ORIGINAL ARTICLE

An exploration of the dynamics and influences upon secondmedical opinion consultations in cancer careajco_1330 41..46

Jennifer PHILIP,1 Michelle GOLD,2 Max SCHWARZ3 and Paul KOMESAROFF4

1Palliative Care Service, St Vincent’s Hospital and Centre for Palliative Care, University of Melbourne and 2Palliative CareService, Alfred Hospital and Departments of 3Medical Oncology and 4Medicine, Alfred Hospital, Melbourne, Victoria, Australia

Abstract

Aim: The aim of this study was to explore the dynamics within second medical opinion consultations inpatients with cancer.

Methods: Semi-structured interviews were held with four oncologists and were subjected to a thematicanalysis to define the broad issues. These formed the basis of a survey distributed to Australian medicaloncologists.

Results: Overall 65 surveys were returned representing an overall response rate of 30% (10% and 63%electronic and hardcopy response rates, respectively). The dynamics in giving second medical opinions areinfluenced by the collegiate relationships of the doctors. Nearly two-thirds of oncologists believed that thefirst doctors’ treatment and recommendations influenced the outcome of the second opinion, more thanone-third believed the outcome was influenced by the relationship between the two doctors, and 41%believed the public nature of a second opinion was influential. In each case, these figures were more thandouble their assessments of patients’ beliefs of these influences. Care was taken not to criticise the primarydoctor.

Conclusion: Second medical opinions provide an opportunity for oncologists to review medical care andengage in enhanced communication with patients who have additional needs. These consultations do not,however, occur in a vacuum but are influenced by the need to attend to relationships between the patient andtheir primary doctor and between the doctors themselves. The second medical opinion is embedded withina network of relationships and within the illness journey.

Key words: Second medical opinion, cancer, decision making.

INTRODUCTION

Second medical opinions are common in the care ofpatients with cancer. The majority of oncologists reportseeing between 1 and 5 patients for second opinionseach month,1 while up to one third of patients withadvanced cancer report having sought a second medical

opinion.2,3 Overwhelmingly patients find second medicalopinions helpful with the most common reasons citedfor satisfaction including improved communication andphysician approach, enhanced information, reassuranceand greater collaborative decision-making.1,2,4 Mean-while, physicians generally view patients who seeksecond medical opinions as having greater needs, bothfor information and psychosocial support.1 Perhaps as aresult of these perceived greater needs they are also seenas requiring more physician time and energy.1

Despite the frequency of the practice and its apparentvalue in terms of patient satisfaction, a number ofpatients report some hesitation about seeking secondmedical opinions. Patients report feeling concerned their

Correspondence: Dr Jennifer Philip PhD, FAChPM, MMed,MBBS, Centre for Palliative Care, PO Box 2900, Fitzroy,Vic. 3065, Australia. Email: jennifer.philip@svhm.org.au

This work was conducted at the Alfred Hospital,Commercial Road, Melbourne, Australia, 3000

Accepted for publication 27 July 2010.

Asia–Pacific Journal of Clinical Oncology 2011; 7: 41–46 doi:10.1111/j.1743-7563.2010.01330.x

© 2010 Blackwell Publishing Asia Pty Ltd

doctor may become upset if they seek a second medicalopinion, and many are mindful of a sense of loyalty totheir first doctor in this process.1 This suggestion thatthe dynamics of relationships within the second medicalopinion may play an important role has not been closelyexamined. This study therefore aims to examine thesecond medical opinion consultation in detail, with aparticular focus upon the physicians’ views of thedynamics and the influences upon outcomes.

METHODS

In keeping with the exploratory nature of this study,interviews were conducted with four medical oncolo-gists on their views and practices around second medicalopinions. The interviews were taped, transcribed, andsubjected to a thematic analysis. The resulting themeswere formulated into a survey in order to evaluate theirbroad applicability amongst a wider group of medicaloncologists. The survey consisted of 14 questions thatexamined the frequency of second medical opinions, theperceived motivations and basis for satisfaction ofpatients, views of the patients’ needs (psychosocial,information needs) and their previous medical care, theinfluences upon the doctor involved and the dual rolesplayed by the doctor as physician and professional col-league (see supporting information published online inTable S1). The survey was reviewed for face validity byfive members of the target group.

The survey was twice distributed nationwide tooncologists electronically through the medical oncologyprofessional group in the Royal Australasian College ofPhysicians and through the Cancer Council of Victoria,Australia. Prompts were sent following the electronicdistribution. It was then distributed in paper form toVictorian medical oncologists, with telephone and per-sonal prompts made to encourage responses. The studywas approved by the Institutional Human Research andEthics Committee, supported by a National Health andResearch Council postgraduate scholarship (JP) and noconflicts of interest are noted.

