When I am the first responder but second opinion giver

Neurosurgery, given its complications, often nudges patients into approaching a second expert; a practice I encourage at the expense of sometimes feeling like a sidekick to the hero.

An arterio-venous malformation is an uncommon lesion of inappropriately formed cerebral vasculature. A rupture of these vessels often results in a cerebral haemorrhage. Depending on the size and location, the nature of the bleeding could have varying results, from a severe headache to a catastrophic neurological deficit, the former being more common.

A sizable portion of patients harbouring this malformation face seizures or epileptic fits that arise out of cortical irritation or hemodynamic alterations. Ravi, a 20-year-old engineering student, was brought to the emergency by his parents after one such convulsion that resulted in a sudden jerking of his left arm and leg, followed by a transient weakness in those limbs. By the time he arrived at the hospital, six hours later, he had already recovered most of his strength.

As we scrolled through the CT angiogram on the monitor, we identified a 3 cm vascular malformation with a tiny haemorrhage just in front of and not actually within the right “motor strip”, the area of the brain responsible for left hand and leg function. This was probably why the paralysis was transient.

“Based on all the characteristics of this lesion, there are a few options we have in treating this,” I explained to the parents with their son tethered to an IV pole beside us. Surgery, radiosurgery, embolization…I made clear what each entailed, concluding that this could wait a few weeks before deciding on an intervention.

The family was well heeled. They expressed the desire to take a second opinion. “Of course,” I emphasised, giving them a detailed report of our meeting. A surgeon should always encourage a patient to take a second opinion rather than get offended by the suggestion. It offers security to the family and bolsters the first surgeon’s decision making when seconded by another colleague.

The family returned two weeks later after having seen a few “top” neurosurgeons and interventional radiologists. They had also asked for and received suggestions from surgeons in the US and UK, I was told. I assumed that they had returned to be treated by me; after all, I was their first responder. I take pride in the discussions I have with my patients.

However, they surprised me with, “Given your expertise in the field, we need you to help us choose between the two doctors we have zeroed in on.” That’s a first, I thought to myself. Again, I realised, there was no reason to be insecure. Our job is to guide patients in the right direction with truth, transparency, and trust. I analysed the notes and offered my advice.

In the past, I have seen a few patients who, after having consulted with me, have had surgery elsewhere. After the operation, they sometimes return to me for follow-ups. One can understand if they were not satisfied with the outcome of surgery and were seeking a fresh perspective, but in most cases, the surgery goes off perfectly and recovery is uncomplicated.

“Ideally, you should be seeing your surgeon so that you maintain continuity in treatment,” I often say, since most of us are keen on evaluating patient progress, recovery, and health over the long term. In return, I sometimes get the response, “We have seen him, but we also wanted to see you,” and I find nothing wrong with that approach either. All of us live our lives wanting to feel validated, so why not our patients?

Patients who visit a private healthcare facility and have the means to afford it often seek a second opinion, especially if it involves brain or spine surgery. Some like to make it clear at the very start that they have come only for a second opinion, while others like to reserve that information till the very end or not mention it at all, probably to be able to obtain an unbiased assessment. Unfortunately, patients sometimes pit one doctor against the other, like small children who dodge parents to get what they want. This can sour relationships. “Never believe what a patient tells you his doctor said,” the famous Sir William Jenner said in the 1800’s.


The online world is fraught with second-opinion clinics providing health solutions over remote consultations. Patients should be encouraged to seek opinions especially when the diagnosis is rare, as the world of academia may have physicians working on breakthrough treatments in the field. Insurance companies in the US also cover the cost of second opinions in order to reduce unnecessary surgery in patients with low back pain. However, it is imperative that these opinions are sourced from credible institutions; there are enough “quacks” selling treatments to those who are distressed or in pain, giving medicine the caustic reputation it is frequently taxed with.

Ravi and his parents returned three months after a successful surgery elsewhere to corroborate the advice given to them by their surgeon on tapering off and eventually stopping certain medication. I was with them throughout his illness, like the sidekick in a movie who is omniscient in every scene, uplifting the hero but never really getting credit for the film’s success. I often wonder what must go on in the minds of patients who seek multiple opinions and in the heads of the countless doctors who give and receive them. But I also realise it is irrelevant: all of us play a part in the life and treatment of each patient; sometimes, we play a key role, while sometimes it’s a supporting role. No matter which it is, it’s important to do the best we can.

 

21 Comments on “When I am the first responder but second opinion giver
  • Vipul Shah says:

    Dear Dr Mazda Sir

    The Article on second Opinion in my opinion shows your Attitude of giving patient full freedom for selection of Surgeon ……..

    It also shows that you are not Money minded & allows patient to make their own choice…..

    Reply
  • Neepa V says:

    Well written..
    Agree…second opinions should be encouraged especially in rare, challenging situations where decision taking might be bit tricky..

    Reply
  • S k sogani says:

    Very well written it’s true that 2nd opinion should always be respected and encouraged in all rare cases which involve S significant mortality and morbidity

    Reply
  • Dr. Vinod Desai says:

    Wonderful

    Reply
  • Supriya says:

    On the few occasions that you’re a “sidekick”, you’d probably do a ton more to heal the patient with your empathy and voice of reason!! At the best of times neurosurgery is greek to most and when coupled with nerve-racking decisions to make, there could not be a better hand to cling to, than yours, Dr Turel!!

