Sunday, January 25, 2009

Throwing the Challenge Flag

This is the worst sports weekend of the year --- everybody is waiting for the Super Bowl, and it ain't happening. Sure, I'll catch some of the NHL All Star game (full disclosure, my brother works for an NHL team), but I'm really jonesing for the big game. No party for me; I'll be serving the community on Drama Call.

Football has changed a lot in the past few years, and one wrinkle I'm not sure I like is the ability to challenge a call. Seeing a grown man throw out a little red hankie on the field is, well, unmanly. It sort of reminds me of old westerns with the town harlot sitting on a piano, dressed in red and black lace, twirling a red boa.

Maybe I'm not a fan because I have to deal with a couple of similar "challenge flags" in my line of work. Once or twice per month, I have a conversation with a new patient that includes some version or another of this phrase:

I have already talked to another surgeon, but I wanted to hear what you have to say.
Really what this means is:
I just want a second opinion.
In other words, the patient is throwing a challenge flag. He doesn't like, doesn't trust, or simply is preconditioned to want more than one physician's input into his problem. This, to me, is generally no big long as I know that this is the case. It is disconcerting to hear this well into the visit, rather than at the beginning. (image source)

Honesty is truly the best policy when speaking with a physician. You see, we can cover a lot of ground in a conversation that is needless if a patient has seen three other physicians for the same problem, and already has a grasp of the situation. It is difficult for me to carefully go through a disease process, its ramifications, its treatment options, and potential complications of surgical options in detail when the patient across from me acts impatient because, well, it's all old hat to him. If we can establish up front that the patient already has heard, and understands, the basics, we can focus more closely upon options and answer questions that have prompted the idea of getting another opinion.

What motivates patients to seek alternate opinions? There are a couple of broad categories.
  • The patient truly has an unusual or complex problem, and the surgeon he sees freely admits that while he can deal with it, the issue at hand is not one he sees commonly. Cool, most docs have no issue with this.
  • The patient is uneasy with, or doesn't care for the surgeon he is sent to see. I'll be honest -- I would much rather that a patient is comfortable with his surgeon than take offense that he or she doesn't like me. Patients should feel comfortable with the guy that has to open them up and rearrange their insides --- if they are not comfortable with me, they will be best served by seeing someone else.
  • The patient has been told, through family, friends, the media, etc., that "you must always get a second opinion before having surgery." Realistically, for most things, this is unnecessary, but I understand the way that some folks have been conditioned.
  • The patient has "issues." This is a patient that is fairly difficult to deal with, as they trust no one in a lab coat, feel that physicians are simply out to make a pile of cash hurting people, and tend to believe in conspiracy theories. To say the least, they don't tend to have good outcomes (from their standpoint), regardless of whether their surgeon is Michael DeBakey or Jack the Ripper.
  • The patient was caught like a deer in the headlights at their first appointment. Sometimes, processing information, particularly difficult to understand or potentially devastating information, is a real challenge (for everybody). I don't mind a bit being the physician that needs to simply reiterate what the first surgeon told the patient, and hopefully reassure them that they are getting the best and most up-to-date advice possible.

My rule of thumb in all of these situations is to offer an opinion. Not a second opinion. Just my opinion, unedited and, as much as possible, unswayed by the information they have gleaned from a prior surgeon. If my opinion jives with what their first surgeon told them, I let them know that they have received good advice, and that I certainly have no magical store of knowledge not available to other surgeons. If they like me better, great. If not, great.

We get into trouble with asking for second opinions in urgent or emergent settings. GruntDoc and the docs at EP Monthly can probably tell a few tales about this. If you are in an ED, and you don't have an established relationship with a surgeon, and you need an operation, it's pretty dang hard to get another surgeon who is not on call to come in and see you if you don't like the recommendations given by the surgeon who is on call. I cannot recall in 15 years of practice an instance when this was requested by anyone other than a patient with "issues." Most folks in an ED who need urgent surgery are well aware that they are sick, and are happy to have a general surgeon available to care for them ---- any port in a storm, so to speak.

On the other hand, the patients with "issues" tend to have well-established track records of firing a number of doctors. In smaller communities, that means that they run out of surgeons that are able to care for them on an emergency basis, and occasionally have to be transferred. Just as Al Davis has a difficult time now finding top tier coaches to hire, these patients have fired so many physicians that they have no other alternatives. This is less than ideal for all concerned.

What about when doctors throw the challenge flag --- at each other? We all hope that when we disagree with the diagnosis or treatment of a patient, it can be handled professionally. Realistically, there are few instances when we have substantive disagreements; generally we will only quietly argue over a fine point or two. The arena of peer review, which is well beyond the scope of this post (and could take up an entire book), is where we go through the painful process of retrospectively evaluating the merits of a particular surgeon's decision-making and care when there are substantive disagreements.