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Reflections on the Value of Transactional Relationships

More and more, I am learning to appreciate transactional human relationships.

Transactional relationships are those that involve the expectation of reciprocity. They are relationships where you expect to get something out of them other than the pleasure (or obligation) of the other person’s company.

The encounter between a shopkeeper and a shopper is a transactional relationship. So is the relationship between a boss and an employee, or with a waiter, grocer, barber or doctor.

In psychology, transactional relationships carry a negative connotation – they are seen as fragile, transient, and conditional. They are viewed in contrast to the ideal of non-transactional, or relational relationships, where the bond is deeper, more durable, and expected to involve sacrifice for the sake of the other person, such as with friends or family.

But as human transactional relationships increasingly get peeled away from us by the app economy, I am afraid we stand to lose more than we realize and certainly more than we gain.

The ideas of Martin Buber are helpful in this regard.

Buber was an early 20th century Austrian Jewish existentialist philosopher whose most famous book, I and Thou, published in 1923, divides relationships into two categories: I/It and I/Thou (let’s call the latter I/You to be more modern).

I/It is a relationship of subject to object, where we use the other for our own benefit, sensation, or utility. Communication in I/It relationships tends to take the form of a monologue, where the other is treated more as a thing than a person. Slavery is the ultimate example of an I/It relationship.

I/You is a relationship of subject to subject, where we view the other with equality, respect, and a sense of unity of being. Communication in I/You relationships takes the form of a dialogue, where the other is treated as a person, not a thing. Love is the ultimate example of an I/You relationship.

The goal, of course, is to minimize the I/It and maximize the I/You in order to live a richer, more creative, and more meaningful life.

Buber doesn’t talk much about a middle ground between I/It and I/You relationships, but that is where I would situate transactional relationships.

On the one hand, they are I/It in the sense that the relationship only exists because we expect to benefit from it in a tangible, usually material way. On the other hand, they are I/You because despite being transient, the relationship can often involve active and authentic interpersonal engagements.

Not only that, but I view everyday transactions as the main bridge over which a relationship can cross from I/It to I/You, and I believe that the chance of this happening increases as a direct function of quantity and time. Transactional relationships are like a thousand layer cake: each encounter/layer may be thin but piled together they become substantial.

I have noticed this effect in my own practice.

When Rachel and I founded Westside Family Medicine almost twenty years ago, good primary care was hard to find – at least if you wanted to use private insurance. We saw a demand, decided to fill it, and hung up a shingle. Our motto: a practice where vintage care meets modern medicine.

Our attitude is very Family Medicine: we are trained broadly enough to be your first stop for anything. If we can fix it, we fix it. If we can’t, we send you to a trusted specialist who can, and make sure to stay in the loop.

Over time, visit by visit, we build up relationships with patients, learn about them and their families, and try to get to the point where any medical issue -whether large or small – is organically interpreted in the context of the patient’s life in a way that uniquely enhances their care.

In other words, continuity of care functions for us as a prerequisite to understanding how illness is woven into the tapestry of a patient’s life.

This approach works just as well today as it did back then, but the landscape is very different. Now there are urgent care centers on every block, telemedicine apps by the dozen, and startups slicing off narrow, high margin areas of care – marketing medications for hair loss, erectile dysfunction, birth control, antidepressants – with ads on the subways and remote doctors rubber-stamping prescriptions based on online questionnaires.

As a result, the delivery of primary care has become more fragmented than ever, and I see the medical fallout from this – in terms of missed diagnoses, incorrect treatments, and especially overtreatments – every day.

But even if you were to argue that the medical care is equivalent, you would still be missing a major downside to treating this problem here, and that problem there, based solely on convenience and without any real oversight or coordination: it’s a lost opportunity to deepen a relationship with one doctor who could otherwise get to know you as a unique individual over time – to fully transition with that doctor from I/It to I/You.

Transactional relationships provide the groundwork and the opportunity for I/You relationships. They are like a feeder, or a funnel, from the world of It to the world of You. As such, the bigger the pool of transactional relationships you have, and the more frequently they take place, the better.

Let me give you a non-medical example.

There is a little bookstore in Windham, NY, called Briars and Brambles. In order to buy a book there, you have to get in your car, drive down the road, park, go in, hunt around until you find what you are looking for, buy it, and head home. The whole process could take half an hour or more.

Or, you could just open your Amazon app, search for the book, click, and you are done less than a minute later. The process is so “frictionless” that the time between deciding what you want and having it delivered has become practically instantaneous.

Either way, the book is exactly the same. It’s not any better of a read coming from Briars and Brambles than it is coming from Amazon. True, Amazon is more efficient and probably cheaper. But at Briars and Brambles you may also get to know the owner, Jen.

At first she is just the person who rings you up. But every time you go in there’s a little conversation, and you get to know her better. Along the way you find out that some of her staff are interns who get paid with books. That’s cool, you think, filing away the information for later use.

Then one day your daughter, who could often be found sitting in the back of the bookstore on the floor reading something she pulled off of the shelf, gets the idea that it would be fun to work there – for “free” books!

After a little lecture on the difference between “free” and “complementary,” followed by a chat with Jen, it happens: next thing you know Georgia is learning all about the book business from a woman who has become a mentor, role model and friend.

At this point, it goes without saying that I have to buy my books from Briars and Brambles – I would get into big trouble with Georgia if I didn’t. But it wasn’t so obvious at first, and so it goes in many areas of life.

The one thing digital sellers all have in common – whether they sell books, food, clothes, or medical services – is that they leverage decreased overhead to undercut local brick-and-mortar businesses, thereby undermining neighborhoods and reducing the opportunity for real-world transactional relationships.

If you like having a neighborhood bodega, then think twice before buying from a 15-minute delivery service that boards up storefronts to use as warehouses.

If you like having a neighborhood boutique, then think twice before going online to buy something that they stock, even if it’s easier, faster, and cheaper. (Fun fact: I recently learned that trying on in a store items that you intend to buy online is forbidden by traditional Jewish law).

And if you like having a neighborhood doctor, then don’t go to CityMD for your sore throat and online for your Viagra. You are not wasting the doctor’s time with these issues, rather you are giving them the opportunity to know and treat you better.

Buber viewed technology as the “tyranny of the It.” And that was before the internet – he must be rolling over in his grave. But I am not a Luddite, despite what you may think. Some of my best friends work at Amazon and I use it all the time; I just try to be selective. And as far as tyranny goes, I’ll take the tech kind over the brick and mortar kind any day of the week.

What I am saying is that the impact of an app on your relationships is a good yardstick by which to measure its value. And that most of the time, a transaction that involves a real human interaction – no matter how fleeting – should be privileged over one that does not, even if it seems more onerous in the short term.

The more intentional we are about cultivating our transactional relationships, the less we have to worry about looking around one day only to find that apps, along with empty storefronts, are all that we have left.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
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