As I participated in the Hope Street Group project to Re-Invent Primary Care, I came to think about how medicine is at a unique opportunity to both converge and diverge at the same time. This creates some tension as different stakeholders favor going in opposing directions. However, I think there is a framework that will enable us to strive for a healthier society. To do so, we should recognize that "health care" is really two things: 1) maintaining health and 2) treating illness.
Maintaining health should be primarily the responsibility of patients and communities. Physicians are, let's be honest here, not really trained to think about maintaining and promoting health and healthy behaviors. These behaviors should be taught in school, supported by the design of communities, and re-enforced by cultural ideals. The health care system (clinics, hospitals, etc) is not the ideal place to instill such education about health. It would be best to decentralize the way we promote health and healthy behaviors. Instead, these should be "outsourced" to families and communities in order to create a culture of health. As a society, we should emphasize that maintaining health is the responsibility of patients.
How? Tough question, for sure. But social and personal media can help -- just think if your cell phone kept track of how far you walked every day, or if your grocery discount card also provided feedback on your diet (in comparison to ideals and other people). This is a realm of huge potential for innovation, particularly if patients/consumers know it is their responsibility to find the tools that work for them.
This is the divergence -- maintaining health as the responsibility of the individual and community. There will be roles for policy changes related to food subsidies, zoning codes for fast food, etc, but the bulk of the power still lies with the individual (which can be encouraged through social interactions).
The opposing tension is the "sick care" system: how we treat individuals when they do become ill. Appendicitis will still happen, as will infections and heart attacks. When they do happen, patients should be treated in integrated, comprehensive care systems that know their past medical history, have a full range of treatment options available (acute primary care appointments all the way up to the ICU and cardiac surgery). When people develop acute illnesses, our system should be consolidated and coordinated to care for them.
This means the era of the solo practice - the "cowboy physician" - is coming to an end. Physicians are more likely to be leading health care teams that care for patients, seeing the patients when needed due to acute illnesses or complex cases, but coordinating care with nurse practicianers when able and appropriate.
We need an integrated, vertical health care system that can treat everything from a minor ailment to highly complex illnesses. This will require consolidation of the health care system, but not every patient and every appointment will need to be seen at a major academic institution. There is still a role for the local provider, but that provider should be connected to (no, integrated with) secondary and tertiary care centers that can pick up the care of patients that exceeds the capacity of the local provider.
So, that's how I see the future of medicine: empowering individuals with the tools and instilling them with the sense of responsibility to maintain their health, while integrating and consolidating the treatment of acute illnesses into multi-specialty health care organizations when they do occur.