I had my annual physical this week and am happy to report that my health is fine, as usual.  I’ve had the same doctor for twenty years. Marcus Welby has nothing on Mark Bauer, M.D. my internist at Harvard Vanguard. Dr. Bauer is conscientious, knowledgeable and compassionate.  Over time, our relationship has evolved in subtle ways.  At the start I trusted him intuitively, now I trust him empirically since we have a twenty-year history of excellent care.  In the early days he made notes as we talked, now he enters information on the computer, but either way he pays more attention to me than to his data entry.  He is more cautious about ordering tests than he used to be; Harvard Vanguard has clamped down as a cost savings measure.  But none of these changes have significantly altered my care. I have few medical challenges, but when I do Dr. Bauer responds immediately and I don’t second-guess his advice.  There is no need to – he knows me and has my best interests at heart.

I’ve been attending the Northeastern University Open Classroom this semester, ‘Policy for a Healthy America’.  The speakers are all informative, but last week’s session, “Is There a Doctor in the House, Maybe Not, but will it Matter?” helped me understand the conflicting dynamics of our healthcare system in a new, comprehensive light.  Tim Hoff discussed the demographics of our healthcare providers – not enough doctors, many retiring soon, not enough primary care docs, too many specialists, more demand for providers, more demands on providers, and high levels of job dissatisfaction among doctors, nurses, and pretty much everyone else in healthcare.  These folks may be well paid, but they are very unhappy.

Some aspects of our evolving healthcare landscape will improve this situation – more doctors are opting to be employees at the same time that integrated care and bundled payments make private practice increasingly irrelevant.  Some aspects of the healthcare landscape will exasperate the situation – medical schools’ focus on tertiary, specialized care are not providing the number or type of clinicians we need. Medical care will become increasingly centralized and team-based as fewer doctors are responsible for more patients, and nurses, PA’s nurse practitioners, and Medical Assistants pick up more and more direct care.

How this will play out is not entirely clear, but one thing is certain.  The relationship I have with Dr. Bauer will become history.  Except for the rich who pay for concierge care, our future will not include a personal relationship with our doctor; we may not have any single person who understands our health from ongoing face-to-face experience.

This is really no surprise; it’s the logical extension of so many other aspects of our lives.  The family farm has given way to corporate agriculture; the neighborhood grocer has become Super Stop’n’Shop, the hardware store has become Home Depot, even the neighborhood newspaper boy, of which I was one, has morphed into a faceless adult who tosses the papers from his car before dawn. This transition is more difficult in healthcare since our health is an intimate concern. But the change is underway and it’s bigger than the Affordable Care Act or fewer private practices or shuttered community hospitals or the dichotomies between our massively expensive private healthcare and meager public health initiatives.

Healthcare evolved from a vocation to a profession, and now it’s a business.  It was based in relationships, but in the future it will be based on transactions.  Ideally each individual’s future health will reside in a comprehensive record that will allow all manner of generalists and specialists to accurately and efficiently assess our needs and then diagnosis, prescribe, and treat accordingly.  The dystopian view is willy-nilly data files with inadequate safeguards and little coordination that put us at the mercy of people making life-threatening decisions based on incomplete information.  Most likely each scenario will play out.  Well-educated and informed individuals will learn how to champion their own needs, while the poor and disenfranchised will get lost in the morass. Healthcare will no longer pair doctors with patients; we will be providers and consumers. Astute consumers will enjoy their choice and influence; passive consumers will live – or die – with what comes their way.

The Agency for Healthcare Research and Quality has determined that 64 million annual physicals at a cost of $7 billion are not cost-effective healthcare experiences.  The study is probably correct; my annual physicals never turn up much of anything.  But Dr. Bauer and Harvard Vanguard are bucking this study; I am still eligible for an annual physical. I accept that at some point in the future it will become a luxury I either do without or pay for out of pocket.  I value my relationship with Dr. Bauer and am sorry that my children will likely not enjoy such a trusting intimate relationship with their doctor.  But I am realistic in accepting that healthcare’s evolving business model is not Dr. Bauer’s doing or Harvard Vanguards or mine; it is the collective result of a society that puts undue value on economic cost until we’ve lost something valuable that cannot be economically measured. People bemoan dead downtowns even as they choose to shop at Wal-Mart. We pine for a life of meaningful relationships, but time and again, if there are a few bucks to be saved, we opt for a transaction instead and then wonder why we feel unsatisfied.