Getting A Second Opinion

In medicine, the same illness may present in different ways and with different severity. And that is one of the challenges of medicine – the same illness may not present the same way in different patients.

Therein however, allows the doctor to put their art into practice – they need to be able to grasp the vital and crucial aspects from taking a history, from performing an examination, and ordering appropriate investigations. The doctor needs to be able to see what is relevant, what are red herrings, and in their mind, piece together all the evidence to support a diagnosis that they make.

Making the correct diagnosis however, is only half the work done. Next, the doctor must give the appropriate treatment.

And that presents another new challenge, because clinical judgement needs to be made on the appropriate extent of treatment. There are guidelines, but one must remember, they are just that; guidelines.

As an inexperienced junior doctor, I have had trouble deciding appropriate management plans for the patient. One patient I had had an elevated potassium level which I thought was fairly high (6.2 mmol/L). She had chronic kidney failure. At such a level, I would have thought that treatment would be instituted, and some textbooks encouraged treatment at this level.

On asking one of the senior doctors, they didn’t think treatment was needed, but suggested just 1L of IV fluids. Being concerned and conflicted over this conflicting management compared to textbooks, I was confused and tried to get a second, then a 3rd senior opinion – in summary, it’s a bad idea. One other said to treat, and the third said not to treat.

In the end, I decided to listen to the first opinion and not treat, but to give some fluids, and added on for a repeat blood test the next day.

On checking the blood the next day, the potassium level dropped to 5.6 mmol/L, and the patient was instructed by the handover doctor to represent in 2 days time for monitoring of K+ (the repeat potassium was 6.9mmol/L – I don’t know what treatment she got).

Moral of the story: stick to the first advice from the first doctor most familiar to the patient. If there is something you find concerning about their advice, use graded assertiveness; ask them why are we doing this, and should any other treatment options be done.

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