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| COMMENTARY |
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| Year : 2021 | Volume
: 4
| Issue : 3 | Page : 92-93 |
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The value of second opinions for doctors
Paritosh Pandey
Consultant Neurosurgeon, Manipal Hospital, Bangalore, Karnataka, India
| Date of Web Publication | 02-Nov-2021 |
Correspondence Address:
Dr. Paritosh Pandey
Consultant Neurosurgeon, Manipal Hospital, Whitefield, Bangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJNO.IJNO_414_21
How to cite this article:
Pandey P. The value of second opinions for doctors. Int J Neurooncol 2021;4, Suppl S1:92-3 |
The other day, I had a sparkly 75-year old man walk into my clinic. He was a retired army officer and his wife, a general physician. He complained of taking more time to walk between his putts on the golf course, and his swing was not like it was before. People did not notice, but he, being an avid golfer, did. Especially when his friends started to beat him more regularly. Finally, when he could not put the golf ball in the hole from the shortest distance, he was concerned and consulted his physicians. As it happens these days, in a single day, he underwent a series of examinations, scans and here he was, in my consultation room. Carefree, eager to get back to his golf course, oblivious of everything else. There was, however, a visible sign of worry on his wife's face.
Unsurprisingly, his wife was the wiser person here, so she told me more. He had become slower over the last couple of months. Sometimes he could not hold his spoon well. Multiple little changes that had seemed innocuous at the time, now seemed meaningful and of serious import. The MRI showed a left thalamic glioma, which was projecting mostly into the left lateral ventricle, and extending into the third ventricle, causing obstructive hydrocephalus. A large proportion of the tumor was in the lateral ventricle, amenable to decompression. The mass had only one diagnosis though- glioblastoma.
Often in medicine, there are multiple options to treat. Decompress the tumor, radically excise the lesion, a less invasive biopsy followed by a ventriculoperitoneal shunt, endoscopic biopsy and shunt. Unfortunately, in a single patient, only one surgery is the option. Hence the decision has to be made with close discussion with the doctor and the patient. What entails the decision making here? There is a definite increase in longevity that is achieved with radical excision, but it comes with a significant risk of neurological deficits, at least temporary ones. The other option was to try to achieve the best functional result even if it does not give the best decompression and longevity? Or should one simply treat the symptoms, which were due to coexisting hydrocephalus?
There are many ways in which neurosurgeons, or for that matter, most surgeons, make their decisions. Some of the obvious ones are based on their own experience, what is advocated in the literature or what they have learned during their training, and so on. In the classic seven step decision making process, the first few steps (identification of the problem, gathering relevant information, identification of the alternatives, weighing the evidence) are quite easy. The difficulty is in choosing among the alternatives and acting accordingly. A lot of morbidity can be avoided by choosing the 'correct' alternative. In any individual surgery, if one takes a wrong decision, the seventh step, reviewing the decision and its consequences, may have little meaning for that particular patient, though it remains an invaluable tool in the learning process and management of future patients [Figure 1].
There are other, less discussed, more insidious factors in surgical decision making, often causing errors in judgement. Sometimes surgeons may make a decision to perform a difficult surgery more for the challenge itself. There could be influences from the last conference they attended, where they were impressed by a newer technique. Not all of these decisions are motivated by personal accolades or challenges. Oftentimes, the surgeon believes that the decision is right for the patient. And that the surgery, though risky, is doable safely. But what exactly is the patient-centric approach? Is it what's best for the patient or what the patient would actually want. This is just one example of factors that surgeons may miss out while making decisions for their patients. It is also an example of how an individual surgeon's decision may not be the best. It is called a blind spot for a reason, after all.
Herein lies the importance of a second opinion from a colleague, mentor, or friend, preferably one who isn't directly involved in the care of the patient. They often see what we have missed with an unbiased eye, identifying details and factors that we may easily miss. In an academic practice, it is probably simpler to confer with a colleague due to the increased cohesiveness of a department, but that advantage might be offset by the fact that many of these departments can be both very fragmented in their work style and having a hierarchical nature. This is harder in private practice, either due to a lack of easily accessible peers or a sense of misplaced competition and multiple other factors.
What does a second opinion achieve? Simply put, it tempers the enthusiasm of the surgeon to perform a more risky surgery, forces them to take a fresh look and get an unbiased opinion in the situations where there are multiple options. It promotes a more patient-centric approach since often a second opinion may not be clouded by the primary surgeon's bias or enthusiasm. This is the surgeon's second opinion, different from the second opinions that the patients may usually take.
To revert to the story at hand, my initial plan was to do a decompression of the tumor and open up the CSF spaces, as daring as it sounds. But since I was unsure, I consulted a colleague in another city, taking all the benefits of modern technology. What he said was something I had initially considered but discarded. He asked me to put myself in the place of the patient. If I happened to be in my seventies and had a malignant thalamic glioma, would I accept a risk of significant deficits, even if as small as 10%, and spend a lot of my remaining life in hospitals, undergoing rehabilitation and other treatment, or would I choose symptomatic treatment and live the rest of my life doing what I liked to?
This caused an epiphany, and the decision I needed to take was crystal clear.
The patient underwent an endoscopic biopsy and shunt placement. The shunt improved his symptoms significantly, and he was back to his favorite hobby sooner than he expected. The biopsy was glioblastoma, and he underwent radiation and chemotherapy, with all efforts made to preserve his function and quality of life. He was very stoic about his condition, and had a remarkable acceptance of the eventual outcome. His kids visited him, he did all the things he wanted to and passed away seven months after the diagnosis.
The most difficult thing in life is to answer the counterfactual. Or as Ghalib asks, yun hota to kya hota. It is impossible to know the counterfactual. Maybe he would have undergone a successful radical decompression, which would have given him a few extra months survival. Maybe. Or maybe he would be in that small, but not insignificant 10%, people with significant postoperative deficits, devastating his lifestyle, and compromising his quality of life. In the end, we never know. What we know is that, the second opinion from a fellow surgeon showed me a perspective that I had more or less discarded in favor of a more radical surgery. Therein lies the value of an unbiased, unfiltered second opinion from a colleague.
[Figure 1]
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