Second opinions have been an aspect of health care both in the United States and in Europe for many decades. (In this article, a second opinion is defined as a patient-initiated second medical opinion concerning an earlier diagnosis and/or treatment suggestion. As used in this discussion, second opinions requested by doctors, eg, in the form of a request to a medical colleague, and second opinions such as those typically sought by tumor boards are excluded.) Recent years have seen an increase in demand for second opinions by patients as well as commercial providers and, particularly, the use of the Internet to gather medical information. Initially, the increase in requests for second opinions was driven by insurers to reduce costs by avoiding unnecessary surgeries.1,2 However, the consumer movement with the evolution of patients into informed partners has accelerated this phenomenon. Second opinions became more common in US hospitals beginning in the 1970s.3 At that time, requests for second opinions were a reaction to ever more complex processes within hospitals and the need to better coordinate the different competencies, roles, and opinions of specialists involved in the care of complex patients. The objective was to better standardize patient treatment as well as control and predict health care costs. At that time, US health insurers were also launching their Surgery Second Opinion Programs (SSOP), which came into force when medical specialists suggested an elective surgical procedure as a therapeutic measure. In some instances, these SSOPs were mandatory for patients, but they could also be an optional benefit.2 Up to the present, the use of second opinions has mainly occurred in procedural medical and surgical specialties, with orthopedics, ophthalmology, and gynecology heading the ranks.4
In contrast, second opinions are not yet standard practice in psychiatry and there is little discussion of second opinions in the psychiatric medical literature. However, there is one area of psychiatry in which second opinions play an important role, even though these requests are not patient-initiated, which is when such opinions are sought in conjunction with involuntary commitment. Many countries have statutory guidelines that stipulate second opinions in the case of hospitalization against a person’s will.5–8 In 2009, the Australian Defense Force established a second opinion clinic for the assessment of psychiatric patients with complex and treatment-resistant conditions.9 Requests for second opinions initiated by psychiatric patients to confirm diagnoses, plan therapies, or improve medical quality are still the subject of controversial debate, despite problems with the validity of psychiatric diagnoses and empirically validated treatment algorithms. Some authors have described such requests as a phenomenon triggered by the psychiatric disorder itself.10,11 These authors highlighted certain psychiatric disorders, such as somatization disorders, as being very susceptible to an increased request for second opinions or doctor shopping. Abnormal treatment-seeking behavior could also be triggered by psychiatric symptoms or psychiatric illnesses such as hypochondriasis and delusional and mood disorders.12
The objectives of this review were to examine the literature on the use of second opinions in medicine in general and in psychiatry specifically and to discuss barriers and obstacles to the use of second opinions in psychiatric practice. We address the questions of why the use of second opinions has been neglected by psychiatrists and psychiatric patients and how the field of psychiatry might benefit from a broader use of second opinions.
It is well established in the literature that people with psychiatric disorders suffer from stigmatization. Just as the general public stigmatizes those with psychiatric disorders, the stigmatization of psychiatric disorders may cause those suffering from these disorders to experience low self-esteem and a feeling of losing control over their decisions and possibilities. One possibility, therefore, is that they may perceive treatment recommendations from their psychiatrist as an exercise of power over them. Thus, we hypothesized that such individuals may avoid claiming their right to a second opinion because undergoing an assessment for a second opinion means once again having to interact with psychiatric specialists, institutions, or situations with the potential for further embarrassment or suffering.
Second, we hypothesized that the various multidisciplinary and heterogenous stakeholders involved in providing care to psychiatric patients often act autonomously and in isolation, without any coordination with other care providers and, at times, even in competition with each other.
Third, we hypothesized that the unique doctor-patient relationship that is a characteristic of psychiatric treatment, particularly of psychotherapeutic care, complicates the expedient generation of a second opinion.
Could Second Opinions Save Costs in Psychiatry?
