Second Opinions

The awkwardness of disagreement

Welcome Back Rheumatology Fans! It is 2025 and for the first post of the year I thought I would dive straight in to something common but challenging.

Second opinions are a topic that get brought up on almost every course I teach, lets go into them in detail.

In This Article

• Introduction

• Difference To Onward referral

• Seeking Help

• Second Opinion Choices

Introduction

Let us start with the caveats here, this discussion will be UK centric, I can’t claim to have experience of this in other health care systems. Some of this will also be dependent upon where you sit in the pathway, your own confidence, relationships with colleagues and more. Individual circumstance is likely to influence process and outcomes a lot. There is no real right or wrong only options.

My clinical case load is predominantly second opinion (third, fourth…). Most of these are MSK Therapist referrals when they are suspicious of an inflammatory arthritis but need some help with differential diagnosis, onward referral and management planning. The rest is patients seeking appointments with me because they are looking for clarification on their diagnosis provided by someone else.

Difference To Onward Referral

I want to differentiate out here before we get into the weeds. Onward referral where the clinician is suspicious of inflammatory arthritis - say Rheumatoid Arthritis - and has the means to refer appropriately then I wouldn’t call this a second opinion really. We are more along the lines of an increased level of uncertainty. This typically is inflammatory arthritis a differential diagnosis or confidence in the pathology being inflammatory but unsure if this is Spondyloarthritic, synovitic, connective tissue disorder etc. This likely requires clarification to best onwardly refer to accurately access pathways or investigations.

Seeking Help

This is the easiest and least likely to cause any aggravation but it does require some bravery and confidence in communication to ensure this is a positive experience for all.

There are 2 distinct scenarios

1. “I have a patient and I think auto-inflammation is the pathologic process but I can’t narrow it down”

2. “I have a patient who I think has Rheumatoid Arthritis (or other) but I am not sure what to do next”

Scenario 1

This is the most challenging on the ego and your processes. Admitting you don’t know is the biggest first step. Second step which can be more difficult than initially imagined is WHO to seek help from.

Once you have admitted you don’t know and are looking for someone to help start local and move outwards. I would suggest initially asking you immediate colleagues biasing toward anyone with a Rheumatological knowledge base (maybe they did my course… ;)). This can often be sufficient to gain the next steps required to plug the gaps, missed questions or reasoning process.

After your immediate colleagues we are looking to trusted sources, by the letter of the medical hierarchy this is probably the persons named GP. In real life I would definitely advise an intermediary step of someone of medical or specialist background to bounce the idea off with whom you are already have a relationship. In Rheumatological context I am obviously at a big advantage here, I go to Professor Bhaskar Dasgupta for Polymyalgia Rheumatica / Vasculitis for example, or James Noake (SEM) for my sportier/younger population. Think about the people you know with the skillset to advise you.

In these Rheumatological examples I am happy to be approached for advise as well as are many Rheumatologists on social media. You could seek one out in this wonderful modern world.

It is likely we will enlist the assistance of the persons GP, they are super useful for knowledge of the pathways and referral processes as we as unifying diagnoses based on previous medical history and investigations.

You should now be on the right track with assisting with differential diagnosis queries.