Patient Safety Comes First in Clinical Decisions on Second Opinion Consultations

Scenario

You are seeing a 42-year-old woman for a self-requested second opinion consultation regarding a septoplasty and endoscopic sinus surgery that had been “strongly” recommended by another otolaryngologist in your community. The patient reports a history of intermittent bifrontal and temporal headaches for the past 20 years, which seem to be concurrent with seasonal environmental changes or personal stress. In the past, she has treated herself with over-the-counter medications, including antihistamines, but with only minimal success. She has never seen an allergist; the otolaryngology consultation was recommended by her primary care physician, who practices in the same building as the original otolaryngologist.

The original otolaryngologist performed a brief history and head and neck examination, according to the patient, focusing primarily on the endoscopic nasal examination. At that time, he indicated to her that the nasal septum was “grossly deviated” and was pressing against the left middle turbinate, and he noted the presence of “pus” in the area of the sinus openings. He also obtained a computed tomography (CT) scan of the paranasal sinuses, which he told her showed “obvious sinus disease with blockage of the sinus drainage openings.” The clinic note, which the patient brought to this second opinion consultation, confirmed the information documented by the original otolaryngologist and relayed by the patient. Additionally, the otolaryngologist noted that the patient has “classic symptoms” of sinus disease and nasal airway obstruction, which the patient denies to you as you review the document with her.

In response to your own questioning, the patient relates symptoms that seem to be more consistent with a headache variant and not suspicious for paranasal sinus disease. You conduct a complete head and neck examination, including endoscopic anterior and posterior rhinoscopy, and see no evidence of a deviated septum or findings suggestive of chronic and recurrent sinus disease. The patient has brought a copy of the CT scan (axial and coronal) for you to review, and you see no radiographic evidence of a septal deviation of any significance. Additionally, the paranasal sinuses appear clear, with patent meati. You confirm that the CT date coincides with the date of the examination and note that the CT scan was performed in the otolaryngologist’s office.

Your opinion is that this patient does not meet the established criteria for septoplasty and endoscopic sinus surgery, based on your review of her history, examination findings, and the CT scan. You are also puzzled by the apparent misdiagnosis given by the original otolaryngologist, along with his “urgent” recommendation for surgery. You do not know the otolaryngologist personally, because he is a relatively new practitioner in your city and does not operate in your hospital system. The patient asks you for your honest opinion about this situation and what recommendations you have for her.

Discussion

This scenario, unfortunately, is not as uncommon as we would wish. It is often the “elephant in the room” of professional ethics, because most physicians do not deal well with calling out another physician for what they feel is unethical, unprofessional, or incompetent behavior. When a patient requests an “honest” opinion about the diagnosis, treatment plan, or care that has been provided by another physician, we usually feel uncomfortable being placed squarely in the middle of a potentially controversial situation. What, then, are our ethical responsibilities to the patient and to our profession under these circumstances?