This is the other 'heading' that most candidates do well in, according to RCGP data. Regardless of this, we have gathered some useful tips to help you to get top marks in this sub section.
I.C.E. : 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 CSA cases. Even In life outside the CSA, it is often vital to ensuring that both parties (the GP and the patient) leaves the consultation feeling satisfied with how things went. It has been shown to have positive effect on health outcomes, and even reduce prescribing within primary care
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" nor "expectations".
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 about 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 does however appear to be two particular points within the consultation that lend themselves well to asking about ICE.
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 in the exam under stressful circumstances, and to score the most points.
Ideas : what do they think?
Most patients will have had 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 may have your own way of course, and thats 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 : Their fears
The reason for a patients attendace to a see a GP can be broadly split up into two main categories:
This concern can take many forms, including concern that their symptoms may indicate a serious underlying diagnosis, concern that their symptoms may interfere or is already interfering with life or concern that symptoms may worsen and/or turn into something worse. As you can see, identifying a patients concern is very helpful, especially if you want you and the patient to leave the consultation happy. It is especially important in the CSA, 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:
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:
Expectations : What the patient wants
Everytime someone walks through your door, they will have (on some level) and 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". What ever 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 a chest pneumonia last year, so now we get him checked out when he has a bad cough to make sure its not going to turn into the 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.
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 CSA 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 CSA, 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