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?

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.

Depending on what you can learn about the physician from the usual sources, you may wish to contact him directly; the patient could be included in this decision. You might consider simply asking the patient if she would like for you to speak with the otolaryngologist to discuss his report and recommendations and your own professional opinion. The patient may wish to just move on with you as her otolaryngologist and not “make a fuss.” On the other hand, she should be made aware, in a tactful explanation, that you do have concerns about the difference between that otolaryngologist’s clinical information and what you have learned from her evaluation today.

You do have an obligation to the profession and specialty to determine, if possible, whether there is a pattern of inappropriate diagnoses and surgical recommendations that should be addressed by the proper authorities. Obviously, the best way to confirm your suspicions would be to speak with the otolaryngologist directly about findings and recommendations. While unlikely, the patient’s name might have inadvertently been placed on the wrong clinical evaluation. We can be hopeful that is the case, so you should try to confirm the facts of the case with a direct phone call or face-to-face visit. The latter, while quite unusual in our professional interactions, would also give you the opportunity to derive a personal impression of the physician. You should also consider the possibility that the otolaryngologist is relatively inexperienced, and you might be doing him a service by helping him understand the importance of adhering to evidence-based clinical guidelines and community expectations, though you would hope that this was properly taught in his residency.

Finally, if your discussion with him indicates a general defensiveness and unprofessional reaction, then your next decision is whether or how to bring your concerns to the appropriate oversight entities. If he practices in your hospital system, then the credentials committee or specialty department leadership could be notified. Perhaps an audit of his operative procedures and their documentation could be performed. Some county medical societies have a professionalism peer review committee that could look into his practice, including working with his hospital system.

Lastly, a concern could be filed with the state medical board, either by the patient—if she is willing to do so—or by you, as a concerned and responsible physician in the community. Be prepared, however, to be identified as the individual who reported the physician, because this will come out in future proceedings. As part of the body of the medical profession, we must be willing to step forward when necessary to protect patients from unscrupulous medical practitioners, if indeed this proves to be the case in this scenario; however, you must be sure of the facts in a case so that when you step forward to accuse the other physician of wrongdoing, you can be confident in your integrity and professional responsibility. One of the three tenets of a profession is the self-policing of its practitioners. If we fail to act on our concerns about patient safety by taking the easy route and ignoring the risk to other patients, then we stand to lose a bit of our professional integrity.

G. Richard Holt, MD, D BE, The University of Texas Health Sciences Center, San Antonio.