The views of second medical opinions and reasons forthe satisfaction afforded to patients by this practice havebeen reported elsewhere,1 with this report focusing onthe dynamics and influences upon the second medicalopinion consultation.

RESULTS

Four major areas of content emerged from the inter-views with medical oncologists: (i) the particularities of

the individual patients and of the doctors involved, (ii)the conduct of the consultation, (iii) the relationshipsbetween primary doctors and patients, between the indi-vidual doctors, and with the community of doctors; and(iv) other forms of second medical opinions. These arediscussed in turn.

The particularities of the individual

patients and of the doctors involved

The oncologists reported that there appeared to be somecommon characteristics shared among patients whoseek second opinions. Most notably, they were reportedto be younger, professional, and highly educated andthey desired substantial amounts of information. Theoncologists noted that if patients themselves suggestedseeking a second medical opinion, the doctors wouldstrongly encourage this. The doctors in turn wouldsometimes suggest a second medical opinion if thepatient seemed unhappy or appeared to have misgivingsabout the approach suggested.

The conduct of the consultation

The second opinion consultation was approached withcare by all the oncologists interviewed. They detailed theneed to establish where the patient had first been seen,determine why they sought a second opinion, under-stand the patient’s particular concerns, check the clinicalinformation, provide information and education, and, inmost cases, provide reassurance. Language was chosencarefully throughout the consultation, aiming to be clearand to avoid criticism of previous practices. Despite themedical information already being assembled, secondmedical opinions were reported to take more time due tothe often lengthy discussions with the patient and thecare taken in corresponding with the primary doctor.

The relationships between primary doctors

and patients, between the individual

doctors, and with the community of

doctors

Each of the oncologists interviewed suggested that at theoutset of the consultation their role was to give anopinion, with the expectation that the patient wouldreturn to the primary doctor for ongoing care. Thisresponsibility of maintaining the patient’s relationshipwith the primary doctor was seen as important. Theyrarely disagreed with the primary doctor’s recommen-dation, and in the setting of comparative approachesthey usually endorsed the primary doctor’s approach to

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avoid creating uncertainty. All discussions and treatmentoptions were framed in terms of what had been saidpreviously.

The oncologists were mindful of their responsibilitiesand reputation within the network of doctors. Secondopinions were viewed as a form of practice available forscrutiny by colleagues. Some colleagues were known bytheir reputation, for example, to offer further treatmentwhen others had recommended treatment cessation.

Other forms of second medical opinions

Second medical opinion consultations were viewed asjust one form of second opinion. A discussion with acolleague who seeks advice in the corridor and a multi-disciplinary cancer meeting were other forms of secondopinion. Meanwhile, consultations with complementaryand alternative medicine practitioners were seen bysome oncologists to function also as a second opinion,albeit outside the realm of conventional medicine.

These themes formed the basis of the survey that wasdistributed nationally. The electronic survey distribu-tions resulted in a response rate of 21/216 (10%). Thepoor response rate prompted a paper distribution of thesurvey in the state of Victoria, Australia. Response ratesfrom hard copy distribution of the survey were higher at44/70 (63%). In total, 65 surveys were returned, repre-senting an overall response rate nationally of 30%.

Six respondents (9%) reported not seeing anysecond medical opinion patients in the past month, 53(82%) saw between one and five such patients, four(6%) saw between sex and 10, and two (3%) sawbetween 11 and 15. Overall 82% of oncologistsbelieved that in general, the recommendations andtreatments from the primary treating doctor were con-sistent with good medical practice.

Oncologists made assessments of their patients’understanding of the influences upon the discussions

and recommendations of a second medical opinionconsultation (Table 1). According to the oncologists,patients are thought to believe that only what occurs inthe consultation is important (66%). Meanwhile, thepatients are thought to believe that their relationshipwith the first doctor, the relationship between thedoctors and the public nature of the second opinion areless important at 33, 20 and 18%, respectively.

Respondents then gave assessments of the actualinfluences upon physicians giving a second medicalopinion consultation, that is, an indication of their prac-tice (Table 1). A total of 63% of respondents agreed thatthey are influenced by the treatment and treatment rec-ommendations of the first or primary doctor, 38% bytheir own relationship with the first doctor, and 42% bytheir awareness that the results of the consultation willbe seen by professional colleagues.

The oncologists reported on the dynamics of theirown practice within the second medical opinion con-sultations. Overall 83% were careful not to criticisethe primary doctor, 72% would not highlight theirmistakes, and 60% were more than usually awareof the potential for medico-legal ramifications. More-over, 52% would modify their recommendationsaccording to what the primary doctor had advised.

When planning for future care for second opinionpatients, most of the respondents plan for a single con-sultation, but will take on care if the patient stronglyexpresses such a wish (75%). A total of 11% willprovide a single consultation only, and 6% statethey are unconcerned and flexible about ongoingcare.