Most of the early studies on second opinions focused on the question of costs versus benefits. The results concerning cost savings, mostly through a reduction in surgical interventions, were controversial, with findings differing concerning whether potential cost savings could justify the expenditures for a second opinion. Study outcomes ranged from reporting savings of 3 to 1 (ie, $3 saved for each $1 spent on second opinions) to as little as 1 to 1.23 in one of the most long-term evaluations.13–15 Although authors of more recent studies have suggested that use of second opinions might lead to a reduction in costs, there is a lack of newer studies to corroborate these assertions.16
The availability of relevant data in psychiatry is very limited. A 2009 study evaluated the use of threshold safety parameters for medications for attention-deficit/hyperactivity disorder (ADHD) (stimulants and atomoxetine) in Washington State Medicaid patients.17 In this program, a second opinion was mandated when thresholds based on dose, medication combinations, or age were exceeded. These researchers found that 5.35% of ADHD prescriptions exceeded safely thresholds resulting in 1046 second opinion reviews, 538 of which (51.4%) led to a prescription adjustment. The review process resulted in a savings of $1.2 million, a 10:1 return over administrative costs. However, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and clinicians’ use of newer brands coming on the market.
Could Second Opinions Improve Medical Quality in Psychiatry?
Most studies that have examined second opinions have focused on the question of whether a second opinion improves medical quality, with the majority of studies conducted in surgical disciplines including urology, as well as surgical pathology and neuroradiology. It should be noted that the studies in pathology and radiology did not involve patient-initiated second opinions. In 1980, Gertman et al18 reported that, of 1591 Medicaid patients required to obtain second opinions before elective surgery, 1411 (88.7%) were advised in favor of surgery and 180 (11.3%) were advised against surgery; 82 of the 180 sought a third opinion, which reversed the negative opinion in 57 cases. Thus, surgery was rejected by a second or third consultant in 7.7% of the patients. The authors concluded that many negative second opinions are due to honest disagreement about indications for surgery and that, while the second-opinion program produced only modest savings in expenditures, it probably resulted in improved health care quality. A number of extensive studies were subsequently done, mainly around and after the turn of the millennium. In a 1999 review of 6171 mandatory second opinion reviews of outside surgical pathology reports for patients referred to The John Hopkins Hospital, Kronz et al19 found that 86 (1.4%) resulted in changed diagnoses leading to major modifications in therapy or prognosis. In 2008, Manion et al20 examined 5629 second opinions of outside surgical pathology slides for cases referred to the University of Iowa Hospitals and Clinics. They found major diagnostic disagreements (potential for significant change in treatment or prognosis) in 2.3% of the cases, which led to changes in clinical management in 1.2% of the cases. In a 2010 study of 4534 second opinion consultations on neuroradiology studies, Zan et al21 found that 347 (7.7%) involved clinically important differences likely to change patient care or diagnosis and that, when a subsequent definitive diagnosis was obtainable, the second opinion was more accurate in 84% of the cases.
In 2006, the German Testicular Cancer Study Group (GTCSG) set up a particularly interesting program, an evidence-based national second-opinion network to improve the care of testicular cancer patients.22 The program involved an Internet-based platform on which urologists could seek advice from 31 second-opinion experts and receive a second opinion on their therapy plan within 48 hours. This project produced one of the largest studies of second opinions to date. Results showed a significant discrepancy between first and second opinions, with only 58% of first opinion recommended treatments corresponding to second opinion treatment suggestions. The more advanced the tumor, the greater the discrepancy between first and second opinions. Of the 926 first and second opinions evaluated by the study between 2006 and 2011, the outcome in 28.1% of cases was a less extensive treatment and in 15.6% a more extensive treatment. One in 6 second opinions resulted in relevant changes to the treatment plan. Overall, patients treated in the second-opinion project had a 2-year progression-free survival rate of 90.4%. The study provided an impressive demonstration of how second opinions can increase the level of evidence-based care in clinical practice. By 2016, >4600 patients had received second opinions as part of this program, with 19% of all newly diagnosed testicular cancers in Germany now being presented in the second opinion network.23
As noted above, all of these studies found that second opinions would benefit patients in their medical treatment. In these studies, the following factors served as indicators of medical quality: involvement of recognized experts, discrepancies between first and second opinions, comparison with final diagnosis, and progression-free survival rate. The same outcomes were examined by Payne et al24 in a systematic literature review published in 2014. These researchers screened 1342 studies on patient-initiated second opinions and concluded that second opinions could improve patient health. They reported that, although a second opinion typically confirms the original diagnosis or treatment regimen, studies also found that 10% to 62% of second opinions yield a major change in diagnosis, treatment, or prognosis. It is, however, difficult to evaluate whether the discrepancy between first and second opinion diagnoses is due to new information being collected or to a more collaborative approach within multidisciplinary teams. The authors also noted that the literature on patient-initiated second opinions is limited, and that follow-up to determine the quality and accuracy of second opinions is generally lacking.
