Medicine did not decide to abandon community. It simply redesigned itself in ways that made community harder to sustain.
Neal Cohen, MD, a professor emeritus of anesthesia and perioperative care and medicine at the University of California San Francisco, has watched that shift unfold from nearly every vantage point, as an anesthesiologist, an ICU director and a department leader.
Anesthesia offers one of the clearest examples.
“Anesthesia has become increasingly dispersed,” Dr. Cohen said. Subspecialization, varied staffing models and the rise of locums have reshaped how care is delivered. Teams that once worked together consistently are now assembled day by day, often without shared history or context.
The result, he said, is not a lack of skill. It is a lack of relationship, and that distinction matters.
“I’ve reviewed malpractice cases where it was very clear the people involved didn’t know each other at all,” Dr. Cohen said.
In one such case, a CRNA and a supervising physician anesthesiologist technically worked together, but for different companies. When the CRNA texted asking for help, the physician assumed the message meant, “call me when you have time.” In reality, it was an emergency.
“Both may have been very good practitioners,” Dr. Cohen said. “But the lack of relationship and shared understanding of roles completely undermined care.”
When teams stop being teams
For much of Dr. Cohen’s early career, anesthesia was practiced within stable, physically connected groups. Clinicians shared space, routines and informal conversations that built professional trust.
“When I began my practice, there were lounges in the operating room,” he said. “People would sit down, decompress, get to know each other, not necessarily be personal friends, but professional friends and colleagues.”
Those spaces did more than offer coffee and quiet. They created a shared language. When someone asked for help, everyone knew what that meant. When tensions ran high, people understood the human context behind them.
Today, many clinicians no longer know who they will be working with from one day to the next. Surgeons, anesthesiologists and nurses may all rotate independently through the same site, often without overlapping relationships.
“If I were a surgeon,” Dr. Cohen said, “I would want to know that the person providing anesthesia had the same commitment I did and was paying attention to what I was doing.”
That alignment, he said, is increasingly hard to guarantee. Cases are assigned by people who may not know the patient, the anesthesiologist or the surgeon. Providers often meet for the first time on the day of surgery.
“The quality of care has to be compromised,” he said, “when people don’t feel they belong to the same community with the same goals and responsibilities.”
When misalignment becomes conflict
The loss of community does not always show up as a clinical error. Sometimes it surfaces as friction.
Dr. Cohen said he has seen growing antagonism between providers, followed by formal professionalism investigations. In many cases, the behavior is not rooted in malice but in misunderstanding.
“For example, ‘I didn’t know the surgeon had been in a car accident before coming to work,’” he said. “‘Or that their child had run away from home.’”
In a shared community, those details matter. They allow colleagues to respond with compassion while still protecting patient care. Without that context, tension escalates quickly.
“When you don’t have a relationship,” he said, “it undermines not only satisfaction at work, but also the quality of care.”
Technology solved one problem — and created another
Dr. Cohen does not argue that the shift away from in-person interaction was intentional. In many cases, it was a byproduct of technology designed to improve efficiency.
But he believes the electronic health record extracted a quiet cost.
“The biggest cost of the electronic health record is the loss of a charting room,” he said.
Before EHRs, clinicians had to be physically present to review charts. Nurses and physicians shared the same space, asked questions in real time and noticed subtle changes in patients without formal alerts.
“Now there are places to chart,” he said, “but nobody’s talking to each other.”
Physicians can review records from anywhere. Many finish documentation at home alone. That flexibility, Dr. Cohen said, has reduced incidental communication, the conversations that surface concerns before they become emergencies.
“You’d hear things you didn’t even know you needed to hear,” he said. “You don’t get that sitting at home in your pajamas.”
Work-life balance and the rise of shift medicine
The push for better work-life balance, Dr. Cohen said, addressed real and serious problems. Long hours and fatigue were unsafe. Restrictions were necessary.
But the pendulum has swung in ways healthcare is still struggling to manage.
“Most anesthesiologists now view what they do as shift work,” he said. “At the end of their shift, they go home.”
In other industries, that handoff is inconsequential. In an operating room, it can be destabilizing.
“It matters for a sick patient,” he said. “It matters to the surgeon when they look up and see someone they’ve never seen before.”
While handoff tools exist, Dr. Cohen said they do not replace face-to-face communication.
“You need to know what you need to know,” he said. “The electronic health record says it is all there, you just have to look for it. But you have to know what to look for.”
Earlier in his career, Dr. Cohen said, physicians felt ownership over their patients even when they were not physically present.
“I felt responsibility 24/7,” he said. “I made sure the person taking over knew what concerned me and what might happen.” That depth of transfer, he said, is increasingly rare.
He also pointed to how anesthesia itself has been divided across preoperative, intraoperative and postoperative roles, turning what was once a single patient relationship into a relay, technically efficient, but relationally thin.
Community is not one thing — it is many
When leaders talk about rebuilding community, Dr. Cohen said, the mistake is treating it as a single entity. “We’re actually talking about communities,” he said.
Some exist naturally. Cardiac anesthesia teams, for example, often work well together because they are consistently paired with the same surgeons and nurses. Other areas, such as general operating rooms or ambulatory settings, are far more fragmented. Each requires a different approach.
Departments, he said, need intentional efforts to create shared goals around quality, safety and staffing. That may include in-person meetings, social gatherings or even virtual forums, imperfect, but better than silence.
At the same time, leaders must recognize smaller communities within the larger structure and support them appropriately. When clinicians feel isolated within their niche, departmental backing becomes essential.
“You can’t leave that support to the people on the front lines alone,” Dr. Cohen said.
The same principle applies in ambulatory and procedural settings, where care is increasingly decentralized. Without deliberate coordination, clinicians end up scattered across facilities with little opportunity to build trust or shared standards.
Relationships still save lives
At the core of Dr. Cohen’s argument is a simple idea: relationships remain one of medicine’s most powerful safety tools.
He illustrated this with a story from the ICU. A nurse he worked with for years did not always articulate problems in clinical language, but she knew when something was wrong.
“If she called me to the bedside, I went,” he said. “She might not have been able to tell me what was wrong, but she knew something was wrong.”
That instinct, he said, comes from experience, and from working closely with colleagues who trust each other enough to speak up.
“You need to understand who people are, where their strengths are and where they need support,” he said. “That goes both ways.”
When clinicians are isolated, that safety net disappears.
At the end of his career, Dr. Cohen is not arguing for a return to an earlier era. The system cannot be rebuilt exactly as it was. But he believes something essential must be intentionally restored.
As healthcare continues to evolve, he said, leaders must decide whether efficiency alone is enough, or whether rebuilding human connection is worth the effort. Because when community disappears, the losses are not abstract.
They show up in miscommunication, in burnout and, sometimes, at the bedside when seconds matter most.