    Reply
  • Kainaz says:

    Dr. Mazda, it’s very rare to come across a doc who doesn’t make u feel guilty of seeking a 2nd opinion and then loose interest in your case since u asked for one. Your openness and ability to stand by a patient by either being the ‘main’ hero or the ‘sidekick’ talks about the confidence in yourself and the compassion you have towards the patient and how focussed you are about not getting bothered about the ‘role’ you played but about the aim of getting the patient up and about !!! Proud of u !!!

    Reply
  • Suresh Nair says:

    Well written Mazda. How many surgeons honestly tell their results if patient or relative ask a question: How many similar cases you have operated with morbidity. In India one can get away, not in US, UK or many European countries and Japan. So whenever you agree to their request for a second opinion, tell them to ask that surgeon’s surgical morbidity . I am not sure whether a surgeon talks same way whenever he sees someone in a government municipal hospital (where patients come with full trust on you) and in a corporate hospital where they go for shopping and to get your opinion regarding a surgeon whom they have already mentally decided. An young surgeon unless he does cases will not get surgical experience. Please record whatever you talk to the relatives and donot waste time by referring to others. Tell pros and cons of surgery and alternative treatment modalities with some brochures and ask them to read and come if they want treatment under you.Tell your experience . If you are very honest they will not go to another surgeon .

    Reply
  • MJC says:

    Well written Mazda. Empathy under all circumstances.Best Wishes MJC

    Reply
  • Chandan Sanjana says:

    I think almost everyone go for a second opinion if it is some major surgery ahead of them. I think the very word surgery frightens many many patients and families looking for an option not to opt for going under the knife ! But I suppose there are lots of times surgery is inevitable.
    One has to have a large heart and open mind when a patient comes to you first and takes an opinion and decides to go to another surgeon for his treatment!

    Reply
  • Ralecha Kopano Mmatli says:

    There is nothing wrong with second opinion as long as all the surgeons are genuine. If they are truly genuine and ethical, they must generally arrive at the same opinion, if the patient is also consistent in the consultation discussion

    Reply
  • Ralecha Kopano Mmatli says:

    There is nothing wrong with second opinion as long as all the surgeons are genuine. If they are truly genuine and ethical, they must generally arrive at the same opinion, if the patient is also consistent in the consultation discussion. Of course some doctors/ surgeons get offended when a patient expresses desire for second opinion . Their view is that the patient doubts their ability may be and they forget that they are human and can make that one wrong decision that can destroy the patient for life

    Reply
  • Nitya Somaiya says:

    I love how these articles have a wonderful balance of medical terminology and life philosophy. It’s so well written and I always leave with more empathy for both, the doctor and patient.
    I hope these turn into a book someday, and reach out to many many more people!

    Reply
  • Rustom says:

    Dr. Mazda, your straightforward n ethical approach will make you very successful. Proud to know you.

    Reply
  • C Deopujari says:

    Mazda, well written as usual and the transparency in your writing is admirable. However, it is always not such innocent opinion seeking and can easily become one opinion against the other. Treating a patient operated by someone else is not easy and may not be the right thing to do unless the concerned surgeon requests you to do so for some reason

    Reply
  • Avinash karnik says:

    Dear Dr. Mazda
    Your honesty and selflessness is reflected throughout in your article. The recovery of a patient Is an only idea behind your thinking. This thinking will take you to great heights and help the patients to walk the paths of their respective paths to success. No wonder that the world says the medical profession is noble. Take a bow.

    Reply
  • Anjali says:

    True that, transparency and honesty in your writing and practice.. way to go dr mazda. Best wishes

    Reply
  • Samjons says:

    This a very rare specie of Doctor among the mass .Kudos to Dr Mazda !!

    Reply
  • Lakshmi Nair says:

    Thank you dr mazda , sometimes a second opinion is only to reaffirm the condition
    However I think it’s generous of you to accept that people can connect with you only in an advisory capacity

    Reply
  • Zubin Bhesadia says:

    Dear Mazda,

    I’ve said it before and I’ll say it again – you are the Epitome of Visual Storytelling in the Medical Field!!! I experienced the complete case-study unravel scene-by-scene in front of my eyes…and I’m pretty sure that many others who read this underwent the same experience.

    It was truly insightful & pleasurable a read – thanks to your simplification of the medical terminologies and the precise anecdotes making their entry at the right junctures.

    It is truly humane, angelic and righteous of you to be upfront, ethical, out-of-the-woods & compassionate in advising patients & their families – not only by explaining the detailed diagnosis, the lines of treatment/options available and the pros & cons, but also, being very supportive of & understanding their need to take second opinions (if so opined by them) or if they return for consultation post-surgery (even if they were operated by another Neurosurgeon).

    This is what Medical Ethics is all about –
    you may play the Lead Actor many a times, but then sometimes, you may have to play the Supporting Actor…both roles having one vision, one mission and one dream – “Saving Lives and Providing a Better Tomorrow”.

    Wishing you & the team the very best in your endeavours. Stay shining…keep winning.

    Reply
  • T George Koshy says:

    Very mature and balanced way of looking at things..great piece of writing as always..even in Medicine and Endocrinology and ESPECIALLY in KERALA we learn to respect the patient’s point of view and ask them to go ahead with how many ever opinions and doctors they want to consult..it’s important not to loose one’s temper and get agitated in such situations

    Reply
  • Gwendoline Remedios says:

    Dr Turel, I have been following your articles lately and you are becoming one of my favorite doctors. Really appreciate your patient care. Most doctors get nasty when they know you are going somewhere else. Even dont care if the patient is a year old.

    Reply

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