Psychologists often give and receive second opinions about clients which is an accepted and acceptable part of standard professional practice. However, there are various ethical concerns and sensitivities associated with providing second opinions, and members frequently contact the National Office for advice in this complex area. Requests for advice usually arise from members who are asked to provide second opinions, but members also seek guidance on how to respond to second opinions offered by other professionals in relation to their own original reports. Complex issues also arise when clients request a second opinion.
The APS Ethics Committee has received a number of complaints about psychologists' conduct and the implied criticism of other professionals in the context of providing a second opinion. As this is an area of uncertainty and concern, the Ethics Committee has prepared a series of questions and answers with reference to the APS Code of Ethics to guide members on this complex issue.
In what context can psychologists be asked to provide a second opinion?
Psychologists may be asked to provide a second opinion at the request of another professional about his or her client, for example, where there is some uncertainty about diagnosis or treatment progress. The request for a second opinion may also come from a third party such as a treating medical practitioner, a legal representative, a court or an insurance funder, where questions may have arisen about the original opinion, or where a particular process must be followed. In addition, clients of psychologists or other professionals may themselves request a second opinion from another psychologist or professional, for instance, where they may be unsatisfied with a diagnosis or treatment that is being planned or has been received.
Second opinions usually are additional opinions, but they may also take the form of contesting opinions or critiques of other professionals' reports on clients. Further, members may have provided an original opinion, then be faced with a second opinion, and be subsequently required to compare them, for example, when being questioned by a client or third party, or challenged in a court of law.
Second opinions may be provided formally, as in a report to a court, or be conveyed informally, for example, to inform a change in treatment strategy.
What sort of complaints come to the attention of the APS Ethics Committee?
Most of the complaints relating to second opinions which have been considered by the Ethics Committee have involved second opinions that require clinical, neuropsychological or behavioural assessments and diagnoses. They can entail complaints arising from analyses of initial reports or complaints about statements made by psychologists in second opinions, particularly those that contest original reports. Resolution can be difficult, because often the criticism of the other professionals is indirect or implied, rather than stated overtly.
Sometimes these implications emerge because psychologists have paid insufficient attention to their professional obligations when providing second opinions.
What guiding principles should be considered when preparing second opinions?
As with the provision of initial opinions, psychologists need to be mindful of their basic ethical obligations in relation to Propriety (General Principle B, APS Code of Ethics):
- Psychologists should ensure they are competent to deliver the services they provide
- They should provide services to benefit, and not to harm
- They should seek to protect the interests of those with whom they work
- They should ensure that the welfare of clients and the public, and the standing of the profession, take precedence over their own self-interest.
In providing second opinions, psychologists also need to be very sensitive to the work and reputation of the other professional who provided the original opinion. Commenting on the qualifications and training, including memberships and registration status, of professionals providing original opinions is not advisable. If asked to do so by clients or third parties, psychologists should restrict themselves to factual explanations of qualifications and registration status. It is much better to be proactively aware of the likelihood of creating implied criticism than it is to try to repair damage afterwards. As part of the ethical obligations of Integrity (General Principle C), psychologists are required to “keep faith with the nature and intentions of their professional relationships” and should refrain from:
- Comparing and contrasting their own qualifications and training, memberships, registration history and experience with that of the professionals who provided the original opinions
- Claiming or implying superiority over the professionals who provided the original opinions on the basis of their qualifications and training (Standard C.2.3.(c)) or methods and techniques (Standard C.2.3.(f))
- Commenting on the competence of other professionals to conduct assessments, interpret results or offer opinions
- Engaging in criticism of other professionals
- Making personal attacks on the other professionals’ characters or conduct.
What should psychologists do if their existing client wants to seek a second opinion?
Clients are entitled to seek a second opinion and psychologists are ethically obliged to offer practical assistance to ensure they obtain competent second opinions. The principle underpinning this obligation is that of beneficence – psychologists strive to “benefit, enhance and promote the interests of clients” (Standard B.8 – Collaborating with others for the benefit of clients). Psychologists need to be aware that a client's seeking of a second opinion has a meaning that should be explored where appropriate, for example, it may indicate dissatisfaction with the psychologist’s current treatment.
If psychologists are asked by a new client to provide a second opinion are they obliged to comply?
When a client has clearly stated that a second opinion is being sought, psychologists should ensure that they discuss with the client the context in which they are being asked to provide this before acceding to the request. For instance, there would be a range of considerations if a client was already engaged in treatment with another psychologist or health professional but sought a second opinion about whether it was the correct treatment. Depending on the circumstances, provision of such an opinion could be neither helpful nor appropriate, for example, where a client has a propensity to engage multiple treatment providers in an uncoordinated way. The context of the client's request therefore needs to be carefully teased out by the psychologist with the interests of the client at the centre, and with the awareness that knowledge of the case is only what
has been provided by the client. The ethical standard to collaborate with others for the benefit of clients may result in arranging a discussion with the original professional with the client's permission.
Is the psychologist obliged to notify the psychologist or other professional who provided the original opinion that they have provided a second opinion?
No, this should only be considered where the client is in a continuing professional relationship with the other provider and following discussion with, and permission from, the client as outlined above.
How should psychologists introduce themselves in reports offering second opinions?
In opening a report that provides a second opinion, psychologists should present information about their competence to provide such points of view in the same way as they would introduce their bona fides if an original opinion had been sought. They should therefore:
- Indicate why and for whom a second opinion has been requested
- State (and if necessary explain) their qualifications and training, APS membership status (including any College memberships), registration status and experience in dealing with similar presentations to qualify them to provide an opinion in this particular instance.
How should the provision of a second opinion be approached?
In providing reports or verbal commentaries, it is important to directly address the issues of why a second opinion has been requested and not be side-tracked into attacking the person who provided the original opinion. Where necessary comments can be made on the choice of assessment methods and techniques which were employed in formulating the original opinion or the accuracy of test administration and scoring in the results of any original assessments.
Where relevant, psychologists should also:
- List and describe any assessments carried out in order to form the second opinion
- Provide reasons for their choice of assessment methods and techniques
- Report and interpret the results of any such assessments
- Compare and contrast the results of their assessments and interpretations with the results and interpretations on which the original opinion was based.
What if it is apparent that the person who provided the original opinion may have behaved unprofessionally?
Conducting oneself professionally in the manner described above by focussing on the nature of the task in question can help minimise the risk of ethical conflict arising. It is not appropriate to identify poor conduct in another professional through the medium of a psychological report, via conversation in a consulting room, or in a court of law that is dealing with a client-related matter. The appropriate forum for airing complaints is a confidential professional exchange between the two parties, and members are reminded of their obligations to draw the attention of other professionals to the actions that are considered to be in breach of the Code of Ethics (see Standard C.7.2) and discuss the matters with them. If such dialogue does not bring about acceptable solutions, then members have a responsibility to bring the problems to the attention of the Psychology Board of Australia or the APS Ethics Committee.
This brief article can only touch on the complex issues related to providing second opinions. The Ethics Committee invites members to identify any issues that have not been identified and to contribute to raising awareness through the letters pages
of InPsych.
Enquiries regarding professional and ethical matters can be directed to the APS Professional Advisory Service by phoning the National Office on 1800 333 497 or 8662 3300 (if calling from Melbourne) or emailing [email protected].