ICE: the crux of the consultation

I.C.E stands for ideas, concerns, and expectations; a concept you should already be very familiar with by now. Its importance can not be overstated, it is the key to unlocking most SCA cases. Even In life outside the SCA, it is often vital to ensure that both parties (the GP and the patient) leave the consultation feeling satisfied with how things went. It has been shown to have a positive effect on health outcomes, and even reduce prescribing within primary care[1]

Unfortunately, it is not enough to merely ask about the patient's ideas, concerns, and expectations, you must ask it in a way that does not interrupt the flow of conversation. As a general rule of thumb, when asking about ICE, you should try not to include the words, "ideas", "concerns" or "expectations". To help with this - it is best to think about it in terms of Thoughts, Worries and Help

As for covering each 'heading' in more detail, please continue to read below, for now, we shall focus more on the question most asked by students around ICE - 'At what point to include it within the consultation?'

When to Ask ICE: the big question

First of all, there are no right answers, everyone has their own style and will usually ask about ICE in their own way at their own time. There do however appear to be two particular points within the consultation that lend themselves well to asking about ICE.

1. The first appears to be near the beginning of the consultation, immediately after the opening sentence, or the history of presenting the complaint. This has a few advantages within the setting of the exam. Firstly it gets their ideas, concerns, and expectations out into the open very quickly in the consultation, meaning you know what path to follow for the rest of that case. Secondly, it means that you are not going to spend time following one line of questioning only to find that the case is focused on something different. It does however have a disadvantage, outside the SCA, asking ICE too early before you've had time to build sufficient rapport with the patient, means they may not divulge such information. This can interrupt the flow of the consultations, ultimately hindering it.

2. The second place to ask about ICE is near the end of the history taking. The advantage here is that you have gathered information already and have built up apart with the patient, so that they may feel more at ease discussing their ideas, concerns, and expectations with you. The disadvantage is that of time, if you find out only then that the patient was concerned about something completely different you may not have enough time to ask further questions.

We found that a good balance was to be flexible with our placement of ICE. We would start by following any cues left by the patient during the initial opening sentence / history of presenting complaint. Often following those cues meant that the patients’ ICE was revealed, if not it gave you an opportunity to enquire about their ICE without interrupting the flow of the conversation. If that opportunity never arose, or if you were unable to ask fully about ICE at that time, then you could revisit it again towards the end of the history taking.

Practising with a varied / flexible approach means that you will be better able to adapt to the exam under stressful circumstances, and to score the most points.

Ideas (thoughts): what do they think

Most patients will have some idea about what's causing their problem. This might either be their own idea, an idea of a colleague or friend, or more commonly a result of a quick Google search.

Establishing what their idea is can be a good way to unlock the rest of the consultations, and can often be one of the biggest cues you get in your consultation. I.e. A patient presenting with a tension headache may think that it's actually caused by stress. This will then open up a whole avenue for you to explore during the consultation - and the stress may actually be the problem that needs dealing with, not the headache.

Asking about patients’ ideas can often be a stumbling block, as it can be difficult to incorporate it into the consultation. So here are a few phrases that you may find useful

• "You've had this for 'x' months/weeks/days, have you had any thoughts as to why this is happening"

• "Have you had any thoughts as to what might be causing these problems"

• "Have you done any searching online around your problem, if so what have you found"

• "What do you think is the most likely reason you have been feeling unwell"

• "have you spoken to anyone or looked up anything on the internet about your symptoms, what did you find out"

• "In your opinion, whats the most likely cause of your problem"

• "Can you think of any reason you might have these symptoms / problems"

You may have your own way of course, and that’s great, the above are merely some possibilities. If you have a suggestion and wish to share it with us so that we can share it with the world, then contact us here

Concerns (worries): their fears

The reason for a patient’s attendance to see a GP can be broadly split up into two main categories:

1. They can no longer tolerate their symptoms and want your help in settling them

2. They are concerned about their symptoms.

This concern can take many forms, including concern that their symptoms may indicate a serious underlying diagnosis, concern that their symptoms may interfere or are already interfering with life, or concern that symptoms may worsen and/or turn into something worse. As you can see, identifying a patient’s concern is very helpful, especially if you want you and the patient to leave the consultation happy. It is especially important in the SCA, as all patients will have at least one concern to explore.

So how do you ask about a patient's concerns? Well, we have created a short list of possible phrases below:

• "You look troubled, may I ask what's troubling you"

• "What's worrying you most about your problems / symptoms"

• "What's the worst thing you feel could be causing your symptoms"

• "What's the worst thing about these symptoms / problems for you"

Patients may not wish to say what's on their mind, for fear of looking silly, or they fear they might be right. For these people there are certain tactics that can be used to coax out such information:

• If they have brought in a partner or someone else with them, you can always ask them directly what they fear might be going on

• If they have not brought in anyone with them then: "If your partner/friend were here and I asked them what they were worried about, what might they say"

• "Many people who come to see me with these symptoms are often worried about cancer/other serious diseases, does the same apply to you"

• "Many people have read on the news / posters about 'x,y,z' symptoms, and that they could be serious, and therefore to come and see a doctor, are you one of those people"

Expectations (help): what the patient wants

Every time someone walks through your door, they will have (on some level) an agenda. For most people, if that agenda is not dealt with in one way or another, then they will not be satisfied with the consultation. The Agenda can be anything, from something as simple, as information - "I wish to know if this is a chest infection or a cold" - to far more challenging agendas - "I wish to be referred to see xyz specialist, and I want in on the NHS within the next week". Whatever their agenda may be, even if you go along with it or not, it must be coaxed out of the patient, and addressed.

