Imagine you have heartburn. For years you’ve managed with antacids, but one day you’re struggling to swallow steak without vomiting. Your gastroenterologist finds a large hiatal hernia, an enlarged opening of the diaphragm trapping part of your stomach. She sends you to a surgeon, who says a surgical procedure will correct the problem but could permanently alter your digestion.

This is your first time hearing that surgery might help you, and you’re just not sure: Should you follow the surgeon’s advice?

As a surgeon focusing on specialized esophagus and stomach procedures, I often treat patients who may want to seek a second opinion. I’m often asked to provide second opinions, too.

Seeking a second opinion is a patient’s right, and it is widely accepted in medical practice today. But it can also feel daunting. You may worry about offending your physician or making them feel you don’t trust them. And it’s not always clear whether your condition, or a treatment the doctor recommends, is straightforward or more complicated. Getting a second opinion also takes additional time and energy.

Understanding the origins of second opinions, how they are used today and what steps you can take to decide whether you should obtain one can help you navigate your care with more confidence.

A brief history of the second opinion

Through the turn of the 20th century, physicians generally embraced a one-way view of the doctor-patient relationship in which they wielded the medical knowledge and technical expertise and decided what treatments best served their patients. But in the early to mid-20th century, a growing recognition of the principles of patient rights and autonomy began to emerge alongside the modern foundation of medical ethics.

In the wake of Nazi atrocities during World War II, the Nuremberg Code and later the Belmont Report established protections for human research subjects. A series of landmark legal cases required doctors to discuss the risks and benefits of surgical procedures with their patients and obtain informed consent – a term introduced in 1957.

As respect for patient autonomy grew, so too did an emphasis on patient advocacy and empowerment. In 1972, researchers at Cornell University Medical College launched the first known surgical second opinion program. Collaborating with insurance companies, they made sure patients could obtain a second surgical consultation before any planned procedure. More than 7,000 patients participated in the program in its first six years – and 28% of them declined the original treatment plan after obtaining a second opinion.

Today, most insurance plans, including Medicare and Medicaid, provide coverage for second opinions regarding surgical care, serious injury or illness – especially cancer. Patients may still be responsible for a percentage of the cost, so anyone considering a second opinion may want to check their plan’s benefits.

The value of a second opinion

One type of second opinion initiated by doctors when required by insurance companies or hospital protocols is called a mandatory second opinion. It is most often seen in cancer care, where doctors at some smaller hospitals routinely collaborate with specialists in larger national cancer centers on a broad range of questions, from confirming a diagnosis to selecting the right medications.

Routine second opinions confirming biopsy findings, for example, resulted in major diagnosis changes in about 7.5% of patients, one study showed. Other studies found that this type of second opinion changed the interpretation of imaging scans or overturned a decision about undergoing surgery, about one-third of the time.

Patients, on the other hand, may have different reasons for requesting second opinions. For example, they may want to find a doctor with more experience with their health condition, or someone who communicates in a way that is clearer to them. Patients might also seek a second opinion if they are experiencing symptoms that are difficult to fit into one clear diagnosis.

Sometimes, a patient with complications or poor results from a prior treatment may need guidance. Or, if a doctor is recommending a course of action that is invasive, has a high risk of side effects or might affect long-term quality of life, a second opinion may boost a patient’s confidence in that course or provide an alternative.

When patients seek a second opinion regarding a cancer diagnosis, they make major changes to their treatment plan in up to 42% of cases, according to one study. For more common issues such as fatigue or abdominal pain, a second opinion might yield a new diagnosis only 10% of the time, but 70% of patients receive advice they find helpful.

It’s not clear whether patients who obtain a second opinion are more likely to complete a particular treatment – but getting another perspective often leads patients to feel more satisfied, confident and informed in their care.

Tips for navigating a second opinion

Hopefully, knowing how empowering second opinions can be both for patients and clinicians can help you feel less guilty or awkward asking for one. Here are a few proactive steps you can take to help you decide whether to seek a second opinion – and to streamline the process if you do.

Plan ahead. Contact your insurance company in advance – if possible, even before your first visit about your concern. The insurer can tell you about your coverage for any specialty care you may need and whether a second opinion would be covered under your policy.

