Virtual second opinions

Special to the Times

After his doctor told him he had a brain tumor that would require a 10-hour surgery, Al Flesh wanted a second opinion. Surprisingly, he never had to leave his house to get it.

Researching his options on the Internet one night, Flesh found that a top-tier hospital in Ohio was offering second opinions online, even for patients with serious illnesses like his. The next day, he typed up his medical history on the Cleveland Clinic’s Web site, had his recent medical records sent through the mail and paid the $730 bill on his credit card.

Just two weeks later, a doctor e-mailed a diagnosis that confirmed what his first physician said. Flesh is now having surgery next month and doctors predict he will make a full recovery. “This has been a rough experience,” says the 53-year-old consumer electronics executive from Fort Myers, Fla. Even if it came online, “being able to get that second opinion made me feel a whole lot better.”


Several of the nation’s best-known hospitals, including Massachusetts General, Johns Hopkins University Hospital and the Cleveland Clinic, have recently started offering patients second opinions over the Internet for as little as $500. Cedars-Sinai Medical Center in Los Angeles is planning to launch a similar service for neurology patients sometime next year.

Although several Web sites and one-shop docs are already providing medicine via cyberspace, the fact that such well-known hospitals are entering the controversial dot-com medicine business is surprising. After all, there are limits to what can be done over a keyboard and many doctors remain extremely skeptical about how well a physician can diagnose a patient he or she has never seen -- whether for a second opinion or not.

What’s more, the hospitals report that up to 80% of their initial inquiries are coming from cancer patients or those with other major illnesses.

Dr. David Goldstein, co-director of the University of Southern California’s Pacific Center for Health Policy and Ethics, says many doctors like him worry that online physicians can miss critical information they might catch otherwise. They may also be unable to adequately convey complex medical information in writing. And is there really such a thing as a virtual bedside manner?

The American Medical Assn. says it recommends against doctors treating patients online whom they have not first seen. Last month, the eRisk Working Group on Healthcare, an online health-care advisory group consisting of state medical boards and medical malpractice insurers, also recommended against the practice.

“[Diagnosing online] is dangerous,” says Goldstein. “This is not what we do.”


Just a few years ago, online medicine looked like health care’s next big thing. While some patients and doctors remain skeptical, the endorsement by world-class medical institutions is convincing more patients to give the idea a try. Still, some patients remain reluctant to replace a physical examination and a doctor visit with the Internet. And doctors have their own qualms. Many are concerned about liability (e-mails are physical records, of course) and the ethical implications of treating patients without personally examining them are murky under these circumstances. Another big hurdle? Every state requires doctors to be licensed in the state in which they provide services. For that reason, Johns Hopkins provides online consultations only to international patients, although it says it is researching how to enter the domestic market.

The hospitals offering virtual second opinions say the practice is safe and don’t have many of the problems of initial consultations online. After all, another doctor first sees the patient in person. And this way, those who are too sick or can’t afford to travel to a major research center have access to some of the best doctors in the country.

Some patients who rely on a local community hospital often want the reassurance of a larger medical center where doctors deal more frequently with complex cases. They may believe that a major center is less prone to make a misdiagnosis. A 1999 study of cancer patients nationwide by researchers at Johns Hopkins University found that 1.4% of pathology results -- or 30,000 patients--were misdiagnosed annually. And 20% of the recommended treatments for cancer patients were also incorrect, the study found.

One recent survey found that two-thirds of people would be interested in online second opinions if they were easy and affordable. An estimated 5,000 patients around the country have signed up for online second opinions through these few hospitals just this year. Some smaller and older second opinion companies not affiliated with hospitals, such as and, report their numbers are rising too.

Most e-second opinion programs work the same way. All patients must first be examined by another doctor. They then fill out an extensive medical history questionnaire online and later have their primary doctor send their medical records, such as CAT scans, X-rays and lab tests, through the mail.

Some hospitals send the opinions directly to the primary doctor so the doctor can discuss it with the patient. Most services cost from $500 to $1,000 and are not covered by insurance.

But what happens when your second doctor disagrees with the first? Dr. Joseph Kvedar, director of telemedicine for Partners Healthcare, which oversees Massachusetts General’s online program, says that happens up to 30% of the time. In such cases, patients are usually asked to visit the medical center in person for an exam.

While the services available today primarily use e-mail, hospitals say they are trying to improve technical capabilities so they can both send and receive the medical information better. Some hope to have video-conferencing next year, while others are counting on new remote real-time diagnostic technology that will allow doctors to scan and diagnose patients without being in the room. “This is only the very beginning,” says Kvedar.