Why you need a second opinion

I'll explain in this post why you should get another opinion, when you should consider it, and common reasons why people don’t do this.

When to get a second opinion

Perhaps you've recently been diagnosed with some hard thing: cancer, Crohn's disease. Maybe you're considering a spinal surgery to fix your low back pain. Or the meds for your chronic condition don't seem to be helping, or are making things worse.

In short, if you’re dealing with any of the following types of issues you should strongly consider getting a 2nd opinion:

• Serious or life-threatening conditions.

• If the recommended treatment is risky or invasive e.g., surgery.

• If you have doubts or unanswered questions - especially if the condition is rare.

• You want to explore alternative treatment options, possibly ones outside those recommended by your doctor.

• If your condition isn't improving as expected.

The best time to get the second opinion is right after you get a diagnosis. You’ll want to do this before making any decisions about the treatment path you’ll pursue. The whole point is to validate the diagnosis and lock in the treatment approach - whether it’s a medication, procedure or even doing nothing.

Why you need a second opinion

When the stakes are high it's important to fully assess your available options in support of the best possible decision. You owe it to your future self - and to your loved ones - to seek a second opinion for all but the most basic medical procedures. Here’s a few reasons why:

1/ Mistakes are irreversible

A good mental model is to consider medical decisions as one-way doors. There's no reversing cellular damage from harsh medications, brain surgery, or radiation absorbed by your cells. When things escalate in complexity and the stakes increase, it becomes ever more important to think critically about each decision.

2/ Medical Errors are *very* common

Is it wise to fully trust any given doctor or medical system? Consider the following statistic:

According to a recent study by Johns Hopkins, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer.

Note this is a higher number than motor vehicle accidents, breast cancer, AIDS - combined! That's not meant to be a slight against doctors. Treat them as you would an expert in any other field. You’d probably shop around for the right college, financial advice or location to move a family. And our bodies are far more complex - comprised of some 35 trillion cells, each with mind-bogglingly complex chemistry.

Specific to 2nd opinions themselves,

A 2017 Mayo Clinic study found that 88% of patients who came for a second opinion left with a new or refined diagnosis, changing their care plan. [ref](https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-researchers-demonstrate-value-of-second-opinions/)

For any system of sufficient complexity we should take it as given that more than one informed opinion will reduce the likelihood of avoidable errors. This is a shocking statistic. And one wonders how many people went uncounted, proceeding with the wrong treatment plan.

3/ Costs are high

At a society level it’s estimated that a medical errors - via preventable injuries and death - cost Americans between $17 billion and $29 billion in terms of lost income, lost household production, disability, and health care costs. This is likely higher since not all such issues are measured or reported.

Beyond the immediate and direct costs individuals pay. But of equal importance, there’s the secondary costs that extend beyond just medical bills. For example people will face other out-of-pocket costs like transportation, medical equipment, home modifications due to avoidable disabilities (for example wheel chair accessible bathrooms). Then there’s the potential for higher future insurance premiums and costs for ongoing care/disability.

Then there’s cascading costs over time that could include both economic and non-economic factors. For example lost wages from longer hospital stays/recovery times. And of course there are the less measurable, non-economic costs like pain, suffering, reduced quality of life.

4/ Confidence matters

This one is personal. When I was dealing with my own diagnosis I knew that I needed full confidence in the diagnosis and treatment plan in order to commit to something as hard as months of chemo therapy. I felt that I’d start second-guessing things if I didn’t lock in the approach up front. Lingering doubts would crush my psyche. Do the work up front. It’ll be easier to maintain a state of equanimity if/when you hit bumps along the way.

Why are there so many medical errors?

There are many causes of medical error. But I think they can be broadly categorized into 2 big buckets:

1. Care Delivery

2. Fundamental biology

Care delivery can include any issue related to the workings of delivering care. Examples would include communication breakdowns (surprisingly common!), surgical errors, staffing and workflow issues, ordering the wrong test/or mis-interpreting the results.

Fundamental biology speaks to the complexity involved in understanding how bodies work. This would include things like diagnostic errors e.g., misdiagnosis. Or simply dealing with issues related to operating at the edge of human knowledge, for example rare diseases. or simply not having the knowledge to diagnose or treat a specific issue. Often times medicine struggles at the edge of knowledge.

Remember, on balance the people inside the system are highly skilled and well-intentioned. But hospitals and medical practices are fundamentally aimed at fixing biological problems at scale, compounding fundamental complexity.

So why doesn't everyone seek a second opinion?

It turns out that a surprisingly low percentage of people seek second opinions - between 20-30% of patients request a second opinion for general surgery (70% of patients don’t!).

It's understandable why some people hesitate. Here's a common set of reasons I've learned, based not only on my own experience as a patient, but also as a Product Manager responsible for managing one of the larger online second opinion products (at Included Health).

1/ It requires a mental shift from consumer to owner

To seek a second opinion is to admit that we may not fully trust our doctor. It also is an admission that answers aren't easy, and we're enmeshed in an imperfect system. Indeed, we must shoulder some of the burden of our own care. This is not a comfortable thing to do! We want to trust our doctors. But willful blindness stands in sharp contrast to critical decisions. It's important to understand that ultimately it's your body and doctors are there to support YOU (not the other way around).

Time spent validating the course of action is probably the best investment you can make, (assuming the treatment is not urgent).

2/ It can be awkward

It's often overlooked that social dynamics weigh heavily on this decision. It can feel awkward to second-guess one's doctor - typically a person with intimate knowledge about our situation. And if we do, will this damage our relationship with the doctor?

This problem compounds if one suffers from an aversion to confrontation (most of us do). In regards to seeking second opinions a systematic review showed this was more common among women, middle-aged patients, those with higher education levels, higher income or socioeconomic status, living in urban areas, and having chronic health conditions.[reference](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475134/)

3/ It requires a good deal of effort

There is really no fully automated or normalized platform that tells us when or how to do this. So we must invent new methods ourselves. We cobble together various systems, opinions, phone numbers and websites, personnel and data to make this happen. There are many fail-points along the way, not least of which is pure exasperation at the effort.

For example, getting and transferring personal medical records can range from cumbersome to nearly impossible.

4/ The costs aren’t obvious, and can be expensive

Some insurance plans will cover second opinions. But this will typically involve a subset of issues. For example: major surgeries, life-threatening diagnoses (e.g., cancer), questions about the medical necessity or if the treatment plan is unclear.

While it's inconvenient and can be costly (typically in the range of $750-$2k) this may be one of the most important investments you make. The costs of getting this wrong can be devastating.

In the next post we’ll dive into the details about how to overcome these challenges.

Did you go through a second opinion, or avoid getting one? Would love to hear what worked or what didn’t work if you went through this yourself.