Practising Holistically
"Patients don't come with a symptom — they come with a story. The story is where the real consultation happens."
📥 Downloads
Handouts, consultation scripts, teaching resources, and presentation slides — all ready when you are.
path: PRACTISING HOLISTICALLY (ICE & PSO)
- 5 things all patients want to HAPPEN.ppt
- 5 things all patients want to KNOW.ppt
- health belief model.ppt
- how much time do GPs spend on issues 2015.pdf
- illness vs disease.ppt
- person centred care made simple.pdf
- person-centred care (TEACHING RESOURCE).doc
- person-centred care.ppt
- physical, psychological & social - triangular thinking for GPs.doc
- remember the patient in your decision making with slide notes.ppt
- research on the gp consultation.doc
- scripts for ideas concerns and expectations ICE2.docx
- scripts for ideas concerns expectations ICE.docx
- scripts for psychosocial occupational PSO.docx
- the ICE box.docx
🌐 Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best pearls are not hiding in the official documents.
⚡ Quick Summary
If you only read one thing — read this first.
Attending to the physical, psychological, social, and cultural dimensions of a patient's experience — not just the diagnosis.
What does the patient think is wrong? What worries them? What do they hope you'll do? Three questions that change everything.
How is the condition affecting the patient's mind, relationships, and work? This turns a disease into a person's story.
ICE & PSO are not tasks to tick. They are windows into the patient's world. Ask at the right moment. Listen with intent.
Two people with the same sciatica live completely different lives. Disease is the diagnosis. Illness is the impact. Always explore both.
Examiners do not reward asking all three ICE questions back-to-back. They reward genuine curiosity about the patient in front of you.
🩺Why Holistic Consulting Matters in GP
General practice is not hospital medicine with a smaller waiting list. It is something fundamentally different. In a hospital, you are usually managing a defined condition. In general practice, you are managing a person who has a condition — and that person arrived carrying a whole world with them: fears, assumptions, work pressures, family worries, previous experiences of healthcare, and sometimes a very specific idea of what they need from you today.
If you only treat the diagnosis and ignore the person, you will regularly give technically correct advice to someone who won't follow it — because you haven't understood why they came, what they're scared of, or what's actually getting in the way of them getting better.
The Gap Between What GPs Think Patients Want and What They Actually Want
Sources: Cartwright & Anderson 1981; BJGP Open 2023 observational study of UK consultations
- Patients feel truly understood
- Treatment plans actually get followed
- Fewer unnecessary prescriptions
- Reduced re-attendance and "heartsink" dynamics
- Better clinical outcomes
- Higher patient satisfaction scores
- SCA examiners notice and reward it
- Patients leave with the "wrong" prescription (one they never wanted)
- Non-adherence is inevitable
- The real problem goes unaddressed
- Patients return repeatedly with the same presentation
- Risk of medico-legal issues if concerns go unaddressed
- SCA marks lost on Relating to Others & Clinical Management domains
What is Practising Holistically?
To practise holistically is to operate in physical, psychological, socioeconomic, and cultural dimensions, taking into account feelings as well as thoughts.
It gives you an all-rounded picture of what is going on — and in so doing, helps you truly understand the impact of a medical problem on an individual's world. Once you understand that, you understand what the priorities might be for this patient (in addition to your own clinical priorities as a doctor).
ICE and PSO are two simple microskill tools that help you explore the holistic side of things in more detail. Think of them as lenses, not checklists.
ICE — Ideas, Concerns & Expectations
What does the patient think is happening? What have they read, heard, or worried about?
What is the patient worried about? What fears are they carrying into the room?
What does the patient hope will happen today? What outcome would satisfy them?
In the 1980s, Pendleton and colleagues studied a group of GPs having notably better consultations than their peers. What distinguished them? They focused on finding out about the patient's experience of their illness, not just the diagnosis. They asked about ideas, concerns, and expectations. The effect was striking — more nuanced diagnoses, better-tailored explanations, and more satisfied patients.
The concept then spread from GP consulting rooms to medical schools across the world. The problem came later — when it became a box-ticking exercise.
