{"id":12585,"date":"2012-07-03T07:25:24","date_gmt":"2012-07-03T11:25:24","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=12585"},"modified":"2012-07-08T14:22:33","modified_gmt":"2012-07-08T18:22:33","slug":"how-american-independence-created-a-new-kind-of-patient","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2012\/07\/how-american-independence-created-a-new-kind-of-patient.html","title":{"rendered":"How American Independence Created a New Kind of Patient"},"content":{"rendered":"

By Michael L. Millenson<\/p>\n

The empowered patient, skeptical of professional authority, is not a new phenomenon: he was actually created by the American Revolution.<\/p>\n

Reading through historian Gordon Wood\u2019s Pulitzer Prize-winning book, The Radicalism of the American Revolution<\/em>, I came across a passage describing how national independence from the British led to an independent turn of mind in other spheres. Wood writes that Charles Nisbet, president of Pennsylvania\u2019s Dickinson College, complained as early as 1789 that Americans<\/p>\n

were carrying their reliance on individual judgment to ridiculous extremes. He fully expected, he said, to see soon such books as \u201cEvery Man his own Lawyer,\u201d Every Man his own Physician,\u201d and \u201cEvery Man his own Clergyman and Confessor.\u201d<\/p><\/blockquote>\n

In fact, New York\u2019s Medical Repository<\/em> wrote in 1817 of a shortage of \u201cprofessional pharmacists\u201d at a time when they did drug-mixing and diagnostic duties. But while the Repository<\/em> acknowledged the lack of professionalism might lead to some mistakes, it continued that \u201cthese mistakes would be no more than occurred in Paris, London or Edinburgh, \u2018where pharmacy, as a profession, is scientific<\/em>, exclusive<\/em> and privileged<\/em>,\u2019\u201d writes Wood. (Emphasis in original) What a remarkable attitude!
\n
\nAround this same time, the word \u201cstatisticks\u201d appeared for the first time in American dictionaries. However, in America, there was a growing opinion that facts could speak for themselves without expert interpretation. As one popular journal put it in 1811, \u201cThe reflections arising out of [the facts] should be left to the reader.\u201d<\/p>\n

Concludes Wood: \u201cThe result of all these assaults on elite opinion and celebrations of common ordinary judgment was a dispersion of authority\u2026.Knowledge and truth, it was argued, now indeed had to become more fluid and changeable, more timely and current.\u201d<\/p>\n

Web printouts at the doctor\u2019s office, anyone?<\/p>\n

Of course, this was also a society where moral judgments still routinely trumped medical ones. (Come to think of it, maybe that era isn\u2019t totally over.) Charles Rosenberg\u2019s acclaimed The Care of Strangers: The Rise of America\u2019s Hospital System<\/em> relates how hospitals in the late 18th<\/sup> and early 19th<\/sup> century were mostly places for the poor or desperate, with laymen on the hospital board limiting admission to the \u201cmorally deserving\u201d in the former category. (A pregnant woman might be admitted if married, for example, but rejected if not.)<\/p>\n

Still, patients did retain some rights. For instance, the Massachusetts General Hospital warned in 1824 that medical students must \u201ccarefully abstain from any gesture or remark which may tend to alarm the sick.\u201d<\/p>\n

Sometimes the independence shown by the sick could be alarming in its own right.\u00a0 As Rosenberg relates: \u201cThe persistence of punishment cells and cold showers illustrates an endemic truculence among at last some antebellum hospital patients, as do repeated thefts of food and the smuggling in of alcohol.\u201d So many patients simply left the hospital without telling the staff that the category of \u201celoped\u201d was adopted along with \u201cdied\u201d and \u201crecovered.\u201d<\/p>\n

Moreover say Rosenberg, \u201cpatients sometimes \u2013 on occasion defiantly, more often surreptitiously \u2013 rejected medicine prescribed by the attending physicians.\u201d<\/p>\n

As I\u2019ve written previously, the American Medical Association\u2019s original Code of Medical Ethics in 1847 advised doctors that \u201cthe obedience of a patient to the prescriptions of his physician should be prompt and implicit. [The patient] should never permit his own crude opinions as to their fitness to influence his attention to them.\u201d<\/p>\n

Looking at the historical record, this seems just wishful thinking. \u201cParticipatory medicine\u201d with an independent-minded patient was always, and will always be, part of the American character.<\/p>\n

Michael L. Millenson<\/a> is president of Health Quality Advisors LLC in Highland Park, IL; the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management; and a board member of the Society for Participatory Medicine.<\/em><\/p>\n

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References<\/span><\/p>\n

Michael L. Millenson. Spock, Feminists and the Fight for Participatory Medicine: A History.\u00a0Journal of Participatory Medicine<\/em>\u00a02011 (3): June 21, 2011. Accessed at http:\/\/www.jopm.org\/evidence\/reviews\/2011\/06\/21\/spock-feminists-and-the-fight-for-participatory-medicine-a-history\/<\/a><\/p>\n

Charles E. Rosenberg. The Care of Strangers: The Rise of America\u2019s Hospital System<\/em>.\u00a0New York: Basic Books, 1987. 18-25; 37; 52.<\/p>\n

Gordon S. Wood. The Radicalism of the American Revolution<\/em>. New York: Vintage Books, 1991. Pp. 360-62.<\/p>\n

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