“Nobody knew health care could be so complicated,” opined President Donald J. Trump on February 28, 2017, as he weighed in on Congressional debates about health care and health insurance coverage. The new president was probably the only American who did not know that American health care is complicated—indeed, most Americans confess that they are very perplexed as to how to navigate the system. Nancy Tomes’s clearly written and very timely Remaking the American Patient contextualizes the complex history of American health care in the twentieth century. Tomes’s central thesis is that the culture of medicine, including the expectations of both patients and doctors, has been shaped by the context of modern consumer capitalism. By exploring this intertwined history, she uncovers why Americans came to assume that “new and improved” medicine is better than old frameworks, and how patients developed the expectation that “expense equals quality.” The current American health care debates loom large here, with Tomes asking penetrating questions like “why has shopping for particular diagnostic tests or treatments come to be likened to the hunt for the best automobile or flat-screen TV?” Tomes traces the answers to the early twentieth century, as modern marketing evolved together with medical innovation and health commercialism. The rise of consumer culture in the twentieth century—advertising, marketing, and commercialism—she argues, blurred distinctions between professionalism and commercialism, complicating what it meant to be both a “good patient” and a “good doctor.” Tomes divides her study into three parts. Part one, “The Hazards of New Choices,” traces the effects of the Progressive Era’s new licensing laws and federal oversight of drug labels together with rapid economic growth after World War I. Developments in science, chronicled in the popular press and the new media of film and radio, promoted what Tomes terms a worship of modern science that meshed with the “cult of the new.” Yet, as she points out, popular media accounts also exposed debates within scientific circles that had previously been hidden from public view. In many ways, these contradictory messages created the idea that the modern patient needed to be “an informed patient”—a consumer of health care rather than someone who would blindly follow professional advice. As lay and medical critics realized, the idealized scientific medicine had the potential to complicate, rather than clarify, the trust between doctor and patient. Part two, “Free Enterprise Medicine,” covers the period from the 1940s through the 1960s. Tomes’s narrative follows the political debates surrounding health insurance immediately after World War II that resulted in private insurance covered by employers. At the same time, she notes the increasing costs of medical care, including new drugs, which made health care increasingly expensive. By the late 1950s, she argues, a broader disenchantment with modern consumer culture among the privileged insured group created a new critique of “scientific authority” and a longing for the “old time physician.” While Tomes does include some analysis of the effects of race, social class, and health insurance, this is the weakest section of the book. While there is a nod to the ways in which working class Americans were left without any sort of health insurance, the bulk of her analysis focuses on the rise of suburban offices populated by physicians who were increasingly concerned about maintaining their status and middle-class patients who were becoming disgruntled consumers. By 1960, both politicians and journalists had declared a full-blown health care crisis in America. Part three “A Consumer’s Revolution,” traces the debates from the late 1960s to the 1990s. For those of us trying to make historical sense of this very recent history, this section offers an excellent, if brisk analysis of the period that began with a radical critique of medicine’s authority and perceived failings and ended with the rise of the patient’s rights movement. The result was that the advertising industry was freed up to directly advertise physician services and even prescription drugs directly to consumers. Today we see ads for drugs to treat advanced diagnoses such as small-cell lung carcinomas, an unthinkable idea even thirty years ago. Patients can likewise find evaluations of hospitals, and even some medical practices. Yet, while many modern Americans enjoy a higher quality of life over a longer life span, the costs and complexity of health care have only increased. The Affordable Health Care Act added somewhere between fourteen million and twenty million Americans who now have health insurance. But current debates in 2017 continue to frame health insurance in terms of “freedom” to choose, and many conservatives believe that any government subsidy of health insurance is anathema. But as Tomes points out, the belief that Americans can cheerfully shop their way out of the current health care mess is and has always been an illusion. At 422 pages of text, this is truly a comprehensive and detailed analysis of twentieth-century healthcare. The length of this book would preclude its use in the classroom, which is a great loss. While Tomes analyzes both the modern doctor’s office and the drugstore, the latter often gets lost in her narrative, and perhaps if she is thinking about a paperback edition, these sections could be eliminated. Remaking the American Patient is a wonderful book; having the opportunity to review it in the midst of some of the most vitriolic political debate about health care in modern memory was a distinct pleasure. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
Journal of the History of Medicine and Allied Sciences – Oxford University Press
Published: Jan 1, 2018
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