Ideas, Concerns and Expectations (ICE)
ICE ( I deas – C oncerns – E xpectations)
1 | Why clinicians use ICE
| Purpose | Evidence & benefits |
|---|---|
| Elicits the patient’s agenda early, preventing “door‑handle” revelations | ⬆ consultation efficiency and patient satisfaction (Stewart 1995; Silverman & Kurtz 2013) |
| Builds therapeutic alliance through empathy and shared decision‑making | Better adherence and clinical outcomes (Haskard Zolnierek & DiMatteo 2009) |
| Clarifies misconceptions that may otherwise lead to conflict or poor follow‑up | Reduces unnecessary investigations and re‑attendance (Lewin et al. BMJ 2001) |
2 | I deas
Patient’s explanatory model of the illness
| What to explore | Practical language |
|---|---|
| ‑ Perceived nature, cause and mechanism of symptoms | “What do you think is happening in your body?” |
| ‑ Personal or cultural beliefs (e.g. hot–cold, humoral, spiritual) | “Many people have their own ideas about illness—could you tell me yours?” |
| ‑ Source of information (internet, family, prior diagnoses) | “Where have you heard or read about this?” |
Tip for OSCE/GPS: Ask open‑ended, non‑leading questions first, then use focussed probes to test understanding. Summarise back to the patient to show you have listened.
3 | C oncerns
Fears, anxieties, emotional impact
| What to explore | Practical language |
|---|---|
| ‑ Fear of serious disease or disability | “Is there something you’re particularly worried this could be?” |
| ‑ Impact on family, work, finances | “How is this problem affecting your day‑to‑day life or your family?” |
| ‑ Emotional responses (guilt, anger, sadness) | “How are you feeling about all of this?” |
Clinical pearl: Legitimize feelings (“I can see why that would be upsetting”). Address concerns explicitly before closing the consultation.
4 | E xpectations
What the patient hopes will happen today and beyond
| What to explore | Practical language |
|---|---|
| ‑ Expected actions (tests, scripts, certificates, referrals) | “What were you hoping I could do for you today?” |
| ‑ Expected outcomes or timeframe | “Where would you like to be with this problem in a few weeks?” |
| ‑ Preferred role in decision‑making | “Some people like the doctor to decide, others prefer to choose together—what suits you?” |
Align & negotiate: If expectations are unrealistic, explain evidence‑based options, outline risks/benefits, and agree on a shared plan.
5 | Integrating ICE seamlessly
- After the opening question (“Tell me how I can help…”) signpost:
“I’d like to understand your own thoughts and any worries or hopes you have.” - Loop: explore Ideas → Concerns → Expectations (may cycle back as new info arises).
- Summarise & check back:
“So you think this might be X, you’re mainly worried about Y, and you’re hoping we can Z—have I got that right?” - Move to explanation & management: tailor the plan to what you just heard.
6 | Special considerations in Australian general practice
| Context | Adaptation |
|---|---|
| Aboriginal & Torres Strait Islander patients | Use culturally safe language, enquire about traditional beliefs, involve family/elders where appropriate (RACGP Cultural Safety Framework 2020). |
| Language barriers | Engage professional interpreters; ICE still applies but questions may need literal, jargon‑free phrasing. |
| Telehealth | Allow extra time for rapport and non‑verbal cues; verbally acknowledge emotions you cannot see. |
7 | Key take‑home points
- ICE = Ideas, Concerns, Expectations – a structured, evidence‑based tool for patient‑centred communication.
- Ask open‑ended, empathetic questions; listen actively and summarise.
- Addressing ICE improves diagnostic accuracy, adherence, and satisfaction.
- Tailor your approach to the cultural and contextual needs of each patient.
Suggested references for further reading
- Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. 3rd ed. CRC Press; 2013.
- RACGP. General Practice Consultation Skills Guide. East Melbourne; 2022.
- Stewart M et al. Patient‑‑centred Medicine. 3rd ed. Radcliffe; 2014.