Respondents described their feelings when they hadtaken on the care of a second medical opinion patient,and then encountered the patient’s original doctor. Inthis situation, 17% were completely comfortable and23% fairly comfortable, but 32% described feeling a bit

Table 1 Oncologists’ assessments of second medical opinions (N = 65)

What oncologists thinkpatients understand

(% agreed)

What oncologists thinkactually occurs

(% agreed)

Patients believe discussions and recommendations are based onlyon that interaction which occurs within the second opinion consultation

66 –

First doctors’ treatment recommendations are influential 34 63Patients’ relationship with first doctor is influential. 33 –Relationship between the first and second doctor is influential. 20 38Public nature of the second opinion consultation is influential since results

of consultation are made available to professional colleagues.18 42

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© 2010 Blackwell Publishing Asia Pty LtdAsia–Pac J Clin Oncol 2011; 7: 41–46

uncomfortable, and 5% were very uncomfortable in thissituation.

Respondents were also asked to describe their feelingswhen their own patient of more than 3 years seeks asecond opinion and elects to continue their care with thesecond doctor. In this scenario, 6% described feelingcompletely comfortable and 18% fairly comfortable but42% described feeling a little irritable, though none feltvery irritable.

A number of respondents offered spontaneouscomment to this question, including four who describedfeeling relieved since it generally meant there had beendifficulty in the interaction, and two who describedfeeling some hurt at the presumed lack of communica-tion or rapport. Second medical opinions raise com-plexities within the relationships between doctors, asindicated by the following spontaneous comments:

(H)ow [do] you feel when you have told a patient there areno further treatment options and then they go and get whatyou consider inappropriate treatment from someone else?

[The] other doctor often does not understand why a par-ticular treatment path was taken and usually no contactoccurs to sort this out., e.g. [a] recent patient went for [a]second opinion and in [the] letter [it] was stated that [he]cannot understand why such a treatment was given. [The]reason was the patient refused all other options, but ofcourse the patient didn’t admit this to [the] doctor.

DISCUSSION

This study represents the first attempt to explore indetail the dynamics and the influence of relationships onthe practice of second medical opinions. As reportedpreviously, most oncologists viewed patients seekingsecond medical opinions as having more psychosocialneeds and greater information needs than the generalpatient population.1 Patients were seen as seeking some-thing additional from the medical system, and this wassteeped in a personal, rather than a physical need, sincemost doctors considered that past care had been consis-tent with good medical practice. It appears that oncolo-gists believe that most practice in broadly similar waysand give comparable care.

The dynamics in giving second medical opinions areinfluenced by the collegiate relationships of the doctors.Nearly two-thirds of the oncologists believed that thefirst doctor’s treatment and recommendations influ-enced the outcome of the second opinion and more thanone-third believed the outcome was influenced by therelationship between the two doctors, and that thepublic nature of a second opinion was influential. In

each case, these figures were more than double theirassessments of patients’ beliefs of these influences. In thesetting of comparable treatments more than half theoncologists would modify their own practice accordingto what has been previously recommended.

A second medical opinion is not an isolated event butoccurs in a continuum of what has gone on previously. Ifthe first doctor has recommended a particular treatment,then, in the setting of comparable treatments, the seconddoctor would also frequently recommend this approach,even if their usual habit was to offer an alternative. Thisresponse may represent a number of motivations such asan attempt to offer certainty, to maintain confidence inthe first doctor–patient relationship and to avoid seem-ingly trumping the first doctor.

There is a long-established ethical structure in theprovision of medical care.5 Behavioural norms guide theinteraction between patients and doctors but signifi-cantly also guide the interactions between doctors. InAustralia there is a tradition of not taking over the careof other doctors’ patients. While this tradition has weak-ened in recent years, doctors are nevertheless mindful ofthis norm and in this study most preferred not to take onthe care of a second opinion patient. When they did, upto one-third felt discomfort.

This professional ethic is also reflected in the caredoctors take to avoid criticism of colleagues. This mayresult not only from attention to collegiate responsibili-ties but also efforts to maintain relationships betweenthe patient and their primary doctor. Reluctance to criti-cize previous care may stem from an awareness thatother narratives exist that are not being heard, namely,that of the first doctor. This was illustrated by theoncologist quoted above who responded to the impliedcriticism of a second opinion physician with indigna-tion. The acute awareness of medico-legal issuesexpressed by oncologists reflects the sensitivity withwhich they approach the consultation and tend to therelationships involved. They viewed second medicalopinions as a method by which their practice was madepublic and were mindful of the impact of these consul-tations on their professional reputation among theirpeers. They were well aware of practice approaches ofcolleagues, and equally aware that their own recommen-dations resulting from second medical opinions wouldsoon be available to these colleagues.

