||When a physician agrees to attend to a
patient, there is an unwritten contract between the two.
The patient entrusts himself to the physician and the
physician agrees to do his best, at all times, for the
patient. This contract disallows the patient from seeing
another medical expert for opinion or advice without a
referral note from his physician. It also enjoins the
physician to respect the autonomy of the patient so that
if the patient so desires, he will refer the patient to
another physician for a second opinion.
Traditionally, the concept of a second opinion is based
on certain assumptions. First, that the physician has
studied the patients medical history and clinical
findings; if he is the patients family doctor, he
has also over time acquired a fund of medical and
socio-economic information on the patient and his family.
Second, that the physician is knowledgeable about the
various specialists in the town or city and their
respective strengths and capabilities, and is thus
qualified to advise on whom to consult for a second
opinion, and provide that consultant relevant and
often-crucial medical information on the patient. Were
the patient to consult another physician on his own,
these benefits would be lost.
However, second opinions are often not sought on these
principles. Some patients move from doctor to doctor
without the primary physicians knowledge. They
obtain a variety of opinions, often conflicting. Without
any one doctor in overall charge of their therapy, they
may follow whatever advice they choose to accept. If a
complication ensues, no particular doctor can be held
Patients who do ask their primary physicians for a note
of referral to another doctor are no better off. Such
requests are often taken as a personal insult and
evidence of lack of faith or trust in the doctor. Some
doctors react by withholding key information, such as
detailed notes on surgical operations. The result is
often a general breakdown in the harmonious relationship
necessary for good patient care.
The problem is compounded by the absence of clear-cut
guidelines on he use of the second opinion. In India, our
medical councils have failed to contribute to the
discussion, or to regulate the use of the second opinion
in any way.
It is in this context that colleagues were asked their
opinions on the need for, and use of, the second opinion.
By recording the views of respected academicians and
medical professionals, one hopes to lay the ground for
further discussion on the question. The following essay
is an attempt to extract, from the responses received,
considered thoughts on some aspects of this issue.
Excerpts from the responses have been included to
illustrate various perspectives.
doctor-patient relationship a contract or fiduciary
medical colleagues agree that the doctor-patient
relationship today is some sort of unwritten contract,
there were many qualifying notes. Ruth Macklin raises a
fundamental question: what kind of contract is it,
anyway, if it is both unwritten and unstated? "A
contract in which the provisions are not clearly spelled
out is not really a contract at all. In a legal sense, it
would be considered invalid. From an ethical point of
view, how can all parties - physicians or patients - be
fully aware of their obligations or, for that matter,
their rights? Contracts in the strict sense of the term
are (usually) written documents that spell out the
provisions clearly, say what all parties are obligated to
do, and also specify penalties or remedies for breach of
contract. That sounds very different from the
physician-patient relationship, which is perhaps better
described as a fiduciary relationship."
Clearly, this question needs further discussion for any
systematic understanding of the issue.
And in fact Thomas George holds that it makes little
sense to talk of contracts and obligations in our health
care system. He would support enforcing the
doctor-patient contract, and expecting referral notes
from every patient, if we had a structured health care
system, "as, for example, in the National Health
Service (NHS) in the UK. Borrowing only one part of the
system leads to a lot of problems for the patient. At
present there is no system at all in India and the
patients are completely at sea as to whom they should
Homi Dastur argues that patients would not accept the
enforcement of such regulations. "Very few patients
would be willing to observe, accept or even understand
(the concept of an unwritten contract), as is evident
from the frequency with which those who can afford (to
pay the different consultants) will seek multiple
opinions. Many patients will reveal that they are under
the care of another doctor only after the consultation is
over. Sometimes one becomes aware (of the earlier
consultant) only after reviewing reports which mention
the name of the referring doctor."
Likewise, Bela Blasszauer suggests that such a contract
would work only in theory, for doctor-patient
relationships rarely develop in the prescribed manner.
"Physician-patient encounters may take many forms. I
may bump into the physician. I may have no other choice.
I may be shopping for a suitable one. And so on."
