Second Opinions
Chat Highlights
August 14, 2002

Norma Devine, Editor

On Wednesday, August 14, 2002, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Second Opinions."

Moderator:  Dr. Rick, when should a glaucoma patient get a second opinion?  

Dr. Rick Wilson:  Whenever the patient is anxious about a particular decision or feels that his or her doctor may not be answering questions adequately, a second opinion may be necessary.

P:  How should I let my doctor know that I would feel more comfortable about making a decision if I get a second opinion? What will my doctor think if I get a second opinion?

Dr. Rick Wilson:  If the doctor has enough self-confidence, he or she will not be threatened by a second opinion and may even welcome it.  Glaucoma is a difficult disease, and patients may not always do well in spite of the best of care.  A second opinion shares the responsibility.  If the doctor gets angry when a patient may want another opinion, then I, personally, would suggest a referral to another specialist.

P:  Is it sometimes more difficult to evaluate a patient's situation and recommend options after treatment has begun?

Dr. Rick Wilson:  Yes, especially if the second opinion doesn't agree with the first. 

P:  Why do some doctors get upset if you want a second opinion and don't help you get one?  

Dr. Rick Wilson:  Sometimes even excellent doctors may not connect with a patient who has a certain personality type, and a second opinion or referral to another specialist may be in order.

P:  This is kind of a dumb question, but how many opinions are enough?  I have had several, and they all seem to agree.  Yet well-meaning people keep urging me to seek more, just because I am still progressing. I am satisfied that all is being done that can be done at this point.  Am I being naive?

Dr. Rick Wilson:  It is quite rare for a glaucoma to progress if the IOP (intraocular pressure) has been lowered to the single digits, even in advanced cases.  In those cases, often other factors like low systemic blood pressure or serious atherosclerosis may play a role.  If you are still progressing, seek the best opinion you can find. 

P:  Even though I had an excellent relationship with my local glaucoma specialist, before I had any of my surgeries, I got another opinion, sometimes two opinions. My doctor encouraged it.  Do you feel that was reasonable?

Dr. Rick Wilson:  If you feel better, and it seems your doctors are happy to have you have the reassurance of several opinions, then it seems quite reasonable to me.  On the other hand, I always told my mother to pick the best doctor she could find and follow his or her directions.  Other opinions are not always necessary if you are comfortable with the expertise and bedside manner of your physician.

P:  There are two schools of thought about getting second opinions.  One thinks the patient should reveal everything, including the name of the doctor.  The other thinks the patient should tell nothing except the essential medical history, so as not to prejudice the consulting physician. Which is more advisable?

Dr. Rick Wilson:  I think a patient must give a complete history, including what the other doctor has done.  The patient does not have to tell what the other doctor has suggested.  If I were a patient, that would be my approach.  I often prefer not to ask, so the patients know they are getting my unbiased opinion. 

P:  Is it better to allow the doctor to refer you to another doctor for a second opinion?  Or is it better to seek one independently?

Dr. Rick Wilson:  Unfortunately, that varies according to the doctor.  Certainly you do not want to be referred to a golfing buddy, who will parrot the opinion.  However, if you seek an opinion independently, it is hard to judge the worth of other specialists.  For instance, I have been profiled in Philadelphia's Top Docs by "Philadelphia Magazine" for many years.  However, there are also doctors selected who are well past their prime, and some that have even quit operating.  "US News and World Reports" also profiles Top Docs, as chosen by their peers, which also suffers from some of the same drawbacks, but is, in my opinion, less subjective and more reliable.  Information on the internet is hard to trust and many doctors who are wonderful people and conscientious, caring physicians may be mediocre surgeons, or worse.  In other words, that is a tough question to answer.  I would rely on the suggestions of several doctors to pick out a consultant.

P:  Would it be better to seek a second opinion from a doctor not in the same geographic area as the original doctor?

Dr. Rick Wilson:  It would probably be slightly better, so that the second doctor would not feel he would be rubbing elbows with the first, and hence have to account for the differing opinion, if that were the case.  On the other hand, there are not that many established glaucoma specialists, especially academic ones.  We usually know one another.  

P:  Is a second opinion desirable for a rare condition such as ICE (iridocorneal endothelial) syndrome?

