Phil Hammond's

A medical degree, at least according to George Bernard Shaw, is no substitute for clairvoyance. I tend to agree: in the uncertain world of medicine the only things we can predict are that smoking probably isn't terribly good for you and that doctors enjoy their cynicism. Unfortunately, what works well in the coffee room doesn't always go down a storm in the consultation.

I tried out a dose of George last Monday on a woman whose symptoms were beyond me. She was distinctly unappreciative. Perhaps I got the quote wrong. Or perhaps she's one of the new breed of consumerist patients who won't accept that doctors aren't Mystic Megs and we can't always get it right first time, every time.

Don't get me wrong, I've got nothing against consumerism. It's entirely healthy that traditionally reticent British patients are no longer prepared to lie back, think of England and mumble "Doctor knows best" before every operation and "Never mind, you've got to learn somehow" after it. These days, you want your doctor to be compassionate, competent, honest, clean- shaven, awake, sober and hundreds of other things not taught at medical school - well not until recently, anyway.

Communication training is fast becoming big business in "the caring professions". Nurses have been doing it for ages and medical schools are grudgingly catching up. But can doctors really be taught to communicate? I sincerely hope so, because I've spent the past three years having a bash at it and I'd feel a bit stupid if they can't.

There's plenty of evidence that doctors can be taught the surface skills to make it look as if they care (such as friendly seating arrangements, getting the patient's name right, waiting until the legs are out of the stirrups to break bad news). Communication, however, is as much to do with attitude as skills and attitudes are much harder to change. If you're a sexist, racist, classist, homophobic, power-crazy bigot, you can put the chairs where you like - you'll still be a hopeless communicator.

Fortunately, most students entering medical schools today are much more patient-friendly (and female) than the hearty stereotype (drink 10 pints, drop your trousers and piss in someone's flower-bed).

True, a few of them have three grade A science A-levels and the social skills of a dead skunk, but for many their rapport with patients is hindered by their world view. If you've spent the first 18 years of your life locked in a minor public school, you may never have seen anyone black, poor, sick, disabled, elderly or of the opposite sex.

As a student my first patient was a dead one. We hacked "it" into pieces, skipped with the intestines, juggled with the kidneys, made penis key- rings and oh, how we all laughed. When we weren't doing that we were slicing up domestic mammals to make their legs move. By the time I got to see a live patient I didn't value life at all. Perhaps I should have been a surgeon.

The medical students I teach at Birmingham now learn their anatomy from plastic models, not dead bodies. Many of them complain they're missing out - I suspect as much on the shocking exhibitionism of the kidney-juggling as the chance to dissect dead flesh. By way of compensation, they're sent out into the community to meet whole, living families with more problems than they could ever imagine. Some of them are shocked by what they see - "He was lying on a urine-sodden mattress with no heating and only a 20-Watt bulb for light" - and some form lasting attachments with their families. If empathy can be taught, I suppose this is it.

These first-year students are idealistic, but the incessant grind and humiliation of medical training means too many emerge in the final year burnt out and cynical. This, as much as anything, dictates how they talk to patients. Even those who survive into house-jobs with their enthusiasm intact find it hard to maintain at the back end of a weekend shift without sleep or food.

One star student, working as a house-officer, is already facing her first complaint. When, at the end of a 90-hour week, she was asked by a man if there was any guarantee that his treatment would work, she said: "If you want a guarantee, buy a toaster." George couldn't have put it better.