Health: Physician, heal thyself

Take heart, wronged patient, your hour may be at hand - but perhaps not quite yet. Thanks to those many readers who took the trouble to write in after our invitation to send us your examples of crass or insulting behaviour by doctors. We had a very healthy postbag and more letters were arriving as I write.

That there is a problem, of whatever scale, is not questioned by the various professional bodies. In fact, the British Medical Association spokesman, Nigel Duncan, expressed surprise that we did not get more letters than we actually did - his estimate was "hundreds". The Royal Colleges and the General Medical Council also accept that a small number of doctors who are rude to their patients need to be dealt with. The question is how, and when. More of that at the end.

Many of your letters contained recurring themes. Not surprisingly, intimate internal examinations represent a particularly fraught arena for interaction. "Did the earth move for you?" one woman was asked while undergoing ultrasound with a vaginal probe. For seediness, how about: "Your virginity is very valuable, and could be sold to an Arab, particularly as you have fair hair"? Another letter describes a conversation between a consultant and a female junior doctor while the internal examination was under way, oblivious to the presence of the patient. "You should go into obstetrics," breezed the consultant, "there aren't enough women in obstetrics." Quite so, thought the patient.

Often readers were hugely relieved to have this opportunity to unload their sense of anger or disappointment with caring professionals, particularly if they had tried - and failed - to pursue complaints through conventional channels. That failure was surprising, given that at least one verged on sexual harassment. One woman said she was asked if she might have any risk factors for HIV. "Apart from being so attractive that you're in danger of being raped every time you go out," he added, as she was dressing.

Although by and large people were pleased with the care that they got and believed that the problem was a small one, the consequences of rudeness were potentially devastating - one woman said she decided not to have any more children after a disastrous consultation. Another woman refused to visit her student health service again after her appointment with a sore throat. The doctor suggested an operation. "For a sore throat?" "No - for your ears. They must be causing you emotional distress, they're so protuberant."

Several of the comments that caused offence seemed to be attempts at jokes that misfired. The boundary between good joker and bad taste is narrow indeed. Naturally, individual sensitivities will vary hugely; and it would be a sad day if doctors could not use humour at all. I suspect the correspondent who told his psychiatrist that he had a storm raging inside him, and was told that psychiatrists were not very good at treating the weather, was aware that the comment was not intended to offend, as was the woman who was told after her hysterectomy: "We didn't sew you right up - after all, Prince Charles is still looking for someone." However, as Dr Ian Bogle, the BMA chairman, has said in his "Right to Reply" to my original article in these pages, such stories are traditional after- dinner speech fodder for doctors. And that is where the crucial problem lies.

That a culture of tolerance about amused contempt for patients exists among doctors is clear. There is a humorous column, written by GPO, in Doctor magazine, called "Copperfield," where (imaginary) patients are regularly pilloried. There are also the elegant but bilious effusions of Dr Theodore Dalrymple in The Spectator, in which his despised (real) patients are mentioned only for their thuggery and barbarism, with libertarian indifference to the conditions that created their plight. These are both treated with amusement by the profession; the question is, are they acceptable to the public?

The health editor of The Independent made the valid point that obnoxiousness is not always one-sided, and that patients can cut up rough, too, even to the point of assault. Clearly the two wrongs do not cancel out, and I would pose these three questions - which of the two subjects has been trained and has the greater experience? On whose territory do the exchanges take place? Who is being paid?

Is anything going to be done? The outlook in Britain is cautiously optimistic. Professor Mike Pringle, President of the Royal College of General Physicians, says that revalidation, or re-licensing for doctors, will indeed address the issue of communication skills. The scheme is currently at the discussion stage between the Royal Colleges, the BMA and the GMC, and the plan is to try to introduce it some time before February 2001.

How exactly the scheme will operate is unclear, but it does seem certain that patients will have some role to play both in structuring and continuing the process. How patients will be recruited is undecided, but as Professor Pringle says, "we are not looking for people with an axe to grind, nor do we want them to be too uncritical". Most likely is a programme where a variety of professional attributes will be assessed on a five-yearly basis. The options for assessment of bedside manner include submitting a specimen video; attending for simulated consultations; having a colleague or a patient sitting in; or by detailed patient survey. Doctors will probably be allowed to choose.

I am sorry that the BMA found this open approach "irresponsible". The same thing was said about the anaesthetist who blew the whistle on the Bristol baby heart scandal. And where did he subsequently have to seek work? Oh yes, Australia. And when did the momentum for change in the profession start to gather pace? Oh yes, it was immediately after Bristol.