Remaking the American Patient

How Madison Avenue and Modern Medicine Turned Patients into Consumers

Nancy Tomes

• Publisher: The University of North Carolina Press
• Year: 2016
• ISBN:
  9781469622781
• Topic: Medicina
• Subtopic: Política de salud

In a work that spans the twentieth century, Nancy Tomes questions the popular--and largely unexamined--idea that in order to get good health care, people must learn to shop for it. Remaking the American Patient explores the consequences of the consumer economy and American medicine having come of age at exactly the same time. Tracing the robust development of advertising, marketing, and public relations within the medical profession and the vast realm we now think of as "health care, " Tomes considers what it means to be a "good" patient. As she shows, this history of the coevolution of medicine and consumer culture tells us much about our current predicament over health care in the United States. Understanding where the shopping model came from, why it was so long resisted in medicine, and why it finally triumphed in the late twentieth century helps explain why, despite striking changes that seem to empower patients, so many Americans remain unhappy and confused about their status as patients today.

Part One
The Hazards of New Choices
The 1920s to the 1940s

Chapter One: Farewell to the Free Trade in Doctoring

When today we lament the loss of a “golden age” when the goods of medicine, both real and symbolic, were untouched by the entrepreneurial spirit of modern consumer culture, we mourn a past of our own imagination. The remaking of patients into consumers started not with managed care or the Internet but with the nineteenth-century market revolution and the rise of modern consumer capitalism, which dramatically changed the way Americans received both their doctor’s care and their medicinal drugs. During the first half of the 1800s, the United States saw the closest approximation of free-market medical care to ever exist. For both practical and ideological reasons, nineteenth-century Americans embraced a freewheeling approach to health care, characterized by enthusiastic self-medication and unapologetic questioning of medical authority. As one contemporary wrote of the national mood in 1848, “We go for free trade in doctoring.”¹

That “free trade in doctoring” began to be curtailed in the late 1800s on the grounds that the patient public needed to be protected from bad and unscrupulous purveyors of medical goods and services. Physicians convinced state legislatures to pass laws tightening the requirements to get a license to practice. City and state governments created new boards of pharmacy that oversaw how and by whom drugs were sold. With the 1906 passage of the Pure Food and Drugs Act, the federal government got involved in the work of consumer protection. Invoking the advance of scientific knowledge, new groups of experts successfully pressed for an end to the “free trade in doctoring.”²

Underlying this restriction was a clear logic: patient-consumers would surrender the freedom to make certain kinds of choices in exchange for the guarantee of better goods and services. That logic met with fierce resistance from both providers and patients, neither of whom wanted their choices restricted. Progressive-era reformers eventually convinced enough voters and politicians to get legislation passed by emphasizing the promise of protection: seek out the licensed physician, use the drug as directed, and all will be well.

But from the outset, the guarantees implied by licensing and labeling reforms raised expectations that they could not fulfill. Manufacturers, physicians, pharmacists, and government officials had different notions of what constituted quality control and full disclosure. The pressure to soften standards to preserve economic interests was strong and unrelenting. As consumer-oriented capitalism accelerated, insulating medicine from the robust influences of commercialism turned out to be very difficult. The resulting tensions in the doctor’s office and the drugstore created the forcing ground for the emergence of a more assertive kind of medical consumerism.

The Free Trade in Doctoring

To appreciate the end of the “free trade” in doctoring in the late 1800s, we need first to understand how it operated. The Progressive-era turn to patient-consumer protection followed decades of great turbulence in medicine brought about by the twin forces of democratization and industrialization. The result was intense battles over the proper balance between self-care and deference to medical authority as well as the necessary distinctions between professionalism and commercialism.

Dating back to the colonial period, the scarcity of formally trained doctors in many parts of the United States had inspired a strong tradition of “Every man his own doctor,” the title of the first domestic medical manual published in the British colonies, which appeared in 1734. The American Revolution fostered a distrust of what its leaders deemed “aristocratic” traditions of law, while the rapid growth of commercial capitalism after the War of 1812 encouraged new forms of economic entrepreneurship. In this climate grew a spirit of medical democracy that bred do-it-yourself approaches to medical care and a questioning of doctors’ skills and ethics that would persist into the twentieth century.³

The democratic mind-set rested on a foundation of confidence in what historians term domestic medicine—that is, home remedies and nursing routines overseen by laypeople, mostly women but also some men. Calling for a professional physician usually came not at the start of an illness but only after other measures had failed. It was a habit reinforced by the fact that in many parts of the rapidly growing nation, trained doctors were few and far between. Early histories of life on the American frontier often included harrowing tales of settlers driven to desperate acts because no doctor was available, as in the case of an Illinois man who amputated his own toe to escape death from gangrene, an event recorded by a local historian as the community’s “first surgical operation by white people.”⁴