Many doctors oppose enforcing contracts because they
perceive the doctor-patient relationship as unequal, and
liable to be misused by unethical doctors. "I would
like to spare the patient the trauma (of having to face a
doctor unwilling to refer his patient for a second
opinion)," writes George. Blasszauer suggests that
such contracts can generally not be made binding on the
patient, since the conditions under which he sought
advice or treatment were heavily weighted against him.
Others perceive the relationship differently. Eugene
Robin and Robert McCauley suggest that the
physician-patient relationship is a partnership and not a
contract. "Either (patient or doctor) is free to
terminate the relationship without cause,
with the doctor having the additional burden of informing
the patient when this occurs, and remaining available for
such time as is reasonable for the patient to find
another doctor who will assume responsibility for
delivering medical care." This is generally true in
the urban US, they state.
Sociologist Rohit Barot suggests that the Indian
situation resembles private sector health services in
Britain. He has been a patient in the UK National Health
Service, as also with private practitioners there, and
comments that the doctor-patient contract and the rules
of referral seem to apply only in the NHS.
American Medical Association
According to the
American Medical Association's code of medical
ethics, physicians should recommend a second
opinion whenever they believe it would be helpful
in the patients care. When doing so, they
should explain the reasons for their
recommendation and inform their patients that
they are free to choose a physician on their own
or with their assistance. Patients are also free
to seek second opinions on their own with or
without their physicians knowledge.
With the patients consent, the referring
physician should provide any information that the
second-opinion physician may need. The
second-opinion physician should maintain the
confidentiality of the evaluation and report to
the first physician, if the patient has given
consent. Second-opinion physicians should provide
their patients with a clear understanding of the
opinion, whether or not it agrees with the
recommendations of the first physician.
Where a patient initiates a second opinion, it is
inappropriate for the primary physician to
terminate the patient-physician relationship
solely because of the patients decision to
obtain a second opinion.
In general, second-opinion physicians are free to
assume responsibility for the care of the
patient. ... By accepting second-opinion patients
for treatment, physicians affirm the right of
patients to free choice in the selection of their
There are situations in which physicians may
choose not to treat patients for whom they
provide second opinions. Physicians may decide
not to treat the patient in order to avoid any
perceived conflict of interest or loss of
objectivity in rendering the requested second
opinion.Physicians must decide independently of
their colleagues whether to treat second-opinion
patients. Physicians may not establish an
agreement or understanding among themselves that
they will refuse to treat each others
patients when asked to provide a second opinion.
Such agreements compromise the ability of
patients to receive care from the physicians of
their choice and are therefore not only unethical
but also unlawful.
on Ethical and Judicial Affairs: Code
of medical ethics. Chicago: American
Medical Association 1997. 191 pages.
patient have responsibilities as well as rights in this
relationship? "The doctors duties, ethics,
standards are well-known in theory and lapses from
accepted norms are recognised in practice," writes
Farokh Udwadia. "It is equally important (to
emphasise) the patients duties, responsibilities
and obligations...It is time for this aspect to be
discussed and the discussion circulated, for it must
never be forgotten that the doctor-patient relationship
is not a one-way street."
Again, this view is a matter of debate. Jagdish Chinappa
and Lawrence White argue that the two groups are very
different. "The patient is the consumer who has
needs based on certain beliefs and attitudes. The doctor
is a service provider. Patients, under the stress of
their illnesses, should be expected to behave
irrationally and inconsistently." Therefore,
Chinappa goes so far as to say, "honest and ethical
action is therefore dependent only on the doctor and has
to be decided upon the merits of every case. Certainly,
the emphasis on autonomy guarantees a patient the right
to ignore a doctors advice, and to seek whatever
opinions are wished. (I believe that this, even though
considered a nuisance and counter-productive regarding
patient care, is nonetheless a good thing.)"
Likewise, White notes, "Just as it is not an equal
relationship in terms of power distribution,
vulnerability, etc, so it is unequal with respect to
promises on either side... it is generally accepted that
patients have the right to do whatever they wish,
including shopping for alternative opinions, etc."
