What Is the Value of Second Opinion Services to Otolaryngologists and Their Patients?

Telehealth services were available prior to COVID-19, but the pandemic certainly escalated its use in many medical specialties, including otolaryngology. Direct-to-consumer telemedicine companies such as Teladoc Health and its subsidiary Best Doctors, along with DoctorSpring and Included Health (Grand Rounds and Doctor On Demand) provide around-the-clock access to care for nonemergency conditions via telephone and live video consultations. One of the more targeted services offered by these online- and telephone-based companies, however, is a second opinion on simple and complex medical issues. (Some medical institutions and health systems provide second opinion services as well to their patients.)

Second opinion services range from confirming an initial diagnosis, helping decide whether a particular surgery is appropriate, and getting options for treatment for a chronic condition. The value of these services comes from the ability to have medical advice tailored to an individual patient’s medical questions, rather than generic advice found through online searches. 

I view my report as a way to create an improved dialogue between the patient and their treating physician by offering some key points that the patient may want to discuss with him or her. —M. Boyd Gillespie, MD, MSc 

Here’s how second opinion services work, in general:

• A patient contacts a service with a medical question or second opinion request. Reviews may also be available for medical charts and radiology materials, depending on the service. 
• The service then opens a case, and a case manager or clinical team member will be assigned to determine which specialist(s) should be involved, ask any additional questions, and gather the patient’s medical records. 
• A physician or team of physicians and other healthcare specialists, by specialty or subspecialty, including otolaryngology, review charts, suggest treatment options, and answer questions. Some services allow the patient to confirm the choice of second opinion physician prior to any consultation. These second opinion physicians may work collegially with a patient’s primary physician to coordinate care, or they may create a report that can be shared with the primary physician. 

Second opinion physicians can be part-time or full-time employees of the service or employed under contract essentially as freelancers, and the services list each physician’s education and qualifications. These physicians may be U.S. or internationally based, but many services employ physicians from medical institutions such as the University of California San Francisco, Massachusetts General Hospital, New York Presbyterian, Stanford University, and Johns Hopkins Medicine. 

Some second opinion services are covered by insurance; fees can range up to $700 for a full chart review and recommendations, but patients should check with insurers prior to ordering a second opinion. It’s important to note that these services provide only medical information rather than actual diagnoses or treatments for second opinions, which means that physicians can answer questions without being licensed in the state where the patient resides. 

Growing Demand

Demand for telemedicine second opinion services is growing, largely due to the high satisfaction of the patients who benefit from them, according to M. Boyd Gillespie, MD, MSc, professor and chair in the department of otolaryngology–head and neck surgery at the University of Tennessee Health Science Center in Memphis.

“These services will usually solicit experts in the field for questions posed by patients or other clinicians,” explained Baran D. Sumer, MD, professor and chief of the division of head and neck oncology in the department of otolaryngology–head and neck surgery at the University of Texas Southwestern Medical Center in Dallas. “Typically, the service will have vetted and known experts in the field who are on standby to answer questions submitted by physicians and patients. The service can function as a check that nothing grossly inappropriate is being recommended and that all options have been considered, especially for patients who lack healthcare choice in their community or don’t have the resources to travel for second opinions.”

Not only do these services help patients looking for an additional diagnosis, prognosis, and treatment plan and primary physicians seeking advice from a colleague or a specialist, second medical opinions can also be requested by third-party insurers looking to minimize their cost and risk (BMJ Open. 2019;9:e025673). 

“These cases are chart reviews, not true second opinions,” explained Dr. Gillespie, who has completed consultations for Teladoc and Grand Rounds. “Without meeting or examining the patient, it’s impossible to make a firm diagnosis or to determine the goals and needs of an individual patient.” He added, “I view my report as a way to create an improved dialogue between the patient and their treating physician by offering some key points that the patient may want to discuss with him or her.” 

Research has shown that most patients are satisfied with second medical opinions and may prefer the second opinion over the first (Isr J Health Policy Res. Dec. 8, 2017. doi:10.1186/s13584-017-0191-y). According to a review published in February 2022, telemedicine serves as an adjunct to in-person care in otolaryngology, increasing patient convenience, access, and engagement; however, because palpation and specific tools are required to examine and treat the ears, nose, and throat, the available technology may limit the scope of otolaryngology that can be performed remotely (Otolaryngol Clin North Am. 2022;55:145-151). Still, study data specific to second opinion services via telemedicine in otolaryngology are lacking. 

Dr. Gillespie and his colleagues completed a prospective chart review to assess the value of second opinions on thyroid nodule management provided via a direct-to-consumer telemedicine service. A total of 37 patient charts were reviewed, with 23 of these patients living in the United States, nine in Asia, three in Europe, one in Canada, and one in Africa. The results, which were presented at the American Head & Neck Society’s 2022 annual meeting, showed that the workup and surgical recommendations initially completed by the original surgeon complied with most of the American Thyroid Association recommendations. In situations in which this was not the case, the virtual second opinion consultation was valuable, enabling additional treatment consideration to guide the patient’s medical decision. (JAMA Otolaryngol Head Neck Surg. Abstract AHNS26)

Pros and Cons

Second opinion services may have benefits for the patient, treating provider, medical expert, and payer. “These services are good in that they provide a ready-made way to obtain a second or even third opinion regarding treatment options. They’re quick, easy, and relatively affordable,” said Dr. Sumer. “The downsides include the lack of a patient–doctor relationship, potential medicolegal problems, and recommendations that aren’t fully appropriate for the specific case or patient, since the consultants haven’t had a chance to meet with the patients.”

