Diagnostic tools

We presumably trust our doctors or we would not be going to them for advice or troubleshooting with our health.

But everyone makes mistakes. People are likely misdiagnosed or prescribed the wrong drugs every day. According to a study published in 2015 by the National Academies of Sciences, Engineering, and Medicine, “it is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.” The report further notes that diagnostic errors — be they inaccuracies or delays in diagnosis — persist in all settings of care, and can harm patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions.

So, when is it a good idea to seek another doctor’s opinion or question whether a drug is the right one for the individual or condition?

Dr. David Beatty, who has served as a general practitioner for more than 30 years across the pond, says most people’s family doctors see a variety of conditions, from those that correct themselves without treatment to ones that require management, specialist referrals in an outpatient setting or hospital care. And they understand another opinion is always a possibility. But if a condition seems to be getting worse, rather than better, it may first be prudent to return to the same doctor, according to Beatty.

“That doctor will usually reassess the situation, possibly considering a different diagnosis or treatment,” Beatty says. “If you feel the doctor has an inflexible attitude or doesn't seem prepared to consider other possibilities, that might be a time to seek another opinion.”

Beatty recommends a similar track for prescription drugs. If people are experiencing any drug-related issues or do not seem to be getting better, they should first discuss that with their doctor, who can likely find them another option.

“Whenever we prescribe a drug, we are weighing the expected benefits against the possible side effects,” Beatty says. “We don't know up front whether you will be the unlucky person to get the side effect.”

If someone thinks the treatment they are receiving is not right for them, Beatty recommends doing some research. For most diseases, people will be able to find guidelines for how they should be managed. They can use that information to seek further help, if needed.

Beatty also says medically severe conditions or rare problems typically necessitate another look from someone who specializes in that condition. Dr. Damien Howell, a Virginia-based physical therapist, adds on his website that people should also consider second opinions when elective surgery is recommended, diagnosis and/or treatment is not clear, when the patient is not given a clear explanation of how to self-manage the problem, or when one’s healthy level of skepticism is growing.

Researchers in a 2016 medical errors study by Johns Hopkins University noted most medical errors are not made by inherently bad doctors but represent “systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability.”

Beatty adds that diagnosis is made after a conversation between patient and doctor, which takes the patient’s history into account, as well as an examination and sometimes further investigation. It is important for the patient to be open and thorough during that process.

“If the doctor isn't given the important parts of the story, it's easy to go on a diagnostic wild goose chase,” Beatty says. “Equally, the doctor may fail to ask the relevant question and fail to lead the conversation in the right direction. The examination may be done in a slipshod way, missing key signs. In some circumstances the examination may be inappropriate, difficult or impossible to do.”

During the investigation phase, resources — particularly in remote areas — also may limit options, leaving doctors to make a “best guess diagnosis,” Beatty says. And most medical problems present with a particular set of symptoms. If that presentation is atypical, that can make it harder for doctors to reach an accurate conclusion, Beatty says.

“For instance, if someone is having a heart attack but isn't complaining of chest pain, it's more likely to be missed,” Beatty adds. “Infants can't tell the doctor what's wrong, so it's relatively easy to misdiagnose an abdominal emergency, such as appendicitis.”

Coexisting conditions can complicate matters, both in terms of diagnosis and treatment. And some symptoms have multiple causes, such as shortness of breath, which could be a sign of pneumonia, heart failure, asthma or pulmonary embolism. Other symptoms, such as fatigue, can be vague and sometimes require a longer list of investigations, Beatty says. And omitting even one key blood test can lead to a doctor missing a diagnosis.

Beatty says seeking help from another doctor also can be for personal reasons.

“Sometimes the doctor and the patient just don't get on because the two personalities just don't go well together,” Beatty says. “Even if the doctor is giving you what seems like the right treatment, you might prefer to find an alternative doctor who you think you might get on better with.”

There are some potential drawbacks to seeking a second opinion, according to Beatty. It can come with extra travel and expenses, depending on the situation. And a general practitioner who has seen a patient multiple times for the same problem will typically begin to ask themselves what they have missed and how to approach it from another angle.

“Someone who is hopping from one doctor to another might never get the benefit of that extra consideration,” Beatty says.

Egos undeniably get involved, too. A doctor’s may be bruised if a patient moves elsewhere, and that doctor may still have to provide care to them in the future, Beatty says. Two or more doctors also could end up approaching a case in contradictory ways of managing it.

“It's fine if it's a hospital consultant leading the management with the general practitioner accepting the consultant's lead,” Beatty says. “However, it doesn't work so well if there are three or four general practitioners all thinking they have the lead on the case.”

Howell writes that while asking for a second opinion may feel uncomfortable, it is always the patient’s prerogative to do so. Good healthcare professionals will recognize a patient’s right to do so and support that.

Howell’s recommendations for seeking that second opinion include choosing a healthcare practitioner who is independent of the first, considering a healthcare professional from different background, taking the time to shop for the best professional to provide a second opinion, verifying coverage of a second evaluation with one’s health insurance company, collecting and sharing records from previous tests, and seeking that second opinion sooner, rather than later. Howell writes that it is up to the patient whether they want to inform their primary healthcare professional that they are seeking another opinion or proceed without telling them. But he recommends consulting with one’s primary care physician if patients are getting conflicting opinions.

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