The relationship between a patient and a doctor is based on trust—the implicit contract that the patient in need of help comes to the physician and the physician will take care of his or her patient, putting that patient’s needs foremost and applying all of his or her skills and wisdom to do what’s best for that patient.
Getting a second opinion somehow seems to strike at the heart of that relationship. It says that you, the patient, are not sure, not comfortable, not fully trusting of the advice you have been given. And, yet, there are a number of situations where a second opinion is not only advisable, it should be almost automatic.
Although physicians usually know a lot more about your problem than you do (after all, that’s why you’re there!), they may not know everything. Further, physicians are human—their opinions are influenced by what they know and what they believe, as well as by their personalities and areas of interest. So, after 20 years of monthly contributions to Classical Singer, I hope you will indulge me if I get a bit opinionated on this important topic.
Remember that, as a patient, you are in a psychologically vulnerable position. You are looking to be taken care of, looking to believe that your problem will be solved by your doctor. You tend to believe what you are told, to accept the treatment you are given. This paradigm is generally helpful, since it enhances the efficacy of your treatment. I have always said that the psychological benefits of medicine (also called the placebo) are a positive force and often help the overall outcome of the treatment. But being open, even somewhat gullible, may leave you in an noncritical frame of mind—and not necessarily able to judge whether your diagnosis and the proposed treatment are right and best for you.
Most singers have ENTs with whom they are comfortable—doctors who are experienced, caring and effective. If you have one of these, don’t change! Enjoy the services of a professional who does his or her work well and puts you and your well being foremost. However, I would like to give you examples of situations where second opinions might be advisable. Just keep in mind that, however your visit went, the purpose of the exercise is not whether you liked the doctor, but to make sure that you get the best treatment for your larynx, your voice, and you.
Two weeks ago a patient consulted me for a second opinion. She was a little hoarse—and a lot confused. She had seen another laryngologist, who referred her to “another doctor in the practice.” This second “doctor” scoped her. I don’t know what was said, but this is what the patient heard: “Your larynx is four times the normal size.” My examination showed mild swelling of the vocal folds. After some phone calls, I found out that the endoscopist was not an MD but a physician’s assistant, an employee of the laryngologist. The assessment was not only completely incorrect, but confusing and alarming.
There should be a special circle in Dante’s Inferno for doctors (and their employees) who unnecessarily frighten singers (or anyone). The patient, already concerned, is looking for reasonable reassurance and not false alarm. And when that alarm is raised with the intent to further frighten, it should be an actionable offense.
So, beware the anxiety makers. Every month I see patients who have been told, “You have burned your vocal folds with stomach acid.” This is absolute rubbish! You cannot “burn” your vocal folds with acid unless you are inhaling gastric contents while vomiting. Even in the worst cases of severe and symptomatic Gastroesophageal Reflux Disease (GERD), the vocal folds are no more than a bit inflamed, except in the rare case of a vocal fold granuloma.
A lesser version is “Your cords are fiery red.” Again it is rare for vocal folds to be fiery red. Even in cases of acute laryngitis, the problem lies not with the vocal folds but with abnormal posturing due to inflammation of the pharyngeal walls. Another variation on the theme is “This is the worst case of . . . I have ever seen.” This is hyperbole in the service not of you but of the physician seeking to impress an already frightened patient.
Yet another “second opinion” situation is where you are told the doctor is the world’s expert in diagnosing a condition, or that he or she is the only one who can treat your problem. If a doctor always or frequently makes the same diagnosis—especially one that doesn’t fit the clinical picture or does not improve within a reasonable amount of time and diagnosis-appropriate treatment—maybe that wasn’t your problem in the first place!
Let’s face it—some laryngologists are better, whether in diagnosis or treatment, than others, but no one is “the world’s expert” at anything. The good news is that in this age of Google and social media, you can do some research both on your condition and your doctor. You will usually find that your doctor is a good one, but likely just one of several physicians who are qualified to help you with your problem.
Yet another situation to consider is when you are shown video images of minor abnormalities and advised to have them surgically treated. Your questions to the doctor should be “Is this what is causing my vocal problems? Can you reasonably assure me that removing this bit of tissue will alleviate my vocal difficulties?” Keep in mind that laryngeal surgery in singers is not cosmetic, but functional. You must always consider vocal fold surgery in context of what your vocal problems are, what your vocal needs are, and how confidently you and the doctor can correlate what you see on the video screen with what you are hearing and experiencing when singing.
A final, and particularly egregious, example is when a doctor says you need surgery “right away.” Are there situations where this is true? Sure. In the field of laryngology, they include impending airway obstruction, cancer, or an abscess—really not much else. But this advice often comes as part of the one-two punch of “you have the worst case of . . .” and “you need immediate surgery.” The reality is this: in the treatment of benign voice problems in otherwise healthy singers, very little needs immediate surgery. At least not surgery that cannot wait for a second opinion.
Some patients are hesitant about getting second opinions—they like and trust their physician and do not look to be confused by another doctor. And, anyway, is that second opinion always correct? Of course not. You are dealing now with another physician who will give an independent assessment of your problem. Human nature being what it is, your second laryngologist may give a different opinion than the first. Why? There are often different ways of looking at, and managing, problems, and as physicians we all like to be smarter than our colleagues.
So my advice is this: don’t discard either opinion, but consider both, and possibly a third, before deciding on a course of treatment—particularly if the treatment is long term, expensive, or surgical.
