Getting a Second Opinion for Cancer Surgery

Second opinions for medical advice is nothing new and an accepted part of modern day medical practice. Practically all doctors are happy to provide second opinions for patients who seek them.  It goes without saying. My own surgical practice has a significant proportion of patients who come through such channels.  I usually ask them how they came to see me and in the vast majority of circumstances it was due to a recommendation from a friend or acquaintance who had been treated by me for the same condition.

Procedural specialties have particularly taken to having an on line presence for marketing of their services.  It makes a great deal of sense.  The more patients you can attract so as to be able to perform procedures, the more income that is generated.  Increasingly we are seeing offers of seeing patients for second opinions appearing on the websites of surgeons. Often there will be a form to complete where you type in your basic demographics and some basic information about one's condition which in turn invites the surgeon or designated staff member to make contact and subsequently encourage the patient to make an appointment.

What concerns me is that the second opinion marketing is mainly directed to newly diagnosed cancer sufferers.  These patients are vulnerable and on the steep learning curve with the acquisition of knowledge about their condition whilst trying to cope with the unknowns that lie before them. The second opinion websites often boast the achievements of the cancer surgeon being promoted but with very little possibility of the reader being able to verify the statements.  

We see statements such as 

“I was the first…” 

“I have done the most…..” 

“I pioneered the introduction of ……..”

Not uncommonly these statements bear zero relationship to the consultative or clinical or technical skills of the surgeon.

Rather than allow these websites seed one's mind about that the current care being received is inadequate, readers should instead consider why is it that such great efforts are being made to promote the availability of a second opinion service.  It is nothing more than a mechanism to goad patients into switching doctors when at their most vulnerable time. There should not be a need to promote that second opinion services are available as this goes without saying. If a surgeon had such a good reputation, why would they need to market for those second opinion cases. Do they have a deficiency of work that necessitates such action?  

There is nothing wrong with seeking out information on suitable surgeons to see for a second opinion but perhaps one could do better than a cold call to a website.  Consider other sources for recommendations. Start with the family doctor and additionally, staff who work at the hospital you would like to attend, if you know any.  Look the overall digital footprint of the provider and in particular independent sources of information.  When searching provider websites, be wary when there is over the top self promotion and whether you feel that a second opinion form is being thrust into your face. If it was from anything other than a medical provider website, you would probably consider it differently.  Remember that marketing is marketing and I'm afraid to say that even doctors partake in provision of information under the guise of marketing.

As a junior specialist, I recall being advised by a senior colleague that my patients would be my best ‘advertisement’.  All I had to do was to treat them with respect and compassion and to do what I would wish to have done for myself or my close relative. This was sound advice and I continue to uphold this principle.  I am grateful that my practice is sufficiently busy to never feel a need to market for second opinions - but why should I need to market for them when it is after all, a normal part of medical service provision.

Note- this piece is written in the context of Australian medical practice

What makes somebody the best surgeon for you?

My colleagues and I have been working on our website with primary aim of being a portal for information about our practice as well as a source of documents relevant for patients of the practice.  We naturally look at what others in our field are doing with their websites to get an idea of what we like about some finished products and what we don’t like.  Some websites provide information to help you think that they are the right surgeon for you.

I found it fascinating to observe what things are said in order to bring in business and to convince the reader that they are dealing with the best surgeon for their condition.  Clearly there are many things that help determine what makes a surgeon the best for the job and amongst those, the things that are materially significant to some may not be to others.  One example is the bedside manner where a surgeon could have the reputation for being a meticulous and technically superior in their operative skills but where the bedside manner is abrupt, arrogant and seemingly uncaring.  Even for myself, I would have to admit that there are possibly some conditions where I would like one surgeon to do the decision making, another to be the technician (and then never see them again) and perhaps another to deal with the longer term monitoring (where you have to see them on a regular basis).

One of the statements made to generate the impression of prestige is boasting that he or she was the first to perform a certain operation in the state of NSW or Australia.  This could be indication that we are dealing with an innovative thinking surgeon who is always looking out for the latest advances to benefit patients but in the same breath could represent the surgeon who seeks to take a risk with their patient in hope of achieving kudos for their efforts.  Does the patient always know that they are the first?  Being the first to do a particular procedure does not necessarily mean that the individual is the most talented and technically adept at performing the procedure.