Disease vs Illness — The Most Important Distinction
This single concept, once truly understood, transforms how you consult forever. Read it carefully — it is not obvious until it clicks.
| Aspect | Patient A | Patient B |
|---|---|---|
| Disease | Left-sided sciatica (identical diagnosis) | |
| Physical impact | Mild niggle — manageable | Barely able to walk, in tears daily |
| Work impact | Desk job — not affected | Postman — cannot work at all |
| Psychological | Unconcerned — expects recovery | Terrified of permanent disability |
| What they need | Reassurance & self-management tips | Pain relief, sick note, mental health support |
| If you only coded "sciatica"... | You'd never know any of this difference exists | |
Both patients have sciatica. But they need completely different consultations. PSO is how you find this out.
PSO — Psycho, Social & Occupational
PSO exploration should become routine — as natural as asking about duration of symptoms. It gives you the FLAVOUR of a disease. It turns a coded diagnosis into a real human story. And crucially, it tells you what your patient actually needs from this consultation.
🧠 Psychological — the mind's response to illness
How has this problem affected the patient's mental wellbeing? Are they getting down, anxious, struggling to sleep because of it? Are they crying? Is it affecting their concentration?
Useful phrases for psychological exploration:
👨👩👧 Social — the ripple effects on relationships and daily life
How has the problem affected the patient's social functioning? Can they still enjoy hobbies? Has it affected their relationships at home? Are they isolated? Has it affected their ability to drive, to get out, to see friends?
Useful phrases for social exploration:
💼 Occupational — work, finances, and practical impact
What is the problem doing to the patient's ability to work? Are they struggling to function in their job? Has it affected their finances? Might they need a sick note? Is their job at risk?
Useful phrases for occupational exploration:
How to Use PSO Information Once You Have It
The real skill is not just gathering PSO information — it's using it. PSO data can and should feed into three parts of the consultation:
| Use it in... | Example | Why it works |
|---|---|---|
| Your explanation | "Mrs X, this is called sciatica — a trapped nerve. The pain can be so bad that it stops you managing the stairs, as you've already found out." | Patient feels heard. The explanation is personalised, not generic. |
| Your management plan | "You said earlier that the pain stops you going out and has had you crying. Would it help if I gave you something for that?" | Prescription feels relevant and wanted — much more likely to be taken. |
| Further history-taking | "You mentioned the pain has had you in tears several times a day. Can I just check — how have your spirits been more generally?" | Natural gateway to a depression or mood enquiry that doesn't feel abrupt. |
🎭 Why Stories Matter — The Emotional Heart of PSO
This is the part of holistic consulting that textbooks struggle to capture. You can understand the concept of PSO intellectually — but the moment it truly lands is when you actually feel what a patient's illness has done to their life. That feeling is not a weakness. It is the entire point.
What Changes When You Listen to the Story
How Listening to the Story Changes What You Do
The Problem With How Most Trainees Do ICE
There is nothing wrong with the concept of ICE. Exploring what a patient thinks, worries about, and hopes for is a deeply patient-centred, ethical, and clinically useful thing to do. The problem is entirely in the execution.
Most trainees treat ICE as a set of three tasks to complete — three boxes to tick. They ask about Ideas, then Concerns, then Expectations, in rapid succession, usually near the start of the consultation. Patients notice. Examiners notice. And it makes the whole thing feel mechanical and performative rather than genuine.
Why Patients Don't Share Their ICE Straight Away
How to Help Patients Open Up
- Ask about ICE a little way into the consultation, not as the first thing out of your mouth. Build some rapport first.
- Create an atmosphere where the patient's input is genuinely valued — not just allowed.
- Tell them how much their thoughts matter: "I find it really helps to understand what's been going through your mind."
- Always reassure when a patient hesitates or says "I don't want to sound silly" — they absolutely do have something to say.
- If they give a non-answer, gently probe: "Not really? Sounds like there might be something?"
The Art of the Gentle Probe
Doctor: "Have you had any thoughts as to what might be going on?"
Patient: "Not really."
Doctor: "Not really? Sounds like there might be something?"
Patient: "Well, it might sound silly, but I was talking to my friend and she said..."
💡 PS — "not really" almost always means "yes really." When a patient says "not really," there is almost always something there — it simply needs a little more safety to come out. The quiet echo ("not really? sounds like there might be something?") opens the door nearly every time. Never take "not really" as a full stop.
Doctor: "Have you had any thoughts as to what might be going on?"
