I’ve been ICEd

I took part in a Twitter exchange about this article. It’s about doctors asking about “ideas, concerns, and expectations” (ICE) a patient might have. As it happens, a day before the discussion I actually saw my GP and I had been asked about my ideas about my condition.

As I am a polite patient and I like and respect my GP, I politely responded. And yet, I wondered why he’d asked me the question. I doubted very much that he actually wanted to know about my take on the ‘aetiology’ of the problem I went to talk to him about. I quickly decided that he was following a procedure, not really wanting to know.

To be completely honest I also didn’t like it. It reminded me of a conversation a few years ago when he asked me about my view on the medication he was about to prescribe me. I responded, politely, that I had absolutely no idea, after all I knew nothing about the drug or the evidence there was on its effectiveness or its iatrogenic action. My GP accepted it (and didn’t prescribe me the medication). And yet, after the Twitter discussion, I gave ICE questions some more thought and here is the result of my thinking. As I am not a medic, I shall focus (as much as possible) on the communicative side of the issue. So I think that, apart from following a procedure, there are two ways in which the question can be understood. One is literal and the other is not. Let me start with the former.

This is a situation in which the GP asks the question and means what they ask, for one reason or another wanting my opinion. If, for example, my cholesterol goes up because I stopped taking my statins (yes, I still take them, despite controversies), I might want to tell my doctor about it. Or about, say, my recent horse trek in the jungle when I didn’t take my malaria tablets. There are plenty of  situations where the doctor might genuinely want to ask me such a question. And my answers might make the diagnosis and treatment easier or quicker.

Yet, such a question would not make much sense, if it asked about prostate cancer, glaucoma, or, indeed, my hypertension. It’s worth remembering, further, that it might make me start looking for what “I have done”. Am I really guilty of what I am ill of? Should I now start wondering what I could have done to prevent what is happening to me, but, stupid and careless me, I didn’t.

And this is the first point I want to make. Clinical communication, like any other, is context-bound and  there are none and there cannot be any rules the following of which is mandatory on the one hand and brings communicative and medical success on the other. Even though this is really not earth-shattering news, sometimes I wonder about the extent it has penetrated the medical profession. After all, it’s mostly said by linguists and other social scientists, which, judging by my experience, reduces the validity of the news significantly. Perhaps a doctor should say it!

Now, I think my GP didn’t ask me the problematic question because he wanted to know my views on a relatively simple issue. My answer was irrelevant clinically, socially, and communicatively. In fact, it violated social rules of communication – we tend not to speak of what’s obvious. And so, I think, he ‘really’ asked me for any other information I might have had, but didn’t share with him yet.

And here we have two problems. First, in the situation I actually did understand the question literally and answered it, probably losing the opportunity to raise any other concerns about things which were not raised subsequently. Whether I did or did not have any such questions doesn’t matter.

Second, I think that clinical communication should probably (and I stress ‘probably’) be as clear and direct as can be. If I am right that the question was about opening a particular communicative space, then its function was hidden, communicated indirectly. And I am not certain why. In other words, why would my doctor choose not to simply ask me a question directly? Surely, the fact that the question might have been ‘difficult’ shoud not matter. After all, I don’t want to  keep wondering what exactly my doctor is asking me. Or asking myself the question whether I should also communicate indirectly with my doctor?

And this is the second point I want to make. In everyday conversations quite a lot of what we say is implied, hinted at. Especially topics around our bodies and their functions, sex, romance, age, illness and many others are communicated indirectly. And so, a man might be asked about his ‘flow’ by a doctor, but it is extremely unlikely to be done outside the medical context. This is exactly the point I made writing about Liz O’Riordan’s blog when she talked about breasts.

I think clinical communication is different. While there is plenty of evidence that patients lie to their doctors (research by Michael Burgoon, for example, comes to mind) and attend to their ‘face-concerns’ (so, oversimplifying, they don’t want to be judged negatively by their doctor, for example as whingey, see research by Kristian Pollock), I think these are our, patients’ rights. Doctors’ communicative rights are different. On the one hand, you may ask me things I cannot ask you (when you ask me about my ‘flow’, I cannot very well ask you about your stool), but I think your rights do not, include hiding communicative goals. (The previous statement must probably be nuanced significantly).

And so, if you want me to tell you more, ask me to tell you more. If it is my opinion you seek, perhaps you might consider asking for it and explaining why you ask for it.


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