Patients have been reported to find second medicalopinions very helpful. This satisfaction stems fromenhanced communication, information, and reassur-ance.1,2 Another factor that may contribute to this sat-isfaction may be an enhanced state of readiness to the

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information and consultation. Patients are constantlychanged by their experience with cancer through diag-nosis, prognosis, multiple interactions with doctors,with their community, and according to their psychoso-cial and spiritual experiences. After each interaction thepatient is changed. Therefore, the patient who is initiallyunable to hear information may at some later stage bemore capable of engaging in decisions and forming arelationship with a doctor. Seeking a second medicalopinion may be an indicator of a preparedness to engagein this therapeutic endeavour.

Patients may consider that second medical opinionsoffer an independent care decision. Their doctors, too,view second medical opinions as an opportunity toreview the medical care that has been given and give areasoned, informed recommendation with due and dili-gent consideration. But this process of review does notoccur in a vacuum. The individual doctor does notpractice in isolation. Instead, there is a strong sense ofscrutiny, accountability and respect within the profes-sion that is apparent in giving second opinions. It islikely that patients are largely unaware of the colle-giate factors that are intrinsically bound up with asecond opinion. The medical professional has respon-sibilities to the patient first and foremost, which theytake with utmost seriousness. Simultaneously, thedoctor attempts to attend to the relationship of thepatient and their primary doctor, their own relation-ship with this doctor and practices within a network ofcollegiate relationships and responsibilities, as well asmedical traditions. Each of these imperatives will influ-ence, to a greater or lesser degree, the outcome of asecond medical opinion. These are the dualities thatthe doctor must negotiate. “There is nothing wrongwith dualities and usually we abide them withoutdemur”.6 They are rarely in conflict. It does not meanthe patient is receiving compromised care. The secondopinion, like the first, is embedded and profoundlyinfluenced. The patient’s needs are attended to prima-rily, and the doctor’s other responsibilities (collegiaterelationships, medical traditions) are usually able to besimultaneously attended to.

There are limitations to this study which must bementioned. The poor national response rates mean itcannot be said that the views expressed represent thoseof Australian oncologists broadly. In a professionalgroup such as this, who have frequent requests to par-ticipate in survey, this methodological approach may notbe productive. The views of Victorian oncologistsreceive greater representation in this study as theirresponse rates to the hard copy surveys were higher.

While the results cannot be generalized to representAustralian medical oncologists, this exploratory studydoes, however, offer new insights into this common areaof care. A second limitation is that doctors were asked toreport on patients’ views rather than directly samplingthe patients themselves. This may not be said to repre-sent patients’ views, but the authors believe it is never-theless useful to understand their physicians’perceptions of these views.

CONCLUSION

Patients with advanced cancer receiving care experi-ence a series of events and interactions with the deliv-ery of the diagnosis, information, and responses, andare altered by each of these interchanges. At differentpoints in that process they have different needs andmake different demands of their loved ones, their com-munity, and their doctor. Patients who present for asecond opinion have been changed by what hasoccurred before, which may instil them with a readi-ness for the second opinion, so that questions may beasked and needs may be more effectively addressed.Therefore, the past modifies the present and willinform the future recommendations emerging from theconsultation.

The second medical opinion is not an isolated eventand is not independent of the participants and the systemof relationships within which it occurs. Instead, it isdeeply embedded, reflecting the past and in turn influenc-ing the future relationships and care interactions.

REFERENCES

1 Philip J, Gold M, Schwarz M, Komesaroff P. Second medicalopinions: the views of oncology patients and their physi-cians. Support Care Cancer 2009; 18: 1199–205.

2 Tattersall MH, Dear RF, Jansen J et al. Second opinions inoncology: the experiences of patients attending the SydneyCancer Centre. Med J Aust 2009; 191: 209–12.

3 Van Dalen I. Motives for seeking a second opinion in ortho-pedic surgery. J Health Serv Res Policy 2001; 4: 195.

4 Mellink WA, Dulmen AM, Wiggers T et al. Cancer patientsseeking second opinion. J Clin Oncol 2003; 15:1492–7.

5 Komesaroff P. From bioethics to microethics; ethical debateand clinical medicine. In: Komesaroff P (ed.). TroubledBodies. Melbourne University Press, Melbourne 1995;62–86.

6 Komesaroff P. Reply. Intern Med J 2006; 36: 68.

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SUPPORTING INFORMATION

Additional Supporting information may be found in theonline version of this article:

Table S1. The following are examples of questions askedin the survey.

Please note: Wiley-Blackwell are not responsible for thecontent or functionality of any supporting materialssupplied by the authors. Any queries (other than missingmaterial) should be directed to the corresponding authorfor the article.

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