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Browsing for a second opinion

Internet sites offer to review cases without examining the patient. Is that a good idea?

By Tyler Chin, amednews staff. April 23/30, 2001.

Since the beginning of the year, FindCancerExperts.com has handled up to 150 requests a month from recently diagnosed cancer patients seeking referrals to nationally recognized pathologists who can provide second opinions on their initial biopsy results.

"That tells me there is demand," said Barry M. Shmookler, MD, a surgical pathologist who founded the company, which serves as a middleman between patients seeking second opinions and the experts willing to provide them.

Just the FAQs
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FindCancerExperts.com, Rockville, Md., is one of several sites that have sprung up over the past several years offering second opinions to patients without face-to-face consultations.

Another is MDExpert.com, headquartered in Palo Alto, Calif. Its oncology experts don't need to see patients in person because they aren't treating or diagnosing, said Julian C. Schink, MD, a gynecologic oncologist at the University of Wisconsin Comprehensive Cancer Center in Madison and co-founder of the company.

"We're rendering an opinion of someone else's diagnosis and treatment," Dr. Schink said, adding that those opinions may include additional therapy recommendations for the treating physician to consider.

Pathologists routinely render thousands of second opinions without seeing patients, said Dr. Shmookler, who plans to resume practicing now that his company is off the ground.

"That's the nature of the specialty," he said. "We don't see patients. We see tissue and biopsy and rely on the clinic to provide information if necessary. If I need more information, I'll just call the [treating] doctor and say, 'Hey, Joe, I just did a little biopsy. How long has this been going on? What did the x-rays show?' "

Other doctors, however, say they won't offer second opinions without examining patients.

Patrick F. Sheehy, MD, an oncologist in Newport Beach, Calif., initially considered offering second opinions through his Web site three years ago, but liability and ethical concerns led him to change his mind. Instead, Dr. Sheehy posted a note on the site stating that he'd provide a second opinion only if patients visited him for an examination. They also have to bring their medical records, including x-rays and lab results.

"I think medicine is an art," said Dr. Sheehy, who charges $300 for a second opinion. "It's seeing the patient, examining the patient ... and saying, 'This what we will do based on the history, physical, review of labs, review of x-rays and review of past treatment' and taking it from there."

The sites or specialists associated with them commonly charge $150 to $300 for a second opinion. One exception, MDExpert.com, charges $800 for an oncology second opinion on the treating physician's diagnosis and course of treatment, based on a review of medical records. That fee goes up to $1,250 if pathology and x-ray reviews are included.

Depending on the site, the second opinion is forwarded to the patient, the specialist or the patient's treating physician. Turnaround is 24 hours to 14 days.

Most sites specialize in pathology and oncology. But any specialty, including cardiology, "where there are multiple treatment options without absolute clear direction about which one to follow" would be suitable for online second opinion services, Dr. Schink said.

While many second opinion sites are one-doctor shops, some, including FindCancerExperts.com and MDExpert.com, have assembled a network of consultants around the country. Both of these sites are open to inquiries from interested physicians who meet their posted criteria.

Some second opinion sites let patients pick the consultant; others don't. To obtain a second opinion, patients generally must fill out a form authorizing a commercial laboratory, hospital or treating physician to release tissue slides, medical records or other data to the site operators.

The sites then ask the laboratory for tissue slides or medical records. Some sites take possession of the material; others arrange for the materials to go directly to the consulting specialist.

But however the sites work, they make some observers uneasy.

Herbert Rakatansky, MD, chair of the AMA Council on Ethical and Judicial Affairs, said he doesn't have a problem with physicians seeking and rendering second opinions, particularly when they involve reviews "of an objective piece of data such as x-rays or pathology specimens."

Those types of second opinions are common and done one physician to another. But, said Dr. Rakatansky, a gastroenterologist in Providence, R.I., "as far as patients contacting Web sites [for second opinions], we don't think that's good medicine. We don't think it's good patient care. You need to talk to physicians and they need to talk to you. It enables the healing process."

Conflict of interest?

Dr. Rakatansky also is concerned that second opinion sites may not act in the best interests of patients should a conflict arise between what's in the best interest of the patient vs. the physician.

There is a basic element of trust in a physician-patient relationship that the doctor will always make a decision in favor of the patient whenever those conflicts occur, Dr. Rakatansky said. "There's no way to know in those e-medicine arrangements if that contract has been entered into by both physician and patient, because in most cases you don't know who the physician is. How do you know who the experts are, whether they pay to get on the [site's] list, what are the financial incentives created? We usually don't know how those lists are compiled."

At FindCancerExperts.com, no money changes hands between the firm and the 60 pathologists it has recruited, Dr. Shmookler said. The physicians bill the patients directly, and the company doesn't get any part of that fee.

At MDExpert.com, less than $300 of a patient's fee goes to doctors, according to Dr. Schink, although he declined to be more specific. "Consultants are paid enough money that they will be happy to keep doing the cases."