Come prepared to maximize your appointment. Before your initial visit, think through how you’ll take notes. Bringing a trusted friend or relative to your appointment may make this easier. Start a running list of questions you can update as they occur to you.

This can help focus your concerns and make the most of your time with the first provider. If you decide to seek a second opinion, this documentation can also define key points you may want clarified or confirmed.

Gauge your comfort with the initial provider’s expertise with your symptoms or condition. Questions you might ask include: Is this a rare or common diagnosis? Are my symptoms typical? Is this a procedure or treatment typically carried out by providers with special training? How often do you perform this procedure or treat this illness? How often are patients with my condition treated at your hospital?

Ask whether the provider has any printed information, research studies or reliable websites they can share to reinforce your discussion.

If you have a rare diagnosis, unusual symptoms or are seeing a provider who doesn’t frequently treat your condition, a second opinion may be more likely to improve your care.

Think about the quality of provider-patient communication. Were all your questions answered? Did the visit feel rushed? Was your provider a good listener? If the visit fell short, either in terms of time or communication, a second opinion can help you feel heard and understood, and demystify points of confusion.

On the other hand, if the discussion was clear and left you feeling confident in your care, but you would still feel more comfortable with another perspective, you can be honest with the doctor about it. Providing feedback to your initial physician is often helpful in maintaining a positive and trusting relationship. Many patients choose to return to their first clinician after exploring other options.

Pin down the time frame for a second opinion. Ask the provider you initially see whether the diagnosis or recommended treatment is urgent or time sensitive. Some medical and surgical treatments must be scheduled weeks or months in advance, while others are more flexible. Confirming this time frame helps your doctor plan ahead, but more importantly it helps you figure out how much time you have to consider your alternatives without delaying needed treatment.

Danielle Friedman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

In the case of United States v. James Brien Comey Jr., the U.S. president’s security is pitted against the bedrock right to free speech enjoyed by Americans.

Two federal charges have been lodged against former FBI Director James Comey and are based on his Instagram post that depicted seashells spelling out “86 47.”

Comey’s post was interpreted by the U.S. Department of Justice as a threat to harm President Donald Trump. The indictment, obtained by the DOJ, alleges Comey violated two federal laws: 18 U.S.C. § 871, which makes it a crime to “knowingly and willfully” threaten, kidnap or “inflict bodily injury upon the President of the United States,” and 18 U.S.C. § 875, which criminalizes “communication containing any threat to kidnap any person or any threat to injure the person of another.”

Comey’s argument against the charges is likely to be twofold: (1) He lacked the requisite intent that the prosecutor needs to prove his case, and (2) even if he had the intent required by the statute, his speech is protected by the First Amendment. U.S. District Judge Louise Flanagan set Oct. 21 as the Comey case trial date.

I’m a scholar of constitutional and criminal law as well as the First Amendment. The charges against Comey exist in a legal gray area that includes the First Amendment and a series of court decisions over five decades that have gone back and forth over what dangers constitute speech that can be punished.

Parsing the charges

In criminal law, there are generally two parts to most crimes – the criminal act and the criminal intent. The criminal act is referred to as the “actus reus.” The criminal intent is known as the “mens rea.”

Some crimes also require a particular result. For instance, murder requires a death of a person. A defendant can neither be charged with nor convicted of murder unless and until the victim dies. If the victim doesn’t die, then at most the defendant can be convicted of only attempted murder.

The criminal charges alleged in Comey’s case don’t require a result, however. The president need not be kidnapped or injured for someone to be charged with violating either of them.

But the prosecutor must still prove the criminal intent and the criminal act for both charges to stick in Comey’s case. In my view, the Justice Department will have a difficult time proving the mens rea against him.

Comey has consistently maintained that he didn’t know “86 47” implied violence against the president.

Meaning and purpose

Comey has stated he came across the shells that spelled out “86 47” while walking on a beach in North Carolina, took a picture and posted it on Instagram.

The term “86” is commonly used to mean “to throw out” or “to get rid of” in American slang. According to Merriam-Webster, the term “comes from 1930s soda-counter slang meaning that an item was sold out.”