This does not mean that many physicians like or accept
(the practice). "However, to demand otherwise will
reinforce the physicians position of power and
elitist attitude, which I believe would be a regressive
doctors should want a second opinion
There are a
number of reasons why a second opinion may be sought.
Traditionally, general physicians and patients seek
specialist opinion and advice with benefit, especially
when the disease is uncommon or the patients
condition serious. The patient with a hole in the heart,
a brain tumour or failing kidneys will do better in the
hands of specialists.
In certain situations a second opinion is almost a
must. "Take for example a
shadow in the lung of undetermined
aetiology," writes Farokh Udwadia. "Is it
tubercle, pneumonia, cancer or a rare disease, for
example, Wegeners granulomatosis? What is the
patient to do about it? In fact, it would be advisable
to take more than one opinion..."
Christopher de Souza adds that young consultants would
welcome second opinions from respected seniors
provided they were sure the patient would return to them
for definitive therapy in order to validate the
line of treatment they propose. The senior
consultants concurrence would protect the younger
colleague against unjust accusations and boost the
patients confidence in him.
B N Colabawalla feels that a second opinion may benefit
the primary physician in yet another way. "Patients
are now increasingly conscious of their rights and it
would be improper for any physician to deny the patient
his autonomy and right to seek a second opinion. It would
be in the interest of the primary physician to make the
necessary reference for a second opinion."
Unfortunately, requests for a second opinion from other
consultants are uncommon. "The practice of referral
from primary to secondary to tertiary, or from general
physician to specialist remains an ideal not
realised," according to M S Valiathan. who has
rarely had a primary consultant seeking a second opinion
from a senior consultant, or referring a patient to him.
"In cardio-thoracic surgery, at any rate... a senior
consultant usually enters the picture only when the
primary consultant fears medico-legal trouble in a given
That is not to say that patients arent asking for
them. One reason why second opinons are relatively
uncommon is the absence of any publicly available medical
audit. "Patients approach several consultants simply
because, at present, they have no way to get authentic
information on the quality of services provided by a
given consultant or institution," says Valiathan.
Outpatients come to Anil Desai because they are
dissatisfied with the information their primary physician
gave them, or with the treatments progress. "I
always request a referral from the family physician, but
(find that) many families do not not have a family
However, the hospitalised patient is unable to obtain a
second opinion without permission from the admitting
physician and even discussing such permission can
be a source of stress for the patient and his relatives.
the second opinion a right?
surveyed felt so, though they did not agree on whether
there were any limiting condiions. Some, like Blasszauer
held that patient autonomy required that it be unlimited:
"The patient has a freedom of choice, and even the
responsibility... to go to as many doctors as he wishes.
It is his life or that of his loved one that is at
stake!" This right becomes particularly important
with the deteriorating physician-patient relations.
"Since trust in the medical profession has been
greatly eroded, it is small wonder that patients (and I,
myself, too) try to find the person who is up to date in
his profession and displays humane features as well. In
an open market system, this is no real problem. Even
where there is a national health care system it may be
cheaper for the system as well, if I can find the
Others would limit that right, mostly to when the
physician ignores the patients wishes. Udwadia
feels that "the patients right to consult
another doctor (independently) is absolute when the
treating physician refuses to allow another opinion in
spite of the patients request; is clearly
disinclined or procrastinates unduly in granting
permission to seek a second or third opinion, more so
when the patients condition is not improving or is,
in fact, deteriorating; when he reacts with anger or
displeasure to a request for another opinion, and the
patient feels that he now no longer receives the care he
expects and needs.
"Also, when the problem ... is of serious, unsolved
diagnostic import (the patient) has an absolute right to
seek as many opinions as he wishes. However, the
physician should caution the patient that ... too many
opinions would only confuse and harm the patient."
But there are limits to this right, according to Udwadia.
