A Second Opinion Isn’t Good Enough

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I’ve stewed over this for years, since 2013 when he was first arrested. But ever since Farid Fata was sentenced to 45 years in prison (ONLY 45!) for fraud, I’m like a dog with a bone. I just can’t let go.

dogbone

Last week I took at look at the Farid Fata case. He is the (former) oncologist who sentenced 553 people to their death or a lifetime of illness or financial bust by lying to them – telling them they had cancer they did not have, then treating them with chemo they didn’t need and ruining their lives. The 45 years he’ll spend in prison were not for the heinous crimes of destroying their health, instilling fear, breaking their hearts and stealing their hard-earned money. Rather he was penalized for defrauding Medicare and insurance.

Beyond the obvious disturbing and distressful aspects of this case, beyond my personal bias about misdiagnosis, and certainly beyond my real sympathy for the victims, is a big concern I have for advocates. Misdiagnosis, whether intentional or not, is happening with more frequency as doctors are spending less time with their patients. It is no stretch to see the responsibility for determination of a correct diagnosis as falling more squarely on the shoulders of advocates.

Despite the fact that we are not doctors or diagnosticians, our role in making sure clients get the right answers will become even more prominent as time goes on. For many reasons we can NOT afford to get it wrong!

Last week’s post was about the steps private advocates would have taken that would have prevented their clients from falling for these intentionally imposed misdiagnoses. Four steps. Four services advocates know to perform. Each by itself could have stopped a client-patient from being misdiagnosed.

But the bone I can’t let go of actually stems from a comment made by one of the post’s readers, Cindi, in reaction to one step – seeking a second opinion.

“Fata was many patients’ second opinion. He offered a better solution…. To assume none of his patients sought a second opinion is insulting…”

For one thing, it never occurred to me that Fata would have been the second opinion oncologist, and would have ended up treating people who had already received an opinion. It should have, but it had not.

But secondly, the more I think about it, that very fact proves that 

…a second opinion is no longer good enough.

I think we need a new regard for the second opinion, a more defined best practice, a higher standard of advocacy care. When a second opinion is called for, we must insist our clients seek an objective, second confirming opinion.

Let’s break it down:

Objective

One thing we know is that doctors are human beings who, like all human beings, have friends and colleagues and professional regard for each other. Ask any doctor and he or she will tell you that “other doctors” (because they don’t consider themselves fallible enough to do this themselves) will rarely contradict their friends or colleagues.

Further, there is confirmation bias. That is, that the suggestion of an answer or solution cements that same answer or solution in a second person’s mind. This is further affected by how much respect (or fear) doctor #2 has for doctor #1, or even how lazy doctor #2 is, or how much of a hurry he or she is in.

(I can also tell you from personal experience that this takes place even in labs. In my own story, the specimen ( a lump) removed from my torso was sent from lab #1 to lab #2 for a “second opinion.”  Lab #2 simply regurgitated the wrong answers from lab #1’s paperwork.)

We have to wonder how many of Fata’s misdiagnosed patients actually went to a second oncologist and were given the same information, the same misdiagnosis, because the second oncologist was either a friend or colleague, or found it just easier for whatever reason to confirm that misdiagnosis?

This points out the need for objectivity in a second opinion – finding a second opinion professional who has no relationship whatsoever to the first opinion professional. In appropriate cases (potential cancer, or lifelong debilitating diagnoses, or recommendations for surgery, etc) as advocates, we must be sure that our clients see an objective second person for an opinion – a doctor who lives and works in another location, who doesn’t practice within the same health system, whose kids don’t play on the same school teams or who don’t go to the same church or temple or mosque. If that means we must find a doctor in another city, or on the other side of the state – or the country – then – we must. 

Because not insisting on that objectivity is at least a waste of our clients’ time, and possibly money. At worst, it may be limiting them to wrong answers which will lead to wrong treatment, which can have a harmful effect on their quality and quantity of life, harm that could have been prevented.

Confirming: 

Knowing those 553 people didn’t have cancer, no matter whether Fata’s misdiagnosis was the first or second opinion – his opinion must have been a different opinion.

(Or was it? See “objective” above.)

In the perfect world, a patient would see two unrelated (objective) doctors and get identical answers about diagnosis and treatment options; confirming information that would allow him to make the right decisions for himself based on that now-confirmed information. If testing was involved, then the tests would be accurate, and their results would be easily viewable, too.

If a second opinion is that cut and dried and was known to be as objective as possible, then the advocate’s second opinion support job is done.The diagnosis is confirmed.

But we don’t live in a perfect world and rarely is it that simple.

A second opinion that is not the same as the first one calls the question “which one is correct?”  And since there is no second, confirming opinion, the job is not done. The correct answer hasn’t been achieved. The patient-client needs to get a third opinion, in hopes of confirming one of the first two. And it needs to be sought from someone who is professionally and personally removed from the first two to be sure it’s objective.

Still not confirmed after three opinions? Then it’s time to look for a fourth. Because no one can know which of the first three is the right one. The patient can’t simply choose the one he or she likes the best!

The patient may need multitudes of opinions. But only two of them need to agree. THAT is the second, confirming, opinion.

goldstandard

The New Gold Standard

This is the new gold standard in advocacy: helping our patient-clients find objective, second confirming opinions.

