Risk tolerance in the NHS will lower further if second opinions are made routine
Dear Editor,
It is saddening to read of the case of a group A Streptococcal infection in a young child, and the Senior Coroner Mary Hassell’s opinion that a second opinion could have saved the child’s life.
I find it troubling that the only solution to missed diagnoses is a second opinion, and the presumption that a physician or diagnostician must have made an error when an incorrect diagnosis or management plan is made.
In making diagnoses and management plans which correlate with the wider health economics of the NHS, there must exist some degree of risk-taking, and a single or even group of cases of a missed diagnosis does not constitute a sound or deductive argument that there is a “lack of appropriate diagnosis”, as stated by the Coroner.
Management plans made in the Emergency Department and in General Practice must consider the cumulative outcome risk of all differential diagnoses. Without significant investigative burden, the negative predictive value of the diagnostic data is rarely 1. Therefore, if diagnosticians are willing to take any risk to spare patients investigation, admission, or treatment, it is inevitable that some diagnoses will be missed when the whole population is considered.
Furthermore, it is not correct to assume that a second opinion necessarily increases the accuracy of diagnosis. Given the same data, diagnosticians are likely to consider the same differential diagnoses and their management plan will depend more on their experience and risk willingness. Where there is a request for a second opinion, it is likely that the diagnosis and management plan made with the lower risk willingness will take precedence, especially if the management plan correlates with the wishes of the patient or individual requesting a second opinion. This will bring down the sum risk willingness in the NHS, and confer significant risks of overtreatment and investigation, and further increase the resource burden on the health service.
Rapid Response:
Risk tolerance in the NHS will lower further if second opinions are made routine
Dear Editor,
It is saddening to read of the case of a group A Streptococcal infection in a young child, and the Senior Coroner Mary Hassell’s opinion that a second opinion could have saved the child’s life.
I find it troubling that the only solution to missed diagnoses is a second opinion, and the presumption that a physician or diagnostician must have made an error when an incorrect diagnosis or management plan is made.
In making diagnoses and management plans which correlate with the wider health economics of the NHS, there must exist some degree of risk-taking, and a single or even group of cases of a missed diagnosis does not constitute a sound or deductive argument that there is a “lack of appropriate diagnosis”, as stated by the Coroner.
Management plans made in the Emergency Department and in General Practice must consider the cumulative outcome risk of all differential diagnoses. Without significant investigative burden, the negative predictive value of the diagnostic data is rarely 1. Therefore, if diagnosticians are willing to take any risk to spare patients investigation, admission, or treatment, it is inevitable that some diagnoses will be missed when the whole population is considered.
Furthermore, it is not correct to assume that a second opinion necessarily increases the accuracy of diagnosis. Given the same data, diagnosticians are likely to consider the same differential diagnoses and their management plan will depend more on their experience and risk willingness. Where there is a request for a second opinion, it is likely that the diagnosis and management plan made with the lower risk willingness will take precedence, especially if the management plan correlates with the wishes of the patient or individual requesting a second opinion. This will bring down the sum risk willingness in the NHS, and confer significant risks of overtreatment and investigation, and further increase the resource burden on the health service.
Competing interests: No competing interests