"It would be unjustified, in bad taste and bad
manners if he seeks fresh medical advice of his own
accord when already under treatment for an ailment for a
considerable length of time by his primary physician. He
should not seek a consultation with a new practitioner
without permission and a referring letter from the
primary physician. If the patient is dissatisfied, for
whatever reason, with the primary physician, he should
have the gumption to tell him so and inform him that
henceforth he proposes to get treated elsewhere. This ...
absolves the primary physician from further care of the
patient. It is not uncommon for many patients to
surreptitiously see many doctors (as if to test the
primary physicians management), and then quietly go
back to the primary physician without the latter even
being aware of this duplicity."
General Medical Council, UK
Medical Council (GMC) recommends that patients
should continue to see specialists only on
referral from a general practitioner. The GMC has
strongly defended the referral system as a proven
feature of medicine in the UK. Specialists should
not usually accept a patient without referral
from a general practitioner. The referral system
is seen as the best way of ensuring that patients
see the right specialist.
Medical Council News, Spring 1997,
don't patients tell doctors that they're 'double
patients behave duplicitously? P. K. Sethi
and Colabawalla see the reason in the behaviour of most
doctors. "In practice this (request by a patient for
a second opinion) seldom happens because the public has
an apprehension that I may be annoyed. It is we, as a
profession, who should work towards dispelling this
impression. We have not done so," writes Sethi. He
holds that patients are justified in breaking their
contracts if physicians are rude at the mention of a
second opinion. And it is "morally, ethically and
possibly even legally unjustifiable" for medical
professionals to withhold information and case history
details, either from the patient or the second opinion
should it be done?
UKs National Health Service, only the primary
physician can refer a patient for a second opinion,
writes Blasszauer. The physician must make the request in
writing and provide all relevant medical details. In
return, he obtains in writing the diagnosis made by the
consultant and his advice on treatment.
But this is rarely done in India, writes Thomas George,
pointing out that patients rarely go up the primary,
seondary and tertiary levels of care. Samiran Nundy notes
that most patients in India do not have a doctor they can
call their primary physician.
V. R. Joshi points out that even the most punctilious of
consultants would find it hard to enforce such a
protocol. "Patients often travel long distances from
other cities or states to reach you. It is only when they
reach your office that they are made aware that a
referral note is required."
"Having come after seeking an appointment, I cannot
refuse to see them just because they have no referral
note," writes P. K. Sethi. "If, however, I
discover that the patient is admitted to a local hospital
and has come to me without informing the treating doctor,
I ask him to go back and bring a referral note. I feel
this is in the interest of the patient and also conforms
to the code of medical ethics... The advice is often not
But it is not always possible to get a letter from the
first doctor, feels Arunachalam, giving the
patients side of the story. He may be unavailable,
or the patient hesitates to inform him, afraid the
request would spoil relations. In fact the second opinion
is often most needed when the patient is in the hospital
and least able to take an opinion without the
admitting doctors cooperation. Desai has always
helped patients under his care obtain a second opinion
without his physical presence, giving them full access to
his case notes and the help of his house physician. On
the other hand, if they seek a joint consultation
something Desai may also sometimes find necessary
he reserves the option on which consultant should be
called in. There are also times when he recommends a
joint consultation with the patient and relatives.
This is not always the practice. "We do not permit
second opinions from outsiders under any condition,"
writes Prakash N. Tandon, arguing that the second opinion
can only be used ethically within a structured format.
Patients wanting such opinions must first get themselves
discharged from the hospital. "Every patient
discharged from our ward, either by us or at his request,
is given a discharge summary with full information on the
various investigations carried out, a copy of the
operation note, our final diagnosis and condition on
discharge. The patient is at liberty to use this
information for whatever purpose he wishes."
Tandons hospital does not provide the patient
copies of X-ray films and other imaging tests, but sends
them directly to the consultant if asked.
Tandon argues that the patients interests are met
through multiple internal opinions. "Every patient
admitted to our wards has the benefit of the collective
opinion of the whole team which includes several senior
consultants. By tradition, every patient is jointly
discussed on more than one occasion.
"Permitting a second opinion from outside would
create administrative problems on the one hand and a
difficult clinical situation." For example, he asks,
what if the second opinion was at variance from the first
opinion? Who would implement it?