Neither firm charges physicians a sign-up fee.

In most cases, Dr. Shmookler said, experts can make an accurate diagnosis off slides and paraffin blocks from the initial biopsy. But under some circumstances, he acknowledged, accuracy may not help patients.

For example, if a patient has a 3-cm mass in his lung and the biopsy needle missed it, then "1,000 pathologists would look at it and not know what is there," Dr. Shmookler said.

In cases involving nonrepresentative samples, the expert is likely to reach the same conclusion as the primary pathologist, which would be small consolation if the mass is malignant, he said. "That's where the clinician has to be astute and say, 'Hey, wait a minute. We saw the mass and you're telling us that it's good lung tissue? Let's go back and start over.' That's the role of the treating physician."

It also would be nearly impossible for pathologists to detect mislabeled or contaminated samples, Dr. Shmookler said. "It is an error for sure, but those are not the kind of cases we're looking for or alerting people to."

MDExpert.com said its in-house staff of physicians and trained oncology nurses meticulously reviews patients' records and tracks any data that are missing before its outside experts review a case, Dr. Schink said.

In addition, the firm routinely asks experts if there is more information or tests they would like to see.

MDExpert.com's more than 200 specialists can render second opinions even when patients live in states where they aren't licensed to practice, Dr. Schink said. That's because the service isn't really new; the specialists already offer thousands of opinions over the telephone or via fax or mail for patients and physicians from all over the world, he said.

Based on his experience with FindCancerExperts.com, Dr. Shmookler believes there is demand for second pathology opinions.

Studies examining the issue of interpretation and misdiagnosed errors in pathology have reported error rates between 2% and 5%, he said. In contrast, a recent Johns Hopkins review of primary pathology for patients who had gone to Johns Hopkins University for cancer treatment showed error rates of up to 9.4%, he said.

But the site has not yet seen enough demand to translate into profits.

Will anyone pay?

FindCancerExperts.com initially charged customers an $80 fee for the names of three pathologists whom patients could contact for a second opinion. Dr. Shmookler estimated that fewer than 50 people paid the fee over a three-month period ending Dec. 31, 2000.

In January, the company eliminated the fee. Since then, it has received 90 to 150 requests a month from patients asking the site for recommendations. Dr. Shmookler said he'll continue providing the service for free for now, "but there will be a point where I'm going to have to say I can't foot the bill anymore."

Dr. Shmookler, who now hopes to make money off advertising and sponsorships, said he spent a six-figure sum to get the site off the ground. He estimates ongoing costs of several thousand dollars a year.

A key challenge confronting his site is that patients don't know what pathology is.

"Our major challenge is to get people to understand pathology ... is the only way an absolutely definitive diagnosis of cancer can be made," he said. "A biopsy has to be done to establish it's cancer. That's part one. But even after a biopsy is done we know mistakes can be made," which is where FindCancerExperts.com comes in.

Another challenge facing second opinion sites is lack of reimbursement.

Generally, insurance companies pay for second opinions within their provider networks but not outside them, said Mohit Ghose, a spokesman for the American Assn. of Health Plans. Ghose said that he believes health plans are looking at covering e-health services, "but that's new and ... it's too early to say how plans will move."

The lack of reimbursement hasn't stopped some people from paying for the service. About 100 people have paid for second opinions since MDExpert.com was launched in January 2000, including 16 last February, Dr. Schink said.

ADDITIONAL INFORMATION:

Just the FAQs

Frequently asked questions about second opinion sites:

How do patients get a second opinion?

Patients usually fill out an online form authorizing a laboratory, hospital or treating physician to release slides, medical records or other data to the Web site. The site contacts the appropriate party, requesting the material it needs. Some sites take possession of the material directly; others arrange for it to be shipped to the specialist. Patients can get the second opinion directly from the site, from the expert who did the second opinion or from their treating physician.

What's the turnaround time?

24 hours to two weeks.

Do patients need to visit the specialist or get permission from the treating physician?

No.

Who gives the second opinion?

Some sites offer access to well-published experts practicing at academic medical centers and teaching institutions. Other experts are practicing pathologists and oncologists in solo or group practice, or who have founded commercial laboratories.

Do patients get to choose who reviews their cases?

Some sites allow that, others do not.

How much does it cost?

Prices vary widely. A review of second opinion sites on the Internet showed prices ranging from $70 to $1,250.

How much do experts get paid?

Fees between $150 to $350 seem to be most common. Not all sites disclose their fees online.

Does insurance pay for it?

Usually not. Insurers generally pay for second opinions only within their networks.

How can physicians hook up with second opinion sites?

Some sites prefer to recruit and identify experts on their own, while others welcome inquiries from interested physicians who meet their posted criteria.

What about liability?

The sites said their experts face the same exposure as any physician. Some sites said they had general business liability or professional liability coverage or both.