There's a contractive affiliation that exists between the university and the health centre and effectively all of the physicians who work in the McGill University Health Centre are professors in their respective specialties. So we carry often two titles: Like I am a professor of medicine at McGill University and I'm a senior physician at the health centre. Absolutely.

It's an academic teaching hospital, so it has the responsibility to teach students and residents in the fields of medicine, all fields of medicine. And it has the responsibility to offer the highest level of care for the patients that it must serve in the province for the province.

We realized that, as one of the important academic institutions in Canada, like UBC, like University of Toronto, that our physicians, our specialists, have actually been doing second opinions for as many years as you can think. Our people have been consulting specialists either by phone or by visiting them just to get another option. Similar to what is done, for example, in the Mayo clinic in the United States. We realized we were doing this on a regular basis and it seemed to us only logical that we try to put this into an organized structure, and offer it as a product whereby people with the right product would be able to access our specialists, to do something that they do on a regular basis.

If you wish.

We are entering our third year of doing this in a formal way.

We thought it would be inappropriate for us to be offering medical Second Opinion on common first line problems. For example, it would not be taking advantage of the expertise of the MUHC to go out and ask for medical second opinion for low back pain or the common cold. But if a person had an unusual diagnosis that would require the skill set of an academic teaching hospital, for example, someone who would go into complete kidney failure or a patient that had a bad traumatic brain injury from a car accident. This is the kind of patient that we take care of on a day to day basis. And as an academic teaching hospital we have a responsibility to keep our medical knowledge right up to the latest and greatest so to speak so that we're always imparting the latest knowledge to our patients. That's our responsibility. We have to do it for teaching and we do it for our patients.

Well you know, that's an excellent question. Normally what we have discovered is that our Second Opinions have provided a modification sometimes to the diagnosis and that we have expanded the treatment options for the clients or patients in their care.

I would say that half the time we have confirmed what has already been done for the patient. And the other half of the time we have made some modifications. There have been times when we have recommended - I can think of one particular case involving an individual that had a problem with the electrical rhythm of his heart. It was a very unusual and a very complicated issue - and we were able not only to solve it but even to recommend where the best centre in Canada was that the patient could go to, and get the care that he needed to solve his problem. And he got it solved. That was a great story... and great for the patient.

If you think about, and I think most of my colleagues would agree with me, one of the most important jobs of a physician is in the area of reassurance. Our job is to reassure our patients and their treating doctors. The link here that is very important is that we want to keep the relationship between the patient and their treating doctor as tightly as possible. We want to help that relationship because at the end of the day, that treating physician for that patient, whether they are in British Columbia or Quebec or wherever, needs to be reinforced because that doctor is going to be the advocate for the patient.

When we can, we will make those suggestions. Sometimes, however, it's better for the treating physician who has local knowledge in the province, for example, to actually do that step. But sometimes we have done it on occasion where we have actually called into a treating institution that we think will offer the best care. But our preference is always to tell the treating physician of the patient where we think the best option is and then have that treating physician make the phone call. He or she, the doctor, is going to be the one who is in the local community taking care of that patient for that next steps. Keeping that relationship is extremely important. We will make the suggestion as to where they can go, but we think the doctor should remain in control of the situation.

Interesting question. We've been asked this many times. It turns out that I think the system is under considerable stress right across the country and we have worked very hard to put the emphasis on that relationship and to make the treating physician feel that we are actually helping the patient and helping them for the betterment of the patient, and in no way are we trying to displace ourselves or put them in a defensive situation. We have worked very hard to make sure that that's the point. That's the last thing - That would be very counterproductive if we were to alienate the physician. It is true that because the client is the one that owns the right to a medical second opinion that he or she can say to us "Listen, I don't like my doctor; I don't want you to send any information to the doctor," and then we would not do so at the request of the client. But the default position of our whole system is that the treating physician receive a copy, and we've had no difficulties with that relationship.

In fact if you see on the letters that we write, you will see that we maintain the expertise by making the specialist available to the treating physician to have an ongoing communication so if there is any uncertainty in the letter that is written the treating physician can always phone the specialist and get an update.

Yes there are. Most well-known is an American organization called Best Doctors and there are two or three other small entities that are operating in Canada, and there are three or four others in the United States. There is actually a Middle Eastern organization that goes by the name of Worldwide Opinion that has its financial origins in the Middle East but offers services throughout the world.

I actually think ours is very much tailored to the Canadian citizen. We think that we understand what our health care system is all about and the difficulties inherent in it, because we live here and we are sensitive to that. We work very hard to try to make it Canadian-specific, and I think we have done a very good job of that and I think if you were to harness or to discuss this with the other clients they would agree that that's the difference.

There are big differences between the way American systems and Canadian systems run. You have to understand the way medicine is practiced here to make this service work as efficiently as it should.

Well if it's in Canada it's probably thousands of dollars to do this. Again, it depends on the complexity, size of the document. You'd probably have to find an independent contractor who would charge by the hour. So you can imagine that if you had a very complex problem with multiple scans with different physicians all contributing, it would take some of them quite a long time to go through all that stuff and be sure it's really correct and then render both an opinion on the diagnosis and the treatment.

In our experience it's in the low thousands of dollars.

We have issued a diagnosis and then received more documents that we didn't know existed in a particular case, and actually helped to refine a couple of diagnoses that led to different treatment plans. The answer is yes we have.

Those particular cases involved the treating doctor calling and discussing with our specialists and then figuring out how to go next steps for the patient. It was very successful.

Those are good examples of a good relationship between the treating doctor and the specialist, not a defensive feeling doctor, upset that someone else is in her/his territory.

If we keep our eyes on the patient, patient focused - And everybody has the patient's best interests at heart, it's hard to go wrong.