"As a corollary, we refuse to provide a second
opinion on patients admitted to other hospitals unless it
is formally sought by the person treating the patient and
with the permission of his administration. For purely
administrative reasons, this is limited to public
hospitals. The opinion is given to the treating surgeon
and not to the patient or the family. At times, a joint
meeting held with the family is addressed by the treating
surgeon and ourselves."
White disagrees with such a practice. "If a doctor
does this, it strikes me that there is a component of
spite and petulance arising out of the doctors own
needs. Patients, particularly if seriously ill, often
feel the need to validate their doctors opinion;
after all, it is their life in the balance. Further,
there are often enormous pressures from friends and
relatives to get another opinion." In
other words, the second opinion can be taken for many
Robin and McCauley add, "If the primary physician
learns that the patient is following advice not
consistent with his principles of treatment, the doctor
should advise the patient of the difficulty/danger as
best the doctor sees it...It is the patients choice
how to proceed. The doctor can be held responsible only
for his own errors, not those of others."
"If the patient is already admitted to hospital
under another consultant, I would under no condition see
the patient unless specifically asked to do so by the
treating consultant," writes Udwadia. "This
would apply even if the patient concerned has been
previously under my care for several years. "
"In the initial stages, before starting on a course
of treatment, a patient may seek multiple advice,"
says Mr Harsh Sethi. "But once treatment has
started, then a new doctor should not accept a patient
without a note of referral from the first doctor
(provided he knows that the patient has been under
treatment). At the last, he should speak to the first
doctor and seek concurrence."
What does one
do when a patient seeks a second opinion without
obtaining a note of referral from his primary physician?
Macklin does not see this as a dilemma. "If a
patient approaches you, seeking a medical opinion
(whether it is a first or a second opinion), the patient
is in need of diagnostic or therapeutic attention. You
can decline to form a relationship ... or accept the
patient in your care and thereby establish a new
Most respondents feel that it is the duty of the second
physician to see the patient even without a note of
referral from the primary physician, though such a note
S. H. Advani adopts a firm stand. "I am absolutely
clear in my mind regarding the patient and doctor
relationship. In this relationship, the patient has the
major say. It is the patient who is going to receive the
treatment and he has to make sure that he receives the
best treatment. I give my frank opinion to the patient
(whether or not he comes with a letter from the primary
physician) because I strongly believe that the patient
has the right to take a second opinion. I dont want
the letter from the primary physician to participate in
the second opinion."
Ashok Bhanage emphasises that the doctor must work at all
times with the patients interests at heart.
"If I realise that I am the second consultant, I
write my notes in more detail and elaborate the reasons
for my decision. The patient is at liberty to show this
note to the first or a third consultant."
Aniruddha Malpani emphasises that the autonomy of the
patient demands that a second opinion, should be
provided. A letter from his primary physician is not
necessary. "My relationship is with the patient and
I am answerable to him, not to his primary doctor."
over the patient
take over treatment of a patient already under the care
of another consultant? This is one fear physicians have
when referring their patients to their colleagues.
Some might argue that this is the patients
prerogative. Arunachalam notes, "If I have changed
doctors, I will certainly expect the second doctor to
take full responsibility in treating me. If I consult
more than one doctor (for getting opinions), I will
retain the right to decide by whom I should ultimately be
Others are unequivocal: "If I find out that the
patient is under the care of another consultant, I advise
him to go back to that consultant," writes Gajendra
Sinh. "I do not take over treatment of these
On the principle that a patient has a right to autonomy
over his decisions, most respondents see no difficulty in
taking over the patients management at his express
request provided such a step is in his interests.
However, Homi Dastur adds, "The suggestion to take
over medical care would, at no time, come from me. It
would have to be broached by the patients general
practitioner, if present, and the patient himself.
Acceptance would follow only when persuasion to return to
the primary physician fails."
Advani differs. "The patient has the absolute right
to be treated by the physician of his choice. If the
patient decides to be treated by me, I would not normally
hesitate to accept. I may inform the primary physician,
though I dont consider this obligatory."
