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Behind the Scenes: with Best Doctors

The internet is just one of the tools that has fuelled greater so-called “patient power”. Madeleine Davies visited the headquarters of a provider of expert second medical opinion in Madrid to find out how it aims to help individuals take more control over their health.

December 2009 News

The fact that medical treatment varies locally and internationally is well-established. In the UK, mastectomy rates for breast cancer patients range from 36% to 53% between regions, and between surgeons from 19% to 92%. Until relatively recently, bed rest was recommended for back pain patients – the opposite of the activity now prescribed.

Both these examples serve as useful reminders that doctors operate within a complex context. While national guidelines exist, there remain difficult choices to be made. Traditionally, such decisions have been taken by the medical profession, with patients the passive recipients of care. This, believes Evan Falchuk, president of Best Doctors, is no longer the case. “There has been a change in how people approach healthcare,” he says. “People are no longer prepared to accept the opinion of one doctor.” Falchuk attributes this to both “generational, cultural changes” and the ascent of the internet. According to one survey, 21% of people consult the web first when facing a health problem. Best Doctors is in the business of riding, and fuelling, this wave, by providing patients with access to a second opinion. And not just any opinion. One of the reports I’m given during my visit to the organisation’s European base in Madrid has been written by the chief of gastrointenstinal oncology at a Los Angeles cancer centre.

He has been selected from Best Doctors’ international database of 50,000 medical specialists and the report itself is the final stage of a carefully-managed process. It starts when an eligible person contacts Best Doctors. In the UK this includes holders of Bupa’s critical illness insurance and members of a Canada Life group income protection scheme or a Medicash cash plan. Best Doctors also has relationship with insurers in Ireland, including Aviva and VHI, the state-owned provider.

Depending on their policy, the caller may have made a claim or have been referred to a specialist. In order to take the case forward, Best Doctors must compile detailed information from both the patient and their treating doctor. Crucially, the patient must provide written consent for the organisation to access their medical records. The most laborious part of the entire process is the collection of these records from hospitals, from MRI images to biopsy samples. Before a specialist is contacted, doctors working for the organisation will assess the patient’s condition, their expectations and the level of information required in order for the expert to make an informed opinion. Dr Jose Luis Baptista, who reviews the medical information in Madrid, is careful to stress that Best Doctors will not interfere with the treatment pathway prescribed by the treating doctor. It can take up to 40 days to collect medical records although once this stage has been completed the final report should be ready within 10-15 working days. In England, cancer patients start treatment within 30 days of diagnosis so would probably undergo surgery before a second opinion was provided. However, in the case of elective surgery it may be safe for a patient to wait for a second opinion before making a decision. In many cases the report will confirm that, in the expert’s opinion, the treating doctor’s recommendations are correct. However, in 15% of cases the diagnosis is modified and in 30% an alternative treatment pathway suggested. The emphasis is on challenging assumptions and taking a fresh look at the case.

“We take a step back, and ask the question ‘do you really have what you have been told you have?’” says Falchuk, whose own brother almost underwent life-threatening surgery before an expert identified family history of a benign condition that required much less risky treatment. Of course, while some patients receive reassurance, others will face difficult news. For example, an expert may conclude that a cancer is more advanced than the original analysis suggested. Both the reports I see have been compiled by American specialists and I ask Dr Baptista about variations in treatment internationally. What if an American doctor recommends a drug not funded by the NHS?

“I have not found any really big cultural difference from a medical point of view,” he says. “Economic and financial considerations are not part of the report.” While the Best Doctors team openly admits that doctors have not responded to the organisation’s work with a united chorus of approval, Falchuk argues that “we are supporting, not replacing, the treating doctor”. Dominic Howard, director of Best Doctors UK & Ireland, says a common misconception is that the organisation was set up to recommend providers of treatment or to manage care to the advantage of insurers or employers. In fact, the report is sent directly to the patient to use as they wish. Given the nature of the service the organisation offers – sourcing second opinions on complex medical cases – Howard does not believe that utilisation figures are the key to demonstrating value. Best Doctors’ ambitious plans to expand in the UK are built on the back of figures demonstrating the impact of the benefit on policy sales and lapse figures.

“We don’t want to be regarded as fluffy nice to have,” concludes Howard. “We know that the service can have an impact on people’s lives and that far outweighs anything else in the ^market.”