In some cases, it can be very easy to find out the agenda, as it may be the first thing the patient says to you "Little Johnny had chest pneumonia last year, so now we get him checked out when he has a bad cough to make sure it’s not going to turn into pneumonia again" (In fact that opening sentence reveals the ideas, concerns, and expectations all in one go!). In other cases, it can be very difficult to find out what the patient wants. So here are a few phrases that you may find helpful.

• "Was there anything you were hoping I would do today"

• "Is there anything you've thought of that may help this"

• "Is there anything you were hoping I could do when you booked this appointment"

• "If you were me, what would you do in this situation"

• "What would I need to do today for you to leave here happy"

• "what would you like me to do today"

Please note that not all of these phrases will be applicable all of the time. You may find a lot of people responding in one of two ways: "Cure me" or "You're the doctor". If they respond with either of the above, then it usually means you've asked the wrong question for them. Try and approach it from a different (or more direct) angle: "Was there anything you were hoping I could prescribe for you today"," Was there anyone else you were hoping to see about this" etc..

Impact on Quality of Life: how is this affecting them

Find out about the person: An important aspect of consultations both in the SCA and in working life, is to enquire about the impact this condition is having on them, their family, and their work. This gives you an insight into how they might be coping and also affords you the ability to better tailor your treatments to that individual. Remember that you are treating a person and not a condition. Within the confines of the SCA, all patients will be affected in one way or another. Often exposing this can give you cues to follow, and may bring to light their ideas concerns, and expectations, without you having to ask directly

Aim to do this around 2 minutes into the consultation, find out specifically about: their Job and Home situation, find out about family, support mechanisms and possible barriers to any management offered

The 6 E’s: don’t forget these

Empathetic: Through out the consultation you must remain empathetic with the patient. This needs to be genuine! It is not enough to simply reel off “ oh, I’m so sorry”. Far too often we see consultation that go like this:

Doctor: So, tell me, who lives with you at home?

Patient: Well it’s just me, unfortunately, my wife died 3 months ago

Doctor: Oh I’m sorry to hear that, do you smoke?

The above is an example of just reeling off a phrase without any genuine empathy being displayed. To demonstrate empathy you need to listen, and respond to their concern / upset etc.. So a better example of the above consultation would be:

Doctor: So, tell me, who lives with you at home?

Patient: Well it’s just me, unfortunately, my wife died 3 months ago

Doctor: Oh I’m sorry to hear that, that must be really upsetting for you. How are you coping?

Patient: Oh, I’m really struggling at times

Doctor: In what ways are you struggling?

This now demonstrates empathy, and allows you to follow a cue that might open up your consultation.

Empowering: NHS England have published their take on patient empowerment:

• Shared decision making, establishing the expectation that people are equal decision makers with clinicians.

• Enabling choice, including legal rights to choice.

• Personalised care and support planning, including enabling people to have access to both read and edit their Personal Health Records.

• Social prescribing and community-based support.

• Supported self-management, increasing the knowledge, skills and confidence (patient activation) a person has in managing their own health and care through systematically putting in place interventions such as health coaching, self-management education and peer support.

Elephant in the room: If there is an abnormal blood test result, or a really big Cue - don’t park it and come back to it later. It is far better to deal with the elephant in the room earlier in the consultation, rather than later.

Explain: We have gone through how to explain in more detail here. You can also use our random condition generator (here) to practise your explanation skills!

Explore: Be curious, be nosey, ask why, how, who, when etc… Often the nob of each case maybe hidden in the subtext of the conversation, therefore it’s important that you explore every cue. Specifically for the SCA, you need to ask about psychosocial context. This is NOT the same as psychosocial impact! For example if we take an imaginary case of a 41 year old patient who is drinking far too much alcohol

Psychosicial impact might be that he has lost his job as a result of his alcohol, lost his driving license due to being caught drunk driving, and he is struggling financially as he is spending all of his money on alcohol

Psychosocial context might be that he was abandoned by his mother when he was 2, brought up in the foster care system. Never finished school, and doesn’t have any higher education to his name. He struggles to keep a job, and has no support from any friends and doesn’t know his real family.

The reason why gathering the psychosocial context is important, is because it might directly alter how you choose to manage that patient.

Encourage: It is important that you encourage patient contribution and encourage them to manage their own conditions, encourage them to engage with the right services, and that you try to attach some positivity to the outcome of the consultation.