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VIEWS & REVIEWS: Des Spence Falling through the ICE BMJ 2009; 338: b5 [Full text]

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Beware of TLAs

Jill E Thistlethwaite   (9 January 2009)

Don't throw the ICE out just yet.

David Haslam   (14 January 2009)

Slippery ICE

Shah M Tauzeeh   (15 January 2009)

The Grassy Knoll

Des Spence   (16 January 2009)

Would you like ICE?

James Lilleker   (21 January 2009)

Beware of TLAs 9 January 2009
Jill E Thistlethwaite, Professor of Clinical Education and Research Institute of Clinical Education, Warwick Medical School, CV4 7AL Send response to journal: Re: Beware of TLAs	As recently appointed director of ICE (Institute of Clinical Education) and a firm believer in ICE (ice, compression and elevation) for soft tissue injuries, I was glad to be reminded of the other ICE (sometimes expanded to ICEE - ideas, concerns, expectations and effects). Such acronyms , like many in health care, are obviously strongly context specific, as are the questions needed to elicit ICEE within a consultation. The shortening of this inquiry to set questions is, of course, not the way that communication skills educators would like the patient-centred approach to be conducted. But we have all seen the reduction of a skilled and thoughtful exploration to a checklist for students, who gain marks particularly at OSCEs by asking ' what are you concerned about?' without knowing how to respond to the patient's answer if he/she is concerned, or worse cannot believe that the patient doesn't have any concerns at all - 'are you sure you're not worried about anything?' As with any questions in consultations, these only work if the earlier part of the patient-professional interaction has facilitated the patient to tell his/her story and often, if this is done well, ICE doesn't have to be applied at all as the patient will have already volunteered the information. Competing interests: None declared
Don't throw the ICE out just yet. 14 January 2009
David Haslam, President, Royal College of General Practitioners Ramsey Health Centre, Cambridgeshire, PE26 1NB Send response to journal: Re: Don't throw the ICE out just yet.	Whilst I absolutely agree that slavishly following any template for the consultation can damage the humanity of the exchange, and that the ICE model can indeed create the very antibodies that Des Spence refers to, there is still a time and a place for it. Most doctors will have consultations which reach a point when they ask themselves, "What on earth is this consultation about?". These are consultations that are doomed to failure because the doctor doesn't know why the patient is there. On these occasions, apply ICE. Without fail, I have found that if I then try and identify in my own mind exactly what I think the patient's ideas, concerns, or expectations are - I will realise that I don't know at least one of the ICE points, and finding out will free up the consultation, melting the impasse. So - apply ICE retrospectively, never prospectively, and it will serve you well. Competing interests: None declared
Slippery ICE 15 January 2009
Shah M Tauzeeh, Associate Specialist Physician Finchley Memorial Hospital Granville Road London N12 0JE Send response to journal: Re: Slippery ICE	Two pieces appeared in the same issue of the British Medical Journal(10/01/09).One by the regular columnist, Spence (BMJ2009;338:b5)and the other is a filler by Lilleker ( BMJ2008;337:a3135). Both are critical, expressing doubts and usefullness of ICE. Would it be unresonable to be suspicious that the BMJ is organising a concerted effort against the ICE? This is my small contribution to numerous "conpiracy theories" about everything umder the sun.Shoud the BMJ now consider stating its official position? shah.tauzeeh@barnet-pct.nhs.uk Competing interests: None declared
The Grassy Knoll 16 January 2009
Des Spence, GP Glasgow G20 9DR Send response to journal: Re: The Grassy Knoll	I actually think ICE is a very good concept but is merely applied in an absolute and blunt way - we need to address the patient agenda. As for conspiracy theory - I wrote about ICE by chance following a recent complaint but I guess no one will believe that! Competing interests: None declared
Would you like ICE? 21 January 2009
James Lilleker, Doctor University Hospital of South Manchester Send response to journal: Re: Would you like ICE?	I personally find ICE a useful tool that can be used to get to the heart of the patient agenda and avoid the situation where the problem the patient has attended for has not been addressed. Unfortunately, I think the latter happens far too often, particularly in the modern target driven NHS. However, like all consultation models and aide memoirs for covering important points, ICE cannot simply be lampooned into the consultation. Nothing prevents effective communication more than a patient being asked a generic series of pre-rehearsed questions. My article (Filler, BMJ 2008;337:a3135, doi:10.1136/bmj.a3135) described a consultation where my clumsy use of ICE had the effect of increasing, rather than decreasing patient anxiety. I have learnt that the consultation cannot simply be broken down into a series of acronyms and 'must-ask' questions. Effective communication with patients should still be regarded as an art form which requires professionalism, experience and judgement. Competing interests: None declared