Why Doctors Have a Love/Hate Relationship With Second Opinions

Making decisions about significant medical procedures or diagnosing an illness is not always a clear-cut endeavor. With complicated medical concerns, a second opinion is often sought by patients. Getting additional medical input, however, can be difficult. Thus, physicians either love or hate this extra input.

A study published in the journal BMJ Quality & Safety reported that as many as 12 million adults, or 1 in 20 patients, that seek hospital treatment within the U.S. are misdiagnosed. Half of these cases involved misdiagnosis that could lead to severe injury. A second opinion could avert some of those cases.

Some doctors are hesitant to have their diagnoses questioned. Others are more open to their patients finding out as much information as they need.

Kathy Miller, a physician and teacher of medicine in The Indiana University of Medicine, told Medscape that she feels it's a patient’s right to obtain a second opinion and  if your physician tells someone there is no need for an additional view, it is time to acquire a different doctor.

There are, in fact, several situations where a doctor could be the one who solicits a second opinion. If a physician is uncertain of a diagnosis, when distinguishing between Alzheimer’s or another type of dementia for instance, acquiring another viewpoint from another physician can be extremely helpful.

Dr. Frank Veith wrote in an article in Vascular Specialist that the existing system of soliciting second opinions and referrals is flawed. In many cases, referrals are derived from known associates, proximity, and sometimes even financial interests. Possibly picking out a physician from a list of “top doctors”, is not foolproof either as many of these lists are compiled from paying a fee or from flawed data.

A second opinion is most beneficial when done by a reliable and trusted specialist who is able to clearly represent the patient’s needs. But getting that specialist is complex. It takes time for a physician to find and vet specialists. Additionally, referrals are discouraged by many insurance policies unless they are done by an in-network physician. Additionally, under the Affordable Care Act, no insurer is required to pay for second opinions.

The policy of Medicare is that a second opinion is justified when the treatment is not an urgent situation and the patient can decide when and if to have the surgery. If the second opinion differs from the first, Medicare recommends further discussing the condition with the first doctor. In some cases, finding a third opinion is allowed. Medicare will cover the costs of these opinions, nevertheless this option is clearly not available to everyone.

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The Case of a Doctor Giving the Correct Medical Advice and Still Getting Sued

Medscape recently had an article on a case affecting a Connecticut physician that was practicing the standard of care, but still got sued.

The case involved woman who had a strong family history of breast cancer. In 2005, the woman had an elective partial hysterectomy for uterine fibroids, which is benign. Whether or not to remove the ovaries too, during the hysterectomy was also considered. The benefit to removing the ovaries is eliminating the risk for ovarian cancer. The negative effects of removal are, if the woman is pre-menopausal, removing the ovaries will mean she will be menopausal post surgery and assume the risks of that condition.

During the pre-operative consult, the physician did note the patient's family history of breast cancer, which suggests a higher risk of ovarian cancer as well. However, the physician did not order a pre-operative genetic evaluation searching for the BRCA gene. This gene, if present, would indicate the patient had a much higher chance of growing ovarian or breast cancer later on.

The hysterectomy was a success, and the ovaries weren't removed. Yet, one year later, the patient was diagnosed with late stage, terminal ovarian cancer that had metastasized to the abdomen. The patient sued the doctor for medical malpractice.

As it turned out, the BRCA gene was negative when the patient was ultimately tested. If the test had been done pre-operatively, most physicians would have proposed that the ovaries not be removed. This fact was not admitted in court. The patient simply alleged that given her family history, the ovaries should have been removed, regardless of the fact that it was not accepted medical practice.

The jury found in favor of the plaintiff and awarded her $4 million dollars. The physician lost on lost on appeal to the Connecticut Supreme Court.  His malpractice insurance only covered $1 million dollars so the doctor's financial assets were attached to cover the judgment.

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What to do when Insurance Companies Overrule Doctors

“That requires prior authorization” is not what we want to hear if we are a patient or a physician. However, requirements for prior approval for certain procedures and medications are here to stay in the health care industry. Problems arise as health care providers’ drive to treat their patients using the finest that medical technology provides clashes with the insurance company, who as a business, desires to control costs as much as possible. The insurance industry pays the vast majority of health care costs in this country and, since they are a business, they wish to make a profit, and controlling costs is a necessary component. Sometimes the requirement to control expenses as well as the need to treat patients can be reconciled. Frequently, however, both of these requirements cause a struggle.

