When my consultant told me that I had leukaemia, she had a hint of a smile on her face. It was not, of course, a smile of glee. Instead, it was one of understated warmth. It conveyed a sense of compassion and hope. Her smile was saying to me: "Sorry this is bad news. But don't worry - all is not lost."

The subtle messages signalled by my doctor's non-verbal behaviour are firmly lodged in my memory - as they are for many patients or relatives given shocking or bad news. But ask clinicians about the first time they told a patient he or she had cancer, a man that his wife was brain damaged from an accident or a new mother that her child was diagnosed with Down's syndrome, and the memory might be hazy.

And not unreasonably; after all it is part of the job to regularly break bad news. Yet formal training for doctors and nurses on how to disclose distressing news to patients or relatives is markedly inconspicuous. In fact, it is often a lowly"special request" or appendage on clinical undergraduate and postgraduate training.

While most professionals develop their own appropriate techniques for breaking such news, they can be inadequate. Some methods, as patients have pointed out time and time again, are horrendously crass. Studies in the child disability field reveal that about 50% of parents are dissatisfied with the way news of their son's or daughter's disability was given to them.

This can have detrimental consequences for parents' subsequent relationships not only with medical professionals but with their own child. "If news of a disability is portrayed negatively by a doctor, it can affect the bonding of parents to their child and particularly their view of disability later in life," says Robina Shah, a clinical psychologist working at St Mary's hospital, Manchester.

In its own effort to address these training inadequacies St Mary's has offered, over the past three years, a "sharing the news" workshop to clinicians and nurses. The participatory workshop, developed by Shah, aims to refine professionals' communication skills when delivering distressing news.

By focusing on the patients' perspective, it allows professionals - perhaps for the first time in their career - to devote a whole day to reflection on the details of how they break unpleasant news.

In what room should they meet patients and relatives? Should they sit or stand? How much or how little should be imparted? How much medical jargon should be used? What is the best tone of voice to use?

General rules about good eye contact, sensitivity and honesty are paramount - as is checking that pagers are switched off and that correct names are used. And even though consultation time is limited, doctors are encouraged to allow patients or relatives the feeling that they have their unwavering attention.

Shah says: "The training offers professionals the time and space to ask themselves the question: 'Can I do this better?' It offers them the opportunity to share models of good practice."

The Royal College of Physicians, which has accredited Shah's course, recognises there is a lack of adequate training in communication skills and urges that training be made "high priority" in formal medical education.

All the more reason, one might expect, for professionals to welcome the opportunity to sign up to such courses. Some doctors, nevertheless, remain sceptical of being formally taught how to communicate. They insist that "hands-on" experience remains by far the most effective source of learning.

Charles Essex, consultant neurodevelopmental paediatrician at the Gulson clinic, Coventry, is convinced that being in the same room as a senior colleague, and watching as they disclose distressing news, is the key to self-improvement.

"I would not have learnt how to break news if I had not been with my senior colleagues and seen them do it," he says. "It is like training to be an astronaut - you cannot do it until you have been with other astronauts. And it is during peer reviews that you learn what works for other consultants, and how one particular way of saying something is perhaps better than another. Reflecting on what you do and say is quite right; but this is something I do the whole time."

Essex, who regularly has to tell parents of their child's disability, or even that the child may not survive long, accepts "there is a place" for courses such as Shah's. But he says he "probably would not go on one".

Aware that this hardened attitude risks others dubbing him as old fashioned, Essex adds that it is a question of crude reality: bad news is bad news and cannot be dressed as anything else. "I often give parents their worst nightmares, and no one will ever say: 'Thank you doctor.' If I say to parents that their child is going to die, or has autism, they should be angry or sad - if not, I have to question whether they have really heard what I said."

It is such understandably distressing reactions by parents, Essex argues, that help explain statistics supposedly showing that relatives are dissatisfied with how bad news is broken to them.

Nevertheless, other professionals who have attended Shah's workshop believe her approach does have place on the learning curve - particularly because peers cannot always be relied upon to give adequate guidance. Ian Dady, a consultant neonatal paediatrician, says: "It is difficult for one doctor to advise or correct colleagues. There is an awful lot to remember when disclosing bad news and it can be beneficial to refine your skills."

In addition, Shah explains, not all doctors have had exemplary peer role models to follow. "They might never have had the opportunity to unlearn inappropriate things they picked up," she says.

With the government emphasising clinical governance and lifelong learning, demands to improve professionals' communication skills are likely to come from the top.

"There will always be doctors who deliver news badly, and patients' complaints will reveal this," says Shah. "This will always be something we have to work on. Formal training will always be a good complement to other forms of learning."

How to deliver a bitter pill

• Sit down on the same level as the patient or relative - it is courteous and reassuring.

• Note questions or topics avoided.

• Respect the patient's right to "denial". They will often "selectively perceive" information they can cope with.

• Realise that most patients become aware of their situation gradually, rather than during one meeting.

• Appreciate that patients can, and do, cope positively with truth about illness.

• End a meeting where bad news has been imparted by arranging to meet again.

• Tell staff what has been said. They might be involved in future discussions.