An arterio-venous malformation is an uncommon lesion of inappropriately formed cerebral vasculature. A rupture of these vessels often results in cerebral haemorrhage. Depending on the size and location, the nature of the bleeding could have varying results, from a severe headache to a catastrophic neurological deficit, the former being more common.
A sizeable portion of patients harbouring this malformation face seizures or epileptic fits that arise out of cortical irritation or hemodynamic alterations. Ravi, a 20-year-old engineering student, was brought to the emergency by his parents after one such convulsion that resulted in a sudden jerking of his left arm and leg, followed by a transient weakness in those limbs.
By the time he arrived at the hospital, six hours later, he had already recovered most of his strength.
As we scrolled through the CT angiogram on the monitor, we identified a 3 cm vascular malformation with a tiny haemorrhage just in front of and not actually within the right “motor strip”, the area of the brain responsible for left hand and leg function. This was probably why the paralysis was transient.
“Based on all the characteristics of this lesion, there are a few options we have in treating this,” I explained to the parents with their son tethered to an IV pole beside us. Surgery, radiosurgery, embolisation…I made clear what each entailed, concluding that this could wait a few weeks before deciding on an intervention.
The family was well-heeled. They expressed the desire to take a second opinion. “Of course,” I emphasised, giving them a detailed report of our meeting. A surgeon should always encourage a patient to take a second opinion, rather than get offended by the suggestion. It offers security to the family and bolsters the first surgeon’s decision making when seconded by another colleague.
The family returned two weeks later, after having seen a few “top” neurosurgeons and interventional radiologists. They had also asked for and received suggestions from surgeons in the US and UK, I was told. I assumed that they had returned to be treated by me; after all, I was their first responder. I take pride in the discussions I have with my patients.
However, they surprised me with, “Given your expertise in the field, we need you to help us choose between the two doctors we have zeroed in on.” That’s a first, I thought to myself. Again, I realised, there was no reason to be insecure. Our job is to guide patients in the right direction with truth, transparency, and trust. I analysed the notes and offered my advice.
In the past, I have seen a few patients who, after having consulted with me, have had surgery elsewhere. After the operation, they sometimes return to me for follow-ups. One can understand if they were not satisfied with the outcome of surgery and were seeking a fresh perspective, but in most cases, the surgery goes off perfectly and recovery is uncomplicated.
“Ideally, you should be seeing your surgeon so that you maintain continuity in treatment,” I often say, since most of us are keen on evaluating patient progress, recovery, and health over the long term. In return, I sometimes get the response, “We have seen him, but we also wanted to see you,” and I find nothing wrong with that approach either. All of us live our lives wanting to feel validated, so why not our patients?
Patients who visit a private healthcare facility and have the means to afford it often seek a second opinion, especially if it involves brain or spine surgery. Some like to make it clear at the very start that they have come only for a second opinion, while others like to reserve that information till the very end or not mention it at all, probably to be able to obtain an unbiased assessment. Unfortunately, patients sometimes pit one doctor against the other, like small children who dodge parents to get what they want. This can sour relationships. “Never believe what a patient tells you his doctor said,” the famous Sir William Jenner said in the 1800s.
The online world is fraught with second-opinion clinics providing health solutions over remote consultations. Patients should be encouraged to seek opinions especially when the diagnosis is rare, as the world of academia may have physicians working on breakthrough treatments in the field. Insurance companies in the US also cover the cost of second opinions in order to reduce unnecessary surgery in patients with low back pain. However, it is imperative that these opinions are sourced from credible institutions; there are enough “quacks” selling treatments to those who are distressed or in pain, giving medicine the caustic reputation, it is frequently taxed with.
Ravi and his parents returned three months after a successful surgery elsewhere to corroborate the advice given to them by their surgeon on tapering off and eventually stopping the certain medication. I was with them throughout his illness, like the sidekick in a movie who is omniscient in every scene, uplifting the hero but never really getting credit for the film’s success. I often wonder what must go on in the minds of patients who seek multiple opinions and in the heads of the countless doctors who give and receive them. But, I also realise it is irrelevant: all of us play a part in the life and treatment of each patient; sometimes, we play a key role, while sometimes it’s a supporting role. No matter which it is, it’s important to do the best we can.