So whatever happened to a good bedside manner? If you have been through the Irish health system you may well be asking this question. Reports from patients' organisations, medical defence bodies, patients' groups and even the medical profession's own governing body, paint a picture of too many doctors being too busy to talk, often rude, leaving patients feeling confused and afraid.
Recent figures from the Medical Council of Ireland show that 10 per cent of complaints about doctors relate to poor communication or rudeness. The Irish Patients' Association reports that the majority of people who make contact with it complain of having bad experiences with hospital consultants.
To tar them all with the same brush is unfair - there are many who are genuinely good communicators, who are compassionate and who take time to build a rapport with patients. However, consultants are almost universally perceived as arrogant, not just by patients, but also by other health professionals.
The latest report from the Irish Patients' Association makes quite depressing reading, detailing the feelings of people who have had experience of the Irish health services.
One health professional who found herself "at the other side of the white coat" expressed her feelings: "Up to now we never had to have dealings with hospitals or consultants from the other side of the counter so to speak. We assumed with good faith that the system would help us through this most vulnerable time . . . What we got was a litany of bad manners to say the least . . . Heaven forbid we questioned their judgment. To be questioned was, it seems, tantamount to a downright slap in the face. It wasn't the treatment, it was the way we were treated." At the recent Wonca medical conference in Dublin, psychiatrist Anthony Clare said doctors tend to ignore patients as people. It was interesting, he said, to see some medical students who were excellent communicators while in training but who had it "knocked out" of them when they got into the hospital setting. But patients, he said, sometimes have unreal expectations as a result of watching programmes such as ER where there is high-tech medicine "but the human aspect of the patient is retained".
Prof Clare pointed out that decades ago a good bedside manner was often all doctors had to offer. While technology has meant huge advances in treatment it has also contributed largely to the "dehumanising" of medicine.
Recently in a blistering attack on the medical profession in the UK the editor of The Lancet Dr Richard Horton described doctors as arrogant, secretive and unaccountable. He told an alarming story about a surgeon who was brilliant but very arrogant. During the 1980s, when he was a medical student, he saw the surgeon deliberately cut a patient's ureter, the tube connecting the kidney and the bladder, simply to teach a colleague how to repair the damage. "This sort of practice, and far worse, is not uncommon," according to Dr Horton.
This culture among doctors is not new. According to one "it is a learnt thing, a complex combination of things, often ego". One Dublin doctor observed that hospital consultants can be very aloof. "There is a haughtiness. A lot of hubris. Hospitals seem to have that effect. It is also an extremely male environment."
According to another a siege mentality has developed. Consultants are busy protecting their patch and protecting themselves from litigation. But the Medical Defence Union (MDU), which insures doctors for lawsuits, points out that there is evidence of a link between communication skills and litigation. "Doctors who are bad communicators, and not empathetic, fall into the group more likely to be sued," Dr Stephen Green of the MDU told The Irish Times.
Medical schools are increasingly aware of the importance of including communication skills as part of training, but clearly more needs to be done. Taxpayers subsidise the almost £20 million paid annually by the Department of Health to cover consultants against being sued in their public work.
It is not just the patients who are complaining. The relationship between GPs and consultants is often not good. One GP pointed out the marked difference in the tone of correspondence from some consultants to family doctors about public and private patients. "A letter concerning a private patient might start `This very pleasant, 35-year-old accountant', while a public patient would simply be `This patient attended for . . .' "
Irish consultants have quite incredible leeway when it come to building up their private practices. Some work full-time in public practice but the vast majority also treat private patients. Consultants have consistently resisted efforts to make them more accountable for the exact amount of time they spend with public patients. A handful of Irish consultants make over £500,000 a year from the VHI. There is also lucrative income from medico-legal work. They may earn up to £400 a day from giving direct evidence in court cases. The Department of Health appears to be unwilling or unable to face them down on these issues.
One consultant described it: "Guys come back from abroad where they have been earning quite moderate salaries. They upscale quite quickly with the combination of public work and private patients and they find themselves in a different league."
In his attack on doctors, Lancet editor Dr Horton also spoke of the culture of secrecy in the British Medical Association and the royal colleges - smaller, more prestigious associations for specialists. This culture is just as relevant here, as anyone who has ever attended a briefing of the Medical Council will tell. "It's like stepping back in time," said one journalist who recently attended a briefing for the first time. Despite the fact they are held following a meeting of the Council the agenda is not made known, and in response to the majority of questions journalists are told it would be inappropriate to discuss whatever topic has been raised or that a particular matter is confidential. If proposals to bring the Council within the remit of the Freedom of Information Act are followed through it would be little short of revolutionary.
In defence of consultants - for there are many who care passionately about their patients, who take the time to explain things to them and see them very much as people - they face a number of difficulties. Operations can be cancelled without notice, wards closed and waiting lists mount. A number spend a considerable amount of time fighting cutbacks with management. Even excellent communicators may have difficulties with some patients. There is no easy way to give bad news to a patient. Often they take time to explain exactly what is wrong and the treatment options available but it simply may not sink in at that time with the patient.
Former president of the Irish Medical Organisation, Dr Cormac Macnamara said hospital consultants generally have excessive workloads. "They are very heavily over-worked. At least in private practice they can control their throughput. But if they did that in their public work they would be accused of working to rule. The average consultant here does a day's work in an hour. They go in at around 7.30 a.m. and virtually none will see their homes before 9 p.m."
Dr MacNamara, a Waterford GP, said consultants may be perceived as arrogant but they are often coming from a completely different perspective to the patient or the patient's family. "A surgeon may have spent six hours in surgery and afterwards the mother of the patient may only want to know `will she have a scar doctor?'. That is not what they want to be talking about. If hospital workloads were organised properly doctors would have more time to spend with people. Consultants have many demands on their time - they are being telephoned by relatives, by solicitors about court cases, theatre sessions are being cancelled, politicians are ringing about urgent appointments for a constituent. It's all very ad hoc."