Patient: [patient shrugs]
Doctor: "For example, has anyone said anything to you about it, or have you read anything online or in a magazine?"
Patient: "Well, I have to admit, I did do a bit of an internet search. I know you're not supposed to but..."
Offering concrete examples ("has anyone said anything / did you read anything") gives the patient a foothold. They now have permission to admit the internet search they're slightly embarrassed about.
Ask at the Right Moment — Not All at Once
The real skill is recognising the natural cues the patient gives you and asking about the relevant ICE component at exactly that moment. You don't need to ask all three in succession. You might explore Ideas in the middle of history-taking, Concerns when the patient hesitates, and Expectations near the end. That is far more powerful than three questions in a row.
Patient: "These headaches are really getting me upset and anxious."
Doctor: "I can see that. Are you anxious because you're worried they might be something serious?" [→ exploring Concerns, prompted by the cue "anxious"]
Patient: "Not particularly serious, no. I just... I've always thought they were migraines but nobody's ever said."
Doctor: "Interesting — what made you think they might be migraines?" [→ exploring Ideas, following the patient's lead]
Patient: "My mum always called them that."
Notice: no checklist. No "Now I'm going to ask about your ideas." The ICE emerged naturally from listening to the patient and following the cues they gave.
Ideas — What Does the Patient Think is Going On?
"Phraseology is everything."
Each ICE component below begins with an example of how trainees commonly phrase the question badly — and why it backfires. Read these carefully. You may well recognise yourself in some of them.
💡 The Strongest Feedback You Can Get
If you have ever been on the receiving end of an irritated, confused, or defensive patient response when asking about their ICE — that moment is priceless feedback. It almost always means the phrasing was wrong, not the concept. Use it to rephrase more carefully next time.
Your aim here is to understand the patient's existing mental model of their problem. They may have searched online, talked to a friend, or simply developed their own theory. You want to know what it is — both to correct misconceptions and to understand what they're responding to.
Dr: "So, what do you think is going on?"
Pt: "I don't know — you're the doctor."
The patient is confused: why is the doctor asking me for a medical opinion? This phrasing makes the doctor look unsure rather than curious.
Dr: "You've had this for a few weeks now. I'd be interested to know — in that time, have you had any thoughts of your own about what it might be? Sometimes people have spoken to someone, or read something..."
The context (duration + normalising statement) makes the question feel natural, not absurd.
Concerns — What is the Patient Worried About?
Dr: "Are you worried about anything?"
Pt: "No, everything's fine at home..."
The patient thinks you're probing for psychosocial problems unrelated to their symptoms. Mismatch of intent.
Dr: "Are you worried about anything serious?"
Pt: "No. I just want it sorting."
This only asks about life-threatening concerns. The patient's real worry (e.g., not being able to walk) goes unasked.
Dr: "Often when people have had a problem for a little while, they start to have worries about it — about what it might be, or what it might mean for them. Have you had any worries about your symptoms?"
This normalises worry. It's clear you're asking about health-related fears, not life problems. And it's open — catching all kinds of concerns, not just cancer fears.
Expectations — What is the Patient Hoping For?
Dr: "So what would you like me to do about it?"
Pt: "I don't know — you're the doctor..."
Again, the patient thinks: surely they should know what to do? This feels like an abdication, not patient-centredness.
Dr: "I've got some thoughts in my own mind about where we go from here. But before I share them with you, I was wondering — did you have any thoughts of your own about what you were hoping we might do?"
This is collaborative. You signal you have a plan. But you genuinely want to know theirs first. Mutual, not deferring.
"So am I right in thinking you were hoping I might arrange an X-ray?"
"No, not at all — I actually just wanted to know whether physio might help."
Even a wrong guess prompts the patient to correct you — and you've still learned the real expectation.
The ICEE Gap — What Research Tells Us About UK GP Consultations
A landmark 2023 observational study from the University of Bristol analysed 92 video-recorded face-to-face GP consultations from 23 GPs across 12 UK practices. The findings are striking — and directly challenge several assumptions trainees hold about how ICE works in practice.
How Often Does Each ICEE Component Appear in UK GP Consultations?
Who Actually Starts the ICE Conversation?
Patient vs GP — Who Raises Each ICEE Component First?
