Giving Unwanted Second Opinions

Show Notes

Dealing with patients who aren't happy when a second opinion turns out to be the same as the first.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Sarah Stein talking about the difficulty of offering second opinions to patients who might be resistant to those second opinions.

[00:00:17] Dr. Stein: It's the scenarios where it's sort of that Gotcha. You know? You've launched into something and then the patient says, Well, that's not what this other doctor told me!

[00:00:30] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast. During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.

I'm Adam Cifu, and today I'm joined by Sarah Stein. Sarah is a pediatric dermatologist here at the University of Chicago. She is an associate professor of medicine and pediatrics, and a fellow in the Academy of Distinguished Medical Educators and a senior faculty scholar in the Bucksbaum Institute for Clinical Excellence.

Welcome, Dr. Stein.

[00:01:10] Dr. Stein: Thank you. It's lovely to be here.

[00:01:12] Dr. Cifu: Thanks a lot for joining me on this. As we like to do in this podcast, I wanna ask you some difficult questions. Okay. I wanna talk to you about caring for and counseling patients who disagree with medical advice, and I wanna be kind of specific. Cuz I like to focus on people who really need therapy.

Okay? These are people who have problems that you sort of know will benefit from therapy and they've gotten advice from multiple different physicians. You're a sub subspecialist, right? You're a pediatrician, a dermatologist, pediatric dermatologist and you commonly see patients who've been referred.

Well, let me say patients who have seen other specialists and are coming to you for whatever, a second opinion, a third opinion, whatever. So how do you approach these visits when you know from the start that you're probably gonna recommend something that has already been recommended to the patient and has probably been, you know, unsatisfactory and that's why they're seeing you?

[00:02:12] Dr. Stein: Yeah, I mean, when I think about this topic, I think specifically about my patients with atopic dermatitis. Because I think that's a classic example. And keep in mind, I'm a pediatrician, so I'm dealing with parents. And the patients. And very often it's the parents who are gonna be in charge of the decision making in terms of therapy, so they're not personally suffering from the condition.

So there is that extra layer of having to address the parental concerns, anxieties, and translate that into making it manageable for the patient.

[00:02:54] Dr. Cifu: Right. And you're also then obviously gonna be relying on the parents to, provide the therapy for the child. And so it not only has to be, you know, something doable for them, but something that they feel is, you know, not gonna be torture for their child,

[00:03:11] Dr. Stein: Right or that they're comfortable doing and that they're not concerned is dangerous for their child. So, you know, I think atopic dermatitis is a good example of this. There is a lot of concern in the community about the use of our standard therapy for atopic dermatitis, and that is topical corticosteroid medications and that concern or phobia about those medicines has been perpetuated by all sorts of different aspects of our culture including I think sometimes the physicians that these patients are coming from. They've somehow been led to believe that these are dangerous medicines and they are often coming with the attitude that they don't want this medicine, they want something else because this medicine is dangerous.

[00:04:04] Dr. Cifu: And in this case it might be sort of the first line medication or maybe the most effective medication.

[00:04:09] Dr. Stein: And you know, in the setting atopic dermatitis it definitely is there are more and more alternative medications nowadays, but the standard first line treatment is still topical steroids because they work reliably and in many cases that's all that's necessary. If the appropriate agent is used appropriately, then you know, you kind of get over the issue and you don't need to move on to these newer agents that we don't have as much experience with.

[00:04:38] Dr. Cifu: And probably we can broaden that out to, you know, any number of therapies and any number of specialties. You know, for me as an internist, I think of people who come in, you know, Hypercholesterolemia, coronary artery disease definitively need to be on a statin. And they're hesitant for what whatever reason. And clearly that's like, this is the medication you can be on. Yeah, we can do other things, but it's not gonna be as effective, it's not gonna be as evidence based.

[00:05:04] Dr. Stein: Yeah. So the way I like to approach these visits is to acknowledge what a family has already learned about the condition and about the therapy. You know, make sure that they feel that I am acknowledging all they've been through and all the things that they've tried.

And so I'm very open about that and I say it very clearly you know, "I know you've learned a lot about this from other people. I know you've tried a lot of things. A lot of what I'm gonna say may sound the same..." but then I ask for just an opportunity to start at the beginning and give my basic discussion of the condition and my approach. Because I'm sure that in many cases, even though many other physicians have given the same information, there's always something different and something different about the way each individual says it that might sink in or impact people a little bit differently. So I always start at the beginning and then I,

[00:06:03] Dr. Cifu: That's gotta be hard for people to hear, right? Because if we're taking a patient who has, you know, maybe seen a pediatrician, maybe then saw a pediatric dermatologist or two before seeing you, they probably feel like they're kind of an expert. And going back to the basic skincare stuff may seem, I don't know, you know, Disrespectful. Right? Like, you know, I know all this already.

[00:06:31] Dr. Stein: You'd think, but I don't generally get that feeling. I think by prepping it with just a brief statement, I know you've learned a lot about this already. I know you've heard a lot about it. But I always like to just start with my spiel. So you've heard it from me, and then I launch into it. And I often will see them nodding and looking surprised that there is something different that I've happened to say. Um, and then I ask for people to just do it my way for one month. So I feel like giving a strict timeline helps people again feel that they have some control. And you know I'm not saying it has to be this way forever, but let's just try it my way for a month come back in a month and let's see where we're at and if all these things that you're doing my way, even if it overlaps with things you think you've tried and failed before, then you know, we can discuss what else there is and how we need to adjust what we're doing. And you know, nine times outta 10, they come back in a month and things are fine. It has worked. So, you know, I think it is often just resetting expectations and re-discussing things yet again.

