The Answer: I can understand why you want a second opinion for a diagnosis that is very serious and life changing, particularly a diagnosis of multiple system atrophy (MSA).

MSA is a disorder where one or more systems in the body degenerate. Poor balance, rigidity, slowness and difficulty with coordination are typically some of the motor symptoms. Low blood pressure upon standing, constipation, and swallowing troubles are some of the non-motor features that can be seen. There is no laboratory or brain scan test to confirm the actual diagnosis.

A neurologist would not lightly hand out this diagnosis unless there was some degree of certainty, according to Robert TerSteege, who as an information and referral associate for the Parkinson Society Central & Northern Ontario, deals with this question from patients often.

“It is not Parkinson’s per se,” said Mr. TerSteege. “MSA is one of the most common types of atypical Parkinsonism. It may look like Parkinson’s initially.”

According to Dr. Mario Masellis, a Sunnybrook neurologist who specializes in cognitive and movement disorders, “any time we see someone in our clinic and we find features that resemble parkinsonism, we have to do other investigations and medication trials to sort out what we think is the most likely suspect.”

In the case of someone presenting with parkinsonism (symptoms of tremor, rigidity, and slowness), neurologists will typically have patients take a medication called levodopa/carbidopa every day for several weeks as a test: if they respond to the doses, they consider the patient to have Parkinson’s. However, some patients may not tolerate this medication well and people with MSA can fall into this category.

“If you have a good, sustained response and you don’t have atypical features, then the diagnosis is most likely idiopathic Parkinson’s disease,” Dr. Masellis said in an interview. “If the dosage is increased to very high levels and they still don’t have a convincing response, it’s likely due to other conditions.”

One of those other conditions would be MSA. A magnetic resonance image (MRI) of the brain would be done; certain features may support a diagnosis of MSA, but these imaging features are not seen in everyone. It typically is a diagnosis of exclusion; doctors cannot make a definitive diagnosis because a brain biopsy is required and that is not the usual standard of care due to the risks involved.

However, there is one important difference between MSA and actual Parkinson’s, the latter being that patients experience slight declines over many years. With MSA, “there is more rapid progression because of the poor response to Parkinson’s medications and because of other features of the condition including the swallowing difficulties and low blood pressure.”

Dr. Masellis said there are several neurologists who are movement disorders specialists across Canada. Many have a one to two-year wait list for a consultation.

“We don’t lightly give that particular diagnosis,” he said, noting that a comprehensive history and physical exam on several occasions helps make the diagnosis plus medical imaging may be used to support a diagnosis. “If the diagnosis is suspected, they watch it over a period of three to six months to see how the condition evolves.”

While there is always value in getting a second opinion, it also depends on where the diagnosis was made. Most neurologists who make the diagnosis initially would refer to a clinic that specializes in movement disorders.

“Once you get an opinion from one of these clinics, the accuracy of the diagnosis is increased,” said Dr. Masellis. However, “if they are really concerned about the diagnosis or have doubts about the diagnosis, one second opinion should be considered.”

To obtain a second opinion, your sister should go back to her family physician and request a referral to a neurologist who specializes in movement disorders.

The post A Second Opinion for a Life-Changing Diagnosis appeared first on Your Health Matters.

The Answer: There are more than 40 different types of lymphoma, a cancer of the lymphatic system, that are typically divided into two main types: Hodgkin lymphoma and Non Hodgkin lymphoma. Since the medical protocols for treating these forms of cancer are standard, most can be easily managed in community and teaching hospitals, according to Eugenia Piliotis, a hematologist who specializes in lymphoma at Sunnybrook.

“In the majority of cases there is no need to be sent to a teaching hospital for treatment,” said Dr. Piliotis, who is also associate professor in University of Toronto’s department of medicine. “Exceptions to that would be if there is a potential for a clinical trial you may be eligible for that you and your physician think you would be a good fit.”

