From the Editor
March, 2019. I have had the good fortune to be a member of the North American Medical Advisory Board for an organization called Best Doctors, Inc., recently acquired as part of Teladoc Health, a large global virtual health enterprise. Best Doctors is a “patient-initiated second opinion program” founded over 28 years ago by a group of Harvard physicians. The organization has developed a proprietary database of more than 50,000 medical experts in over 450 specialties worldwide, with a mission to “engage patients and physicians to work together to improve outcomes.” It serves as a benefit provided by large corporations as part of their employee benefit package, and it is also offered by health plans as a policyholder benefit. I would say that the basic principle underlying this important work is that, to quote the founders of the Menninger Clinic where I work, “two heads are better than one, and three are better than two.” Best Doctors emphasizes that its role is to identify an expert physician in the appropriate specialty who can review a given patient’s medical issues, collaborate with the patient’s treating clinicians, review all available laboratory and test results, and then provide an expert, outside, second opinion to the patient and the patient’s treatment team.
Ideally, we should all have the humility not to claim to know it all, and to welcome input from other knowledgeable expert sources. In the busy rush of practice, however, it isn’t easy to find the time to reach out for such input. And, if patients or families request to see another provider for a second opinion, it can complicate things. No matter how much we routinely welcome advice and input, we may not be familiar with the outside consultant or his or her qualifications.
It’s hard to know how often this kind of second opinion occurs in psychiatric practice. When I was asked to join the Best Doctors Advisory Board in 2014, a large variety of medical specialties were represented on its expert panels, but there were no experts or programs in behavioral health. The organization readily acknowledged that this was a shortcoming, and, subsequently, starting in Canada and now in the United States, behavioral health is increasingly well represented on its roster of experts. In the November, 2018 issue of this Journal, Heuss and colleagues presented a thoughtful review paper entitled “Second Opinions in Psychiatry,” in which they emphasized the value of second opinion programs, and they discussed speculative reasons why such services have been so slow to develop in the field of psychiatry. The ubiquitous stigma surrounding mental illness, for example, may deter patients from revealing their issues to yet another stranger, given how difficult it was to seek help in the first place. There may also be the fear that it won’t really help and in fact could be like insurance companies’ determinations of “medical necessity,” where too often there is not support for ongoing treatment. Hopefully, however, we are moving to a better comfort zone in these matters, as the importance of integrated care, where collaboration is essential, is recognized.
In this issue of the Journal, Coulter and colleagues focus on a specific type of second opinion with respect to early-onset psychosis. Citing the known importance of prompt identification of an emerging psychotic condition, and that early implementation of treatment in such cases leads to better outcomes, these authors studied the records of patients referred to a specialty early psychosis consultation clinic. They found that 55% of the patients in the study had a primary diagnosis at referral of a schizophrenia spectrum disorder. However, in 42% of those cases, a primary diagnosis of a psychotic disorder was not justified, in the opinion of the experts in the consultation clinic. The potential risk, therefore, of overdiagnosing schizophrenia is an important lesson suggested by the findings of this study.
John M. Oldham, MD