Blasszauer argues that the doctor must have good reason
to take over the patients care, such as the other
doctors incompetence. In fact, in such a case, it
is your duty to take over by convincing the patient about
Macklin agrees. "You presumably believe you need to
take over the care of this patient because the other
doctor was incompetent, mistaken, negligent, or in some
other way not acting in the best interest of the patient.
Patients need physicians who seek to act in their best
interest. Physicians owe more to the patient before them
than they owe to other members of their profession. Even
if physician etiquette dictates that one
doctor should not treat another doctors patient,
medical ethics demands that patients receive the best
medical care. Notes of referral and reluctance to treat
patients under the care of another doctor are elements of
physician etiquette, not medical ethics as understood
Barot feels that the second consultant is duty-bound to
approach the primary physician for all relevant medical
information on the patient.
Colabawalla outlines his approach: "If I am aware
that the patient has been under the care of another
colleague, I will offer my opinion and leave the choice
to the patient. I would not take over the
case by ascribing to myself the arrogance that I know
better! I would then try and persuade the patient to
allow me to discuss the case with the primary physician.
"The difficulty arises when the patient
unequivocally informs you that he does not wish to be
treated by the primary physician, and requests you to
take over the management. I would try to resolve that
dilemma -- not that any dilemma can ever be resolved --
by accepting that the patients autonomy and right
to choose must be respected."
"If the patient is being looked after correctly I
would persuade the patient to return to his
consultant." writes Udwadia. "If the
patients problem has been wrongly diagnosed and if
it is critical or life-threatening (e.g. a dissecting
aneurysm of the aorta or an impending myocardial
infarction), I would admit him to hospital under my care,
inform the primary consultant and request him to see the
patient in hospital as and when he wishes, so that we can
jointly look after him."
dangers of mixed therapy
will see several physicians to obtain a clutch of
prescriptions, selectively following that advice which
suits them. How can we help such patients avoid the
complications that may follow?
Udwadia has seen patients who have gone through half a
dozen or more physicians. "This is not uncommonly
revealed to me at the end of the consultation! I ask that
the treatment advised be carried out under the
supervision of any one doctor of the patients
choice, as I would be unable to follow-up on his problem
as often as I would like to. I then write a letter to
that doctor , outlining what I feel about the
patients problem and how, in my opinion, it should
best be tackled. (Finally,) I tell the patient that if he
wishes to see me again he will now have to get a letter
from this doctor."
White agrees that selectively following advice offered by
several physicians is courting trouble. "These are
difficult situations, and in my opinion there is no one
right answer. If I have a patient who is mixing and
matching, I gently tell him he is receiving
fragmented care, and that this is dangerous. Usually I
tell the patient that I wouldnt continue management
without a clear mandate. I feel strongly that patients
have the right to several opinions, but that one doctor
must quarterback the actual care. If he should suffer a
complication, which of his medical attendants would be
the state of the bypassed...
that the primary physician is justified in terminating
his relationship with the patient. Valiathan sums up this
sentiment: " The primary physician is not obliged to
treat a patient who consults another physician or follows
another line of treatment without his knowledge. When a
doctor undertakes to take care of a patient he accepts a
sacred contract with obligations on both sides. I do not
agree that the doctor must take care of a patient
under any circumstance. Even Charaka, who
imposed many strict conditions on the physician,
recognised situations when a physician can terminate his
At times, the bypassed physician feels rejected and acts
accordingly. Sometimes a seriously ill patient is told,
"You have decided to consult X without informing me.
I do not wish to have anything further to do with your
medical care. Please go back to X."
All our experts frowned upon such behaviour. White
writes: "Under these circumstances, the
doctors behaviour would be considered
patient-abandonment. I would consider it a breach of
ethical standards on grounds of beneficence,
non-maleficence, fidelity to patient, and respect for
patients autonomy. What would be the
physicians reasons for wanting to do this? The
relationship starts out unequally, with the doctor having
more power. This is counterbalanced, in my opinion, by
the greater responsibility of the doctor, who needs to
put his needs and wants aside and honour what is both a
contract and a covenant. This is a critical issue - the
physicians failure to put the patients needs
ahead of his own."
