ICE, ICE Baby!
How to tackle the ‘Relating to Others’ domain in the SCA exam
How to tackle the ‘Relating to Others’ domain in the SCA exam
🧊🧊 A quick reminder about ICE. ICE is probably one of the most important bits in the history taking component and it is covered under the ‘relating to others’ domain. Here’re some helpful notes I’ve made about the domain and how to ace it in the exam. We discuss SCA cases and techniques in the SCA WhatsApp group here: https://chat.whatsapp.com/HzAU1K6bXH82FYrFQy2lQ0
➡️ Relating to Others:
ICE: The Core of the Consultation:
ICE, which stands for ideas, concerns, and expectations, is a concept you're likely well-acquainted with by now. Its significance cannot be overstated; it is often the key to resolving most SCA cases. Even outside the SCA, ensuring both the GP and the patient leave the consultation feeling satisfied is crucial. Research has shown that addressing ICE positively impacts health outcomes and can even reduce prescribing in primary care.
However, simply asking about the patient’s ideas, concerns, and expectations isn’t enough—you must do so in a way that doesn’t disrupt the conversation. As a general rule, when asking about ICE, try to avoid directly using the terms “ideas,” “concerns,” or “expectations.” Instead, think in terms of thoughts, worries, and help.
For now, we will focus on the most frequently asked question: “When should I ask about ICE during a consultation?”
➡️ When to Ask ICE: The Big Question
There are no definitive answers; everyone has their own style and approach to incorporating ICE.
However, two points in the consultation seem well-suited for addressing ICE:
1. Near the Beginning: After the opening sentence or presenting complaint. This approach has several advantages, especially in exam settings. First, it brings the patient’s ideas, concerns, and expectations to the surface quickly, providing a clear direction for the consultation. Second, it avoids pursuing one line of questioning only to find the patient’s primary concern is something else. The downside is that, outside the SCA, asking too early may prevent you from building sufficient rapport, causing patients to withhold important information.
2. Near the End of History-Taking:
The benefit here is that you’ve already gathered information and established rapport, making the patient more comfortable sharing their ideas, concerns, and expectations. The drawback is time— if you discover late in the consultation that the patient’s concern is different from what you’ve focused on, you may run out of time to explore it further.
A balanced approach is to remain flexible. Start by following any cues the patient gives during the opening or presenting complaint. Often, following these cues will naturally reveal their ICE. If that doesn’t happen, or if you cannot address ICE fully, revisit it towards the end of history-taking.
Practicing this flexible method will help you adapt under exam pressure and maximise your score.
➡️ Ideas (Thoughts): What They Think
Most patients have some idea about what’s causing their issue, whether it’s from their own thoughts, a friend, or a quick Google search.
Discovering their thoughts can unlock the rest of the consultation.
For example, a patient presenting with a tension headache may think it’s due to stress, leading you to explore the stress itself rather than just the headache.
Incorporating this question into the consultation can be tricky, so here are some useful phrases:
- “You’ve had this for ‘x’ weeks/months/days; have you had any thoughts on why it’s happening?”
- “Have you thought about what might be causing these symptoms?”
- “Have you looked online about your problem? What did you find?”
- “What do you think is the most likely reason you’re feeling unwell?”
- “Have you spoken to anyone or looked anything up about your symptoms? What did you learn?”
- “Can you think of any reason you might have these symptoms?”
➡️ Concerns (Worries): Their Fears
Patients typically visit the GP for one of two reasons:
1. They want help managing their symptoms.
2. They’re worried about their symptoms.
Concerns can vary, from fears of a serious diagnosis to worries about symptoms worsening. Identifying a patient’s concerns is vital, particularly in the SCA, where all patients will have at least one concern to explore.
To address concerns, here are some useful phrases:
- “You look worried. May I ask what’s troubling you?”
- “What’s your biggest concern about these symptoms?”
- “What’s the worst thing you think could be causing this?”
- “What worries you most about these problems?”
If the patient is hesitant, consider these approaches:
- If they’ve brought someone with them, you can ask the companion directly about their concerns.
- If they’re alone, ask, “If your partner or friend were here, what would they say you’re worried about?”
- “Many people with similar symptoms worry about cancer or serious diseases. Does that apply to you?”
➡️ Expectations (Help): What the Patient Wants
When a patient comes in, they often have an agenda. It could be something simple, like wanting reassurance, or something more complex, like seeking a specialist referral. Even if you don’t agree with their expectations, it’s important to understand and address them.
Some patients make their agenda clear right away, while others are more subtle. Here are some phrases to help uncover expectations:
- “Is there anything you were hoping I’d do today?”
- “What do you think might help?”
- “What would I need to do today for you to leave here satisfied?”
- “Was there anything you were hoping I could prescribe today?”
➡️ Impact on Quality of Life: How This Affects Them
It’s important to ask about the personal impact of the patient’s condition. This provides insight into how they’re coping and helps tailor your treatment. Focus on their job, home life, family, and support mechanisms. In the SCA, all patients will be affected in some way, and revealing this impact may offer cues to explore further.
🚨 The 6 E’s: Don’t Forget These
- Empathy: Genuine empathy is crucial. Simply saying, “I’m sorry,” isn’t enough. Listen and respond to the patient’s concerns.
- Empowerment: NHS England emphasises shared decision-making, enabling choice, and supporting self-management. Help patients feel like equal decision-makers in their care.
- Elephant in the Room: Address any obvious issues early in the consultation.
- Explain: Clearly explain diagnoses and treatments.
- Explore: Be curious and dig deeper into every cue, particularly the psychosocial context.
- Encourage: Support the patient in managing their own condition and engaging with the appropriate services.
The next newsletter will focus on the ‘Data Gathering and Diagnosis’ domain of the SCA and how to ace it. If you’ve found this useful then please share with other colleagues and friends you think might find this helpful!