What These Findings Mean for Your Practice
9 in 10 consultations contained at least one ICEE component. But the vast majority of these were initiated by the patient, not the GP. This means trainees who claim to "do ICE" may simply be listening when patients volunteer it — rather than actively creating space for it.
Only 3.3% of GPs directly asked about Expectations. Expectations are perhaps the most powerful driver of patient satisfaction — and the one component that almost never gets explored unless the doctor actively asks.
Effects on life (the PSO equivalent) occurred in only 42.4% of consultations — the lowest of all four components — yet was documented in the patient record more than any other component. GPs recognise its importance but systematically under-explore it in real time.
Patients aged 75+ and those from the most deprived neighbourhoods had fewer ICEE components explored in their consultations. The patients who arguably need the most holistic attention receive the least. This is an important reminder that patient-centred consulting requires active effort, not passive allowance.
What the GP Training Community Consistently Reports
Across UK GP training communities, exam preparation platforms, deanery feedback sessions, and trainee accounts, the same patterns come up again and again. These are not exam myths — they are consistent, corroborated observations from trainees, trainers, and examiners who have seen hundreds of consultations.
The Five Ways Trainees Consistently Get ICE Wrong
Patterns Reported Consistently by UK GP Trainees
One of the most commonly reported SCA experiences is doing ICE correctly "on paper" but having the examiner still score it poorly. The universal explanation: the trainee asked the questions but the answers didn't change anything in the consultation. The patient's concern was acknowledged and then functionally ignored. The management plan looked identical to one that would have been given without any ICE exploration at all. The lesson: ICE has to be used, not just gathered.
Trainees who memorised fixed ICE phrases consistently report that under exam stress, they either forgot the phrases entirely or delivered them so woodenly that the examiner noticed. The trainers' consistent advice back: practise the underlying intent, not the phrase. If you genuinely want to know what the patient is worried about, you will find the words. If you're retrieving a memorised sentence, the patient and examiner will both feel it.
Trainees who receive SCA feedback about poor "Relating to Others" scores very often identify, on reflection, that they skipped PSO entirely. They focused on the clinical problem, delivered a competent management plan, and scored poorly because they never understood the patient's world. The consultation felt doctor-centred to the examiner, even though it was clinically correct. PSO is not an add-on — it is what separates a clinical interaction from a GP consultation.
This is one of the most frequently cited training challenges, especially for IMGs and trainees earlier in the programme. Hospital medicine trains you to be directive and efficient. GP consulting requires you to be curious and collaborative. Trainees who struggle with ICE often describe it as a cultural shift rather than a skill acquisition — they had to learn a fundamentally different way of thinking about their role in the room. The fix is volume of practice in GP, not just reading about the concept.
Consistently, trainees describe one or two phrase changes — suggested by their trainer, often during a COT debrief — that transformed how patients responded. The most common example: replacing "Are you worried about anything?" with "Often when people have had a problem like this for a while, they start to have worries about it — have you had any?" The normalising frame completely changed the quality of the responses they got. This is the value of iterative, feedback-driven practice over theory reading.
The "Over-Scripted" Problem — What the Exam Preparation Community Consistently Identifies
UK GP exam preparation communities, including those running trainee SCA courses, consistently identify the same top consultation failures. The most common are listed here in order of frequency:
| # | Failure Pattern | What It Looks Like | Fix |
|---|---|---|---|
| 1 | Overly scripted | Formulaic questions, robotic delivery, fixed phrases regardless of context | Practise intent, not lines. One new phrase per real clinic session. |
| 2 | Unnatural ICE | Three ICE questions back-to-back, out of context | Follow patient cues. Let ICE emerge. Time it right. |
| 3 | Failing to contextualise | Generic management plan that doesn't reflect what the patient said | Explicitly link plan to their specific ICE/PSO findings. |
| 4 | Hospital-style consulting | Doctor-led, closed questions, directive management | Open questions first. Listen. Follow the patient's lead. |
| 5 | Rushing past PSO | Time spent entirely on clinical history; no social or psychological exploration | Always ask one PSO question. Build from there. |
| 6 | Shared decision-making as performance | "We have a couple of options" — then lists them without involving the patient in choosing | After listing options, ask: "What feels right for you given everything you've said?" |
Source: synthesised from UK GP exam preparation communities and deanery feedback sessions — these patterns are consistent across multiple sources.