Colabawalla writes that the physician should
"gracefully end the contract... in his own
interest" if he feels that he has lost the
patients confidence "for whatever
Barot strongly feels that the primary physician must pass
information about the patient to the consultant or
whoever else the patient may have chosen to deal with on
health matters. The underlying ethic is that the primary
physician should provide all necessary information as it
concerns the patients health (potentially a
question of life and death).
Blasszauer agrees. "The primary physician should not
shed his responsibility to the patient without clarifying
his patients motives," he writes. "The
physician should ... understand: he may have failed the
patient; the patient may be out looking for hope, or
proof that his doctors diagnosis is right or that
the recommended therapy is the only solution. If he
cannot find the answer for his patients motives,
than he should sit down with the patient and have a frank
discussion. If he sees that the patient had no ground
whatsoever to abandon him, he may advise the patient to
look for another physician, since without trust no such
relationship could be beneficial. But until that moment,
I believe, he does have some responsibility. The patient
should not fall between two stools. The primary physician
should be available till he -- on acceptable grounds --
terminates the relationship officially. An
insult to my vanity is not an acceptable ground."
Gajendra Sinh concurs with the need for reform within the
profession. "Unless we put our own house in order it
is difficult to see how we can restore the doctor-patient
a second opinion clinic work in India?
a group of consultants from different disciplines offers
counsel on the clear understanding that they will not
take over the patients medical management. Would
such a clinic work in India?
"It is fairly common in the U.S., in this
connection, for a patient to be referred to a second
physician for a decision about, say, the desirability of
hysterectomy," write Robin and McCauley." The
ground rules here are that the consultant will not be
involved in the surgery; is not affiliated with
(preferably doesnt even know) the treating doctor;
and is paid the same, whatever his opinion. As you may
imagine, this system has its own flaws and a long essay
could be written about the good and bad aspects of this
Several respondents fell that such a clinic has little
chance of success. Chinappa holds that it could not work
in "an unorganised health care facility like that in
India. You need a high level of education in the patient
and a high level of ethical and moral integrity in the
medical profession for this system to work."
Colabawalla adds that the idea is good, but "I doubt
if it will ever be welcomed by most professional
colleagues. There will always be the doubt that patients
would be misappropriated." Also, most medical
professionals in India think they are too good to be
Udwadia agrees. "You require a general improvement
in ethical standards for this to come about. When this
does happen, specialist clinics for second opinions would
Bhanage expresses some hesitation: "It is virtually
impossible to get a genuine second opinion in private
practice where even the most senior doctors are very
insecure and distrustful of their colleagues. A second
opinion clinic will have to be manned by a senior doctor
with a reputation for integrity.
White sees a similar problem in the US. "Medicine
here has rapidly become a market commodity
(unfortunately, in my opinion). A physicians income
often depends on capturing market share from
other physicians. Thus physicians and hospitals engage in
extensive marketing and advertising, to steal
patients from others."
Can a member of the clinic reject the patients
request for treatment after he has attended the clinic?
Hemraj Chandalia feels that if a patient insists he be
followed up by the new consultant, "I will not deny
the patient such an option."
Bhanage cautions: "The medico-legal role of such a
clinic will have to be defined. I feel it will be
predominantly used by dissatisfied patients. Once it is
seen by doctors as a forum used by patients to obtain
evidence against them in a court of law, its role will
shrink to this purpose only."
in medical ethics -- Drs. H. S. Mehta and H. I. Jhala --
taught me the procedure to be followed when referring a
patient for a second opinion: a formal referral through a
telephone call making the appointment and a confirmatory
note also carrying a report on the patients medical
history, findings and precise reason for referral. I
believe it can only work in the patients best
interests. This practice was routine in Bombay some
decades ago. It can function with the strengthening of
the role of the family physician.
I fully agree that the consultant must send the patient
to the referring physician with a full report on
diagnosis and advocated treatment. Taking the patient
over when the referral was for an opinion is unfair,
immoral and unethical. However, where surgery is
indicated, the referring physician must always choose the
surgeon based on the single criterion of competence.
