The Decline in Public Support

Beginning in the 1960s, the rise of the civil rights and feminist movements increased popular emphasis on questioning rather than obeying authorities. These changes helped foster the feminist health movement, the disabled rights movement, and the patients’ rights movement, all of which encouraged consumers to take charge of their own health, obtain second opinions, demand more egalitarian relationships with their doctors, and consider using nonmedical health practitioners. These movements have stimulated major changes in medical practice ranging from the sharp decrease in use of general anesthesia during childbirth to the routine use of informed consent forms before patients receive experimental drugs.

Other structural changes also have reduced patients’ willingness to accept medical dominance. The rise of managed care—and the political backlash against it—has fostered a steady stream of news stories about doctors who supposedly withhold needed care from patients to meet the dictates of managed care organizations. Such stories have left patients less willing to trust their doctors’ advice or motives.

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Meanwhile, because of the shift from fee-for-service medicine toward insurance-paid medicine, far fewer consumers enjoy long-standing relationships with primary care doctors (i.e., doctors in family practice, internal medicine, or pediatrics who are typically the first doctors individuals see when they need medi- cal care). Instead, employers (and consumers) routinely change insurance programs, and insurance programs routinely change their lists of contracted doctors, so con- sumers often must start new relationships with new doctors. As a result, doctors less often enjoy the sort of trust from their clients that can only develop over time. This loss of trust has been amplified by frequent news stories on the dangers of medical errors and the financial incentives for doctors to recommend costly tests or drugs.

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