When to ICE

And why
One of the most important and useful bits of feedback I find myself giving time and time again is to elicit the patients ideas, concerns and expectations (aka, ICE) early in your consultations. Not just in exams but in day to day practice as well.
A bone of contention at several CSA preparation courses I’ve worked on is when to cover ICE. Several times I’ve heard that leaving ICE until toward the end of the consultation is by far the best approach. The reasons I hear for this is that its best to build rapport first and that ICEing early might not produce anything as the patient isn’t ready to divulge their ideas, concerns or expectations.
I also think part of the reason people leave ICE until last goes right back to year one at medical school. Many institutions have ICE as the last box on their exam mark sheets. This falsely gives the impression that ICE should go at the end of the consultation and becomes the de facto structure for history taking.
I often experience consultations where people take the history of the presenting complaint and maybe take a bit of social history, during which they decide on the management plan they think most appropriate but before telling (not sharing) the patient the plan they squash in ICE. This can lead to one of two outcomes.
Outcome one – the patient’s ICE doesn’t conflict with your hoped for management plan, they are open to suggestions or have no specific expectations
Outcome two – the patients expectations are quite divergent from your suggested treatment, they have concerns you haven’t thought of or their ideas are incorrect and need to be addressed.
In option one you are going to face no problems, and can move onto management, safety netting and follow up whilst laughing at how wrong this blog was.
In option two you’re in trouble, you might not have time to go back, gain understanding of their ICE, build that into your plan, and address the issues that need addressing. Its like running three quarters of a marathon without checking where the finish line is, only to find out you were heading in the wrong direction only to have to double back and start again. Sounds pretty foolish doesn’t it, but I see it time and time again. By checking ICE early you can and will save time with little to no risk.
Imagine a patient who is adamant they have a brain tumour after a couple of tension and wants a CT scan and an MRI. They might initially not mention this as they are worried about a serious diagnosis or want to see if you confirm their self-diagnoses from their symptoms. By specifically checking their ICE early on you can reassure and educate about the risks vs rewards of radiation and scans rather than use the last couple of minutes arguing over having potentially harmful investigations.
So, what about this concern that you can’t get a patients ICE without first building rapport? I would counter that argument by saying if your having a convocation with someone and they don’t show you that they are interested in your ideas or concerns would you feel much rapport with them? Would you feel they were worth taking to? Would you feel they wanted to help you? Personally I wouldn’t and I suspect your patients would agree with me. Finding out and understanding someones ICE is one of the best ways to build rapport I know of. Checking ICE early will build that relationship and speed up your consultation – your patient will open up, give you more cues, give more open answers and do most of the work for you. Again, saving you time.
Finally, if you don’t think your patient will divulge their ICE early on in the consultation I would suggest that you take a look at how you are trying to elicit that information. Are you just asking straight questions… “So what did you want us to do?” “What are you worried about?” “What do you think it is?”
These can come across as quite blunt and not very empathetic.
If you try and show that you really want to understand the patients situation and help to the best of your ability they will more than likely be very happy to tell you all about their ICE. Try summarising what the patient has told you initially and empathise…
“So you have come in with X, I can see you’re concerned about this, can I ask if theres anything else concerning you?… Did you have any ideas about what might be causing this?… And were there any things you were hoping we might be able to do?…OK, well let me just ask some more questions to get a better understanding of how best to help you.”
Can you see how this approach might help elicit whats under the surface and where you need to aim for in your consultation so you avoid wasting time going in the wrong direction?
So remember, both in exams and in practice, ICEing early not only will improve your patients experience, it will also speed up your consultations and reduce your stress levels by making your job easier. The next time someone tell you to ICE late, point out that its not the only or even the best way to do things, they will come to thank you in the future.

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