Although most studies concerning the impact of second opinions on quality of medical care have focused on other areas of medicine, 2 studies25,26 in specialized psychiatric hospitals in tertiary medical centers (eg, university hospitals) found that consultations concerning complex or treatment-resistant conditions resulted in symptomatic improvement in the treatment of affective disorders. Another study of psychiatric second opinions at the University Hospital Leeds in the United Kingdom showed that an alternative diagnosis was offered in 31% of cases and a new treatment plan was recommended in 68% of cases, resulting in an improvement in health for the patients involved.27
Why Do Psychiatric Patients Seek a Second Opinion and Do Their Reasons Differ From Those of Patients in Other Medical Fields?
A large group of studies on medical second opinions has focused on the reasons and motivations of patients and doctors who request such opinions. In a 2003 Dutch study concerning cancer patients seeking second opinions, Mellink et al28 differentiated between internal and external reasons. Among external reasons, they listed patient dissatisfaction with the services of the doctor seen in the first consultation, in particular regarding communication or unfulfilled expectations. Among internal reasons, they listed doubts, uncertainty, and the patient’s desire for confirmation of the first opinion, with the study finding that 62% had only internal motives, such as the need for reassurance and more certainty, whereas 38% also had external motives related to negative experiences or unfulfilled needs. They found that personal reasons were crucial in the decision to seek a second opinion, followed by concern about the performance of the first doctor who was consulted. A study on second opinions in orthopedic surgery by van Dalen et al2 found that only 30% of people seeking a second opinion were motivated by dissatisfaction with the doctor providing the first consultation or by a lack of information, and a 2009 Australian study by Tattersall et al29 found similar results. In the latest study from Germany published in 2016, Geraedts and Kraska30 distinguished among 3 groups: (1) patients who opted for a second opinion because of bad experiences with examinations or treatment (43%) or because of a lack of trust in their doctor (19%); (2) patients who felt generally unsure concerning their decision (53%) and were thus comparable to the patients with “internal” motivation in the study by Mellink et al28; and (3) patients who sought a second opinion because of recommendations from family and friends.
Very few data are available concerning reasons and motivations that lead patients to seek second opinions in psychiatry. Just as for reasons for seeking a second opinion in somatic medicine, reasons in psychiatry can also be divided into internal and external categories (Table 1). External reasons include uncertainties about diagnosis and treatment,27 which can originate from the patient and/or from the treating psychiatrist and can result in requests for specialists in tertiary hospitals to provide second opinions.26 In addition, as noted above, psychiatric disorders such as anxiety disorders or depression, can themselves be the driving force to seek second opinions, particularly in patients who also have somatization disorders.32
The Patient-Doctor Relationship and Second Opinions
Because of frequent references in the literature concerning how a lack of information and/or a lack of trust in the doctor-patient relationship may contribute to requests for second opinions, several studies have investigated these issues. One of the first studies in this area, published by Rosenberg et al35 in 1989, surveyed patients to assess their reactions to a mandatory second surgical opinion program in the United States and measure the accuracy of communication between the patients and their physicians. Among the 902 respondents, the most frequent reactions were that the consultations provided reassurance (59%), helped in deciding whether to proceed with surgery (49%), and provided a chance to ask important questions (29%). Relatively few patients felt that the program caused anxiety (12%) or confusion (5%). Patients were generally pleased with the administrative aspects of the program but less satisfied with the consultant physicians they had seen. In examining satisfaction with second opinions in oncology patients, Cifaldi et al36 reported similar findings. In a more recent survey in Germany, the Asklepios Group found that 94% of patients who had requested a second opinion in the past were satisfied with the results from the secondary consultant.37
Despite expert recommendations concerning the value of obtaining second opinions for patients with psychiatric disorders,38 it is apparent that psychiatrists in particular show considerable reluctance to make use of these consultations. This may be due to the impact of uncertainty, overconfidence, the alleged isolation of psychiatrists in single practice, or the impact of the culture among local psychiatrists (ie, their openness to asking colleagues for supervision or a second opinion) on requests for help or indeed offering help. Lack of availability of or access to local expertise in the clinical area of interest is also a possible factor. Hesitancy to request help may be reflected in excessive time from referral to diagnosis, which, in turn, may be related to treatment delay and worse outcomes.27 One result of this reluctance to seek consultation may be that many patients with difficult-to-treat conditions receive high doses of psychotropic medications on a long-term basis. Both psychiatrists and community nurses have been found to consistently underestimate the prevalence of both extrapyramidal symptoms and endocrine side effects,39 resulting in high levels of dissatisfaction with both treatment and side effects.40 A more complex problem involves second opinions in psychotherapy, in which psychiatric disorders are treated predominately with psychotherapeutic communication strategies in which the patient-therapist relationship is central to the treatment. The Australian Psychological Society guidelines stipulate that its members have to support patients in obtaining second opinions, and that members also have to make themselves available to provide second opinions in relation to psychotherapies being provided by colleagues.41 Scientific studies on the effect of second opinions on psychotherapeutic treatment are lacking.
