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Scenario: When is a second opinion needed, and how should surgeons respond?

Patients for whom surgery is recommended often have many questions, concerns and fears. The process is fraught with ethical issues that frequently go unrecognized.

Reply:

Consider a 52-year-old woman whom I recently saw for an indeterminate thyroid nodule. Although the needle biopsy of the nodule did not show clear evidence of cancer, the cytologic findings were consistent with a follicular neoplasm. The patient has a 15% to 20% risk of having thyroid cancer. I certainly will recommend that she have an operation so that cancer can be definitively ruled in or out. Most patients do not want to undergo surgery, so it's not unusual for them to request a second opinion.

How should a surgeon respond to this request? It is essential that the surgeon facilitate the patient's effort to get a second opinion. A fundamental principle of medical ethics is respect for patient autonomy. If the patient feels that further information or another opinion is necessary before deciding whether to proceed with an operation, the surgeon should not make it difficult for the patient to get another opinion. It is particularly helpful to offer the patient names of surgeons who have enough experience in treating the diagnosed (or suspected) condition to render a sound second opinion.

As seemingly straightforward as this scenario is, the initial surgeon easily and inappropriately can thwart the patient's desire for another opinion. If, for example, the first surgeon suggests that the operation should be done right away, the opportunity to obtain a second opinion is limited. Although the optimal timing of an elective procedure such as a thyroidectomy for an indeterminate nodule is open to discussion, few could convincingly argue that it must be done immediately. Thus, pressuring the patient to have an operation immediately limits his or her ability to make a choice. Certainly, there are times when postponing surgery for a few days would be detrimental to the patient's health. In such cases, the surgeon should explain why this is so and encourage the patient not to wait to obtain a second opinion.

Must every patient who needs surgery be encouraged to get a second opinion? Out of respect for patient autonomy, it is important that patients have their questions answered adequately before an operation. And in complex clinical situations where there is significant disagreement in the surgical community, a second opinion may be important to help the patient correctly understand the range of options. But it is not necessary for all patients to get a second opinion.

The challenge for each surgeon is to be sensitive to those situations in which obtaining a second opinion may be critical to the patient's decision-making. In fact, numerous situations are possible wherein the surgeon has an ethical obligation to recommend a second opinion:

• The patient has a problem that the surgeon lacks the necessary expertise or institutional support to manage. Consider a patient sent to see Surgeon A for a large right adrenal pheochromocytoma. This is an unusual tumor for which the operative management is complex from both the surgical and the anesthetic point of view. In addition, the patient will need appropriate medical management before surgery to make the operation safe. If Surgeon A lacks the experience or the anesthesiologists available to Surgeon A lack the experience, the patient should be encouraged to obtain another opinion.
• The surgeon has limited experience and poor results with a complex problem for which other surgeons have more experience and better results. This scenario may be difficult for a surgeon to acknowledge. Most surgeons are interested in taking on a challenging case, especially when more experience with such cases may benefit future patients. Such enthusiasm must be tempered with an honest assessment of what will be in the current patient's best interest. Although in recent years, malpractice cases have raised questions about what data surgeons must disclose to patients about their personal experience with the procedure in question, there can be no doubt that the ethical standards of informed consent necessitate such a disclosure. If information about the surgeon's experience with the procedure will be important to the patient making an informed decision, then the surgeon has a responsibility to provide that information.
• The surgeon believes that the patient will not follow through with the recommended surgical therapy. Consider a case of biopsy-proven sigmoid colon cancer. The surgeon to whom the patient was referred recommends an operation, but the patient, for whatever reason, does not believe the surgeon and expresses a desire to not have surgery but to pursue "herbal treatments." In this case, it is clear that something has gone awry in the relationship between the surgeon and the patient, who is ignoring a recommendation for potentially life-saving surgery. The surgeon may have tried to develop the relationship and may have exercised exemplary skills in explaining the risks of not having surgery. Nevertheless, if the patient is unwilling to consider surgery, the surgeon should recommend that he or she seek a second opinion. Another surgeon may have more success in establishing a trusting relationship, or the patient may simply need more time to consider the recommendation. In either instance, a second opinion is essential to ensuring that the patient fully understands the ramifications of the choice not to have surgery.

Sometimes patients seek a second opinion after having had an operation that they think had a less-than-optimal outcome. This difficult scenario raises a number of ethical issues for both the initial surgeon and the surgeon providing the second opinion.

Consider the following example: a patient has undergone a parathyroid exploration for primary hyperparathyroidism. Preoperatively, the localization studies to identify the abnormal parathyroid gland were negative. During the operation, Dr. X carefully explored for the abnormal parathyroid gland but was not able to find it. Three normal glands were found and biopsied. The fourth parathyroid gland could not be found, and the intact parathyroid hormone (iPTH) level remained elevated at the end of the procedure.

Despite Dr. X's having taken care to avoid injury to the recurrent laryngeal nerve, the patient awoke with a hoarse voice. On the first postoperative visit a week later with Dr. X, the patient's calcium and iPTH levels remained elevated, and he continued to have hoarseness. An examination revealed that the right vocal cord was not moving.

It is not surprising that the patient in this scenario was unhappy with the outcome of the operation and requested a second opinion. Dr. X should be careful to explain fully to the patient what occurred. He also should help the patient obtain a second opinion, and he would be wise to make all of his records readily available to the next surgeon. It is particularly important for Dr. X to recommend an experienced parathyroid surgeon (Dr. Z) to the patient. Furthermore, Dr. X should be sure that Dr. Z completely understands what transpired in the operating room.

Dr. Z also will be in a difficult situation. He or she may be asked whether Dr. X did anything wrong, or whether negligence was involved in Dr. X's not being able to find the abnormal gland and causing, at the very least, a temporary nerve injury. Since it is often difficult to fully understand the scenario that Dr. X faced, Dr. Z should be hesitant to assign blame.

One cannot conclude that the operation was performed in a negligent manner simply because a complication occurred. If, however, the facts of the case were changed, and Dr. Z did believe that Dr. X had performed below the standard quality of surgical care, then Dr. Z would have a moral obligation to answer the patient's question truthfully.

Disclosure of one's own errors in the operating room is an ethical challenge for a surgeon. Even more difficult is the prospect of disclosing a possible error committed by another surgeon. In such circumstances, the importance of being truthful should be emphasized, along with the realization that an honest assessment by Dr. Z of what happened in the operating room with Dr. X most likely will benefit the patient.

As this discussion has suggested, requests for second opinions always should be facilitated to better meet the patient's informational needs and to respect the patient's autonomous decision-making. For both the initial surgeon and the second-opinion surgeon, an honest assessment with a clear recommendation most likely will lead to the greatest benefit for the patient.

--Peter Angelos, MD, PhD, professor and chief of endocrine surgery, associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago

Ethics Forum discusses questions on ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654; fax 312-464-4613. Opinions in Ethics Forum reflect the view of the author and do not constitute official policy of the AMA.

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