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America has evolved. Politics used to be “local.” Businesses were also local. My parents’ generation knew their grocer, the milkman, and the owner of the hardware store. There was even a bread truck and a milk truck that delivered to our house. And of course healthcare was a local phenomenon. Health care of the era was best personified by Marcus Welby MD. Physicians made house calls. Hospitals served a local community and were run by health care professionals. Pharmacies were also largely independently owned. Business owners forged individual relationships with the customers they served. Health care professional were likewise independent professionals.

As the world has evolved many small, independent businesses evolved into large corporations. Large chain stores dominate the marketplace. As customers we no longer have a relationship with the grocer but with the “brand.” Chain Pharmacy brands now dominate the community pharmacy marketplace. Hospitals continue to merge at a phenomenal pace and are evolving into large, diversified into health care systems. These large corporate enterprises are changing the way health care is delivered, the relationship of patients to healthcare professionals, and even the very nature of what it means to be a professional.

My goal here is not to wax nostalgic or speak in opposition. The one thing that is certain is change and the world will not stand still or return to its former state. There are many ways that change will positively impact patient care. The growth of increasingly large systems will facilitate the opportunity to harness big data leading to better care. Innovation has been accelerated, access improved, and care is becoming more standardized. Another positive is that pharmacists and being utilized as care providers and our role is expanding as team-based care models replace historical “paternalistic” models.

While there are many good things about this evolution we should also be aware of the dangers. Some pharmaceutical manufactures seem to have adopted Gordon Gecko’s “Greed is good” mantra from the iconic movie Wall Street. This is best epitomized by the unapologetic Martin Shkreli, the new poster child for corporate greed. Health care providers are not immune from the influence of financial interests of corporations. As health care corporations face more pressures to contain costs, business decisions will increasingly come into conflict with professional ethics. The ASHP Foundation’s Pharmacy Forecast 2016-2020 has a section on ethics, which predicts that health professionals are “…are facing increasing ethical challenges, stemming partly from consolidation of payers and provider organizations, growing weight of the business imperative in healthcare, tension between population health and individual healthcare, and the rapacious pricing of some medicines.”

Helper’s work on pharmaceutical care emphasized the professional covenant with the pharmacist and the patient. Corporations make business decisions and professionals make care decisions. Sometimes these two roles come into conflict. As professionals become employees the lines can become blurred and ethical dilemmas can emerge. And as the number of layers between the decision makers and the patient increases there are risks that decision makers will lose some degree of empathy and connection with the needs of the patient versus those of the corporation.

Health care will continue to evolve. Sometimes in the moment it is difficult to see the impacts this evolution will have on us both as individuals and as a profession. Change marches on but we would do well to pay attention to our core values as professionals and ensure that we do not lose sight of the very purpose of professions which is to provide care to those in need.