Second Opinions on the Internet
The Internet is regarded as the number one information platform for health questions.42 The wealth of information, accessible to everyone may be both a blessing and a curse for many reasons. Research has shown that patients may retain only 21% of information given to them by medical staff.43 The Internet allows patients to research and digest relevant information and search for answers to questions that can arise before their next consultation. Patients may need to come to terms with their diagnosis and treatment or to obtain information to help them prepare for treatment. Theoretically, the Internet can provide access to medical information at anytime and anywhere in the world.
Although information from the Internet does not constitute a second opinion, it can open the path to a second-opinion portal. In 2014, Schook et al44 published a study concerning the website of the Dutch Lung Cancer Information Center (DLIC), launched in 2003, which includes an “Ask the Physician” page, where visitors can ask an online lung specialist questions anonymously and receive an answer quickly. Schook and colleagues investigated the reasons lung cancer patients and caregivers were seeking information from the Internet. They found that the reasons did not differ from those cited by patients seeking second opinions from another doctor instead of the Internet. Obtaining additional information about diagnosis and treatment as well as practical support in dealing with the diagnosis were important priorities for lung-cancer patients and their caregivers. Emotional support was also identified as important to Internet users. Patients and caregivers stated in this study that they would have been unwilling to ask the treating physician many of these questions, especially personal ones. Their stated reasons included feeling ashamed about asking specific questions, feeling that their questions were irrelevant and not important enough to disturb the doctor with, or feeling that the doctor would not have time for such questions.
In Germany, the second-opinion portal “Vorsicht Operation” was launched with great media attention in 2011.45 The portal, since renamed medexo (https://medexo.com), was started by surgeons who had criticized their German colleagues for their commercialization of medical practice. On the medexo.com websites, patients can obtain a second opinion without difficulty or delay. For this service, patients pay a fee of 300 euros. Currently, many health insurance funds reimburse these costs for their members.
The Internet can be a very attractive option for psychiatric patients, as it provides them with a tool to gather information about their health anonymously in their own homes, while avoiding the potential shame or stigma associated with in-person psychiatric consultations. However, this benefit may come at the expense of quality, as the information may not be accurate and the source of the information is not always clear to users.46 In accordance with the guidelines of the Swiss-based “Health on the Net Foundation,” reputable providers are expected to display authors’ qualifications and information, support not replace the doctor-patient relationship, respect privacy, clearly indicate the sources of their information which should be confirmable, indicate possible confounding variables, and clearly separate advertisements from information.34 In 2008, Luo33 described various potential uses of the Internet to support patients, such as online screening instruments for different psychiatric disorders and the option to refer a potential patient to a psychiatrist. In addition, there are programs for the assessment of drug interactions and online forums for exchange of information with other affected people. In a study published in 2008, Khazaal et al47 found that 64.7% of psychiatric patients frequently used the Internet to search for illness-related information, but that approximately half of the users were not satisfied or were only partially satisfied with the information they found. This finding is consistent with the results of a systematic review in which the authors concluded that most medical websites are problematic with regard to the quality of their contents.48
The increasing demand for second opinions delivered via the Internet is likely to lead to more patients seeking second opinions, but studies and data concerning this development are lacking.