While such dramatic episodes of do-it-yourself medicine earned a place in communal folklore, domestic medicine was more often associated with the nineteenth-century equivalent of “Dr. Mom.” Learning how to treat symptoms and nurse the sick formed part of what American mothers taught their daughters about how to run a home. In dooryard gardens, women cultivated plants prized for their healing qualities, mixing Old World standbys such as angelica, chamomile, feverfew, and foxglove with New World additions such as bee balm, goldenseal, and American pennyroyal. They shared favorite recipes for homemade pain relievers, fever reducers, wound cleansers, and bowel openers and traded advice about managing specific illnesses as well as the dangers of childbirth. This trading of information expanded to include Native American and African American cures along with those from a variety of European immigrant groups.⁵

Within the broad tradition of domestic medicine, laypeople who showed a special talent for managing illness became sought after by their neighbors; such was the case with midwife Martha Ballard in Maine, housewife Mrs. Gardner Randolph in Illinois, and African slave Binah in South Carolina. In the first half of the nineteenth century, trained physicians and lay healers usually cooperated rather than competed with each other. For example, when Ballard faced a difficult delivery, she called in the local doctor for assistance; he in turn let her care for uncomplicated cases and concentrated instead on the more difficult births.⁶

Trained physicians represented the very narrow tip of the medical-care pyramid, to be consulted only when the domestic store of solutions had been exhausted. Most people regarded seeking out the doctor as a serious step, one not to be entered into lightly, an attitude that would persist well into the twentieth century. Moreover, they did so with the expectation of getting specialized services that domestic healers could not provide, such as bone setting and bloodletting. Physicians also had a broader armamentarium of drugs. They could prescribe plant-based drugs in much higher concentrations than could be achieved in homemade brews, among them aconite (from monkshood), digitalis (from foxglove), and opium (from poppies), and a wide array of strong-acting metals, minerals, and salts such as mercury, borax, and alum.⁷

Until the mid-1800s, most doctors learned their specialized skills by apprenticing to other doctors; only the most ambitious attended medical school as well. They delivered their medical services almost exclusively in patients’ homes. While practitioners in cities and towns began to maintain offices, usually located in their homes, they treated only a tiny percentage of cases there—chiefly those involving single men.⁸ Hospitals existed only in very large cities and then primarily served the “poor and friendless”; even wealthy people had surgery or delivered children at home. For all but a very few doctors, making a living was not easy. At a time when cash was still scarce, patients often paid with cords of wood or bushels of fruit.

Although some aspects of this medical system, including the preference for self-medication and the reluctance to go to the doctor, would long persist, the dynamics of medicine began to change in the 1810s and 1820s.⁹ High rates of literacy, especially in the North and the Midwest, coupled with technological breakthroughs in paper and printing, enabled a rising tide of health advice and advertising to enter American homes. The print revolution cheapened the cost of almanacs and home health manuals, adding to the store of domestic medical knowledge. Many American households came to possess not only a copy of the Bible but also family medical guides such as William Buchan’s or John Gunn’s Domestic Medicine, the latter evocatively subtitled Poor Man’s Friend, in the Hours of Affliction, Pain, and Sickness. More drugs and drug advertising also began to enter the American home as changing methods of making glass and paper containers brought down the price of store-bought remedies, such as Thomas Dyott’s line of Dr. Robertson’s remedies. Taking advantage of the very favorable postal rates set by the U.S. Congress, which wanted to encourage an informed citizenry, newspapers became a major vehicle for promoting proprietary medicine products. The bundles of reading matter arriving in the American backwoods that so impressed French observer Alexis de Tocqueville in the early 1830s included an abundance of drug advertisements.¹⁰

As the possibilities for self-education and self-dosing expanded, so too did the number and types of trained doctors available for consultation. In the new republic, the ranks of regular physicians expanded rapidly, as did their efforts to upgrade their educational standards. By the 1830s, nearly every state in the Union had a medical society in operation, and state legislatures had granted most of them authority to issue medical licenses. But regular physicians found themselves challenged by new medical sects that disdained the prevailing “purge and puke” methods, including homeopathic, Thomsonian, botanic, and eclectic practitioners. These alternative doctors created their own medical schools, professional societies, and journals. Faced with warring groups of physicians, state legislatures proved reluctant to favor one over the other. In some states, alternative practitioners were permitted to set up their own societies and licensure systems; in others, the main licensing body was required to include representatives of different sects; in still others, licensing laws were eliminated altogether.¹¹

