Second Look at Second Opinions

Do they help reduce surgery, or increase it?

Each year about 20 million operations are performed in the U.S. Though surgeons claim that at most only 1% of these are unnecessary, some observers put the figure at more than 15%. Among the procedures said to be the most overdone: hysterectomies, tonsillectomies, gall bladder removals and operations on the the spine. To cut down on excessive use of the scalpel and, not incidentally, soaring medical-care costs, in the past few years federal agencies and insurance companies have been urging patients to get an independent second opinion whenever nonemergency surgery is recommended. Now comes the surprising suggestion that second opinions may actually be increasing the number of operations.

In a program offered to 6 million of their subscribers, Blue Cross and Blue Shield of Greater New York provide patients whose own doctors recommend operations with the names of three surgeons from whom a second opinion may be sought; the one chosen by the patient receives a $50 fee. Surveying the first 1,500 patients taking advantage of the program, Blue Cross found that in 70% of the cases, the second doctor affirmed the need for the operation. In the remaining 30% of the cases, moreover, only about half the patients were told they did not need surgery at all. The rest were urged to try some other form of treatment first or simply delay the operation pending the results of further tests. Says Steven Sieverts of Blue Cross: "We have come to believe that one of the consequences of our program is to decrease the number of people who do not follow their surgeon's recommendations for surgery. Because there are many more confirming opinions than nonconfirming ones, it seems logical to wonder whether the overall impact of the second surgical opinion program could actually be to increase the volume of elective surgery."

The Blue Cross survey appears to run counter to other studies, which have shown a decrease in surgery where second opinions were sought. In any case, say critics of the Blue Cross study, the key question is not the extent to which first and second opinions agree or disagree, but how many patients follow the advice they receive. For example, some patients decide to forgo surgery no matter how many opinions they get advising an operation. Whatever the effect of second opinions, the effort to promote them is not likely to be abandoned. Says Bruce Steinhardt, of the Health Care Financing Administration in Baltimore, which is now evaluating several programs: "They put information in the hands of consumers and help them make a better-informed decision."

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