By Karen Finucan Clarkson

With major surgery staring her in the face, Debbie Stein went looking for a second opinion. "Actually, my doctor said she wouldn't do the surgery—unless it was an emergency, which it wasn't—without a second opinion," said the Bethesda resident.

But finding a physician who met her criteria turned out to be more time consuming and frustrating than Stein imagined. "I was looking for a gynecologist who knew the latest technologies and was available on short notice," she said. "Whatever I chose to do, I had to do quickly as I was out of work and on pain killers."

An inquiry on 20817BB, a neighborhood listserv, was of little help. "My own doctor's name came back and while that was reassuring, it didn't help," said Stein.

Stein then turned to major research hospitals. "Every doctor that I wanted to see would be weeks if not months," she said. After finally making an appointment, Stein was disappointed to learn that the individual she was to see was a fellow. "I cancelled it. They just weren't upfront with me about the person's background."

Eventually, she was "lucky enough to get an appointment with someone on staff and knowledgeable in the field at George Washington University Hospital," said Stein. "She confirmed that I really didn't have any other options."

Assured that she was making the right choice, Stein returned to her original gynecologist and scheduled the surgery. "I felt comfortable with what I finally did but getting to that point, just navigating the system, was a real challenge," she said.

Reassurance is what roughly 70 percent of all patients who voluntarily seek a second opinion receive. "Second opinions give patients a lot of comfort," said Dr. Tyler Cymet, an osteopathic physician who works for the American Association of Colleges of Osteopathic Medicine in Chevy Chase. "Most second opinions come to the same diagnosis but give a broader range of options."

Many health insurance companies, including Medicare, will pay for second opinions. Some require them before approving major surgical procedures. Getting a second opinion is not a betrayal of your doctor. It is done frequently.

"One of the reasons we welcome a second opinion is simply because no one thinks of everything," said Dr. Reed Shnider, director of Preventive Cardiology and Wellness at Montgomery General Hospital in Olney. "Sometimes another doctor will point you in a new direction you hadn't considered. If our goal is to act in a patient's best interest, it's hard to imagine someone not being in favor of a second opinion."

Dr. James Heltzer of Champlain Ophthalmology in Bethesda suggests that patients ask their primary care physician or the specialist who diagnosed them for names of other doctors. "The doctor taking care of you is in the best place to recommend someone with similar expertise," he said. Heltzer once broke his clavicle on an outing and was diagnosed at the bottom of a mountain by the physician who operated on Tiger Woods. "And I still got a second opinion."

Dr. Shishir Khetan, an internist with Premier Physician Group/Rockville Internal Medicine Group in Rockville, relies on feedback from patients and personal experience to continually refine the list of specialists to whom he refers. "I usually try to ask when I next see a patient how things went. If I get any negative feedback, I may not refer again. My patients need to be able to trust that I will refer them to someone who will give them the best care," he said. "Every now and then when we do pre-ops, we'll get the runaround from that doctor's office. Then I imagine what the patient must being going through and don't refer again."

"What all this really argues in favor of is having a routine care doctor you know and trust," said Stein, the surgical patient. "If something happens, and you don't have faith in your primary provider, how can you trust any recommendations she makes?"

Other sources of referrals include friends and family members, theMontgomery County Medical Society, local hospitals, insurance companies, Medicare, medical certification boards, publications such as Washingtonian magazine and Consumers' CKECKBOOK.

The Internet, in addition to identifying physicians and their specialties, has itself become a source for second opinions. Web sites such as Partners Online Specialty Consultations and MyConsult offer second opinions online. Despite their affiliation with prestigious medical establishments, these second opinion services have yet to be fully embraced by local medical practitioners.

"Internet-based medical decisions don't take you or your general health into consideration," said Cymet, the osteopathic physician. "They answer a question. ‘Do I need surgery?' but may not look at other ways to resolve the problem, such as lifestyle changes."

"While more than two-thirds of second opinions confirm the initial diagnosis, there are still times when the two opinions diverge. "Patients should go back to the first doctor and present the second opinion," said Shnider, the cardiologist. "The doctor-patient relationship should be as collaborative and comfortable as possible, even in uncomfortable situations."

If the two opinions clearly conflict, a third opinion may be warranted and covered by insurance. More than three opinions are generally frowned upon by the medical profession and insurers alike. While non-emergency procedures do allow patients to seek other opinions, the passage of time can adversely affect many medical conditions, thereby nullifying earlier medical opinions.