5 Diagnoses That Call for a Second Opinion

or if there's any
question about whether it's truly cancer -- seek a second opinion from a
pathologist who has expertise in diagnosing this type of malignancy. After all,
the diagnosis will determine which treatment is best.B B

"There are certain kinds of tumors that provide a lot more difficulties
in diagnosis," says John E. Tomaszewski, MD, FASCP, vice chairman of
Anatomic Pathology-Hospital Services at the University of Pennsylvania School
of Medicine. For example, sarcomas -- an uncommon cancer of soft tissues, such
as muscle or fat -- can be complex to classify. "A general pathologist may
not see a lot of soft-tissue tumors," he says.

Major medical centers that see larger numbers of rare or unusual tumors are
often a better choice for a second opinion than a smaller hospital, according
to John S.J. Brooks, MD, FASCP, president of the American Society for Clinical
Pathology. "These folks that have very rare tumors, [a hospital] near them
may only see very few," he says.B

Getting that second opinion can help catch errors.

"Anytime there's uncertainty, it's always fine [to get a second
opinion]," Tomaszewski says. "Pathology ... is like every other area of
medicine. There are things that are very clear and things that are on the
borderline."

2. ADHD in Children Under Age 6

With no specific lab test for attention deficit hyperactivity disorder
(ADHD), the problem can be tough to diagnose accurately. A doctor's judgment
comes into play; he or she may diagnose ADHD if a child shows hyperactivity,
inattention, and impulsivity in at least two settings, such as home and
school.

When a child under age 6 is diagnosed with ADHD, parents may want a second
opinion from a specialist, such as a child psychiatrist, says Sara Rizvi, MD,
assistant professor of pediatrics at the Baylor College of Medicine. That's
because ADHD symptoms, such as too much talking or fidgeting, can overlap with
behavior that's typical among young children.

"Many of the symptoms are common among preschool children," Rizvi
says. "Part of it is because of their developmental stage and level of
activity and normal short attention spans." A second opinion can help
determine if symptoms are serious enough to be classified as ADHD.

It's also crucial to rule out other mental disorders that can be confused
with ADHD, according to Rizvi. These include developmental problems, learning
disabilities, anxiety, and depression. Sometimes, children who witness domestic
violence may behave in ways that suggest ADHD, Rizvi says. "They tend to be
more inattentive to their class work, more impulsive. A lot of those children
are actually misdiagnosed with ADHD when in fact they may be manifesting
symptoms of posttraumatic stress disorder."

3. Parkinson's Disease

"Parkinson's is one of the most difficult diseases to diagnose. There's
no blood test, X-ray, or instrument that would give you an answer," says
Executive Director Robin Elliott of the Parkinson's Disease Foundation.

Diagnosis of this neurological disorder -- marked by tremors, slow movement,
muscle stiffness, and loss of balance -- is based "not on a very specific
test, but a cluster of features," says David C. Dale, MD, president of the
American College of Physicians. Parkinson's can be especially difficult to
diagnose in the early stages.

The rate of misdiagnosis among people with Parkinson's may be as high as
25%-30%, Elliott says. In the elderly, the trembling and movement problems of
Parkinson's may be dismissed as normal aging. Conversely, patients may be
wrongly diagnosed with Parkinson's when their symptoms actually stem from side
effects of drugs they're taking, such as certain psychiatric
medicines.B

Even well-trained internists and general neurologists can have trouble
diagnosing Parkinson's disease, especially if they've had little experience
with the disorder, according to lliott. As a result, the Parkinson's Disease
Foundation suggests that people diagnosed with Parkinson's consider getting a
second opinion from a neurologist who specializes in movement disorders and has
extensive experience with Parkinson's.B

4. Heart Procedures

What prompts heart patients to seek second opinions?

"Probably the most common situation is that someone has been advised to
have open heart surgery or a coronary intervention or a catheterization, and
they're wondering if they really need that," says David L. Rutlen, MD, vice
chairman of ambulatory programs at the Froedtert and Medical College of
Wisconsin, which has a cardiac second opinion program. In other words, patients
want extra advice before consenting to invasive heart procedures that carry
serious risks, such as blood clots, stroke, infection, and even death.

A second opinion makes sense "if the patient has any concern that this
is a treatment plan that may not be best for them," Rutlen says. For
example, patients may wonder whether they truly need bypass surgery or if,
instead, they can undergo balloon angioplasty to open up blocked arteries.

Some patients also seek out a second opinion in hopes of finding an expert
with greater experience in performing the procedure they require, Rutlen
says.

Also, if a patient remains undecided after the first cardiologist has listed
multiple treatment options, "a second opinion from another cardiologist
would be an excellent consideration," Rutlen says.

5. Depression and Bipolar Disorder

Primary care physicians often diagnose cases of depression, but sometimes a
second opinion from a psychiatrist is in order.

If patients diagnosed with depression don't improve after trying at least a
couple of antidepressants, or if they develop adverse effects, such as mania,
they may actually have bipolar disorder, says Florence Kim, MD. She is a
psychiatrist and director of the Menninger Clinic's Comprehensive Psychiatric
Service, where patients can obtain psychiatric second opinions.B

Why do the two disorders become confused? Some patients with bipolar
disorder -- also called "manic-depressive illness" -- don't have a
manic episode early on, so it's easy for doctors to mistake the two diseases.
In fact, patients with a less severe form of bipolar disorder may never develop
intense mania, but instead have milder manic episodes that alternate with
depression.

In fact, as many as 69% of bipolar patients may receive a wrong initial
diagnosis, according to Mark Graber, MD, chief of the medical service at the VA
Medical Center in Northport, N.Y. Graber has done research to find ways to
reduce diagnostic errors.

A proper diagnosis matters. Doctors treat depression with drugs such as
antidepressants, while bipolar disorder typically requires mood stabilizers,
such as lithium, either alone or in combination with antidepressants. When
bipolar patients take antidepressants alone, they're at risk of switching into
mania or developing rapid cycling between the highs and lows.

"I'm actually all for psychiatric intervention in the primary care
setting," Kim says. "I think it's perfectly reasonable to try an
antidepressant, but people just have to be educated. They have to know that if
they're having adverse effects to the medication that they should see a
psychiatrist. Or if they do start to feel manic effects from the
antidepressants, they should see a psychiatrist."B B B

But some patients balk, Kim says. "You almost have to hit them over the
head to go to a psychiatrist. They would rather tough it out with their primary
care physician because that way, they don't have to tell people they have
psychiatric problems."

By Katherine Kam
Reviewed by Louise Chang
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