The Second Opinion

Earlier this week, my cell phone rang just before six a.m. and the caller’s number was one I did not recognized. Before I could answer the phone, the call went to voicemail. It was from a woman who was calling for advice on her sick kitty. This is not an unusual event in my life as a feline specialist. I promptly phoned the caller back and she described the situation: An older cat who was sneezing blood intermittently for several months. Antibiotics cleared up the problem, but the sneezing (and blood) returned as soon as the medication was discontinued. Could she make an appointment with me as soon as possible?

I explained that what I wanted was the best for her kitty and the “best” at this point was a diagnosis. Given the patient’s age and the ominous clinical sign of sneezing blood, my concern was that this patient had a nasal tumor (cancer). Rather than have the client come to see me, I recommended that she proceed directly to a local specialty hospital where they had the capability of performing appropriate diagnostics, in this case a CT scan and an MRI. The call ended with the cat guardian promising to follow up with the specialty hospital. I hope she did, as those scans (and possible rhinoscopy) would provide the quickest answer to the kitty’s problem, providing a diagnosis, prognosis and recommendations for therapy (if any).

Throughout my career, I have met a number of clients who have brought their cats to me for a second opinion. In one case, I was the 17th (yes!) veterinarian to see the patient over the course of two years. At times, the clients have spent all the funds they have and I am not able to do much more. In other circumstances, the patient is best served being referred for advanced procedures to a specialty hospital. However, for many cats, I have been able to provide a diagnosis and thoughtful care.

When is a second opinion warranted and how does a client go about getting one? Who should be seen for a second opinion? These are all important questions and the answers to them depend on each individual case.

If your kitty has a chronic problem that is being treated but is not responding, a second opinion in warranted. Often times, clients first opt for empirical therapy: Asking the veterinarian to provide his or her “best guess” as to what the problem may be and treating the patient accordingly. Empirical therapy works sometimes, but in my experience, it often ends up with a frustrated client (and veterinarian) and a kitty who is not measurably better. Empirical therapy often is costly, as multiple medications are often utilized. In this situation, there may need to be a period of time during which the medications are discontinued, in order for the problem to be diagnosed without medications complicating interpretations of tests. This is often the case when steroids are used empirically–we typically prefer that the patient not receive these drugs for 14 days prior to further testing. Sometimes, however, this is just not possible.

A second opinion can be sought for additional diagnostics that your veterinarian cannot offer. For example, your kitty may need an ultrasound examination of the abdomen, or an echocardiogram of his or her heart. While some general practices have veterinarians who are very skilled in these procedures, the learning curve for both is quite steep and a specialist (veterinary radiologist, internist or cardiologist) is often the best choice for these diagnostics. The same may be true of endoscopy, advanced oral surgery, orthopedics or ophthalmology.

I discourage clients from visiting a number of general practictioners for the same problem. If after a reasonable amount of time (four to six weeks is a good timeframe; much sooner, if the kitty is very ill), your cat is still not getting relief from a problem, the time is right for you to seek the advice of a specialist. Where does one find these individuals? Your veterinarian most likely has a list of specialists that he or she refers to on a regular basis. Specialists (surgeons and internists) can be found at the veterinary medical teaching hospitals connected with the nation’s veterinary schools, as well on the staffs of the many specialty and referral hospitals that have been established. The American Board of Veterinary Practitioners certifies veterinarians in various species specialty (feline, canine/feline, avian, etc.) and these practitioners also may be excellent choices for second opinions. There are now few locations in the States that are more than a few hours away from this type of specialty care. In some major cities, there are multiple specialty hospitals available from which to choose.

Many clients are afraid of asking for a referral, thinking that they will somehow anger or cause hurt to the kitty’s primary veterinarian. This cannot be further from the truth. A compassionate and responsible veterinarian has only one goal: Returning a sick patient to the best possible quality of life. Without a diagnosis, medical and surgical therapy cannot be tailored appropriately and time (and sometimes precious little lives) are lost in the process. If a veterinarian, despite appropriate testing, still cannot pinpoint the problem, referral makes good sense. With our knowledge base in veterinary medicine expanding on what seems to be a daily basis, no one can know it all and having a primary veterinarian work with a specialist is typically a win-win situation for all concerned: Patient, client and veterinarian.