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Little is known about what factors determine when a patient decides to seek a second opinion from an internist. The Canadian health care system, which places no responsibility for payment on the patient, allows a unique opportunity to assess such factors when financial influences are minimized. We hypothesized that in such a milieu patients with functional diseases might be more apt to seek a second opinion. In a university-based gastrointestinal unit we investigated how many of the patients, referred for the first time, were seeking a second opinion—i.e., a second consultation within 2 years of seeing a gastroenterologist. We compared the characteristics of 20 patients with 246 patients referred for the first time to a university-based gastrointestinal unit. All patients were interviewed at clinic registration, prior to seeing the gastroenterologist. Variables assessed included demographic characteristics, health care utilization within the last year, and perceived health status. A second questionnaire was offered to second opinion patients to determine (1) reasons for seeking a second opinion, and (2) whose decision it was to seek the second opinion. Following the interview, the patient's referring physician was contacted and asked identical questions. Both referring physician and gastroenterologist assessed every patient on a functional rating (FR) scale of 1 to 5 (with 1 being definitely organic and 5 being definitely functional). Patients who sought a second opinion were more apt to (a) have symptoms for >2 years (75 versus 41%, p < 0.01), (b) perceive their health to be fair to poor (90 versus 41%, p < 0.001), (c) fewer than two have seen general practitioners in the past year (50 versus 23%, p < 0.001) and (d) have spent >6 days in hospital in the last year (35 versus 12%, p < 0.01). There were no differences in the FR for either group. Second opinion referrals were generally patient-initiated rather than physician-generated. These patients either (a) believed that the original gastroenterologist had not spent enough time with them or (b) wanted a confirmation of the original diagnosis. There were no significant differences in costs of evaluating either group of patients.