Second opinion

1. Second opinion

2. Need felt by parents Respect the need felt by parents (parents may be apprehensive due to previous experience / they may feel comfortable with senior doctor�s opinion / they may be pressurized by relatives) Cooperate to organize second opinion Suggest 2-3 alternate names but accept the choice of parents (even any other)

3. Need felt by treating doctor Genuine indications *Disease with guarded prognosis (risk of death/ chronic course with high morbidity/irreversible damage) *Disease requiring long term treatment *Disease difficult to control Secondary indications *Parental anxiety/not meeting with parental expectations of improvement

4. Ideal way Choose ideal person for second opinion (cooperative, credible, knowledgeable, open to discussion, non-exploiting) Discuss the problem ahead of time Be present at the time of second opinion Be transparent about the fees Follow the agreed therapy and report

5. Rules for opinion giver Never run down the colleague Give frank opinion without appearing to be against what has been done before Spend time to explain the problem Take final decision with the concurrence and suggestions from the referring doctor Avoid subtly direct contact with the patient

6. Concept of group practice

7. Need for group practice Quality maintained with increasing quantity (no control over quantity, one cannot refuse a needy patient) Offers opportunity for problem solving and keeping updated / time for family and leisure / time for maintaining health Shared physical and mental stress Academic enrichment

8. Models of group practice Multispecialty group practice Pediatric super specialty group practice General pediatric group practice Ideal model - sharing patients, premises and profit / Alternate model - sharing premises but not patients or profit (keeping assistants or locum is not group practice)

9. Ideal model Works best on small scale with 3 partners Partners preferably of different seniority (6-8 years difference between each of them) Junior partners join the senior with existing facility (can be updated with equal share)

10. Ideal model Outdoor services run continuously for > 12 hrs a day and part time on holidays / parents choice to see any one (genuine second opinion free) / different fee structure and senior�s non-availability incentive for junior

11. Ideal model Protocol for management decided together and followed by all Rational management feasible with equal high quality of practice Indoor patients are seen 4-5 times a day (with single daily charge)

12. Ideal model Common lunch time discussion / common academic involvement Outdoor profits shared unequally (more one works more one earns) / indoor profit shared equally (rational practice has small indoor profit)

13. Prerequisites for success Partners must have same wavelength � selection of partners most vital Senior must promote junior initially (work is not split but increases rapidly) Manager for administration � junior partner takes decisions (supported by others)

14. Prerequisites for success Ensures happiness that bonds the partnership (senior is happy as he gets more leisure and junior is happy as he gets more work and earns more)

15. Alternate model Good for large practice with 6-7 partners � MOU agreed and signed / equal investment � each partner responsible for a day / week (24 hours) at the hospital Outdoor services at individual premises Indoor facilities are shared, not patients

16. Alternate model Better patient care / sharing responsibilities of serious patients / increasing work & profits Academic activities / training programs possible

17. Shortcomings Similar quality and rationality cannot be ensured between all the partners Varying academic interests and competence Dissimilarities may lead to parental preference of one doctor over another � it may cause embarrassment

18. Shortcomings With increasing work and profit, not all the partners may maintain same enthusiasm Larger the number of partners, more is the chance of misunderstanding