Therapeutic Lemons?

 Various professional sources estimate that:

Surgeons in the United States perform two-thirds of hysterectomies through a large incision in the abdominal wall;

40 percent of women are unaware that they can choose a less-invasive alternative;

98 percent of women expect their physician to disclose the existence of such alternatives, even if the physician must refer the patient to another surgeon;

90 percent of women would pursue a second opinion if they knew of other options;

8 percent of obstetrician/gynecologists would choose the more invasive hysterectomy route for themselves or their spouse.

What’s going on here?  Why are Ob/Gyns doing unto others what they would not have done to themselves?  Why the breach of the ‘Golden Rule?’

The truth is sometimes medicine unwittingly markets what, for lack of a better metaphor, amounts to a therapeutic lemon. 

As with a car whose defects show up after we buy it, the therapeutic lemon fails to produce the best overall health outcome.  The therapeutic lemon persists because consumers/patients can only know so much about care alternatives.

Borrowing again from the more familiar consumer setting of buying a used car, before resources sprang up – particularly on the Internet – for checking the reliability of used cars, potential buyers looking over the car lot struggled to distinguish the 'cherries' from the lemons.  The dealer had a better, albeit imperfect, sense of this distinction. According to economist George Ackerlof, the difference between what the buyer and the dealer knew about the available cars tended to drive out the good ones. So to make a profit, dealers sold the lemons because that was all they could afford to sell; they weren’t necessarily being dishonest (as with those Ob/Gyns who perform more invasive hysterectomies), but the dealers incentives worked against helping the buyer acquire a cherry – a car with a minimum of hidden, ticking time-bombs.

Fueling the market for lemons is consumer ignorance. Buyers would pay more if they only knew they were getting a cherry.  Trusting the dealer to sell buyers what they pay for could help fix the problem.

Admittedly, medical care is more complicated.  And yet patients still trust health care professionals to 'sell' the therapeutic cherry and not the lemon.  Information asymmetry is the fancy economics term describing a setting where clinicians know more than patients.  Curiously a fiduciary relationship, the sort of relationship that describes what is between a patient and clinician, acknowledges a setting of information asymmetry and the peculiar need for trust to bridge the information divide.

Trust isn’t the sort of thing that you find in a medical school curriculum.  Being trustworthy is a virtue and virtues are a matter of ethics.  Professional ethics can be a remedy for the mischief information asymmetry can breed.  Narrowing the information divide between patients and physicians – helping them understand their treatment options and outcomes are important steps toward finding the therapeutic cherry.  Likewise making clinicians more aware of their personal treatment outcomes is also a powerful referent.  In the end better-informed patients and clinicians establishes the referents needed for better professional ethics and we need good ethics, lest we all, sooner or later, buy a therapeutic lemon.

Postscript:

Some of you may be thinking, “The robot will fix the hysterectomy problem.”  Nope.  While the surgical robot may change the numbers of minimally invasive hysterectomies, it also could evolve into a lemon ‘swap’ relative to the open most invasive technique: costing more, and with growing evidence that it yields no differences in the pain or the mobility that the patient experiences after open surgery, at least in the setting of benign gynecologic surgery.