Al Merati, MD, professor and chief of laryngology in the department of otolaryngology–head and neck surgery at the University of Washington School of Medicine in Seattle, has worked extensively with Best Doctors, and less so with Grand Rounds. “It’s a great way for an outside, ideally unconflicted, expert to assess the written record and studies to shine some light on what might be going on clinically and diagnostically with a patient, and to provide perspective on solutions,” he explained. “The patient can also get 25 years of expertise without getting poked at or paying to travel or to see an expert, depending on their insurance coverage for second paper opinions.”  

It’s a great way for an outside, ideally unconflicted, expert to assess the written record and studies to shine some light on what might be going on clinically and diagnostically with a patient, and to provide perspective on solutions. —Al Merati, MD

For the insurer, it might be less expensive to get this information—a reaffirming opinion or a game-changing suggestion—than to wait, delay treatment, or pursue the initial course of treatment. “However, the positives were tempered by the fact that you hadn’t actually seen the patient or talked to them,” added Dr. Merati. “I felt that it was important to direct my comments to the care team.”

According to Dr. Gillespie, with second opinion services, patients have access to the reviews of a wide range of specialists who may be experts in certain subspecialties that aren’t readily available in their location. “Patients can have some of their questions answered about a disease process that weren’t answered to their satisfaction or understanding during their interaction with their provider. More often than not, they can be reassured that a proposed plan of care is sound and consistent with current guidelines and high-quality care. Rarely, patients can be informed that there are less invasive or less morbid options that should be considered and discussed with their provider.” 

Positives for the treating provider include increased trust from the patient if the expert agrees with the plan of care. “The expert may offer additional points that the treating provider may want to consider in their treatment plan,” Dr. Gillespie said. “Along with the financial compensation for the work, the expert providing the second opinion will have the satisfaction of promoting high-quality care on a global level.” 

As for the payer, “most of these [second opinion] services are covered by the patient’s insurance plan,” added Dr. Gillespie. “The expert can reinforce that a proposed plan of care is within the standard of care and of high quality.”

Steven S. Chang MD, director of the head and neck cancer program at Henry Ford Cancer Institute in Detroit, noted that virtual second opinion services are good generally for patients and providers, allowing patients to seek additional opinions outside of their region. 

“Many institutions and regions have their own biases or menu of treatment options that will differ from those at other institutions,” Dr. Chang explained. “One difference is that institutions usually maintain a specific portfolio of clinical trial offerings based on the preferences and populations they serve. Some areas may offer de-escalation trials, while others offer surgical trials for the same disease type. Some places may have a new drug that was developed locally and will offer it to their own population. Even in the absence of clinical trials, these services allow patients to seek expert opinions without having to travel—they can determine ahead of time whether it’s even worth traveling for an alternative treatment.”

Dr. Chang said that he sees very little downside from second opinion services when they are used correctly. “The biggest drawback is usually the lack of a good physical exam for certain conditions,” he said, “but much of the discussion can be performed without a physical, and if there’s enough interest, an in-person visit can be scheduled,” he added.

“Now, with the current financial reimbursement available, they allow for physicians to bill the time that they spend doing this,” noted Dr. Chang. Although a few places already had second opinion services that charged a flat fee and usually took a long time to turn around, this is no longer the case.

According to Dr. Gillespie, other potential negatives to second opinion services are that the expert may have limited knowledge of the patient and local resources. “An opinion like this cannot offer definitive decisions—only points that should be discussed between the patient and their local provider,” he said. Also, because the expert may not fully know which options are available in the patient’s location, said Dr. Gillespie, any opinions given must be empathetic and supportive of local physicians and must avoid sowing mistrust within the primary doctor–patient relationship.

Ethics and Finances

While second opinion services fit well into the medical landscape ethically and financially, there certainly are some challenges. “They’re an adjunct to medical care and nothing more,” said Dr. Sumer. “They cannot and should not replace the primary doctor–patient relationship but supplement it only.”

Ethically, Dr. Chang believes that the provision of second opinion services is the right thing to do—the only ethical concern is with diversity, equity, inclusion, and justice. “Some patients may not have the capability to access a second opinion service and instead may need a clinic-to-clinic telemedicine visit, which can be more challenging to schedule but is still something that can be done to accommodate a patient,” he noted.

“It’s always ethical to improve a patient’s understanding and knowledge of their disease process,” said Dr. Gillespie. He noted that most of the information shared by the expert is already available to the patient online. “The expert fills a critical role as a personal filter of sometimes conflicting information online for patients who may be overwhelmed. They offer the best evidence in a way the patient can more easily understand.” He noted that the cost of the second opinion consultation is “generally low compared to the total cost of a patient care pathway and is a good value if it increases patient trust and adherence with the ultimate plan of care.”

Otolaryngology Focus

But how much of an otolaryngology focus can a patient expect from one of these services? How many otolaryngologists serve as staff members for them? 

Based on Dr. Merati’s experience at Best Doctors and Grand Rounds, he said that the companies were good at understanding what information otolaryngologists needed. In joint reviews, for example, if a laryngologist and a gastroenterologist both reviewed a case, the notes from the non-otolaryngologist expert were quite high level.

Dr. Gillespie noted that many of these services rely on identified experts who are leaders in their area of subspecialty and are expected to be well informed in high-quality care and current treatment guidelines. Unfortunately, according to Dr. Sumer, the number of otolaryngologists available on these platforms tends to be limited relative to the overall number of experts these services typically field.

Dr. Chang suggested that as devices that record physical examinations improve, such second opinion services will become more common. “I think this is the right thing for the patient experience and patient care,” he said. 

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Katie Robinson is a freelance medical writer based in New York.