Patient Safety Comes First in Clinical Decisions on Second Opinion Consultations

First of all, we must let the dyadic ethical principles of beneficence/non-maleficence guide us in our course of action (See “Everyday Ethics,” ENTtoday January 2014, p. 1 for a discussion about beneficence and non-maleficence). Our initial concern would be for the safety of this patient—that is, that no non-indicated and unnecessary surgery be performed on her without a clear diagnosis and according to evidence-based clinical guidelines. It would be very difficult, indeed, to justify surgical procedures on this patient in the face of a relatively negative history, negative physical findings, and a negative CT scan. It would be appropriate to tell the patient that you see no cause for immediate surgery and recommend canceling the surgery at this time, pending further evaluations and time for thoughtful decision-making. While septal and sinus surgery complications are, fortunately, relatively low in incidence, you cannot discard the risks out of hand. As with all clinical therapeutic decisions to be made by the patient, based on accurate information of their pathophysiologic status, a risk/benefit analysis must be considered. From the information you have at this time, the risks seem to outweigh the potential benefits. This analysis might change in the future with additional information and/or clinical status change, but, at this time, you are obliged to weigh in on the side of patient safety.

If you have had a positive interaction during this visit with the patient, she may ask if she can transfer her otolaryngologic care to you. In fact, as you explain your opinion about her condition, it is very likely she will do so. Will you accept her in an ongoing patient relationship? There are a lot of reasons to do so, and not many that would negate your willingness to care for her. Physicians have a duty to be honest with patients, as well as a duty to be compassionate for their particular circumstances. This patient does have recurrent headaches that likely have an etiology or etiologies other than sino-nasal—she deserves an appropriate evaluation from an allergist and a neurologist as a baseline. As a responsible otolaryngologist-head and neck surgeon, you can recommend such evaluations and work with the patient and her primary care physician to seek the most appropriate diagnosis and treatment.

Helping the patient medically might well be the easier aspect of this ethical dilemma, but there is still the issue of how to deal with the original otolaryngologist’s apparently incorrect diagnosis and ill-advised recommendation for surgical procedures. In this scenario, you do not personally know the otolaryngologist, which may make any sort of interaction with him more difficult, especially if/when you make an effort to discuss the case. It might be wise to first perform some due diligence on his background—perhaps you know someone who trained him in residency or someone who might have worked with him prior to his moving to your city. You could check on the status of his medical license through the state medical board, a process that may also reveal any problems that have occurred in other states. Information on practitioners in the National Practitioner Data Bank is not available to non-registered entities but would be available to hospitals and medical societies going through a peer review process, if it came to that.