A highly thought-provoking and relevant new book,Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers by history professor Nancy Tomes (Chapel Hill, NC: University of North Carolina Press; 2016), puts in sobering context today’s widespread perception that post-millennial healthcare consumers are savvy shoppers, newly activist, and well-informed. Tomes thinks that’s a myth—and has plenty of highly readable evidence to back it up.
The “shopping model,” Tomes writes, “still works best for affluent, middle-class, college-educated Americans.” Significant barriers to accessing accurate healthcare information that can help inform treatment choices exist especially among “vulnerable populations: the elderly; low-income, minimally educated families; and recent immigrants.” Yet these groups (the elderly in particular) are high-volume consumers of healthcare services and products. She cites studies by the National Center for Education Statistics suggesting that only 12% of Americans were proficient in health literacy, that is, possessing the reading and mathematical skills needed to use the decision-making tools being developed for them. For others, while they may have smartphones, the apps designed for them may exceed their ability to digest and apply the medical concepts built into the software.
What Tomes fears is that increasing reliance of American medicine on a consumer-choice-driven model burdens patients with responsibilities they are ill-equipped to fulfill. It’s one thing to eliminate travel agents and thrust responsibility for booking flights and hotels into the hands of consumers (something many struggle with); it’s another thing when their lives, and those of others, depend on their healthcare choices being good ones.
Deep roots to medical consumerism
The most fascinating part of Tomes’ book deals with the history of medical consumerism in America, exposing its 19th-century roots and the ongoing tug-of-war between America’s health practitioners over who should decide (and profit from) healthcare choices. In pre-Civil War days, for example, rival camps of physicians bitterly attacked each other and competed for patients while few had anything approaching what we now consider to be scientific training. Consumer self-care was the norm; doctors were a last resort and hospitals places to die, not heal. Their disempowerment has been, in part, the result of active and passionate efforts of the American Medical Association during the 20th century as it fought tooth and nail against the participation of informed and educated consumers in making healthcare choices.
Even so, the 1950s healthcare consumer was often the one demanding medical interventions. Tomes describes cancer-fearing neurotics seeking hysterectomies from surgeons whose motto was, “Give the lady what she wants.” The balance between consumer demands, physician motivations, under-treatment and over-treatment has seemingly been constantly shifting for many decades. So, as Tomes asserts, if at least some of today’s consumers are indeed better-informed than their parents, it’s a swing backwards of a pendulum rather than a new and unprecedented phenomenon spawned by the Information Age.
Evolving roles of pharmacies
Among other things Tomes describes, in this lucid and compelling 500-odd page report, is the evolution of the American pharmacy both physically and in the role of the pharmacist, and the effect of increased competition from supermarkets and big-box stores in turning medicine into a consumer commodity. As might be expected, too, the pharmaceutical industry comes across at various times as both an advocate of patient involvement and an opponent of informing the consumer.
The New York Times called Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers, “a fluent and immensely readable chronology, minutely referenced, instructive and ruefully entertaining.” I couldn’t agree more.
Available from Amazon.com.