It is common practice to highlight one’s background training.  Fortunately for us in Australia, the overall standard of surgery is very high and what we call 'average' is frequently well above average for many other western countries.  Some countries have the most prestigious institutions performing high quality opinion leading work but in the next town, there might be an institution that is perhaps a little ordinary.  Okay, if a surgeon goes to a prestigious institution to round off their surgical training in Australia or to subspecialise, does this mean that they can lay claim to being the best at what they do?  The answer is yes and no.  With the yes, they may be exposed to the latest techniques, benefit from state of the art training and also taught to think critically with complex cases.  We rely on these surgeons to return to Australia and become key opinion leaders in their field.  Contrary to this, we have surgeons who were ‘clinically and technically average or even below average’ when they departed for additional training overseas in a prestigious institution and on their return to Australia, they are still ‘clinically and technically average or even below average’.  I have often heard of trainees who lament that a particular surgeon was very disappointing technically for what they expected - this was not said meaning to say that a particular surgeon was inadequate, but more that there was a higher expectation that we would be better given the constant reminders of where he or she had some training after obtaining their Australian qualiftications. Some of the most prestigious institutions to much surprise may also provide a less than satisfactory experience and hands on training and simply trade off their reputation as a place to seek further experience.  In terms of hands on experience, there are notably institutions in the USA where the surgical fellows are merely glorified surgical assistants who will tolerate stifling employment conditions knowing that it is simply a means to an end.  I sometimes tempted to say to some surgeons who cannot help but to tell you that they have been to the best institution in the world for additional training as follows:- "Listen here honey, you're back in Australia now and have to prove yourself and not ride on the back of the success of where you have been."  I am a great advocate of surgeons undertaking additional fellowship training following the completion of their surgical qualifications in Australia.  I do however, urge you all to remember that whilst being able to say that one has been the best institution in the world to have further training, it does not mean that the training in Australia should be devalued in any way and it does not mean that the surgeon has necessarily become a better surgeon for it. We should not underestimate the worth of the training that was received in Australia which really matches the best in the world.

What about how many of a certain type of operation one performs and how many they have done over their career?  A high career volume or a high annual case volume intuitively reflects experience, which is valued in whatever endeavour is undertaken.  Some surgeons only need to do an operation a few times to be performing it as well as another who does many more.  It is possible to do large numbers of certain procedures but perform all of them badly.  Levels of skill and the uptake of these skills can vary considerably as is the case with any profession.  There is no easy solution for navigating through this minefield when trawling through individual surgeon’s websites.  Perhaps the best question one can ask is as to whether they are performing audit of their surgical results.  In other words, are they getting the results that they think they are getting?  As surgeons, how do we know what we are doing if we do not measure our outcomes?  I have personally found the practice of audit to be both humbling and illuminating and the best guide to assist with making improvements to my outcomes.  But suggesting that we all aggressively audit our cases has the potential of coming at a price to the community.  If surgical results become the primary focus of marketing campaigns, it runs the risk of influencing surgical case selection in fear of damaging one’s ‘figures’.  It would be disastrous and simply unethical if we were to find ourselves in an environment where surgeons refused treatment to higher risk patients in order to protect their own statistics.

This discussion is not intended to create confusion over the meaning of certain claims made by surgeons who market their surgical practices on the internet.  The aim of this discussion, is to introduce a healthy questioning of what is stated on various surgical websites.  Being a good surgeon includes more than just the operating and all of you need to consider what is important for you when making your decision. If you are not comfortable with your existing opinion, think about getting a second opinion.  Funnily, the surgeons who actively trawl for second opinions are probably the ones that I personally would not see.  If they are that gifted and appreciated, they should not need to waste any space on their website enticing readers to come in and see them for a second opinion as they surely must be the best.  Great surgeons who are comfortable with what they do and who are recognised for what they do are well patronised from word of mouth and do not need to cast out invitations to see them for a second opinion.  My own feeling is that the good old-fashioned approach of seeking out personal recommendations still has a great deal of merit.  If you know of somebody who is going to have surgery of ANY sort, forward them this blog link and see what they think after reading this.