It was the only time I’ve had lunch in someone’s garage. Lockdown had eased over the summer, but a member of Peter Tate’s family was continuing to shield, and a downpour put paid to our plan to eat in the garden. So Peter spent the morning reorganising boxes, garden machinery and tools to create room for us.
We’d kept in touch, but it had been 20 years since I’d last seen him, at a meal to mark his early retirement on health grounds. The remnants of a Newcastle accent still lent a rich colour to his voice; his expression still exuded an air of amusement with life. It was remarkable how little he’d changed from the mentor who had guided me through GP training in the 1990s.
I’d wanted to become his registrar within minutes of arriving for interview. He met me in the practice lobby, announced he was taking me for “a pint and a pie”, and as we chatted in the pub I learned that he, too, was a writer. He had co-authored The Consultation, the 1984 text that helped revolutionise understanding of what goes on when a patient comes to see a doctor. And his Doctor’s Communication Handbook featured on every GP registrar’s reading list.
Peter’s interest in doctor-patient communication began when, as a young GP, he had started to experience sudden losses of consciousness. He was admitted for investigation and gained a first-hand appreciation of quite how badly doctors in the 1970s communicated. The ward round would appear, opinions would be dispensed, then the ward round would move on. No one was interested in eliciting, let alone addressing, the fears Peter had about the rare heart condition he’d been diagnosed with. He left hospital with a pacemaker and a determination to do something to change the culture.
His great achievement was the concept of “ideas, concerns and expectations” – ICE – the myriad things that teem in the mind of any of us when unwell, but which most of us are too embarrassed or afraid to voice. No longer was it enough for a physician to opine a diagnosis and prescribe a treatment; they also needed to help each patient articulate their unique perspectives and take account of them in arriving at a shared understanding. ICE has been pivotal in the reinvention of the physician as the patients’ expert ally.
In the 30-odd years since Peter first helped describe the concept, ICE has become ubiquitous. My daughter – now a clinical medical student – tells me they had ICE drummed into them from their first year. I thought Peter would be pleased to hear how far-reaching his work has become. But when I told him over our garage lunch, his reaction was surprisingly subdued. “It’s still very patchy,” he said. “And our great mistake was in not defining how to do it.”
While medicine has come a long way, there are still too many stories of shockingly poor communication. I spend a lot of time helping my registrars develop good skills; they are aware of the need to elicit ICE, but many lack finesse. Bald questions such as, “So, what do you think is wrong?” make doctors appear clueless and undermine patients’ confidence. An awareness that people usually research their symptoms can be used to open conversations much more naturally: “What did you find out from Dr Google, then?” And health matters are usually extensively discussed at home: “So, what does your wife think about it all?”
Twenty years post-retirement, Peter continues to pursue the cause. His Doctor’s Communication Handbook is now in its eighth edition, and he has just published Bedside Matters, a memoir of his mission to transform the way medicine is practised. “Back in the Eighties,” he told me, “I thought it would be done and dusted within my lifetime.” But changing long-established cultural norms often takes more than a single generation.
This article appears in the 02 Dec 2020 issue of the New Statesman, Crashed