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News
AMONG MEDICINE’S MOST ENDURING MYTHS
Michael Monette
CMAJ September 18, 2012 184 (13) E705-E706; DOI:
https://doi.org/10.1503/cmaj.109-4254
Michael Monette
CMAJ
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There are any number of valid reasons why a patient might want to seek a second
medical opinion. He may want reassurance before embarking on a treatment plan or
undergoing invasive surgery. He may have felt that he was rushed out the
doctor’s door without having had the opportunity to obtain answers to all his
questions. Or he may have felt the physician overlooked some information in his
diagnosis
One of the precepts of Canada’s health care system is that aggrieved or confused
patients always have the option of seeking a proverbial second medical opinion.
But is that more than an enduring, and perhaps reassuring, but entirely
meaningless myth? Is it really feasible or even possible to get a second medical
opinion?
Possibly, although observers note that the wait for a second opinion can be even
longer than the wait for the first opinion, particularly when it comes to
getting the second opinion of a medical specialist.
Not that getting a medical opinion from a second family physician is necessarily
any easier than getting one from a specialist. Already, Canadians are on long
waiting lists just to obtain a family doctor. It almost makes the notion of
finding a family physician who’d be willing to provide a second opinion entirely
comical.
Given the lengthy wait times, the majority of patients balk at getting a second
medical opinion, notes Sholom Glouberman, president of the Patients’ Association
of Canada. De facto, wait times have turned getting a second medical opinion
into “one of those things that’s available in principle but unavailable in
practice in Canada.”
Others fear that getting a second opinion will compromise their treatment, and
ultimately, their health, says Heather Chapman, founder of the Saskatoon,
Saskatchewan-based Patient Factor, an advocacy group and “an independent online
source” for news and opinions about health care (http://thepatientfactor.com).
Patients less than impressed with a doctor’s diagnosis can seek second opinions
but may have to wait even longer than for first opinions, particularly if
seeking them from a specialist.
Image courtesy of © 2012 Thinkstock
Compounding the situation, particularly when it comes to obtaining an opinion
from a second specialist, is the fact that patients are already being
prioritized on wait lists, she adds. Those seeking second opinions typically get
pushed to the bottom of the roster.
But there are other barriers, including the not entirely unjustified concern
that patients will offend the delicate sensibilities or egos of their physicians
by seeking second opinions, Glouberman notes.
Such physician resistance to second medical opinions isn’t appropriate, says Dr.
Ruth Wilson, a professor of family medicine in the Department of Medicine at
Queen’s University in Kingston, Ontario, and past president of the College of
Family Physicians of Canada. “We’re not perfect and thinking about things from a
different point of view or through a second set of eyes can sometimes turn up a
different diagnosis or a different approach that’s more helpful to the patient.”
What research is available certainly supports the proposition that there is
value in obtaining a second opinion. A study of 466 surgical oncological
patients concluded that “one third of patient-initiated second opinion
consultations resulted in a discrepancy with the first opinion” and that half
resulted in “major changes in therapy or prognosis” (EJSO 2006; 32:108–12).
Another study of 814 cases of patients facing head and neck surgery found that a
second review of the pathology “resulted in 54 (7%) changed diagnoses. Of the
changed diagnosis, 13 (24%) involved a change from a benign to a malignant
diagnosis; 8 (15%) involved a change from a malignant to a benign diagnosis; and
33 (61%) involved a change in tumor classification” (Head Neck 2002; 24:684–93).
Similarly, a review of the pathologic material of 213 patients suspected of
having a urologic malignancy found that there was a difference of opinion in 10%
of cases, leading to the conclusion that “a second opinion review of surgical
pathology for urologic malignancy can result in major therapeutic and prognostic
changes” (Urol Oncol 2011; 29:194–8).
By international standards, Canada appears to be one of the worst performing
nations when it comes to second medical opinions, according to reports issued by
the Health Consumer Power-house, a private company based in Danderyd, Sweden,
and the Frontier Centre for Public Policy, an independent think tank with
offices in Winnipeg, Manitoba; Regina, Saskatchewan; and Calgary, Alberta.
In all three reports, Canada received the lowest grade in the “right to a second
opinion” performance indicator, a mark reserved for those countries that don’t
ensure the right to a second opinion or those with “severe obstacles that very
often cause difficulties accessing a formal right” to a second opinion.” The
most recent iteration, Euro-Canadian Health Consumer Index 2010
(www.fcpp.org/files/1/ECHCI2010%20Final.pdf) states that “many of the provincial
bodies that license doctors do explicitly note that patients have a right to a
second opinion. But since a second opinion from a specialist requires a referral
and often a lengthy wait, even those regions that seek to provide second
opinions have great difficulty in translating this into reality. … (Further) the
literature indicates that the accessibility of second opinions remains much
worse than that of specialist referrals in general.”
