ICE in medicine: ideas, concerns and expectations

The short version

• Ideas: the patient's own view of the cause, diagnosis or treatment. Concerns: what they are worried about. Expectations: what they hope will happen today (BJGP, Matthys et al. 2009).
• ICE is part of the RCGP curriculum ("Knowing yourself and relating to others") and appears in the SCA toolkit under both data gathering and relating to others.
• In the SCA, finding ICE is only half the job. The toolkit also asks you to use it in the plan.
• The most useful ICE often comes from a cue: a passing comment ("my uncle had something like this") that you pick up and explore.
• Ask ICE in your own words, at a natural moment, not as a single robotic "any ideas, concerns or expectations?"

What ICE means

A widely cited definition comes from a 2009 BJGP paper on general practice consultations by Matthys and colleagues:

ICE matters because two patients with the same symptom can need very different consultations. A cough that worries one person because "it's probably just a cold" is a different conversation from the same cough in someone whose father died of lung cancer.

Where ICE sits in the RCGP curriculum and SCA

The RCGP is the clearest official source on ICE for exam candidates:

• Curriculum. The "Knowing yourself and relating to others" area says the GP "explores the patient's ideas, concerns and expectations".
• SCA toolkit, data gathering. One of the eight data-gathering items is "Discovers patient's ICE". Next to it sit "Identifies cues" and "Discovers patient's psycho-social context".
• SCA toolkit, relating to others. "Shares and uses ICE in plan" and "Clarifies and explores cues offered".
• SCA feedback statements. Under relating to others, one statement reads: "The person's agenda, health beliefs and/or preferences were insufficiently explored".

So in the SCA, ICE shows up when you gather information (did you find it?) and when you relate to the patient (did you use it?). The SCA marks each case in three domains: Data gathering and diagnosis, Clinical management and medical complexity, and Relating to others.

How to explore ICE: five steps

1. Let the patient finish their opening story. Many patients give their idea or concern in the first minute if you don't interrupt.
2. Listen for cues. A pause, a change of tone, a mention of a relative, "I read something online", "I'm not sleeping".
3. Pick up the cue and ask about it openly. "You mentioned your uncle. Can you tell me more about that?"
4. Ask the parts you haven't heard. Ideas, then concerns, then expectations, each in your own words.
5. Use what you found. Address the concern directly in your explanation, and say what you will and won't do about their expectation, and why.

Phrase bank (written by Confetto)

Ideas

• "Have you had any thoughts yourself about what might be causing this?"
• "What do you think is going on?"
• "Sometimes people have an idea in the back of their mind. Is there anything you've wondered about?"

Concerns

• "Is there anything in particular that worries you about this?"
• "What's the worst thing you've thought it could be?"
• "You seem a bit worried when you talk about that. What's on your mind?"

Expectations

• "What were you hoping we could do for you today?"
• "Was there anything specific you were hoping for, like a test or a treatment?"
• "How can I best help today?"

Picking up a cue

• "You said 'after what happened to my uncle'. Would you like to tell me about that?"
• "You mentioned you've been reading about it online. What did you find?"

Using ICE in the plan

• "You told me you were worried this might be a brain tumor. I want to answer that directly…"
• "I know you were hoping for a scan. Let me explain why I don't think it will help right now, and what we'll do instead."

Worked example: a hidden concern from a cue

Example written by Confetto for practice (not a real exam station). It works as a 12-minute SCA case. Clinical details are kept general.

Candidate instructions: Mr. Daniel Price, 34, has had headaches for six weeks. Take a history, explain what you think is happening and agree a plan.

Doctor: Hello, I'm Dr. Shah, one of the GPs. What brings you in today?

Patient: These headaches. Six weeks now. It's like a tight band round my head, most afternoons.

Doctor: That sounds tiring. Tell me more about them.

Patient: They build up through the day. Work's been mad. Paracetamol takes the edge off. I just… with everything you hear about, you know.

(Cue: "with everything you hear about". A candidate who carries on with closed questions misses it.)

Doctor: You said "with everything you hear about". What have you been hearing?

Patient: A lad at work, his brother had headaches and it turned out to be a brain tumor. He's 36. I keep thinking about it.

Doctor: That must have been frightening to hear. Is that your main worry, that this could be something like that?

Patient: Yeah. I haven't told my wife.

Doctor: Thank you for telling me. I'm going to ask some questions to check for warning signs, and then I'll come back to that worry. Before I do, what were you hoping we'd do today?

Patient: Honestly? A scan. Just to know.

The candidate then checks for warning signs (for example, the headache waking him from sleep, worsening when he coughs or strains, new weakness, vision changes, confusion, vomiting, fever) and finds none. Then:

Doctor: From what you've told me, this sounds like tension-type headache. It's very common, often linked to stress and long days, and it isn't caused by a tumor. You asked about a scan. When there are no warning signs, like with your headaches, a scan isn't usually recommended, because it wouldn't change what we do. What I'd suggest instead is… (plan, including avoiding taking painkillers on too many days, since that can cause headaches of its own). And I'd like you to call 999 or go to A&E straight away if you get a sudden, very severe headache, or a headache with weakness, confusion or a stiff neck with fever. How does that sound?

Why this scores (our reading of the published domains):

Common ICE mistakes

Practice this with an AI patient

Confetto isn't affiliated with the RCGP.