Pros and Cons of Getting a Second Opinion Online

When Vo Clark learned that his wife, Marilyn, had a rare form of cancer called leiomyosarcoma, he did what millions of other Americans do when they want to learn more about health options—he turned to the Internet. During one of his searches, Clark stumbled across a Web site called Partners Online Specialty Consultations, an online second-opinion service offered by the Harvard-affiliated physicians at Massachusetts General Hospital, Brigham & Women's Hospital and Dana Farber/Partners Cancer Care. Since Marilyn's doctors had admitted they didn't have much experience with treating her disease, the Web site was a welcome find. "I know there's a lot of junk on the Internet, but sometimes you hit a gold mine," says Clark, a retired engineer who lives in San Diego. "Even though we're across the country, I found a way to tap into the minds of a bunch of experts. It's pretty amazing."

Though the online second-opinion market currently comprises only a fraction of the patients seeking information about diagnoses and treatment options for various health problems, it's likely to be a growing trend. "These services are a precursor of things to come," says Jonathan Linkous, chief executive officer of the American Telemedicine Association. "Medicine is slow when it comes to adopting technologies that aren't directly related to patient treatment. But what we are seeing is a move toward greater consumer convenience and consumer control. If patients start to demand it, doctors and hospitals are going to have to find a way to comply."

While many large health-care systems provide telemedicine options for their international patients, only a few provide online domestic second opinions. But those that do are heavy hitters, and with their second-opinion services, they cover nearly every specialty and diagnosis. Partners Online Specialty Consultations has done roughly 5,000 domestic consults since it began nine years ago. The Cleveland Clinic's MyConsult program, which started eight years ago, has provided about 1,700. Johns Hopkins, which has a robust international online consulting and second-opinion service, offers online second opinions in gastroenterology and hepatology for domestic patients. That program has done only about 50 consults, but Hopkins may expand its domestic second-opinions service in the future, says Minilla Kanwar, operations manager for Johns Hopkins Medicine International. The Mayo Clinic is "ramping up" its efforts to enter the space, says pulmonologist Dr. Eric Edell, medical director of the clinic's Internet Services, and he's pretty excited about the prospect: "I'm an average doctor, but practicing at Mayo, I become a superdoctor, and that's because of collective knowledge. And as medicine becomes more integrated, through technology advancement, we'll see more sharing of that collective knowledge."

But experts don't come cheap. Second opinions done the old-fashioned way are normally covered by medical insurance. The online second opinion, however, is still largely an out-of-pocket expense, with prices ranging from $550 to as much as $1,000 if doctors need to look at radiology and pathology tests. Insurance giant Cigna does cover online second opinions with the Cleveland Clinic for certain patients, and if patient interest continues to grow, other insurers may re-evaluate their policies.

Though the programs are all in the business of giving second opinions, they do operate somewhat differently. The Cleveland Clinic, for example, does not require a referring physician and will send recommendations directly to a patient and his local doctor, if requested. If the patient lives in a state that requires a referring physician, the Cleveland Clinic site guides him through the process of getting a referral. Partners' service is more physician-to-physician, requiring a referral, as does the Hopkins program. Both the Partners and the Cleveland Clinic programs have dedicated staff members to assist patients if they have questions or problems. Another challenge for patients is that local medical boards regulate the online services, and not every board has jumped on the bandwagon. If you live in Guam, North Dakota or California, you are excluded from remote second opinions from the Cleveland Clinic. Patients in Oregon, Iowa, Louisiana, South Carolina, Tennessee and certain U.S. territories currently can't use Partners' service. But in the future, these regulations are likely to change to keep up with technology, says the American Telemedicine Association's Linkous.

While the idea of tapping into the knowledge and expertise of specialists at well-respected and renowned medical centers is appealing, the process can be cumbersome. It's important to provide the consulting physician with everything she needs to assess your case, and gathering the necessary medical records can involve calls and visits to several of your providers' offices. Once you have gathered the information, getting it to the service isn't that tough, since the records can be e-mailed, faxed or mailed. Typically, you'll get an opinion from your online doc in about 10 business days—patients or their doctors are notified via e-mail that the report is ready, and can then view it online at a secure Web site. But just because you get an opinion from an online doc doesn't mean you become that doctor's patient. The Cleveland Clinic estimates that only about 5 percent of people using its service actually switch doctors after receiving an online second opinion. Changes in the diagnosis are uncommon, but do happen. The consulting docs most often recommend changes in treatment plans, such as medication increases, different drug regimens, surgical alternatives or no surgery at all.

That's what happened when Susan Walaska decided to seek an online second opinion. In her 40s, Walaska was diagnosed with a common heart condition called mitral valve prolapse, which often requires no treatment except routine examinations. In some cases, medication is used. Last summer, during a routine checkup, her local cardiologist told her she required surgery. "I was absolutely terrified," says Walaska, a 59-year-old education consultant from North Liberty, Iowa. "I was feeling fine, and I just didn't understand why surgery was recommended. I had absolutely no confidence in the treatment plan."

As she was cruising the Internet looking for information, Walaska came across the Cleveland Clinic's site and decided to get a second opinion. "To be honest, my doctors didn't discourage me from getting a second opinion, but they didn't actually encourage me either," she says. She believes her persistence paid off. Based on her medical records, the Cleveland Clinic's heart doctors told her that she didn't require surgery, at least for now. "I was absolutely thrilled," says Walaska. The hardest part of the experience was collecting her medical records. But once she got through that, "I felt empowered," she says.

Doctors seem to enjoy the process, too. Not only is it sometimes more efficient than an office visit, but it also helps them reach more patients in need. Like many specialists, Dr. George Demetri, director of the Center for Sarcoma and Bone Oncology at the Dana Farber Cancer Institute, gets many unsolicited e-mails from people asking for help. "Medicine is in the details, and you can't give an opinion when those details are lacking," he says. There is also the thorny issue of whether an e-mail response from a doctor to an unknown individual is even legal or ethical. "As a physician, you want to help as many people as you can," says Demetri. "Now [with Partners Online Specialty Consultations] we have a controlled way to provide our expertise to patients and their doctors no matter where they are. It just makes good sense."

The American Medical Association doesn't oppose online second opinions, but it does say in-person visits offer more benefits. "There is nothing that really beats having a doctor see you and examine you," says Dr. Joseph Heyman, chair of the AMA board of trustees. Joseph Kvedar, founder and director of Partners Center for Connected Health, acknowledges that online second opinions have their limits. "We aren't providing the whole care package," he says. "An online second opinion doesn't replace the caring part of medicine; it's much more technical. That's why we are so keen on having a local partner."

But for the Clarks, who are united in battling Marilyn's rare disease, having choices is what matters most. Their local doctor and the Partners expert agreed that a chemotherapy regimen was a good idea to help battle Marilyn's cancer. Though the two parties agreed on the drugs being used, the online doc recommended waiting until another tumor appeared before starting that regimen. But Vo and Marilyn decided that they wanted to be "aggressive" and went ahead with the local doctor's recommendation. Right now, Marilyn is doing fine. But as they continue their battle with cancer, they will go back online for a "second, third and even fourth opinion," says Vo. "Getting this second opinion and getting hooked up with the best minds in the country makes us feel good. It makes us feel strong." Despite all the technological advances in delivering health care, that may be the best medicine of all.

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