An experienced ST4 trainee writing for the RCGP blog put it best: rather than overhauling your entire consulting style, try one new phrase in every other consultation for a few days. Don't think too much about it. Just try it once. Then reflect. Then adjust. This iterative, low-pressure approach embeds new language organically — the same way all consultation skills actually develop — rather than producing the stiff, self-conscious performance that kills natural consulting.
Suggested phrases to try one at a time:
- "In that time, have you had any thoughts of your own about what it might be?"
- "Often when people have had something like this for a while, they start to worry about it — have you?"
- "I've got my own thoughts — but before I share them, did you have any hopes about where we go from here?"
- "Has this been causing any problems at work or at home?"
Teaching Pearls for Trainers & TPDs
🟣 Common Trainee Blind Spots on This Topic
- The three-question sprint: Trainees often ask all three ICE components in rapid succession. They need to understand that the timing and naturalness of ICE matters as much as whether they ask at all.
- Gathering but not using: Many trainees successfully elicit ICE but then proceed with a generic management plan that ignores everything the patient said. Point this out in feedback — it's more common than any other ICE error.
- Confusing PSO with depression screening: Trainees sometimes jump straight to PHQ-2 when they should have explored PSO first. PSO is richer, less clinical, and much more natural.
- Giving up too quickly: When a patient says "nothing really," many trainees move on. They need to learn to gently probe — because "not really" is almost always a cue, not a dead end.
🟣 Tutorial Ideas & Scenarios
- The "same disease, different illness" exercise: Present two identical diagnoses (e.g., two patients with IBS) and ask the trainee to interview both. Debrief on how differently they need to be managed once illness is explored.
- The "what changed?" debrief: After any consultation role-play, ask: "What in the patient's ICE changed what you did? Give me a specific example." If they can't, the ICE was decorative.
- The "not really" exercise: Role-play a patient who gives non-answers. Practice the skill of gentle probing without persistence that feels interrogating.
- COT/audioCOT review: Play a recording and identify every ICE cue the patient dropped. How many did the trainee catch? How many sailed past unnoticed?
🟣 Reflective Questions for Tutorials
- "Tell me about a patient where you found out something through ICE/PSO that genuinely surprised you."
- "Can you think of a time when a patient's expectation turned out to be completely different from what you assumed?"
- "If you had to choose just one — Ideas, Concerns, or Expectations — which do you feel you explore most naturally? Which is hardest? Why?"
- "When you ask PSO questions and get a significant answer, how do you use that information? Walk me through a real example."
- "What's the difference between asking about ICE and caring about ICE?"
🟣 Useful Assessment Points on This Topic (CBD/COT)
- Did the trainee elicit ICE at an appropriate point, or did it feel like box-ticking?
- Did the trainee use ICE/PSO findings to modify their explanation and management plan?
- Did the management plan directly reference something the patient mentioned about their illness (PSO)?
- Was the safety-netting tailored to the patient's specific concern?
- Did the trainee notice and follow up on non-verbal cues (hesitation, affect, body language)?
❓ FAQ
Do I have to ask about all three ICE components every time?
What if a patient gets annoyed when I ask about their ideas?
Is PSO always relevant?
In the SCA, how do I know if I've done ICE well enough?
What's the difference between ICE and PSO in practice?
As an IMG, I find these kinds of open questions culturally quite different from my background. How do I make them work for me?
Seeing Through the Examiner's Eyes
The RCGP SCA Consultation Toolkit is the official resource given to trainers and trainees for SCA preparation. It contains the precise language examiners use to grade ICE and PSO exploration. Reading it reveals exactly what is being assessed — which is often more nuanced than trainees realise.
The Green/Red Descriptors — Exactly What Examiners Are Comparing You Against
- Makes an appropriate assessment of the patient's ideas and/or concerns about their symptoms and their hopes for treatment
- Fluently and sensitively explores ICE and cues at an appropriate time
- Introduces questions about psychosocial functioning in a natural manner
- Demonstrates a curious approach to the patient's illness and life
- Shows active listening — picks up on cues, responds to them
- Management plan is patient-centred and negotiated with reference to ICE
- Makes little or no assessment of the patient's ideas, concerns and expectations
- Elicits ICE using jarring phrases and/or at an inappropriate time
- Introduces psychosocial questions in a jarring or insensitive manner
- Consulting to a fixed script rather than adapting to the patient
- Management plan not linked to patient's ICE or psychosocial context
- Fails to respond to verbal and non-verbal cues from the patient
The word the RCGP toolkit uses repeatedly for poor ICE technique is "jarring". A jarring question is one that disrupts the natural flow of the consultation — it feels out of place, abrupt, or performative. It can be technically correct ("have you had any concerns about this?") but feel completely wrong because of the timing, tone, or context in which it is delivered.