The other exception is if you have a rare type of cancer, such as cutaneous t-cell lymphoma, high-grade lymphomas, or other rare, aggressive types of lymphoma that require super specialized treatment by clinicians as well as pharmacists and nurses most familiar with them.

What I am wondering, though, is if this is a treatment issue or one if you are lacking confidence or are having trouble trusting the oncologist. When a patient has been diagnosed with cancer, it is almost always the worst thing that has ever happened to them. It’s not a surprise, then, if you are wondering whether the treatment your father is obtaining represents the best possible care.

If your father does not have a favorable response that may be due to a cancer that is not responding to treatment and requires another protocol, rather than a clinician who is not providing the best care.

Having said all that, it is reasonable to ask for a second opinion if you are having doubts or you want to confirm the diagnosis and treatment plan. However, to obtain that second opinion, it is best to ask the treating oncologist to arrange it – not your family physician. Just having this conversation with the oncologist may help dissolve some of your concerns.

If you want a second opinion and you are concerned about offending the oncologist, don’t be. So long as you word it politely, it should not be an issue – oncologists are used to being asked for second opinions.

You may want to word your question something along these lines: “I have faith in you but I’m anxious. This is a big diagnosis and I want to make sure I’m doing the right thing for myself. Is it possible to get a second opinion?”

That oncologist is the best person to facilitate the second opinion as she or he can tell the other cancer specialist what treatments, tests and scans you have had.

“Most often patients get here and we tell them the exact same thing that their primary oncologist has already explained, so usually we are just reassuring,” said Dr. Piliotis. “Everyone deserves a second opinion if they have concerns.”

The post What Should I Do if My Father’s Cancer Treatment Doesn’t Work, a Patient Asks appeared first on Your Health Matters.

The Answer: Some patients in Sunnybrook’s emergency department are just like you: they have a medical issue they want solved, be it abdominal pain, the long wait to see a specialist or the need for a second opinion. Most physicians empathize with what prompted you to come here – in some cases, difficulty accessing timely specialty care – but that is rarely an emergency.

“Patients are doing what they are legitimately allowed to do,” said Dr. Jeffrey Tyberg, Chief of the Department of Emergency Services at Sunnybrook Health Sciences Centre. “You understand why people are doing it.”

Canada has one of the worst rates of access to specialty services. A Commonwealth Fund study of 11 countries found specialist queues particularly worrisome, with 41 per cent of patients waiting two months or more. That lack of access is partly responsible for driving up emergency visits in hospitals across the country.

“The emergency department is the only place where you can walk in and say, ‘I’m here, I’ve been to four other hospitals and I want you figure out what happened to me,’” said Dr. Tyberg.

For physicians trying to manage a limited resource of health services, it represents inefficiency to the system. If a patient has already seen a specialist and received an answer, repeating a series of tests and imaging studies will rarely yield a new insight into their medical condition.

It can be frustrating for patients, who have waited many hours in emergency, after having driven long distances – Vaughan, Barrie, Woodbridge and Peterborough – in the hope of achieving a definitive diagnosis at a top teaching hospital.

Some patients come for severe head pain, other times, they come, after having seen three other neurosurgeons for back pain for which there is no surgical remedy. Even more are stuck in long queues, waiting to see a specialist.

“They can’t work, they say it’s 14 months to see the spine surgeon in Scarborough,” said Dr. Tyberg. “What’s the guy supposed to do? You understand why people do that. It’s the only door open to a lot of people.”

To in answer to your question, you do have the right to go to any emergency department you want if you think you are experiencing a medical emergency.

To go to emergency for a second opinion or specialist consultation, while understandable due to a problem with accessing care, is not necessarily going to yield that definitive diagnosis you were seeking.

“Maybe we need to manage expectations,” said Dr. Tyberg. “People think they can come for any problem at any time. Sometimes we have to say ‘This isn’t the time or the place.’”

The post A Second Opinion or an Emergency? appeared first on Your Health Matters.