A Clean Slate.

It was a few months after the COVID-19 pandemic, and a young girl was on my clinic schedule for a second opinion—perhaps a third or fourth—regarding relatively new-onset bilateral arm weakness. I remember sighing, knowing I would be running behind; second-opinion visits always seem to fall on overbooked days, and this one was no different. Just before seeing her, my fellow—who had not yet met the patient—presented a detailed summary of her extensive prior evaluations with multiple surgeons, mostly obtained from the electronic medical record (EMR). She had been diagnosed at various times with long thoracic nerve palsy, bilateral Parsonage–Turner syndrome, functional movement disorder, factitious disorder, scapular dyskinesia, and thoracic outlet syndrome. I walked into the room thinking about all of her prior diagnoses, already forming my own opinion before I sat down. Then it dawned on me why she was there. She was frustrated, scared, and confused—and she was seeking an unbiased assessment. I paused, reset, and started from the beginning. I took my own history and performed my own physical examination. This was not factitious. Not a movement disorder. Not long thoracic palsy, thoracic outlet syndrome, or Parsonage–Turner syndrome. Something else was going on, although the pieces of the diagnostic puzzle were not yet falling into place. COVID precautions were still ongoing, and all patients were masked, as they had been for the past year. I examined her, still without a diagnosis forming, and finally asked her to remove her mask. She questioned why, noting that none of the other surgeons she had seen during the pandemic had asked her to do so. I asked her to smile. The diagnosis was immediately clear. She had facioscapulohumeral muscular dystrophy, later confirmed by genetic testing as a spontaneous mutation, which only started to manifest itself over the past several years. She was appropriately referred to our muscular dystrophy clinic for further management as well as planning for a future bilateral scapulothoracic fusion. A surgical second opinion exists for a reason. It is meant to confirm diagnostic accuracy, determine whether an operation is truly indicated, and consider alternative nonoperative or surgical strategies. At its best, it provides an independent perspective that minimizes bias, reduces uncertainty, and helps patients gain clarity and confidence. It supports shared decision-making aligned with a patient’s goals, expectations, and risk tolerance. But once the chart is read, it cannot be unread. A diagnosis begins to form before the patient is seen, and by the time the surgeon enters the room, a narrative is already established—or at least well underway. The encounter is no longer fully independent, and the slate is no longer clean. I often reflect on how close I came to denying this patient a true second opinion by allowing prior diagnoses by other surgeons to shape my thinking before I ever met her. In an era of electronic medical records, overbooked schedules, and increasing pressure for efficiency, it has become routine for residents, fellows, and attendings to review outside records before clinic to streamline diagnosis and treatment. When done thoughtfully, reviewing a referring physician’s note can be helpful during an initial consultation. However, in patients seeking a second opinion, a deep chart review performed too early may do more harm than good. It risks biasing objectivity and, more importantly, deprives the patient of an evaluation unburdened by prior conclusions. Electronic medical records were designed to improve care, not replace clinical judgment. When consumed before the patient encounter, they can narrow our thinking rather than expand it. They may subtly guide the history, shape the examination, or abbreviate it altogether in an effort to confirm what has already been documented. If second opinions are to retain their value, they must be protected. They require restraint—the discipline to meet the patient before the chart, to listen before concluding, and to examine before confirming. Our patients come to us not for validation of prior diagnoses, but for judgment formed in the room, grounded in observation and experience. Our second-opinion patients deserve a “Clean Slate”.