One common area of conflict is in the use of antirejection medications for transplant patients. Transplant medications must be taken by transplant patients for the rest in their lives. This is often very expensive which is why insurance providers usually only cover the generic form of the drug, not the brand name. While generics generally work fine for some more common conditions like blood pressure, many physicians don't trust the generic type of antirejection drugs, frequently for good reason. However, because the expenses are being paid by the insurance companies, patients are typically left acquiring the generic medications against their doctors’ advice.

CBS News “60 Minutes” recently described the clash between insurance companies and physicians regarding mental illness. Cases of insurance providers, who never see the individual, are declining to cover the full course of treatment which has triggered needless suffering and in some cases, death.

Medical economists explain that the cost of complying with all the prior authorization requirements is time consuming and very costly. However, without a public policy solution for the issue, there are certainly a few things the physician may do to streamline the process.

First, if an insurance business is slow to pay or is too rigid in granting approvals, the doctor may consider not seeing patients with that insurance. If enough healthcare providers do this, insurance companies will begin to get the message and may modify their techniques.

Second, doctors must try to structure their prior approval processes in the most efficient way. Strategies include: use the insurance company’s website instead of calling on the telephone; try to get blanket approvals for common procedures and common medicines; centralize the approval operations; and lastly, doctors should learn which drugs and procedures do not require prior authorization and use those if they are appropriate.

Although these recommendations won’t resolve the situation of working with insurance providers, they may make the process a little easier.

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Prescription Errors, New Professional Standards Lead to Greater Pharmacist Liability

Historically, the pharmacist job was pretty straightforward and pharmacist legal liability was considered minimal. A drug would be dispensed by a pharmacist based on the prescription. The responsibility to warn patients about their prescriptions has commonly been put on the drug manufacturers who make the drugs and compose the drug labels, as well as the doctors who write the prescriptions.

According to the National Association of Chain Drug Stores (NACDS), courts generally ruled that physicians bore more responsibility since they were the ones choosing which drugs to prescribe. The standard pharmacist defense has been that the pharmacist's duty extends only to accurately filling the prescription as written. In fact, 40 years ago, according to the Code of Ethics of the American Pharmaceutical Association, it was not professional for a pharmacist to even tell the patient the name of the drug unless they had permission from the prescribing doctor.

Recently, however, drug injury cases are increasing and some of these injuries are based on prescription blunders including, patients given the wrong dose, or even the wrong drug. The rise of these kinds of mistakes is putting pharmacists at an increasing legal risk.

Courts in some states are ruling that pharmacists have a duty to warn their patients about potential drug risks, moving away from the opinion that physicians must bear the majority of responsibility. Other states have considered the pharmacist's duty to warn is limited to certain situations such as when there are threats from drug interactions or prescription mistakes that were clear.

Professional responsibility is being emphasized by new pharmacy industry standards. The old perspective of limited responsibility is counter to the means that pharmacy schools train and teach today. The courts are seeing that failure to fulfill this responsibility is pharmaceutical negligence and are starting to understand this increased duty of pharmacists.

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Should Unhealthy Behavior Result in More Expensive Health Insurance?

The increasing cost of healthcare is continually in the news today. Frequently, that discussion is turning to the function of the patient in the cost of their own care.

Medscape recently surveyed more than 21,000 physicians from 25 specialties and asked them: "Should patients who engage in unhealthy behavior pay more for health insurance?" Their findings illustrated the doctor community replied with a booming "Yes!"

The majority of physicians believed that patients who don't follow their advice about losing weight or quitting smoking, or other unhealthy behaviors, should have to pay more for health insurance. The doctors noted that such patients are hence more expensive to insure and present a higher health risk.

Another argument is the fact that a higher insurance premium could inspire patients to change their behavior. Others consider it is an issue of fairness. Patients who do follow doctors' orders and maintain their well-being shouldn’t pay the same rates as people who don't.

Just 15 percent of physicians that replied to the survey opposed using patient behavior to calculate insurance prices. Some said using this approach would penalize patients without resulting in any behavioral change and others didn't want to cast judgment of their patients.

