A Second Opinion Arnold S Relman

Understanding and Using A Second Opinion by Arnold S. Relman

The column A Second Opinion by Arnold S. Relman ran in newspapers across the country from 1978 until he stepped down in 2001. It was not a medical journal piece with dense citations. It was straightforward prose aimed at everyday people trying to navigate a healthcare system that did not make sense to most of them. I used to collect back issues and clip articles whenever I could find them. The thing that struck me was how specific and practical Relman always was. Relman was a Harvard physician who edited the New England Journal of Medicine for a long time, but he never wrote the column like someone giving a lecture. He wrote like a doctor who had watched too many patients get burned by confusion, by miscommunication, by people who assumed the system would look out for them if they just showed up and asked politely. That assumption was always wrong in his experience.

A Second Opinion Arnold S Relman What the Column Actually Covered

The column covered a wide range of topics. Insurance billing problems. Drug pricing. Hospital discharge practices. Misdiagnoses. The gap between what doctors knew and what patients understood. He wrote about how specialists often talked past each other when a patient was transferred between departments. He wrote about the awkward silence that followed when a doctor delivered bad news without giving the patient any real information about what came next. One thing I noticed going back through old issues is that Relman rarely offered solutions that required systemic change. He focused on what an individual could do. What questions to ask. What records to request. How to follow up when a test result came back with no explanation attached. That approach was deliberate. He knew most readers could not rewrite healthcare policy, but they could show up to their appointment with a written list of questions.

How the Column Worked in Practice

Each episode typically followed a pattern. Relman would present a real situation, sometimes anonymized, sometimes not. He would describe what went wrong. Then he would explain the mechanics behind the problem. Why the billing error happened. Why the referral got lost. Why the specialist never read the original doctor's notes. The explanation always came before the recommendation. I found this structure useful when advising friends and family members. The problem was not that people lacked information. The problem was that nobody explained the chain of events clearly. Relman did that consistently. If a patient received a bill for an service they did not remember authorizing, he would walk through how that authorization might have been implied rather than explicit, and what documents to request from the billing department to prove it.

Common Problems Relman Addressed and How to Handle Them

There were several recurring issues in the column. Insurance pre-authorizations was one. Doctors would order tests assuming the insurance company would cover them. They did not always check. Patients ended up with large unexpected bills. Relman suggested calling the insurer before any procedure, getting the authorization number in writing, and keeping a copy of that confirmation along with the procedure details. Another recurring issue was discharge planning. He described patients who were sent home with instructions that made no sense because the discharging physician had never actually explained anything beyond a vague handed-over packet. His advice was to ask specifically about what symptoms should trigger a call to the office versus an emergency room visit. Write down the answers. Do not rely on memory. Drug information was a third major theme. Relman pointed out that pharmaceutical companies funded a lot of the continuing education that doctors attended. This did not mean every prescription was wrong. It meant the information flow was skewed. He recommended patients review medication lists with their doctors at every visit and ask about side effects they had not been told to watch for.

A Personal Encounter With a Relman-Style Problem

I dealt with a situation a few years ago that matched one of the scenarios Relman described. A specialist referred a patient to a radiology center without confirming whether the center was in network. The patient assumed the referral meant everything was covered. The bill came out to nearly four thousand dollars. The specialist's office said they had not known about the out-of-network status. The radiology center said they had provided no upfront cost estimate. The workaround was exactly the kind of thing Relman would have recommended. I requested the itemized bill from the radiology center. I compared each code against the insurance policy's in-network provider list. I filed an appeal with the insurer citing the referral as justification for coverage. The insurer denied it initially. A second call with the specialist's office, asking them to confirm the referral was made in good faith and that they should have verified network status, changed the outcome. The appeal was approved after three weeks. The whole process took about twelve days of follow-up calls and two written appeals. Without that structured approach it could have gone unresolved for months.

Where the Relman Approach Falls Short

The individual-focused strategy has limitations. It works well for billing disputes and communication gaps. It does not help much when the problem is a structural one, like a shortage of specialists in a rural area or a hospital system that prioritizes throughput over continuity. In those cases, asking the right questions at the right time still matters, but the outcome is often the same regardless of how thorough the patient is. There is also the question of energy. Following Relman's advice requires time and persistence. Many patients are dealing with illness, fatigue, financial stress, or family obligations. The suggestion to keep every document and make every call is reasonable but not always realistic. I have seen people drop the pursuit of a billing error because the stress of fighting it was worse than the cost of the error itself. That is a valid choice, even if it is not what Relman would have recommended.

How to Access the Work

The A Second Opinion column ran in newspapers including the Boston Globe and several other dailies. The original run ended in 2001 when Relman retired from the column. Some of the articles are available through newspaper archives and library databases. The Robert Wood Johnson Foundation also published collections that included selections from his work. There is no single official website hosting the complete archive. The most practical route is through university library access to the major newspaper databases, or through interlibrary loan requests for specific columns. The core lesson is consistent across every column. Assume nothing. Verify everything. Keep records. Ask specific questions. Follow up in writing. These are not complicated principles. They are also not consistently applied by healthcare systems, which is why Relman kept repeating them for twenty-three years. If you are dealing with a current medical billing issue, a referral problem, or a situation where information seems to have been lost between providers, start by gathering the documentation. Itemized bills. Referral letters. Insurance correspondence. Once you have that in front of you, the path forward is usually clearer than it appears from the outside. The column was built on that premise. The system is not designed to make things easy for patients. It is possible to navigate it anyway.