Why medical students are lacking in bedside manners

Alan has told 32 people about his blood pressure this morning. He told each one that he'd been diagnosed three months ago, had taken tablets for a month but then stopped because it went back to normal. He said that his father had died of a stroke aged 55, when Alan was only 14. Alan explained over and over again that he stopped the tablets because he doesn't really see the point, they make him tired and he hates swallowing pills. Most of the people listened a bit, interrupted a lot and told him what to do in a bossy kind of way.

Never mind! What kind of nutcase tells the same story to 32 random people anyway? Except, in this case, Alan is an actor, paid to play a part for medical students while their performance is assessed by a doctor. I was the doctor, and I was horrified by what I saw. It's not that the medical students aren't presentable and generally polite. But the thought that in another year they will be qualified doctors, ready to be set free among the public, is profoundly worrying.

They all knew which drugs to prescribe for high blood pressure, but only the exceptional few discussed lifestyle measures as a serious alternative to taking drugs. When pressed, most would say: "It's good you don't smoke, try to eat lots of fruit and veg, don't eat too much salt and keep up regular exercise." But it didn't sound sincere. Not compared to their relish for the drug options.

Their task was clear. Each student had a minute to read the synopsis of Alan's story. Forty-five-year-old man, two young kids, high blood pressure picked up at a work medical, blood pressure checked again by his GP and found to be high. Alan had been prescribed the drug atenolol but hadn't taken it for more than a month because it made him so tired. He also hates taking tablets.

The medical student had to play the part of a GP who was seeing him now to discuss his blood pressure. The aim was to explore Alan's ideas, concerns and expectations. Crucially, the student was told to "reach a shared decision" with Alan about how to deal with his high blood pressure.

I wanted to fail all but two of the students. I thought it unforgivable that when Alan said his dad had died of a stroke aged 55, the majority failed to show any sympathy. These poor students seem to be dehumanised to the extent that most glossed over this sad information, or seized on it as a medical point that proved how Alan needs to control his blood pressure to avoid the same fate as his dad.

I suppose I'm being a bit harsh. After all, these twenty-something students have been in an academic hothouse since they were tots. They are probably all straight-A students and they are spending the best years of their lives reading textbooks and attending lectures.

They were being examined on skin diseases, child health and general practice in this exam, with just six minutes for each scenario. They get one minute to read the task, and just five minutes to perform. No wonder they couldn't ask Alan relevant open questions and listen carefully to his answers. And yet most of the doctors-to-be used language that I thought had long gone out of fashion. Patronising, confrontational and scaremongering stuff such as "We want to get your blood pressure right down", "Why have you failed to turn up for your follow-up?", "Why aren't you complying with your treatment?" and "You'll bleed into your brain if you don't take the tablets."

One made me inadvertently laugh out loud with his euphemistic questions about whether the drug was making Alan impotent. "Everything alright in the bedroom?" he asked. "Not really. I told you, I'm not sleeping," said Alan, refusing to play ball.

Dr Joe Rosenthal, senior lecturer in general practice and head of primary care education at University College London, says that communication skills are taught far better now than they used to be. "When I was studying medicine, the first two years was anatomy, physiology and chemistry. Now we run a professional development spine throughout the five-year course. For one day a week, students study communication skills, ethics and the law and clinical skills. The students often think these 'softer' topics are a waste of time. In fact, I sense a bit of a backlash. As we focus more on the 'soft stuff' and less on academic facts, some older surgeons and even some GPs are saying to us 'Well, the students are lovely to patients but they don't know anything!' Obviously we've got to get the balance right."

Dr Rosenthal believes that by the time they leave medical school, most would-be doctors know how to act in a caring way. "Whether or not they mean it, or can sustain it under pressure, remains to be tested," he says.

Things are certainly better than 30 years ago when journalist Louise Davison was exhibited by an orthopaedic surgeon who was due to operate on her bent spine (scoliosis). "Come and look at this deformity," he said to a bunch of medical students, while Davison cowered in humiliation.

The medical schools are undoubtedly trying to teach communication skills. There are more graduate entry students now who have had a chance to live life a bit before embarking on the course. But the majority of new recruits are still very young and frighteningly academic. Is that really the best raw material to start with?