Wanting A Second Opinion

The other day I had a request from a patient for notes, as he wanted to seek a second opinion. The thing I noticed was that he was very apologetic and seemed a bit embarrassed about the whole matter. I reassured him that I never take seeking another opinion personal.

I’m in this line of work to help people get better, not to make my ego feel better.  I understand completely (having done this for so long) that when a patient is not getting better, they start to feel that maybe someone else has the answer they are looking for.

In this case they should seek that second opinion without embarrassment or hesitation.  Now, I say this, not because I think we have missed anything.  In thirty years of doing this, I’m unaware of a single patient who went elsewhere, and then they found a totally different (and more accurate) diagnoses than the one I had given them. This does not apply to patients who go to complimentary and alternative (CAM) therapists and are given a different diagnoses such as curvature of their neck being out, cranial bones shifted, adrenal failure, gluten intolerance, black mold exposure and/or allergies.  While I respect professionals in those fields, they live and think in a different world than we in evidence-based medicine. The diagnoses mentioned have not been validated in our way of looking at things, through the scientific method. However, with that said, if I have a patient who goes to a CAM therapist and that therapist helps them get better, I want to hear about it.  I’m open to changing my mind and I’m open to sending that therapist more patients.

When I worked at Mayo Clinic, virtually all our patients were coming there for second opinions.  We had access to the brightest minds in the world, encompassing virtually all specialties of medicine. Despite that, it was very rare that we stumbled on a diagnoses that had been missed, at least a serious diagnoses. Sure, many patients had been diagnosed as “Tension Headache” that we re-diagnosed as migraine. But within our whole group of six headache providers, I don’t recall anyone in which we discovered a more fundamental medical problem that could be fixed and the headaches resolved. It does happen, but rarely.

Many headache types are a mystery even to the brightest minds. The most notorious is what we call, New Daily Persistent Headache (NDPH).  This headache comes on right out of the blue and does not respond to treatment very well.  I just heard the world’s number one authority on NDPH (Peter Goadbsy, MD) say in November that after years of work on this disorder, he has no clue what causes or how to treat it.

Besides the mystery headaches, the more common ones, such as migraine and cluster headache, can be very difficult to treat.  Almost twenty percent of chronic migraine sufferers are “intractable” meaning that nothing works for them. I suspect that the number is higher for cluster headache patients. So it is not offensive or surprising if someone is not getting better that they want another opinion. I am happy to facilitate the second opinion with a highly respected headache specialists (and friend) in Seattle or even to my old colleagues at Mayo Clinic.

I will close with a story, a true story and illustration of the extreme, worst attitude a provider could have in this matter. I will also make the point that this is the opposite view than what I carry.

When I was a headache specialist at Mayo Clinic, I once had a chronic cluster headache patient from Michigan. He had been seeing a neurologist and headache specialist near him for several years. Despite that, his headaches were intractable.

I looked over his case. He had had excellent care and despite that, he was still getting about three horrible attacks per day.  As I studied his case I only had one idea that he had not tried.  It was a new daily medication therapy.  As was typical for us, seeing out of state patients, I started him on the medication and turned him back over to his family doctor.

About four months later he showed back up.  I had been very, very lucky that the therapy I started him on was very successful.  He was headache free.  What surprised me was the way his headache specialist back in Michigan reacted.

The patient decided to follow up with his old headache specialist to get refills on the medication.  When his headache specialist came into the room he asked the patient, “So how’re doing?”

The patient replied, “Fantastic! I haven’t had a headache in over three months!”

Old Headache Specialist: “Wow, did drug ‘X’ finally start working?”

Patient: “No . . . it wasn’t that. You see, I went to Mayo Clinic and saw Michael Jones.”

Old Headache Specialist’s face turned red, “Michael Jones!?  He’s nothing but a damn PA. I didn’t give you permission to go to Mayo Clinic!”

Then the patient said he did the strangest thing. He stood up, in rage, and threw the chart at the patient, hitting him in the head and screaming, :”Get the hell out of my office now!”

I was totally perplexed by that. So, if you are a patient of mine, and yow went to Joe Smoe and he made you better . . . hey, I will pop the champagne bottle with your and send Joe Smoe a thank you card.  I’m on your team. You having a better quality of life is all that matters to me. If Joe Smoe cures all headaches . . . I would be happy to seek employment doing something else . . . hmm . . . maybe a crab fisherman.