don't trust the doctor in front of me, it just means that I want to explore if there are any other options, if there is any hope that whatever I have is not just as bad, if some drastic treatment can be avoided and a milder course might lead to good results too. After all it's my body and my life, and that is a lot to trust on a person I've only just met, especially if I have no way of telling if s/he is very good at what s/he does, or not. In another post you mentioned that the worst student to finish med school is called a doctor. Well, how do I as a patient know if the doctor in front of me was the best or worst of his class?

    About Crohn's disease: I followed the link you posted. One thing stuck out: Being Jewish puts one on a higher risk to get Crohn's disease. Why? Does it have to do with nutrition (the whole kosher thing - not that I'm pretending to know a lot about that, other than that it is quite difficult)? Is it something genetic? So the higher risk thing wouldn't apply to people who are converted Jews or the kids of two converted Jews, and born Jews that abandoned their fate or religion alltogether would still be at a higher risk? I'm really curious here, because I can imagine race being a factor in risk for illnesses as there are clearly genetic differences, but religion?

    1. I'm not Jewish, but as I understand it, you are Jewish if your mother is Jewish. End of.

      Of course, not everyone who is born Jewish is a practicing Jew but they remain "Jewish". Equally, I understand that conversion to Judaism is not as simple as just believing.

      Different populations of humans have developed and lost different tolerances, especially for food, during our evolutionary history. Lactose tolerance in adults is a classic example. Equally alcohol tolerance. Anything that stopped providing a selective advantage for enough generations, or which co-inherited with something negative is ripe to be lost.

      I am only speculating but my guess would be that in the 3000 or so years that the Jewish people have existed as an ethnic group, a genetic trail giving them a predisposition to Crohn's disease has become more than usually established in the Jewish population.

      People of certain ethnic groups often have different colour skin/hair etc. This is likely to be the same idea.

    2. Crohn's disease and a few others (like Tay-Sachs disease) are more common in Ashkenazi Jews only, not Sephardic Jews. Ashkenazis are European in origin while Sephardic Jews are from the Middle East. It probably has something to do with a gene that mutated at some point in the past and was propagated in the close-knit community.

  5. I can understand your frustration here Doc, but you need to remember that mostly your patients do not know how good you are.

    There are quite a few professions where it is difficult for the user to know how good the person they are employing actually is. This is why law firms have huge fancy offices - it says "we are successful therefore we must be good at what we do". However, most of the contracts that they write or advice that they give will not be tested until it's too late to change it. They can't judge on results so they use the criteria that they have. In that case perceived success.

    Your patient would not know how good a doctor you are until her condition has either eased or become much worse due to inaction. Since she has no experience of receiving this type of diagnosis from you, there are only two things that she can rely on - qualification/seniority and experience. Until doctors introduce and e-bay style feedback rating, that's all patients have to go on.

    Time to grow a beard!

    1. I have essentially no facial hair, which only magnifies the "baby face" image.

      I would completely agree with you if she hadn't said the only reason she wanted the second opinion was because I looked young. She told me directly that she had complete confidence in my abilities, but she just wanted the opinion of someone who LOOKED older.

    2. Sometimes it's denial as well. She may have been thinking someone older may have seen a case that looked like Crohn's but ended up being something else; more of an "expierence" thing than competency. I can understand the frustration but most of the time its our own fear more than mistrust in our Dr. that makes us second guess the Dx.


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