2nd Opinions

David Newman-Toker toker at JHU.EDU
Tue Mar 5 03:36:36 UTC 2019


I suspect there are two different sorts of effects here:

  1.  “Equivalent expertise” second opinions
  2.  “Different expertise” second opinions

The “equivalent expertise” effect assumes that the two providers are of the same type with roughly equivalent training, experience, and average error rates for the particular case/diagnosis in question. If there is some inter-observer variability (i.e., not every provider uniformly misses exactly the same cases/diagnoses all the time), then each incremental read by another similar provider will, on average, produce some incremental benefit, as Mark suggests. If these inter-observer variations truly amount to “random” error (rather than specific observer bias) with respect to the case, then even the same observer at two different time points might suffice (e.g., a re-read by the same radiologist a few days later, unbeknownst to the radiologist). There will be diminishing marginal utility of each successive (second, third, fourth, … ) opinion, and the value of the (first) second opinion will be greatest. Overall, these effects on improving diagnosis are likely to be real but usually modest, unless the error rates for typical providers for this sort of case are very high (e.g., as in the Herzog study, attached).

The “different expertise” effect assumes that the two providers are of different type, training, or experience. They are presumed therefore to have different overall average error rates for the case in question. Generally one would be seeking a second opinion from a provider (or group of providers) believed to have greater (rather than lesser) expertise. Every specialty consultation from a general care provider is intended to be a second opinion of this type. Likewise, so are academic second opinions after referral from a community hospital (e.g., sending a patient to a cancer center for a multi-disciplinary case review for diagnosis or staging after an initial determination by a community oncologist). These effects on improving diagnosis are probably fairly profound and positive, if the referral is to the correct provider type (e.g., when a patient who can hear their eyeballs move [that turns out to be due to superior canal dehiscence syndrome] is sent to a neuro-otologist). The impact of referral might actually be negative, however, if the referral is to an incorrect provider (e.g., when the same patient is sent to a psychiatrist).

David


David E. Newman-Toker, MD PhD
Professor of Neurology, Ophthalmology, & Otolaryngology<http://www.hopkinsmedicine.org/profiles/results/directory/profile/0015937/david-newman-toker>
Director, Division of Neuro-Visual & Vestibular Disorders<http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
Director, Armstrong Institute Center for Diagnostic Excellence<http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
Core Faculty, Brain Injury OutcomeS (BIOS) Clinical Trials Unit<http://braininjuryoutcomes.com/>
President, Society to Improve Diagnosis in Medicine<http://www.improvediagnosis.org/?page=BoardMembers>

Johns Hopkins University School of Medicine
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From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
Sent: Monday, March 4, 2019 8:28 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] 2nd Opinions

YES YES YES  - Fresh eyes catch mistakes.  Obtaining a second opinion may be one of the most effective interventions we have to address diagnostic error.  Second opinions have been extensively studied in radiology and pathology, including some studies that included longer-term follow-up to see if the second opinion was actually correct.  There IS a finite error rate with the second opinion as well, but by combining the two your odds of getting the correct answer clearly improve.  A large number of diagnoses change with a second opinion in general medicine too – see the attached review and article.  The Mayo Clinic, the Cleveland Clinic, and many others have been providing this kind of service for years – the Mayo cites a 20% rate of changing diagnosis, which is very much in line with our literature review and study of the second opinions provided by “Best Doctors”.

There may also be value in the ‘STOP AND THINK’ approach – ie getting a second opinion from yourself ;<)   No data on that option yet, but it seems plausible.

Mark

Mark L Graber MD FACP
Chief Medical Officer; Founder and President Emeritus, SIDM
Professor Emeritus, Stony Brook University, NY
[cid:image004.jpg at 01D4D2D7.4D3C8340]


“This is a second opinion. At first I thought you had something else”.

[cid:image007.png at 01D4D2D7.4D3C8340]



From: Io Dolka <iodolka at GMAIL.COM<mailto:iodolka at GMAIL.COM>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Io Dolka <iodolka at GMAIL.COM<mailto:iodolka at GMAIL.COM>>
Date: Monday, March 4, 2019 at 4:20 PM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] 2nd Opinions

Dear SIDM friends and colleagues,

Would you have any tips, advice or pointers regarding the issue of 2nd opinions?

I will be giving a webinar next month at www.washaa.org<http://www.washaa.org> on the topic, geared towards professional patient advocates, nurses, social workers, and the general public.

Is there a point of view worth talking about that is hardly ever addressed? Any pointers on the various areas covered would be greatly appreciated:

1) Data/studies on effectiveness, diagnosis or treatment plan change after 2nd opinions,
2) When to seek (and when not to seek?) a second opinion
3) How to select another provider for a second opinion
4) Second opinion companies, their pros and cons as a resource
5) Insurance issues with second opinion visits, diagnostics, etc.

If you prefer a quick phone call instead, please let me know.  You can email me directly if you prefer.

Many thanks in advance for your help!

Io


Io Dolka, MS
GreyZone, LLC - Managing Director & Chief Care Advocate
SIDM-Patient Engagement Committee Member

Direct: 206.355.1285  |  Email: iodolka at gmail.com<mailto:iodolka at gmail.com>
[vcs]

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