To fend off these challenges, regular practitioners banded together in 1847 to form the American Medical Association (AMA), a national organization dedicated to professional uplift. In 1848, the AMA issued a code of ethics designed to clarify what made its members superior to both sectarian physicians and the makers of proprietary nostrums. A good physician, the code specified, did not openly criticize his fellow doctors, steal patients from his colleagues, claim to have secret remedies that cured deadly diseases, or advertise his own services. But the AMA’s efforts were all too often undercut by the behavior of their fellow regulars, who in the entrepreneurial spirit of the era rushed to found for-profit medical schools that churned out poorly trained doctors and started up proprietary medicine companies that offered cheap alternatives to visiting a doctor.¹²

By the eve of the Civil War, then, the American medical marketplace was deeply fragmented and relatively unregulated. Medical training and medical licenses did not provide a very reliable guide to a doctor’s skill or trustworthiness. Physicians were divided into rival camps that attacked each other ferociously. Coupled with the growing profusion of health advice and drug advertising, the free trade in doctoring meant that potential patients confronted a very rich and confusing set of choices. The burden of that confusion was likely lightened by the fact that all this competition made for relatively affordable doctors’ fees—from as little as fifty cents to a dollar for a consultation early in the nineteenth century to an average of two to five dollars by its end. Doctors used what today we would call a “sliding scale,” charging more for wealthier patients than for the poor. Since doctors delivered the great majority of care in patients’ homes, they had ample opportunity to assess the family’s circumstances before deciding on fees.¹³

Looking back from a twentieth-century perspective, many commentators would characterize this free trade in doctoring as an abundance of care, none of it any good. At worst, patients had the freedom to be defrauded by outright quacks and charlatans; at best, they had the option of being cared for by well-intentioned but ineffectual doctors. But that perspective requires serious qualification. Patients’ notions of what worked did not reflect a modern sense of the scientific method—as yet nonexistent in 1850—but rather a personal sense of relief. According to this standard, laypeople valued home remedies to soothe sore throat or sour stomach and respected the midwife’s experience in delivering a great many babies. When people decided to seek out trained physicians, they did so out of conviction that such practitioners had valuable knowledge and skills—for example, how to manage a difficult birth, set a compound fracture, reduce a dislocation, prescribe a stronger drug, and perhaps most important, relieve pain. In short, nineteenth-century physicians by no means approached their patients empty-handed. As the distinguished dermatologist William Allen Pusey wrote of his physician father, “For 90 per cent of the ills of life, he gave them useful service,” and the high regard he enjoyed in the community reflected that value.¹⁴

Nineteenth-century patients respected the specialized skills that trained physicians offered but do not appear to have approached them with extreme deference or passivity. As the letters and diaries they left behind suggest, many patients felt entitled to patronize a wide variety of healers. If they encountered a doctor whose treatment they found unsatisfying, they had no compunction about moving on to another one more to their liking and letting all their friends and relations know why. As physician Arthur Hertzler recalled of old-time country practice, the older women in the community could make or break a doctor’s reputation: “The doctors of that day were tried at the quilting bees of the community, not in courts of law.”¹⁵

Yet even at its most lightly regulated, the free trade in doctoring operated according to rules designed to protect patients against the special harms posed by bad doctoring or dangerous drugs. In fact, nineteenth-century medicine produced some of the clearest exceptions to the principle known as caveat emptor (Latin for “let the buyer beware”). First recorded in a 1534 English case concerning a horse trade, “caveat emptor” came into widespread use in the late eighteenth century, as the free-market principles championed by Adam Smith and others became dominant. As Kent’s commentaries on American law observed in 1840, caveat emptor “very reasonably requires the purchaser to attend, when he makes his contract, to the quality of the article he buys.” Should the product prove to be defective—as was the case with the sixteenth-century horse—buyers had no legal claim against the seller. Hence the buyer had to exercise great care when making a purchase.¹⁶

But American courts also recognized that in contracting for medical care or buying medicinal drugs, patients needed some degree of protection from the incompetent and the fraudulent. As free-market principles gained favor in the 1800s, American jurists began to recast the old common-law concept of medical malpractice, redefining the doctor-patient relationship as a contract in which the doctor promised the patient a specific service. Medical malpractice cases began to increase rapidly in the 1840s, largely as a result of cases involving surgeons charged with badly setting broken bones, a concrete procedure whose outcome was comparatively easy to assess. In deciding such cases, American courts held that patients had the right to expect an “ordinary standard of care, skill, and diligence” from their physicians and turned to physician experts to establish what constituted this “ordinary standard” of care. Although malpractice represented neither an easy nor a cost-effective way to resolve disputes, it reinforced the contractual view of medical practice ...