But patients who’d like second medical opinions, particuarly those with deep
pockets, aren’t entirely without options.
There’s always the option of seeking a second opinion from a private clinic,
Chapman notes. There are also online services, based in the United States, that
allow patients to submit their medical records and obtain second opinions
remotely for a fee, typically on the order of US$500–US$1500.
As well, there are services such as Best Doctors Canada and WorldCare, which
collect a patient’s medical records, test results and other pertinent data for
review by physicians. But membership is required to access these services, which
are provided strictly within the parameters of employee benefit packages or
private insurance plans.
When it comes to obtaining a second opinion from a second specialist, some
physicians say the hurdle isn’t as high as many believe, and generally doesn’t
involve marathon wait times.
It depends in large part on “the acuity of the patient’s situation,” says Dr.
Danielle Martin, chair of Canadian Doctors for Medicare and a practising family
physician in Toronto, Ontario. “If the reason for the second opinion is because
it appears the person is really ill, they’ll get their second opinion very
quickly. If the reason that they want a second opinion is because they want
another discussion of the pros and cons of a treatment they’re already taking,
they may wait a very long time and I actually don’t think that’s necessarily
inappropriate.”
Moreover, Martin argues, triaging such patients according to the urgency of
their condition promotes good use of specialists’ time, even if it means that a
lower priority patient has to wait longer for that second opinion.
As well, patients who want a second specialist’s opinion can always consult
their family doctor, Martin adds. “You serve a translation function as a family
physician. We tend to have more time to spend with our patients, we have that
longitudinal relationship... We know a lot more about them because we’ve known
them for a long time. So we can provide that context that the specialist who is
seeing a patient for the first time may not have.”
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18 Sep 2012
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Among medicine’s most enduring myths
Michael Monette
CMAJ Sep 2012, 184 (13) E705-E706; DOI: 10.1503/cmaj.109-4254
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requires a physician leader who places a high value on innovation and
developing highly collaborative relationships to continue to advance the
mission of CBS. Are you ready to embark on a meaningful and inspiring
journey, where what you do matters? Be part of Canada’s lifeline. Because we
can all be the reason, the connection, that keeps Canadians living. To apply
for this position, please visit boyden.thriveapp.ly/job/2437 . For more
information, please email Paul Marshall at pmarshall@boyden.com . Diversity
and inclusion play a vital role in ensuring health equity for patients across
Canada. Canadian Blood Services is committed to reflecting Canada’s
population in its organization and fostering an environment where all
employees can be their authentic selves, with equal opportunities to succeed
and contribute. To protect the health and safety of its employees, all
Canadian Blood Services’ employees are required to be fully vaccinated
(COVID-19 vaccine doses as approved by Health Canada), subject to any medical
or other human rights grounds. Persons who have been vaccinated outside of
Canada must contact their local Public Health Unit to obtain a vaccine
equivalency certificate. We thank all applicants for their interest, however
only those under consideration for the role will be contacted.
* Department of Radiation Oncology, Princess Margaret Cancer Centre, UHN:
Academic Radiation Oncologist
The Princess Margaret Cancer Centre (610 University Ave, Toronto, ON, M5G
2M9) is seeking an academic Radiation Oncologist within the Radiation
Medicine Program (RMP). The successful candidate is expected to have a track
record of successfully obtaining grants and peer-reviewed publications, and
will provide outstanding care in areas of clinical need within the department
such as: lymphoma, breast cancer, and/or genitourinary cancers. Candidates
with experience in radiotheranostics are encouraged to apply. The successful
candidate will also lead an impactful research program in areas relevant to
radiation oncology, aligned with their sites of practice, and serve as a role
model, teacher and mentor to students, residents and radiation oncology
fellows. Preference will be offered to individuals who are certified, or
eligible to be certified, in Radiation Oncology by the Royal College of
Physicians and Surgeons of Canada. The successful candidate must be eligible
for an academic appointment in the Department of Radiation Oncology,
University of Toronto, and must hold and satisfy physician licensure
requirements in Ontario. All candidates must be able to demonstrate
functional proficiency in English. Preference will be given to candidates
with permanent residency or citizenship status in Canada. The Radiation
Medicine Program (RMP) is an academic department within Princess Margaret
Cancer Centre/University Health Network (UHN) serving the radiation oncology
needs of the Toronto central area. RMP is a tertiary referral resource for
the Greater Toronto Area and the province, serving Ontarians and Canadians
for specialized programs and services such as pediatric radiation oncology,
sarcoma, head and neck cancer, ocular oncology, gamma knife, brachytherapy,
and stem cell transplants (total body irradiation). RMP aspires to be the
leading Radiation Medicine Program in the world by providing exemplary
patient care, research and education; we value and expect innovation in all
aspects of our activities. The Department of Radiation Oncology is currently
staffed by 37 radiation oncologists, providing >7,000 new patient
consultations, and delivering >10,000 courses of radiation treatment
annually. There are state-of-the-art imaging and radiation treatment
equipment including three CT-simulators, a MR simulator, 16 linear
accelerators (Elekta and Varian), two gamma knife units, and a MR Linac.
