The limitations of ICE

4 May, 2019

In recent years, clinical communication skills training has focused heavily on ICE (Ideas, concerns and expectations). It’s taught from the first stages of medical school, has whole sections of the mark scheme in exams dedicated to it and is considered by many to be the be all and end all of what counts as the mark of a good consultation.

It’s drilled into health care professionals that they must find out what the ideas, concerns and expectations of their patients are. What do they think is the problem, what do they feel about what’s happening, what’s worrying them about the issue and what do they expect to happen? It’s that expectation that’s the really useful part, but often it’s misunderstood. A patient will often be asked “and what do you expect from today?” Which may get an answer such as “well I probably need antibiotics” or “I don’t know, do I need an X-ray?”. This, however, misses a huge part of what the patient actually expects. What they expect and what they want to achieve might be two very different things.

After 15 years of working in communication skills training, all over the world, I’ve more and more come the conclusion that it’s far more useful to think about the patient’s agenda rather than their ICE.

 

Everyone has an agenda. The patient has come to this appointment for a reason, they want something, be it a referral, some advice, a prescription or simple reassurance, they always want something. You as a health care professional also want something, to give the best care possible (in a time efficient manner). Unfortunately, sometimes though, these two similar sounding agendas don’t match up as we would expect and that’s when things get challenging. It can actually be very frustrating when this happens. You as someone with a high level of specialist knowledge, often know what needs to be done far more than the patient themselves, but if the person you’re trying to help isn’t listening to you, or accepting what you’re saying, then how do we deal with this?

Unless you understand the patients agenda and what they want to achieve from your time together, you’re going to be working at cross purposes. However, when you explore what someone wants to achieve, you can then negotiate a shared agenda that you can both work towards and so achieve an outcome everyone is satisfied with.

The way I usually explain this to people is to tell a story about my son. I love my kids very much and I enjoy talking about them, so please forgive me.

 

At the time of writing this, he is 2 ½ years old and is curious about everything. I was walking through town with him and my daughter not long ago and had decided to try him on some reigns to make sure I had him under control while I pushed my daughter in her pram.
As usual, he wanted to look at everything, in particular, every pigeon he saw, which he calls quack quacks (for some reason).

We needed to get to the shop before it closed but all he wanted to do was look at the pigeons. “Daddy, quack quack. Daddy quack quack.”

I knelt down and said, “we need to get to the shop or we won’t have any dinner for tonight”.
Predictably, my son didn’t care. “Daddy, quack quack. Quack quack daddy!”

It was important we got to the shop, but that was my agenda. My son didn’t care about my agenda, he wanted to see the “quack quacks” and was pulling against his reigns as hard as he could, going limp (doing his 2 year old’s impression of Tom Cruise in Mission Impossible hanging from a harness) and shouting “quack quack”. He went through every trick in the book to get his own way, making things as difficult as possible and making it impossible to move on.

If I wanted to achieve my agenda, I had to take his agenda into consideration. I knelt down again and said, “ok, we’ll look at the quack quack for one minute, but then we have to go to the shop and get you some dinner, ok?”
He looked at me with his big blue eyes and said, “ok daddy”.
We then spent one minute seeing to his agenda (which consisted of him failing to get a pigeon to stay still long enough to let him play with it) and then we went to the shop.

By not dismissing his agenda and spending a short amount of time on it, we managed to achieve the outcome that was in his best interest and mine… dinner!

 

Now, does this mean I am saying not to bother exploring the ideas, concerns and expectations of your patients? No, of course not. ICE is one of the best ways to uncover an agenda, but it isn’t the ultimate objective of a good consultation. The shared agenda is.

So, once you have discovered what the person opposite you wants, how do you use that knowledge to move things forward?

First, you have to let them know you have heard them and know what they want. By summarising what you have learned from the patient, both their ICE and their agenda, you are demonstrating to the patient that you are taking them seriously, listening to them and know what they want to achieve. This can’t help but reassure them that they will get what they want.

Next, you can negotiate a shared agenda. After summarising what the patient wants from the consultation, make it clear that there are also some issues you think are important to cover and tell them why.

If the patient is adamant that they are only here to discuss the issue that is at the heart of their agenda then you may need to accept this. You can always discuss the possibility of making another appointment to talk about any issues that cant be covered today if necessary.

For a patient to feel hears and respected, we can’t dismiss them and their agenda. And simply asking them what their ideas are, what they are worried about and what they expect isn’t going to achieve that in every situation. That’s why understanding the agenda of your patient and trying to meet it is the best way to have a successful consultation.

Unless you understand the patients agenda and what they want to achieve from your time together, you’re going to be working at cross purposes. However, when you explore what someone wants to achieve, you can then negotiate a shared agenda that you can both work towards and so achieve an outcome everyone is satisfied with.

I’m sure there will be people who disagree with me on this and I hope you will make your thoughts known in the comments below. It would be great if there can be some discussion on the experiences of the readers of this post and how ICE vs Agenda has impacted their consultations.

 

Our time: 3:45am BST

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