The fact is that health costs are rising and health insurance premiums are rising to cover those costs. Some of the increase is because of the well-being of patients, especially those with long-term conditions for example cardiovascular disease and diabetes. These illnesses are among the most expensive to care for and are often the result of unhealthy behaviors.

The AMA's code of ethics states that some ailments and illnesses can be avoided by a healthy lifestyle and patients "should take personal responsibility when they may be able to avert the development of disease".  The AMA further argues that not only should patients share responsibility for their health, but also for the cost of their healthcare.

Learn more about the role that patients play in the cost of health care and insurance, contact us.

Good Samaritan Laws and Medical Malpractice

Legally, a Good Samaritan refers to someone who renders aid to an injured person in an emergency on a voluntary basis.  That volunteer does owe the person they're rendering aid to a duty of being fairly cautious. Someone isn't required to offer first aid in most states, unless it is part of their job description, however if someone does not at least call for help, some states will consider it an act of negligence.

Good Samaritan laws apply to anyone who renders emergency care or first aid in the scene of an accident, injury or illness, or disaster. This includes EMS personnel, fire fighters, police officers, and even off-duty doctors. While the level of medical wisdom and skill will differ from person to person, the law extends its protection to anyone who falls under its umbrella.

These laws are crucial, since fear of legal repercussions could make many bystanders afraid of stepping in to help an injured or ill individual. For instance, someone is walking on a beach and sees a person in trouble while swimming in the ocean. The good Samaritan goes in and saves the swimmer, brings the unconscious individual to the beach and starts chest compressions, saving his life. Regrettably, during chest compressions, several of the casualties ribs were broken (a fairly common event).  Good Samaritan laws would prevent the victim from suing the rescuer, even though he sustained injuries.

There are a few circumstances where Good Samaritan laws to not apply. If a victim is conscious and verbalizes that they do not want help, their wishes must be respected even if it looks like aid is required. A bystander can help on the grounds of implied consent, if a victim is unconscious and cannot respond. Crises that occur in hospitals or other healthcare facilities, where care is offered by men and women during their routine employment (physicians, nurses, etc.) do not fall under Good Samaritan laws. 

Laws vary in each individual local and state region, so it is vital that you get familiar with the laws where you reside, work and possibly even vacation.

To find out more on medical malpractice and also the law, contact us today!

Female Viagra Recommended for Approval

After three tries, the FDA Advisory Panel recommends approval of Flibanserin, also called “female Viagra” or “the little pink pill”.  Flibanserin has been recommended for approval for the treatment of Female Sexual Interest/Arousal Disorder (FSIAD).  This disorder is diagnosed in the absence of another cause and includes a persistent absence or deficiency in sexual fantasies and desire that causes distress or interpersonal difficulties.

Initially, Flibanserin was studied in 2006 as an antidepressant.  It acts to decrease serotonin and increase norepinephrine and dopamine in the brain.  This is quite different to how Viagra works by altering the blood flow to the penis during sexual arousal.  Flibanserin was not effective as an antidepressant, but had an unexpected side effect on sexual desire in women only in the study.

Additional studies designed to calculate the degree of effect on sexual desire, decrease in distress, and the number of satisfying sexual events per month showed statistically significant improvement in desire and an increase of 1 additional sexually satisfying event per month.

The primary side effects include dizziness, fatigue, sleepiness, and fainting episodes.  The studies on this medication have only included healthy premenopausal women in a very selected environment. The FDA was concerned that the risks outweighed the small amount of benefit and denied the applications for approval on two earlier occasions.

Concerns remain about the use of Flibanserin in combination with other drugs and a study in mice that showed a possible increase of breast cancer.  The longest study to date was only 18 months, not long enough to conclusively find any breast cancer risk in a relatively young age group of women.

On June 4, 2015, the FDA Advisory Panel recommended the drug for approval.  They also strongly recommended training for physicians and pharmacists on prescribing of the medication.  Black box warnings were also recommended concerning the use of alcohol and other medications in combination with the drug.

The FDA generally follows the Advisory Panel recommendations, however not always.  It is possible that the FDA will override the recommendations and deny approval for a third time.  A decision is expected in the next few months.

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