Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers by Nancy Tomes (review)

Millions of Americans greeted the Affordable Care Act of 2010 with euphoria, which turned to frustration as its troubled implementation generated confusion, misinformation, and, for some, higher premiums. In this impressive and indispensable work, Nancy Tomes reveals the long history of such high hopes brought low by complex, opaque institutionalization. Remaking the American Patient is less a history of medicine than of Americans’ experience in and changing expectations of health care across the long twentieth century. Weaving together commercial, regulatory, political, and scientific narratives, Tomes argues that Americans and their doctors have had a stormy relationship characterized by cycles of reform, elation, and then disillusioned critique. She traces the transformation of the American patient through intertwined histories of the medical profession and its practitioners, pharmaceutical firms, retail drug stores, marketing, advertising, consumer activism, and the federal government. The book’s massive research base incorporates archives of medical and consumer protection organizations, reformers, journalists, businesses, government records, trade journals, medical literature, and the popular press, along with a century of pamphlets and advice literature. This broad sweep enabled Tomes to craft a study of deep insight from a wealth of detail.

Remaking the American Patient argues that the rise of a consumer-driven economy, along with the fundamentally commercial nature of American culture, transformed retail medicine and patients’ experiences. The small-town solo physician gave way to highly individuated specialists in group practices or managed care. Docile patients used to house calls and a warm bedside manner were replaced by doctor-shopping consumers alienated from bureaucracy and insistent upon full collaboration in their care. The driving element in these transformations was “critical medical consumerism,” expressed in the patient’s bill of rights identified by President Kennedy: “the rights to be safe, to be informed, to make choices, and to be heard” (p. 5). Medical consumerism produced a century of agitation and change. Savvy consumers used the leverage of the market and the influence of politics to gain more information, safer products, and greater say in their care. However, the price of this change was increasing complexity, runaway costs, and continued dissatisfaction for all concerned, except perhaps stockholders.

Tomes covers three distinct periods of debate and reform: the interwar era, midcentury, and the late 1960s into the 1990s, tracking industrial, emergent white-collar, and neoliberal economies. Each section pairs chapters on drugstores and on the doctor’s office, the two sites where patients encountered medicine in daily life. At the same time, she chronicles the enduring dominance of insurance providers and pharmaceutical and device manufacturers. Tomes also highlights the role of the American Medical Association, whose stubborn refusal to engage patient concerns or publically funded health care undermined its legitimacy. While patients successfully claimed agency over decades, forces arrayed against them only grew more powerful.

Interwar medical consumerism originated in the popular success of 100,000,000 Guinea Pigs (1933), by F. J. Schlink and Arthur Kallet. This best seller sparked interest in medical reform among recently installed New Dealers as well as the educated middle class. An extended congressional battle resulted in some expansion of the FDA’s scope and powers; debates over Social Security brought medical benefits to national attention. Postwar medicine tacked decisively toward a free enterprise model, with the AMA and an ascendant business class both resolutely opposed to regulation or public health care, and committed to expanding markets with rising costs borne by the consumer. Tomes argues this dynamic “worked not to allay the worries of the skeptical patient but rather to reinforce the absolute authority of the physician” (p. 156), which came back to haunt professionals, when patients revolted in earnest against in the 1960s. Finally the latter third of the century witnessed multiple critiques of traditional medicine, generating “intense political arguments about the causes and symptoms of the ‘sick society’ and its ‘sick care’ system...