[00:07:46] Dr. Cifu: So let's talk about the people who you failed on. You know, we've all experienced those people who... because of their kind of relationship with previous doctors or with the medical community to begin with, come in and they're like "Look, either we've done this and it hasn't worked, or I need you to take treatment X off the table, because we just refuse to do that". Okay? And so you're almost put in the position of, Ugh, you know, I can't win this person over and I'm stuck with prescribing something that maybe I feel is second line. Um, are you okay with that? How do you, sort of pitch that stance? How do you feel about that?

[00:08:32] Dr. Stein: Well, I absolutely am always aware of trying to avoid a power struggle. There's clearly an impression that, you know, the doctors wanna be in control and when patients ask for something that the doctor isn't offering, that you know, they're gonna get shut down. So I try to be very aware of that and if there is that sort of disagreement I try to be compromising and talk about the pros and cons of whatever is being suggested.

And then again, offering a time period to give it a try. So, you know, if you feel strongly about wanting to go this direction, let's give it a try for two weeks or a month, and then we can see how we've done and, and reassess.

[00:09:24] Dr. Cifu: Good. You know, we always talk about when we are working together, you know, as a doctor and a patient or two people, one in a doctor role, one in a patient role, let's say, um, that, you know, the interactions kind of work best where the doctor is in charge of you know, sort of the medical information, right? As the medical expert and the patient is sort of in charge of, you know, the values, like what ends I wanna achieve, what I'm willing to do to achieve those ends. And that we run into problems where either of us step on each other's toes, right? Where the doctor starts saying like, Oh, well you really wanna, you know, end up like this.

Or the patient starts saying, you know, This is the medication I should be taking. Um, is that part of these discussions? I sort of think about in today's world where, you know, many people come into the office equipped with information, whether it be from just a Google search or actually from, you know, real experience with medications, you know, and treatments before seeing you.

[00:10:36] Dr. Stein: Yeah, I think that there is some degree of, you know, people having some preconceptions of what will work for them and that can clash sometimes with what we are advising. And... so I'm always left kind of speechless because it always seems to me, well, you know, whatever you're doing isn't working.

Because that's why you're here for me to do something for you. So sometimes I try to gently point that out as well... when people start listing all of the products that they are using and I'm trying to counter that with, well, these are the ones that I would recommend.

And I'm sort of like, "Well, you know, that hasn't really worked". So we need to go a different direction.

[00:11:22] Dr. Cifu: And sometimes it's time, right? It's that things aren't gonna go perfectly on visit one or visit two, but you know, you're sort of playing the long game and... look, you know, I'll work with you at the beginning and maybe we'll get to the place that not only will you accept the treatment that I think is gonna be most effective, but that, you know, you as the physician, are gonna learn something from those interactions about the person... not only what they'll accept in treatment, but what actually works for them. Right? Since, you know, there are idiosyncratic responses to our therapies.

[00:11:57] Dr. Stein: Sure, yeah. And, then again, in the pediatric setting, you're again also having to work in the patient. And sometimes it's the parent who's, you know, accusing the child in some way of, you know, "well they're doing this and that's what's making it worse". And so dancing around that and avoiding blame is, always also interesting.

[00:12:22] Dr. Cifu: I think every extra person in the room increases the complexity by like a factor of 10, right? Whether it's a medical student or a resident, or a child or a family.

Do you have a sense, and maybe you've sort of already said this, but you know, I think we all have those interactions, um, where we walk out of the room and we're like, "Oh boy, you know, that could have gone better." You know? And then we have other interactions where we're like, "Ah! That was great."

Um, just in terms of this, you know, of the patient coming to you for a second opinion, unhappy with previous opinions, which are maybe in line with what your opinion is. Um, do you have a sense, like what makes those visits successful and what makes them fail?

[00:13:11] Dr. Stein: Well, I definitely think it goes better if it's clear to me that I'm providing a second opinion. Um, cuz that way I can kind of acknowledge what might have been discussed previously and you know, why that might have made someone anxious or unhappy or dissatisfied. And I can kind of direct my explanation and recommendations a little bit more towards those issues. It's the scenarios where it's sort of that Gotcha. You know? You've launched into something and then the patient says, you know, "Well that's not what this other doctor told me." And that always feels much more antagonistic.

[00:13:51] Dr. Cifu: That's interesting to hear. Cuz as you know, I'm a general internist, so I'm almost never... well, I'm seldomly in like a consulting relationship with people, but there are people who come to me clearly with well-established other relationships and a place, you know, like University of Chicago or any other academic medical center. You'll often get patients who come from, you know, far away and you're like, "Boy, this can't be easy if you're gonna use me as your primary care physician."

You know, And so I sometimes find. The place where I have to ask like, what do you see my role as here? Um, which then as you say, I think really helps to say, okay, you know, what role am I playing? How am I acting here? Um, am I providing a letter to the patient and another physician, you know, or am I really like, Okay, I'm gonna take charge here and it may take us a while to get to square one.

[00:14:50] Dr. Stein: Yeah.

[00:14:52] Dr. Cifu: Good. Well, thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.