I recognise the need for patients to obtain a second
opinion, especially when a potentially hazardous form of
treatment such as surgery is advocated. Towards this end,
a second opinion clinic is to be welcomed, provided the
clinicians categorically state that they will not take
over the patients treatment.
Unlike Dr. Bhanage, I strongly support an additional
medico-legal role for those working in this clinic.
Current regulations require that the aggrieved patient
seeking redressal from a court obtains two independent
medical certificates on the validity of his claim,
without which the case will not be admitted for hearing.
Most doctors are reluctant to provide such certificates.
By analysing the patients case dispassionately and
providing such certificates when its experts are
convinced that a valid case has been made, the clinic can
help patients who have suffered from medical negligence
or malpractice. It can also support and help doctors who
practice ethically and conscientiously by testifying on
their behalf, thus helping frustrate frivolous or
malicious litigation and restore the fair name of the
I remain unsure on whether I should treat a patient who
is under the care of another neurosurgeon in Bombay,
without a referral being made to me. Whilst I recognise
the autonomy of the patient, I am also concerned about
the motives and outcomes of the current fashion for
doctor-shopping. I often see patients obtain
contradictory advice, experience delay in treatment,
ending up confused and impoverished. I make every attempt
at guiding the patient back to the original consultant.
Of late we have unreservedly accepted patients who have
come to the K. E. M. Hospital because they cannot afford
treatment in a private hospital. This seems to be an
ethically valid ground for taking over even without a
The clinician refusing to refer a patient elsewhere
deserves censure. He would be well within his rights to
terminate his relationship with the patient even as he
writes a detailed note of referral. As has been stated
effectively above, the interests of the patient must gain
precedence over his own feelings.
I am sorry that the doctor-patient relationship - one
that should be imbued with trust, friendship and an urge
to help - has degenerated into mere commerce. I have had
the good fortune of experiencing the ideal doctor-patient
relationship during my childhood and youth and can only
wish that we do all we can to restore it.
and colleagues who offered their views:
Dr. S H Advani,
chief, department of oncology, Tata Memorial
Arunachalam, visiting professor, department
of humanities and social sciences, Indian
Institute of Technology, Chennai
Barot PhD, department of sociology,
University of Bristol, UK
Bhanage, consultant neurosurgeon,
Dr. Ravi Bhatia,
consultant neurosurgeon, Apollo Indraprastha
Hospital, New Delhi
Blasszauer, medical ethicist, Medical
University of Pecs, Hungary
Dr. H B
Chandalia, consultant endocrinologist, Jaslok
Chinappa, consultant paediatrician, Manipal
Dr. B N
Colabawalla, consultant urologist, Mumbai
Dr. Homi M
Dastur, consultant neurosurgeon, Jaslok
Dr. Anil D
Desai, consultant neurologist, Jaslok
de Souza, consultant E.N.T. surgeon, Holy
Family Hospital, Mumbai
George, consultant, Orthopaedic Hospital,
Railway Hospital, Chennai
Dr. V R Joshi,
consultant physician, Hinduja Hospital, Mumbai
Macklin, medical ethicist, Albert Einstein
College of Medicine, New York, USA
Malpani, consultant in assisted fertility,
Mamdani, professor of medicine, Cook County
College of Medicine, Chicago, USA
Mamdani, professor of neurology, Chicago, USA
Robin and Robert McCauley, medical
Nundy, consultant gastrointestinal surgeon,
Gangaram Hospital, New Delhi
Mr. Harsh Sethi,
associate editor, Seminar, New Delhi
Dr. P K Sethi,
consultant orthopaedic surgeon, Jaipur
Sinh, consultant neurosurgeon, Jaslok
Dr. Prakash N
Tandon, professor emeritus of neurosurgery,
All India Institute of Medical Sciences, New
Dr. Farokh E
Udwadia, consultant physician, Breach Candy
Dr. Lawrence W
White, medical ethicist, Berkeley,
Dr. M S
Valiathan, vice-chancellor, Manipal Academy
of Higher Education, Manipal