To be clear, it’s not that I’m trying to prevent a redux of this Fata case. I can’t imagine in my lifetime a second Farid Fata anymore than I can imagine a second Ted Bundy or John Wayne Gacy.

No. This is about understanding what it’s like to be misdiagnosed and have one’s life totally upended because of it. It’s about making sure misdiagnosis, one of the most preventable of medical errors, is routinely uncovered so patients-clients get what they really need.

What do you think?  As advocates, are we willing to begin promoting, and overseeing a new standard of diagnostic determination? 

Are you willing to say that for all appropriate clients, you will insist on helping them seek an objective, second confirming opinion?

I think you must. Because to do any less puts their lives – and our profession – in jeopardy.

Find additional posts about the Farid Fata case and patient advocacy:

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Photo: “Do not take his bone” by David Shankbone – David Shankbone. Licensed under CC BY-SA 3.0 via Wikimedia Commons

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Comments

  1. Martine Brousse  July 20, 2015

    As a billing manager for a busy oncologist for several years, I can attest that more patients than none are already seeking a second opinion when the C diagnosis is first given them. I know of a number who had up to 5!

    while every such patient should meet with another oncologist, the problem most often lies with the pathology results. Oncologists take the pathology report at face value, except in rare instances: the results are out of line with previous findings, are inconclusive or the pathologist is not trustworthy.
    WHAT CANCER PATIENTS MUST ASK FOR IS A SECOND READING OF THEIR PATHOLOGY SAMPLES TO CONFIRM DIAGNOSIS, STAGE AND TYPE. It is their right under the ACA, and the insurance must cover it.

    This scenario happened to a friend of mine, diagnosed with breast cancer after a biopsy, who had a mastectomy. Before beginning chemo, she and her oncologist had the samples re-read to further map the type of cancer cell, and it turns out she did not have cancer. Good news, although she went through months of recovery for an unnecessary surgery!

    There is already another system in place to double-check any chemo order, via the authorizations process at commercial insurances. Specialized nurses or MDs review the medical records and must agree that the prescribed treatment is (1) medically necessary, based on the pathology and imaging reports (2) up to the standards of medicine per the Compendia, the “bible” listing every cancer and treatments (3) up to FDA regulations for the prescribed dosage, frequency and number of cycles before an authorization is given.
    What is truly unbelievable to me, is how did these patients’ insurances allow and pay for these treatments, without a pathology report confirming the diagnosis and mapping the type of cancer and without regular imaging reports showing whether treatment was effective? No insurance would allow payment after the normal run of an established regimen, without going through the authorization process again. Trust me, the longer the patient is under treatment, the harder it is to get a new authorization, especially for non-generic drugs!

    Unless all of these patients had straight (non advantage) Medicare.
    Medicare does not require authorization before chemotherapy, the right diagnosis code on a claim form is enough to get payment within 14 days. (In CA, Medicaid will require records before authorizing a treatment).
    For these patients, the review process was non-existent.

    But this story also implies that someone at that office knew how to get around the very complicated oncology coding, and how to get paid for years of treatment. It is not possible to give chemo for years without changing diagnoses, altering medical records, faking imaging reports, and being extremely intimate with the types of chemo regimens available as a condition goes from an early stage to final stages, as would be the case for treatments over a number of months, or failing to get cured.
    This level of sophistication implies that either this so-called Dr did not act alone, or that his staff, especially nursing and billing, bears responsibility for knowing and not saying anything. Quite sinister an implication…

    I would definitely recommend that any patient given a cancer diagnosis be referred to a second opinion, but also thoroughly do research on the pathologist and oncologist. Check with the State’s medical association, whether any disciplinary action was ever taken for errors, or whether malpractice suits had ever been filed.
    If possible, ask the oncologist or the facility holding the frozen samples to arrange for transfer and reading by an outside pathologist.
    The insurance must coordinate this process upon request by the member, and should either pay at the in network rate for a non contracted provider, or have an in network provider perform the service.

    This case is the exception, however the lesson to only trust any report, physician, diagnosis to a point should be communicated to our clients. After all, would you blindly believe what a mechanic, home contractor or plumber would say without further questioning, or would you want confirmation that the problem is indeed as extensive and expensive as they make it to be? Why would anyone’s health be subject to lower standards?

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  2. Sydney Zaremba  August 30, 2015

    Fata did lie about everything to everyone. The 553 were not all misdiagnosed. many were over treated, treated inappropriately or told they had one kind of cancer, when they had another. He was evil of the purest kind. I totally agree that someone should have noticed. In fact, many were medicare patients, so as Martine mentions, authorization was not required prior to chemo. Maybe that needs to change since the elderly are vulnerable as it is. A lot must be done to change things. We hope to advocate for enhanced legislation and changes that help to prevent this from ever happening again.

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  3. peggyrcc  September 8, 2015

    Thanks for this article, and for the responses. I am new to Medicare, though not to cancer, and could not understand how people were getting the sheer number of treatment through Fata that were mentioned in several news articles.

    This is an issue that must be addressed in an objective and careful way, so as to protect patients from this type of criminal, while providing some flexibility in giving chemo and related treatments. As we find more about the various subtypes of cancers, which can drive treatment choices beyond the tumor-based data, this will be increasingly important, yet more difficult for patients.

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