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Policy on Second Opinion for Pediatric Oral Health Care

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that second opinions are one avenue for additional information regarding health care issues. Parents frequently seek additional information and/or other opinions in order to address their child’s health care needs and make informed decisions. This policy is intended to provide guidance regarding what should be obtained and documented when providing a second opinion, as well as ethical and legal obligations involved in the process.

Methods

This policy was developed by the Council on Clinical Affairs and adopted in 2010. This document is based on a review of the current dental and medical literature related to the concept of second opinion in dentistry and medicine. Electronic searches were conducted using the terms: second opinion, medical second opinion, and dental second opinion. Documents relating to principles of ethics of dental and medical organizations also were reviewed.

Background

Patients today are more informed about their medical and dental problems and treatment options and are playing an active role in decision making with their doctors. Medical and dental knowledge and available treatment options are evolving at a rapid pace. As a result, patients and health care providers are seeking second opinions so that more informed decisions based on the risks and benefits can be made regarding the patient’s health care.

For minor health problems, second opinions usually are unnecessary. However, a second opinion is recommended if the patient disagrees with or questions the diagnosis or the treatment plan of the health care provider, has multiple medical problems, or is diagnosed with a life-threatening disease such as cancer. Second opinions also are recommended when there is no improvement in the patient’s condition, when there is a communication barrier between the patient and the provider, and when extensive oral care needs or high cost may make treatment prohibitive. For health care practitioners, a second opinion or referral may be warranted if they are unsure of the diagnosis or the diagnosis/treatment is beyond the scope of their expertise. Furthermore, a second opinion may be necessary when required by a third-party payor.

There is a debate among health care providers about whether to provide a patient with a blind second opinion (i.e., when medical/dental records, test results, and first provider’s opinion are not made available to the second provider) or if the patient’s diagnostic information and diagnosis should be shared with the provider giving the second opinion. The advantage of the blind second opinion is that it cannot be influenced by previous information. The provider will develop his/her own unbiased opinion. The disadvantage is that the provider performing the second opinion may have to repeat diagnostic tests and the patient will incur additional costs. The second provider may not be able to explain to the patient why his/her opinion is different without knowing the patient’s previous history and the basis of the first provider’s opinion. A third option would be to provide test results, radiographs, and other information without the first doctor’s written diagnosis and treatment recommendations. This would allow for an unbiased opinion without having the patient incur unnecessary charges or radiation exposure from repeated radiographs.

When presented with requests for second opinions, practitioners should consider the legal implications of such requests. Health care providers rendering second opinions unwarily could be involved in litigation, either on behalf of the patient or in defending themselves against other practitioners, as a result of the consult. The fact that one is the second or third professional consulted does not mean that the provider is exempt from liability.1  A dissatisfied patient could file a lawsuit naming not only the treating doctor, but also the doctor rendering the second opinion as defendants. In addition, a colleague who believes his or her professional reputation has been damaged by statements made to a patient during a consultation could file a lawsuit for defamation of character. Patients should be advised of their health status without disparaging comments about their prior treatment or previous provider. 

Policy Statement

The AAPD recognizes that:

  • A patient has a right to a second opinion. A provider who is trained and experienced in diagnosing and treating the condition should provide the second opinion. Internet sites or a telephone conversation cannot be relied upon and should not constitute a second opinion.2
  • A health care practitioner has the right to request a second opinion from one or multiple practitioners/ specialists as deemed necessary to facilitate the optimal clinical outcome.3 
  • Educating the patient regarding the diagnosis and available treatment options, including their risks and benefits, should be the goal of a second opinion consultation. Health care providers may disagree on the best treatment for an individual patient. Any opinion should be rendered only on careful consideration of all the facts and with due attention given to current and previous states of the patient. Instances of gross or continual faulty diagnosis or treatment by other providers may require that the provider be reported to an appropriate reviewing agency as determined by the local component or constituent dental society.3 
  • A provider has the ethical obligation on request of either the patient or the patient’s new provider to furnish records, including radiographs or copies of them. These may be beneficial for the future treatment of that patient.3 Health Insurance Portability and Accountability Act (HIPAA) privacy rules4 and state laws apply to all exchanges of health care information.
  • Second opinions may be mandatory by third-party payors. The provider should be independent and the opinion should be based on best outcomes for the patient and not financial incentives.
  • Most second opinions are voluntary. It is the responsibility of the patient to check with his/her insurance carrier for specific policies and benefits regarding coverage of second opinions.
  • When presented with requests for second opinions, practitioners should consider the legal implications of such requests. Patients should be fully advised of their health status without disparaging comments about their prior treatment or previous provider

References

  1. Machen DE. Legal aspects of orthodontic practice: Risk management concepts. Am J Orthod Dentofacial Orthop 1990;93(3):269-70.
  2. U.S. Department of Health and Human Services, Office on Women’s Health. How to get a second opinion. Available at: “http://www.womenshealth.gov/publications/our-publications/second-opinion-how-to.pdf ”. Accessed August 23, 2015.
  3. American Dental Association. Principles of Ethics and Code of Professional Conduct. With Official Advisory Opinions Revised to January 2010. Chicago, Ill. Available at: “http://www.ada.org/en/about-the-ada/principles-of-ethics-code-of-professional-conduct”. Accessed August 23, 2015.
  4. U.S. Department of Health and Human Services. Health Information Privacy. Available at: “http://www.hhs.gov/ocr/privacy/”. Accessed August 23, 2015.