Open the door to care using ICE

As a house surgeon at a provincial hospital, I recall being in theatre assisting a surgeon to remove an abdominal tumour the size of a football.

It took us four hours to get it out. How pleasing it was to throw it into a steel bucket and send it for histology.

And how well we did looking after that woman postoperatively. The icing on the cake was the benign histology. A happy ending and a medical job well done.

I met that woman’s son in the street about two years later and he remembered me, because I had been nice and caring, as I am, and I asked after her and he told me a story I will never forget.

“She is okay now,” he said, “but she was very ill for a long time after that surgery, stayed home, couldn’t work, the GP could find nothing, but it’s okay, we took her home and she’s seen the tohunga and she’s all good.

“Māori sickness,” he said.

What’s the point of getting the diagnosis right if the treatment isn’t taken?

Recently a registrar told me how interesting it was sitting in with a Māori GP. This was because of the whakawhanaungatanga, of course, but also, the GP asked all the “FIFE” and “ICE” questions before he asked any medical questions at all.

Brilliant. Why didn’t I think of that?

Why didn’t I think of that 30 years ago, when I was being a great young doctor firing medical questions at a Māori woman with a mass in her abdomen, covering all the symptoms and red flags and getting a past history and family history and social history.

Maybe if I had just started with who this wahine was, and what her world was like, and what her feelings, ideas, fears and expectations (FIFE) were; then, again, what her ideas, concerns and expectations (ICE) were then maybe, just maybe, I might have heard her story and understood her world. And maybe we could have put our world of medicine and our story of her alongside her version and maybe things would have gone better for her.

From where I am now, however, I know it would have taken a lot more than that, because there was a wide chasm between my white coat and the tohunga, and anyway it’s grandiose of me to think she could have trusted me with her story at all.

You might say this is an extreme example; patients wouldn’t often have such different views from our own and most patients tell us they want to know what we think, that’s what they are paying for.

But how would we know if the patient in front of us has a whole other version of events and ways of making meaning when all we do is say, nicely, “How can I help?”, then fire closed medical questions at them?

I suspect we mostly don’t know, or fail to ask – or, if we ask, it isn’t safe enough because we are on such a roll with our medical interrogation that it might be hard for the patient to chip in with their own thoughts at all.

People keep telling me that a huge percentage of patients don’t fill the prescriptions we give them or don’t take the medication once they have picked it up. Clearly, we are doing something wrong, and I think it’s something about the medicine taking up all the space, us being too big and the pressure of time making us focus on tasks.

But what’s the point of getting the diagnosis right if the treatment isn’t taken by the patient?

I had a light-bulb moment the other day while teaching communication skills. A registrar asked, “How do you do shared decision-making?”

And I was expertly pointing out that the FIFE and ICE questions at the end of the medical history are what lead us into a shared conversation about what to do, but the light-bulb flash was realising most of the time I don’t do shared decision-making at all.

What I say is, “This is what I think is wrong, this is what I think you should do, here’s a script and some information. Any questions?” And we wonder why the script isn’t filled. It’s quite confronting, but I reckon we GPs need to ask ourselves how much of the time we just simply miss the point.

Tomorrow I am going to put the ICE in first.

Lucy O’Hagan is a medical educator and specialist GP working in the Wellington region