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MY FAMILY WANTS ME TO GO FOR TREATMENT OF MY BLADDER CANCER TO THE “TEACHING HOSPITAL” IN THE CITY MY LOCAL UROLOGIST IS COMPETENT AND CARING AND I TRUST HIS JUDGEMENT SHOULD I LISTEN TO MY FAMILY AND SWITCH UROLOGISTS?

As we have discussed in the preceding questions, finding an excellent urologist to partner with is a must. A physician established at a “teaching hospital” (a hospital where physicians are trained in their respective fields of specialty) is at the minimum, competent. A large teaching or academic center would not risk its reputation on an individual who is sub par. Some individuals may be world class surgeons, but not all will be. An individual may be an average surgeon, but a gifted teacher or researcher, making them invaluable to their academic center. Your local community urologist will likely be an individual trained at one of these academic teaching hospitals. In addition, community hospitals also have credentialing and quality review programs to weed out incompetent physicians. In general, it is true the academic center will have more stringent standards and review of their staff. Nevertheless, excellent physicians can be found at the community hospital as well.

ISN’T IT TRUE THAT ACADEMIC OR TEACHING HOSPITALS WILL HAVE THE BEST TECHNOLOGY OR MOST UP TO DATE INFORMATION TO TREAT MY CANCER?

These hospitals generally are at the forefront of innovation regarding technological advances, testing and implementation of new surgical techniques and chemotherapeutic regimens. However, no one center can be excellent in all spheres of medicine. Each will have particular strengths and weaknesses. We are however, fortunate medical knowledge and innovation are shared openly via medical journals and conferences and other means of information exchange. New information and proven effective techniques are rapidly disseminated throughout the medical community. Some teaching hospitals may be “centers of excellence” for a particular procedure or innovative approach that is available at only a few sites in the country. There is naturally a lag time for some procedures to spread to the local level, and if in fact a new procedure carries substantial benefits compared to the standard, and is not available locally, then a referral may be appropriate.

Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with bladder cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

IF I HAVE MY MAJOR SURGERY PERFORMED AT A TEACHING HOSPITAL, WILL THE ATTENDING PHYSICIAN PERFORM MY SURGERY AND TAKE CARE OF ME AFTERWARDS?

At a teaching hospital, physicians are in training to master their skills before going out into “practice” in their respective fields. Interns are fresh out of medical school with limited practical training. Often they are referred to as PGY 1 (post graduate year 1). Years of training follow (PGY2, PGY3 etc.). Urology residents are required to generally have at least two years of training in a surgical program followed by four years in urology residency. It is the responsibility of the residency director to provide adequate training for these future urologists while assuring patient safety. Practically speaking, there are usually one or more attending physicians who supervise the work of the physicians in training. The attending physicians are board certified, experienced physicians who treat patients while simultaneously training physicians. The residents will be a key component in your care. They will be assessing you both pre- and post-operatively and will be writing orders directing your care. How much of the surgery they get to do is dependent on their years of training and their skills. They will be under the direct supervision of the attending physician. If you have concerns, you should address them with your attending physician.

MY UROLOGIST ALWAYS KEEPS ME WAITING, DOES THIS MEAN HE DOESN’T CARE?

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

WILL THERE BE OTHER PHYSICIANS INVOLVED IN MY TREATMENT OF BLADDER CANCER?

You may need to be referred to an oncologist, a physician specialist in the medical therapy of cancer. At times, a referral to a radiation oncologist, a specialist who treats cancer with radiation, may be required. Other individuals may need to be consulted as well. It is important for your urologist to keep your primary care physician up to date so that he can coordinate your care and if required by your insurance plan, make the appropriate referrals.

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On a regular basis, magazine articles, books, and television shows implore those with major illnesses to seek out a second opinion. The general consensus is there is much to be gained and little to be lost, so why not seek out a second opinion? The issue certainly is more complicated than generally addressed, and deserves a review. The following chapter provides a second opinion on second opinions.

WHAT ABOUT SECOND OPINIONS?

In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

WILL MY UROLOGIST BE UPSET WHEN I REQUEST A SECOND OPINION?

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.

WHY DOESN’T MY UROLOGIST WANT ME TO GO FOR A SECOND OPINION?

Often, the urologist may believe the second opinion is unnecessary and will delay treatment. He may be concerned you will not only have a second opinion, but transfer your future care to the urologist providing the second opinion. He may believe that you may get bad advice. It is possible he may feel threatened the next urologist will not agree with his work up or care of you to date.

WHERE DO I FIND A SPECIALIST FOR A SECOND OPINION?

Start by asking your primary care physician. You may be able to see another urologist in your community. Do not see another urologist in the same group as a conflict of interest may deter a different opinion. If you are considering a different course of action, such as radiation or chemotherapy, a referral to the appropriate specialist should be made.

Many times your urologist will be highly supportive and suggest a second opinion. He will offer his recommendations and facilitate your visit to the appropriate physician. If there is an issue regarding the care given at your local hospital, you may wish a referral to a “tertiary” or teaching hospital. In most areas, a referral for this reason is unnecessary, as excellent care is obtainable in the community hospital.

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