"The Conversation."

            As the exchange between patient and family physician becomes increasingly filtered through the computer, I fear the conversation becomes less personal and less spontaneous.  Before the conversation becomes medical, I have frequently found it has to  become personal.  In  many situations a rapport has to be developed before an adequate and accurate history can be obtained.   The introductory exchange before talking 'business' is often as important a source of relevant information as the actual clinical history.  For many patients, the visit is a source of anxiety and it is difficult to get an accurate history from an anxious patient.   It is especially difficult when the physician's gaze is focused on a computer screen and his attention is on his typing, and filling in the algorithmic boxes, many of which have no bearing on the patient's health. Eye contact is at a minimum  The  fee schedule, which rewards the brief and superficial interview and penalizes those who spend more time taking a thorough history and performing a physical examination contributes to this in no small measure.  It's easier to send the patient to the  lab and x-ray after a short history than to waste time delving into the history details and discussing whether the tests are really necessary, as the 'Choosing Wisely' program urges, without giving any consideration to the time it  may take to convince a patient that the test they 'know' they need, isn't necessary at all.. 
           The completion of  the templates, whether relevant or not, are used as a measure of the physician's thoroughness and competence, which they certainly are not, and a bonus system is frequently based on what the administridiots have designated as model practice. The College of Physicians and Surgeons are no more discriminating and make inappropriate judgements based on them.
             Some people,  have a natural  talent for communicating with others, while many do not.  So, what should the conversation be - some warm fuzzy bit of nonsense?  Certainly not.  It should be the establishment of comfortable lines of communication between two adults that sets the tone at the outset of  the relationship. The rapport that it builds will be the prelude to a detailed initial history and physical examination and in fact set the tone to all  further visits.  I received my medical education at a time when the history and physical examination were considered to be the foundation for everything that follows.   It is often very difficult for a patient to share some of their innermost concerns with a physician  they barely know.  A significant amount of time was spent in educating us how to communicate with and examine patients under direct observation.  Many students and residents today are rarely directly observed doing these deeds and having their skills documented.  The art of medicine is largely the art of communication, insight and  understanding and complements the essential scientific skills and knowledge that every physician must have.  High  tech as wonderful as it is, does not replace the art of medicine.   Frequently, a thoughtful history alone allows an accurate diagnosis to be made, or at least points in  the right direction.  Unfortunately, those essential hands-on skills are being allowed to atrophy because they take  time and effort.   The commitment that was evident in previous generations of physicians  is nowadays often considered to be a bit of  arrogance, a bit of a joke (who did they think they were, the paternalistic old fools, God?).  No bright young person going into medicine these days is stupid enough not to put their own and their family's needs and requirements first.  Maybe they are right.   Medicine was a vocation, almost a religion and now it's a job.  Why expect more from physicians than from  anyone one else in any other job?  I guess docs will  just have to get used to doing what their bosses tell them.  Not everyone would agree but that's sort of sad for professionals once recognized as independent thinkers and individualists.   
               I've wandered away from the point a little, but lets hope 'the conversation' will  survive, even if there isn't room for it in the fee schedule.