Them no-good two-timin' patients

When patients and oncologists get off on the wrong foot, second opinions are inevitable. But sometimes breaking up is hard to do

By Wendy Banks

Volodymyr Szymczuk, recently diagnosed with prostate cancer, has arrived at his first appointment with his oncologist. His son, David, is in tow with a long list of questions culled from a men's health website. The oncologist has a schedule that's booked solid for the day, and has about 10 minutes to present Mr Szymczuk with his recommendations for treatment. Nobody's opened their mouth yet, and already the they're off to a bad start.

The doctor begins explaining what kind of cancer Mr Szymczuk has and how far it's advanced. David interrupts with a question about additional tests. "I'm getting to that," the doctor replies. David asks the question again. The oncologist sighs and explains briefly.

By the end of the 10-minute appointment, he has explained about two-thirds of what he meant to and Mr Szymczuk and David have asked just three of their 30 questions. The atmosphere in the room is adversarial; both doctor and patient are frustrated; neither feels listened to.

"Dad," says David, as they exit the waiting room, "I think you need a second opinion."

LASTING IMPRESSIONS
Requests for second opinions are rare in Canada, according to Dr Andrew Maksymiuk, Director of Oncology at CancerCare Manitoba, but when they occur, it's often due to a breakdown in the relationship between specialist and patient. "The way the system is organized, it's not easy for people to ask for a second opinion," he says. "But the most common reason is a personality conflict between the specialist and the patient. What people expect when they see a physician is someone they can trust and relate to, and sometimes there are problems with that."

He notes that family physicians tend to have more of a long-term relationship with patients, so if they don't like each other, there's always the possibility of rupturing the relationship. "But a specialist doesn't have that luxury. You get what's referred to you — and personalities don't always mesh." In a field like oncology, where stakes are high and care can continue for years, this can be a serious problem. "You have to deal with disappointments sometimes, challenges, toxicities," says Dr Maksymiuk. "If the patient's starting to have problems with the relationship, they sometimes will ask for a change of doctor or another opinion if they don't like what they hear."

Working in a large institution, Dr Maksymiuk says transferring a patient to another doctor isn't a financial worry, it's a logistical one — oncologists are busy people. Emotionally it can be tough too. "It can be a bit of a disappointment, a discouragement," he says. "It's a sign of failure, in some ways, that you haven't been able to satisfy a need that's there."

GOING SHOPPING
The way medicine is practised has changed a lot — it's now almost a client/service-provision arrangement, according to Dr Maksymiuk. "People seem to take it less seriously than they used to — they go doctor shopping," he says. That change tends to mitigate specialists' feelings of discouragement. "A lot of specialists will look at a patient who asks for a second opinion, and say to themselves, 'Well, I'm probably better off not to have to deal with that person,' " he says. The main problem, then, is the guilt the specialist feels palming a difficult patient off on a colleague.

Another by-product of second opinions is medico-legal concerns. "People worry about litigation, and when a patient asks to see another doctor, that raises red flags," says Dr Maksymiuk.

And then there's the old 'squeaky wheel syndrome.' "Some people are happy in a Volkswagen, and other people aren't happy in a Cadillac."

When it comes to things running smoothly, family doctors have an extremely important role to play. Explaining what patients can and can't expect from an appointment with a specialist beforehand can help a lot. "Education is very important. There's a lot of ignorance out there about the difference between specialists and family doctors," observes Dr Maksymiuk. "It's best for a patient to go to a specialist, get the thing done, and then go back to the family doctor for the positive relationship."