Dr. Rick Wilson:  For a glaucoma specialist, an ICE syndrome is not that rare and the treatment up until surgery is fairly straightforward.  When surgery is required, then consensus is less likely and a second opinion may help.  

P:  When the second-opinion physician's opinion differs from the first-opinion doctor's, will the patient be told why?

Dr. Rick Wilson:  Yes.   Patients should be privy to the reasoning behind the opinion, so they can compare to some extent how well thought out the opinions are.

P:  When treatment options differ, how can the patient decide which treatment would be better?  

Dr. Rick Wilson:  Sometimes a third opinion is required.  Sometimes the patient just has to decide which doctor's opinion they trust more.

P:  I have a fantastic doctor, with extensive surgical experience.  But Mama always told me to get a second opinion whenever you need surgery.  I have let my doctor know I will do that.  Do you agree that, unless they are in the emergency room, patients should always get a second opinion when surgery is involved?  

Dr. Rick Wilson:  No, only if there is some question in the patient's mind that the suggested surgery is the best and safest course for the eye, or if there is a personality conflict with the surgeon and the patient feels he or she would be more comfortable with another surgeon.

P:  Do most health insurance plans pay for second opinions?

Dr. Rick Wilson:  Most do, as it may save them money if the second opinion weighs in against surgery.

P:  If I need my primary care doctor's permission to get a second opinion and he or she refuses, is there anything I can do?

Dr. Rick Wilson:  There should be an appeal process sanctioned by the insurance company.  If the company is adamant, you can go to the state insurance board or supervisory agency.

P:  Do second opinions about glaucoma and treatments usually affirm the first doctor's opinion?  

Dr. Rick Wilson:  I would guess they do many more times than not.  I agree about 75% of the time.

P:  Do doctors often consult other doctors seeking additional advice?

Dr. Rick Wilson:  Yes.  The American Glaucoma Society has a list serve, and there is an international list serve of glaucoma specialists.  Doctors are always putting problem cases on the Web for other ideas.  I have been helped several times, once by one of my former fellows, who turned out to be correct.

P:  Dr. Rick, if a surgical procedure has been poorly done, is it realistic to think that a second-opinion doctor will state that?

Dr. Rick Wilson:  Probably not flat out.  The opinion can be couched as: "The first surgery does not look like it has worked out as well as was hoped, because . . ."

P:  As it is difficult for patients to ask several doctors about a good glaucoma specialist for a second opinion, what would be an alternative way?  

Dr. Rick Wilson:  I feel that patients are usually a less-than-optimal source of referrals.  Their opinions are usually based on personality more than knowledge, experience, and surgical prowess.  A lucky result could make them jubilant about a particular doctor.  A national magazine that rates the "Top Docs" may be of some help, as would the subspecialty society.  However, the best would be a referring doctor who, over the years, sees patients with both good and bad results.  

P:  It's my observation that some patients place an undue emphasis on the "bedside manner" of the physician.  In the best of all worlds, the importance should be placed on the physician's skill and expertise as opposed to how effective he or she is at making a patient feel at ease.  What is your opinion?

Dr. Rick Wilson:  When I asked arthropods I knew for suggestions for a knee surgeon, I was offered an excellent surgeon with a brusque bedside manner or a slightly lesser surgeon with a great bedside manner.  Not needing a lot of hand-holding, but wanting the best result I could get, I chose the former and have been happy with him for many years now.  For others, having someone who will take the time to discuss their questions and put them at ease is the most important quality for a surgeon.  That is very important to them and may be crucial to their well being.

P:  Do patients sometimes seek second opinions because they are running from scientific and medical facts?

Dr. Rick Wilson:  Many patients may have difficulty facing the news that they need surgery.  Denial may play a large part in their behavior.  For such patients, seeking a second opinion gives them the opportunity to find a doctor who may say no surgery is needed.  If the second doctor agrees with the first though, then the patient is usually forced to face the reality of his or her situation. 

P:  What special training does a glaucoma specialist have that a regular ophthalmologist does not have?

Dr. Rick Wilson:  A glaucoma specialist has one to two years of additional training just in glaucoma beyond what a general ophthalmologist gets.

End of highlights for August 14, 2002.

On August 21, Dr. Wilson discussed "Medications and How They Work" in the Chat room. Click here for highlights of that meeting.

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