Prevalence of Second Opinions in the General Population
To the best of our knowledge, we are aware of only 2 studies that have evaluated the seeking of second opinions by a general population, rather than studies restricted to a particular patient group, such as those with breast cancer. In 1999, Wagner and Wagner49 published the results of a study conducted in the United States and estimated that every fifth patient received a second opinion. On the basis of a 2016 representative study in the general Israeli population, Shmueli et al50 estimated that every sixth patient in Israel seeks a second opinion. No studies concerning the increasing utilization of second opinions were identified.
Second Opinions in Psychiatry: Summary
As discussed above, second opinions have become an increasingly important aspect of clinical practice in many medical specialties. Their greatest advantage lies in the opportunity to improve quality of treatment for individual patients, and they are accepted and appreciated by medical specialists and patients as well as by insurers. In psychiatry, by contrast, the practice of obtaining second opinions at the request of patients is not yet established. As discussed above, there may be multiple reasons for this difference from other medical areas.
The Doctor-Patient Relationship
The uniqueness of the doctor-patient relationship characteristic of psychiatric treatment, particularly psychotherapeutic care, complicates the expedient generation of second opinions. As the doctor-patient relationship is central to psychiatry, a sound and viable therapeutic relationship is essential to the process of obtaining second opinions. Requesting a second opinion may put a strain on this relationship and may be the reason that the use of second opinions is not established in psychotherapeutic treatment.
Stigmatization of psychiatric disorders continues to be a reality,51 and patients often fear being labeled as mentally ill.52 For these patients, even a first consultation with a doctor may require great effort, and the psychological strain of sharing personal or intimate details with a stranger may make such patients reluctant to make a second effort. Undergoing an assessment for a second opinion means having to interact again with psychiatric specialists, institutions, or situations with the potential for further embarrassment or suffering. In this context, the Internet as a platform for second opinions can offer advantages. However, at the same time, it must be taken into account that psychiatric examinations are heavily based on observable data, clinical interaction, and exploration. The advantages of the Internet as a platform for second opinions are thus reduced by the absence of interpersonal interaction.
Involvement of Multiple Stakeholders
The frequently complex psychosocial circumstances in which psychiatric patients live, combined with the fact that it may be difficult to clearly distinguish among biological, psychological, and social issues, result in numerous stakeholders (eg, government agencies, health care insurers, disability insurers, social security agencies) being involved in the patient’s treatment as well as the financing of services.53 Financial institutions involved include disability insurance, unemployment insurance, sick pay insurance, health insurance funds, social security, and accident insurance.54 In an effort to reduce costs, commercial insurance companies have implemented peer reviews to assess medical necessity of treatment. Although psychotherapy is clinically accepted as a first-line treatment for many psychiatric illnesses, insurance companies, referring to their own definition of “medical necessity,” regularly refuse to reimburse for psychotherapy altogether or at the prescribed frequencies.55
In the United States, there has been a shift to a more fragmented approach to care, with new stakeholders (eg, government agencies, health care insurers, the criminal justice system) playing a major role in mental health.56 In addition, employers bear a share of the costs for lost working hours. Given that health insurance companies were the main driver for the introduction of second opinions in other areas of medicine, the question arises as to why a similar approach has not taken in the treatment of psychiatric disorders. The many stakeholders involved in mental health care may hinder a coordinated approach, and the distribution of total costs across many institutions may result in a lack of collaboration, as the gain for each individual institution may be too small compared with the required effort.
In most medical specialties, second opinions are well established and provide a valuable addition to clinical practice, leading to improved quality of care and increased trust in an already ongoing treatment or a future medical intervention. Although use of second opinions in psychiatry is still in the early stages, the high costs of inadequately treated psychiatric disorders on a societal as well as individual level should be a driving force to encourage making second opinions readily available. As in other medical specialties, involved stakeholders, including private insurers, government agencies, regulators, and employers, should encourage implementation of second opinions as a viable means of improving the quality of mental health care and potentially reducing overall costs both for individuals and society (eg, disability pensions, lost productivity in the workplace). New technologies and media are potential sources of second opinions, with the Internet, in particular, offering new options for psychiatry. As part of this process, an important priority should be the continuing de-stigmatization of psychiatric disorders and patients, which will make it possible to transfer the positive aspects of second opinions found in other medical specialties to psychiatry.
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