- Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers by Nancy Tomes
In Remaking the American Patient, Nancy Tomes challenges popular understandings of when patients became "consumers." Many commentators have traced "medical consumerism" to the 1970s, with the women's health movement, arguing for an explosion in "patient empowerment" in the 1990s with the coming of the internet. In contrast, Tomes begins her history of how patients became consumers in the late nineteenth century, and traces the growth of "health commercialism" to the 1920s, coinciding with the rise of the advertising industry. Insisting that there was never a "'golden age' of placid doctor-patient relationships," Tomes demonstrates patients questioned physicians' motives and authority throughout the twentieth century. While acknowledging that "patients had been complaining about doctors… long before the 1920s," Tomes finds an important difference in the nature of complaints from this period onward. Even as acceptance of "the legitimacy of modern science and the values of professionalism" had become widespread, there were growing concerns that these values were compromised by "too close an embrace of commercial values" (2–5, 118).
Noting that physicians in the United States often critique the rise of "consumerism" among patients, associating the term with the "late twentieth century advent of managed care and the growing limits placed on medical autonomy by third party payers," Tomes argues that the medical profession itself has "played a huge if inadvertent role in producing the modern doctor-shopper." The centrality of "free enterprise medicine" to health care in the United States, and emphasis on "physician autonomy" and rejection of any "centralized forms of professional control" produced the "uneven [End Page 628] standards of care and forms of medical entrepreneurship that seemed more commercial than professional in spirit" (9). While acknowledging that physicians in many countries support "innovation and progress" in medicine, Tomes argues that the "comparatively decentralized status" of the medical profession in the United States, "its unusual insurance system, and most of all, the promotional culture of advertising and marketing" has fostered a greater focus on "new and improved medicine" and a greater temptation to "overtreat and overcharge patients to make money" (9–10). Thus, in the absence of stronger state control, patients in the US had to assume the responsibility of ensuring not only that they were receiving the "best" medical care, but also that they were charged a reasonable rate for their care, leading to the development of "medical consumerism."
In tracing the rise of medical consumerism, Tomes draws on research in archives devoted to the history of medicine and the history of advertising in the United States, discussions of health care in newspapers and popular and medical journals, and a broad reading of the secondary literature on the history of medicine in the United States. She ultimately presents a compelling argument that while becoming an informed "patient consumer" is a worthwhile goal on an individual level, patients cannot by themselves control the spiraling costs of American health care by more careful health consumption. American patients have since the 1920s been attempting to educate themselves on how to negotiate a health care system of growing complexity, and have not been able to hold down health care costs. For one thing, as Tomes points out, "no one goes looking for a bargain basement neurosurgeon or oncologist" (415). Even more fundamentally, while physician income has been falling over the past few decades, the health care system as it stands works very well for most of the important stakeholders:"pharmaceuticalcompanies, medical device makers, insurance companies and hospital corporations." The system "works quite well at what it is designed to do — provide a good return on investment" (416). Tomes confines herself to showing why medical consumerism is not a viable solution to the problems of the American health care system and does not advocate any other specific remedies. Nonetheless, her book provides powerful arguments to those who favour more state involvement in controlling medical...