Historian and author Dr. Nancy Tomes recently visited NIH to give the second annual James Cassedy memorial lecture in Lister Hill Auditorium.
How do you find a good doctor?
When Zagat recently partnered with WellPoint to offer their patients a guide to physicians, it struck a nerve.
WellPoint, the largest licensee of Blue Cross Blue Shield, has millions of members nationwide
and a portfolio in the billions of dollars. Zagat publishes guides to restaurants, hotels and other recreation.
The assumption that we should choose doctors the way we choose bistros is problematic, says Dr. Nancy Tomes of the State University of New York, Stony Brook.
A historian and author of Impatient Consumers:
Consumer Culture and the Making of Modern
American Medicine, Tomes recently visited NIH to give the second annual James Cassedy memorial lecture in Lister Hill Auditorium. Her talk, “The Information Rx,” was sponsored by NLM’s History of Medicine Division.
“Choosing a physician is not like choosing an automobile,” Tomes said. “It’s not something you can reduce to a report card.”
Zagat’s doctor reviews let patients rate physicians
on a 30-point scale for trust, communication,
availability and office environment.
Quality of care isn’t measured.
“This raises the question,” Tomes said, “of what constitutes good information.”
She tracked an ongoing battle over who controls
the metrics and access to information such as quality assessment, therapeutic issues, costs and technology.
The ancestors of consumer health guides predate
the Internet, she said.
Medical school “report cards” in the late 19th century were compiled and offered to experts, not patients or students. But the turn of the century’s Progressive era yielded the Pure Food and Drug Act and other reforms to advance consumer safety.
Tomes described how, during the Great Depression,
when making wise choices became crucial, the first peer-to-peer buyers’ guides appeared. These in turn yielded what became a mainstay of popular consumption, the journal Consumer Reports.
“It’s hard to imagine,” she said, “that these early
consumer organizations were portrayed as fronts for the Communist Party and were subject
Nineteen-sixties activism brought “sheer faith in more democratic decision-making,” and by 1971, Ralph Nader’s group, Public Citizen, had become expert in “critical information-gathering,”
When Nader’s group published a Prince George’s County directory of physicians willing to provide unmarried women with contraception,
the Federal Trade Commission took note.
So did the American Medical Association, whose code of ethics banned physician advertising.
In a 1982 lawsuit, the court ruled against the AMA.
“Ironically,” said Tomes, “consumer requests for more information led to more advertising.”
The 1980s saw several trends merge: post-Watergate
levels of media accountability; massive databases
of programs like Medicaid; the computer revolution; and the rise of managed care.
After the Health Care Financing Administration
began compiling data on hospital mortality
rates, the New York Times prepared to file a Freedom of Information Act lawsuit to force its release to the public. Advised by its legal counsel
that the suit would undoubtedly succeed, HCFA made the information available.
Tomes called this revolutionary.
“And this often gets left out [of the discussion],”
she continued. “There was a parallel rise of market research and health care advertising [formerly] constrained by the medical profession,
which considered it unseemly.”
As advertising championed consumer rights, “the for-profit hospital chains spent heavily on marketing,” said Tomes, “forcing the nonprofits to do the same and to spin and buff the public image of the institutions.”
Then came the ’90s with mass-media consumer guides to hospitals and “Best Doctors.”
“‘Bad Doctors’ are harder to publish,” she said.
“There are long battles about resistance to publish
There are indeed national practitioner data banks with such cases, but these are exempted from release under the Freedom of Information Act, she added.
“No consumers [including journalists] can use this information,” said Tomes, “only institutions.”
Although Public Citizen challenged this finding in court, “the public’s right to know was crushed.” But Public Citizen did win a seat on the oversight board of the National Practitioner Board and began to publish its own list of problematic
The Internet accelerated many of these trends. Yet “the deluge hasn’t produced results,” Tomes noted, “and patient choice is still for the affluent.”
The middle-class educated consumer, in spite of access to information, finds medical rankings
and ratings hard to use, while “quality measures don’t always address what matters to them”—such as complementary and alternative
As for the information explosion’s impact on the behavior of institutions and providers, it’s tough to measure because of what Tomes calls “gaming strategies.”
Witness a 2005 Annals of Medicine report citing
cardiologists who avoided treating critically ill patients because the doctors feared it would affect their scorecards.
“Better information sources,” said Tomes, “have not turned out to be the magic bullet to correct the dysfunctional health care system.”
Pushed and pulled by health services research, health care marketing, consumer movements and full-spectrum journalism, the public may in fact need what she called “a trusted intermediary…
who has no direct financial payoff.”
An audience member noted that the current explosion of information coincides with widespread
Information doesn’t cure everything, Tomes said. In fact, Zagat doctor guides reveal “a reified
model of decision-making of a minority…of what ‘normal’ people can do, while others struggle.
“There’s an inequity there that doesn’t get enough attention,” she said.