Ideas, Concerns and Expectations
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General communication skills
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Ideas, Concerns and Expectations (ICE) – OSCE Guide

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Introduction

Establishing a patient’s ideas, concerns and expectations, often called ICE, during consultations (both in real life and OSCEs) is essential for understanding a patient’s viewpoint and is a cornerstone of patient-centred communication.

Using ICE helps establish a patient’s health beliefs, reach a shared understanding and results in a more effective consultation. Understanding patients’ perspectives leads to increased adherence to treatment, reduced unnecessary prescriptions, improved shared decision-making and greater patient satisfaction.

Using ICE in consultations and OSCEs can be challenging. In this article, we will cover how to use ICE when communicating with patients and include some example phrases you can use.

Ideas

Ideas should cover the patient’s prior or baseline knowledge about the situation or their condition. This is an opportunity to clarify misconceptions, improve understanding and build rapport. Ideas may include their thoughts about their condition’s nature, cause, or progression.

Be mindful of your wording, and use open-ended questions encouraging the patient to share their perspective freely:2

  • “What thoughts have you had about this/what are your thoughts on this?”
  • “What do you think is causing this?”
  • “What do you think might be going on?”
  • “What ideas do you have as to what is going on?”

Concerns

Concerns will address the patient’s fears and anxieties surrounding the situation. Concerns can relate to the seriousness of the issue, potential implications for the future or unpleasant feelings and emotions.

  • “What worries do you have about these symptoms?”
  • “Is there something specific worrying you about this?”
  • “What is your biggest worry at the moment?”

Expectations

Establishing the patient’s expectations ensures you and the patient have the same agenda, ensuring that the consultation addresses the patient’s expectations, whether this is therapeutic options (e.g. prescribing a medication), advice or referral.

  • “What do you hope to get from the consultation?”
  • “What were you hoping I might be able to do for you today?”
  • “You’ve clearly given this some thought; how would you like to go forward with this?”
  • “What do you think might be helpful for you?”
Example of ICE in a consultation

A 52-year-old man, employed as a postman, presents to the GP with progressively worsening knee pain.

Ideas

  • “I’ve been thinking that it might be some kind of arthritis. My mother, during her later years, had to get a hip replacement due to severe joint pain and she really limited movement in her hands.”

Concerns

  • “I’ve been worrying about the impact on my work. I spend all day on my feet, and this knee pain is making it incredibly difficult. I worry that I need time off work or even have to change job. The pain is almost unbearable after a full day of walking and standing”

Expectations

  • “I’m hoping that you could arrange an X-ray or some other tests? Having a diagnosis would give me some peace of mind and help me plan for the future.”

Establishing ICE will help you address the patient’s concerns (impact on work) and expectations (X-ray) during the consultation.

Integrating ICE

ICE is not just a box-ticking exercise. Instead, it should flow naturally within your conversations. This can be challenging, and developing your ability to integrate ICE within the consultation requires practice. Actively listen and respond empathetically to patients’ answers, ensuring their concerns are not brushed aside or skimmed over.

In real-life consultations, try not to see ICE as an isolated part of the consultation but as woven throughout the interaction by effectively listening to the patient.

For a structured approach, consider incorporating ICE during the ‘gathering information’ stage of the Calgary-Cambridge model. Using open and closed questions, you can explore patients’ problems comprehensively. Using ICE at this point will lay the foundation for a patient-centred consultation and provide a structured framework for the remainder of the consultation.4

OSCE examiner’s tip

It’s important to cover ICE during communication skills OSCE stations (e.g. history taking and counselling stations). Most patient scripts and examiner checklists include ICE, and you can lose marks if you do not cover this within your consultation. 

References

  1. Tate, P. (2005). Ideas, concerns and expectations. Medicine, 33(2), 26-27.
  2. Murtagh, G. M. (2023). A critical look at ideas, concerns and expectations in clinical communication. Medical Education, 57(4), 331-336.
  3. Whitaker, P. (2021). Ticking the ice box: the future of doctor-patient communication in a post-covid world. BMJ, 373.
  4. Denness, C. (2013). What are consultation models for?. InnovAiT, 6(9), 592-599.

 

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