Comey later removed the image from Instagram and posted a statement that read, “I posted earlier a picture of some shells I saw today on a beach walk, which I assumed were a political message. I didn’t realize some folks associate those numbers with violence. It never occurred to me but I oppose violence of any kind so I took the post down.”

Even though Comey has insisted that he thought it was a silly picture of shells arranged in a clever way to express a political viewpoint, the Trump administration argues that Comey not only knew the meaning of “86 47” but that he purposefully threatened the president.

What’s plausible?

The first crime charged in the indictment, 18 U.S.C. §871, requires the defendant to have “knowingly and willfully” threatened to kidnap or inflict bodily injury upon the president. This is the statute’s mens rea; the defendant must have known that he was threatening the president of the United States.

Comey’s statements suggest that he didn’t know the threatening nature of his Instagram post. Thus, he cannot be convicted of “knowingly” threatening the president if he didn’t know its meaning.

To convict Comey, the prosecutor must prove that he did, in fact, know the meaning of “86 47” when he posted it.

Comey’s career as a federal prosecutor and his tenure as the FBI director may work against him here. In my view, it’s more than plausible that Comey encountered the threatening version of the term “86” in his career. It’s also more than plausible that the term appears in documents, records and court filings that Comey has drafted and signed over his career, all of which could be used against him at trial.

But even if the Justice Department can prove Comey did, in fact, know the threatening nature of “86 47,” its case against him is not a slam dunk.

And that’s because of the First Amendment.

Testing what’s protected speech

As a constitutional law scholar, I’d expect Comey to argue that his Instagram post was protected speech.

Even though the laws charged in Comey’s case are generally valid and constitutional, criminal defendants can always argue that otherwise valid and constitutional laws are unconstitutional as applied to them and their particular case. Comey is likely to argue this in his defense, but it won’t be as straightforward as one might think.

The First Amendment is not absolute – not all speech and expression is protected by the Constitution.

In Chaplinsky v. New Hampshire from 1942, Justice Frank Murphy wrote that it’s “well understood that the right to free speech is not absolute at all times and under all circumstances.”

In 1969, the U.S. Supreme Court held in Watts v. United States that while “true threats” are not protected by the First Amendment, political hyperbole remains protected speech. The Supreme Court defines true threats as statements where the speaker means to communicate a serious expression of intent to commit an act of unlawful violence against a particular individual or group of individuals, but the speaker need not actually intend to carry out the threat.

Watts v. United States involved a threat against the sitting president of the United States, Lyndon B. Johnson. In that case, Robert Watts expressed his strong opposition to the military draft at a public rally, saying, “If they ever make me carry a rifle, the first man I want to get in my sights is L.B.J.” He was subsequently charged and convicted under the same statute, 18 U.S.C. § 871, used in Comey’s case.

The Supreme Court reversed the conviction, ultimately agreeing with Watts, who had maintained that his statement was “a kind of very crude offensive method of stating a political opposition to the President.”

As the court explained, quoting an earlier decision on press freedom, “For we must interpret the language Congress chose ‘against the background of a profound national commitment to the principle that debate on public issues should be uninhibited, robust, and wideopen, and that it may well include vehement, caustic, and sometimes unpleasantly sharp attacks on government and public officials.’”

Since Watts, countless defendants have faced similar charges for threatening the president. Many have been convicted.

In the 1970s, Eugene Hart was convicted of threatening the president after his brother reported Hart’s plan to assassinate President Richard Nixon. An appellate court affirmed his conviction, concluding that Hart’s verbal threat coupled with his detailed assassination plan couldn’t have been “uttered in jest or in the nature of a hyperbole.”

In the 1980s, David Hoffman was convicted of threatening President Ronald Reagan when he mailed a letter to the White House stating, “Ronnie, Listen Chump! Resign or You’ll Get Your Brains Blown Out.” And in 1999, Donald Adams was convicted of threatening the president when he approached the White House gates telling Secret Service officers, “I want to kill the president.”

But in those cases and others, the defendants took concrete steps that demonstrated their sincerity and conscious awareness of the threatening nature of their speech. In my estimation, both are absent in Comey’s case.

Wayne Unger does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.