There are advanced clinical and research programs in IGRT, SBRT,
brachytherapy (HDR), adaptive planning, MR-guided RT, genomics, radiomics,
and translational research, with personalized radiotherapy approaches
including an active clinical trials program in collaboration with
international cooperative groups. There is a robust education program ranging
from undergraduate to postgraduate medical, physics and radiation therapy
training within the University Department of Radiation Oncology, including
over 20 Radiation Oncology Residents, and over 20 Clinical and Research
Radiation Oncology Fellows. Remuneration will be commensurate with
experience, with an expected range of $340,000 - $400,000 per annum (which is
comprised of payments from the Ontario Association of Radiation Oncology and
fee for service billings). Benefits may include group insurance benefits
package and relocation benefits. There is an allowance for annual leave and
additional allowance for professional development activities and scientific
meetings. Applications will be accepted until December 5, 2023 or until
filled, with a target start date of summer 2024. CONTACT INFORMATION: If you
wish to apply for this position, please forward your CV and a letter of
intent to: David Kirsch, MD, PhD, FASTRO, FAAAS Head, Radiation Medicine
Program, Princess Margaret Cancer Centre Head, Department of Radiation
Oncology, University Health Network Senior Scientist, Princess Margaret
Cancer Centre Peter and Shelagh Godsoe Chair in Radiation Medicine Professor,
Departments of Radiation Oncology & Medical Biophysics, University of Toronto
610 University Ave, Toronto, ON, Canada M5G 2M9 Tel: 416-946-2094, Fax:
416-946-2038 Email: patricia.lee@uhn.ca
* One Health Medical Centre: Family physician (One Health Medical Centre)
Vacancies: 3 Terms of Employment: This is a full-time position, 36 to 40
hours per week. Must be available in the daytime, evenings, and weekends.
Part-time, Casual or Locum opportunities are also available. Anticipated
Start Date: As soon as possible Salary: Fee for Service (Approximately
$260,000 to $360,000 per year) Location: 407 Iroquois Shore Rd. Unit 6F
Oakville, ON L6H 1M3 Experience: Minimum one year Education: Doctor of
Medicine Work Setting: Family Medicine Walk-in Language: English License :
CCFP / College of Family Physicians Certificate Licensure by Provincial or
Territorial Authorities / Medical Council of Canada Family physician's
primary duties: Examining patients and taking their histories Order
laboratory tests, X-rays, and other diagnostic procedures Consult with other
medical practitioners to evaluate patients' health Prescribe and administer
medications and treatments Inoculate and vaccinate patients to prevent and
treat diseases Advise patients on healthcare Communicate health
promotion/disease prevention to patients Provide Counselling and support to
patients and their families on a wide range of health and lifestyle issues
Please apply by: Mail or in-person: 407 Iroquois Shore Rd. Unit 6F Oakville,
ON L6H 1M3 Email: onehealthoakville01@gmail.com
* Meadowvale Medical Centre: Family physician (Meadowvale Medical Centre)
Vacancies: 01 Terms of Employment: This is a full-time position, 36 to 40
hours per week. Must be available in the daytime, evenings, and weekends.
Part-time, Casual or Locum opportunities are also available. Anticipated
Start Date: As soon as possible Salary: Fee for Service (Approximately
$260,000 to $360,000 per year) Location: 6750 Winston Churchill Blvd.
Mississauga, ON L5N 4C4 Experience: Minimum one year Education: Doctor of
Medicine Work Setting: Family Medicine Walk-in Pharmacy Language: English
License : CCFP / College of Family Physicians Certificate Licensure by
Provincial or Territorial Authorities / Medical Council of Canada Family
physician's primary duties: Examining patients and taking their histories
Order laboratory tests, X-rays, and other diagnostic procedures Consult with
other medical practitioners to evaluate patients' health Prescribe and
administer medications and treatments Inoculate and vaccinate patients to
prevent and treat diseases Advise patients on healthcare Communicate health
promotion/disease prevention to patients Provide Counselling and support to
patients and their families on a wide range of health and lifestyle issues
Please apply by: Mail or in-person: 6750 Winston Churchill Blvd. Mississauga,
ON L5N 4C4 Email: aa01901@sympatico.ca
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Citation Toolsclose
Among medicine’s most enduring myths
Michael Monette
CMAJ Sep 2012, 184 (13) E705-E706; DOI: 10.1503/cmaj.109-4254
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