The toolkit explicitly asks trainees: "Do you find out about ICE in a way which avoids either damaging rapport, or being patronising or perhaps jarring at inappropriate points in the consultation?"
This is what separates a natural consultation from a scripted one. Not the words. The feel.
Three Self-Reflection Questions the RCGP Toolkit Asks Every Trainee
"How often do you obtain information about ICE just from the information offered by the patient — without asking directly for it?"
This question challenges trainees to notice patient-initiated ICE — and recognise that actively listening may be more valuable than asking.
"How seriously do you take ICE? It can be easy to fall into a trap of seeing it as 'something that needs to be done' — but this risks it not being taken seriously enough."
The toolkit's most honest challenge. Do you actually care about the patient's ideas, or are you performing care?
"Is it easier to discover both ICE and psychosocial context when the consultation is still 'open' at the start and the patient is telling their story?"
The answer is almost always yes — which is why keeping the opening open-ended and uninterrupted is so important.
Why Failing to Use ICE Cascades Through the Whole Consultation
A Special Case: Holistic Consulting in Chronic Disease
In chronic disease consultations — asthma, diabetes, hypertension, depression — the ICE landscape is different from acute presentations. The RCGP toolkit specifically notes that:
- Ideas in chronic disease are often about prognosis and disease progression — "will this get worse?" "will I end up like my father?"
- Concerns in chronic disease are frequently about treatment side effects, long-term medication use, or fear of dependency
- Expectations may be shaped by previous healthcare experiences — and may be low ("nobody has ever explained this properly to me")
- PSO in chronic disease is the entire management landscape — the psychological burden of living with a long-term condition is often the dominant issue, not the clinical parameters
🎯 SCA Tips — Exploring Holistically with Authenticity
This is the section that separates candidates who pass from candidates who excel. The SCA does not reward the performance of holistic consulting. It rewards the real thing.
Every examiner can tell the difference between a candidate who is genuinely curious about this patient and one who is executing a learned script. The difference shows in tone, timing, follow-up questions, and whether the answers the patient gives actually change anything the doctor does next.
If you ask about ICE and then ignore the answer, you have scored zero on person-centredness — no matter how cleanly you delivered the question.
The LISTEN-FOLLOW-USE Framework — Consulting Naturally
This three-part framework is the key to making ICE and PSO feel natural rather than scripted. Think of it as a mindset shift, not a new checklist.
LISTEN — Actively hunt for cues
The patient will almost always signal their ICE before you ask. A pause, a shift in tone, a qualifying phrase like "I was a bit worried that..." or "my friend said..." are your cues. You don't have to ask out of nowhere — you have to notice and respond. Train your ear to catch these moments, because they are always there.
FOLLOW — Ask at the right moment, not on schedule
When a cue appears, follow it immediately. "You mentioned your friend said something — what did she say?" This feels natural because it's a direct response to what the patient just told you. Contrast this with asking the same question five minutes later, out of context, because you "haven't done ICE yet." That feels like a tick-box. The timing is the entire difference.
USE — Let the answer change what you do next
This is the make-or-break step. If the patient tells you they think their headache is a brain tumour, that information must visibly change your consultation. You address it. You acknowledge it. You don't just nod and move on to blood pressure. When examiners see the patient's words influencing the doctor's response in real time, that is holistic consulting. When those words seem to go nowhere, it looks like performance.
Authentic vs Scripted — See the Difference
"Can you tell me your ideas about what might be going on? ...And do you have any concerns? ...And what were your expectations from today's appointment?"
Three questions. Rapid fire. Asked back-to-back at minute two. Examiner thinks: "This is a checklist, not a consultation."
Patient mentions they've been googling their symptoms. Doctor responds: "What did you find? What was going through your mind?"
Later: patient hesitates. Doctor asks: "Something in your face tells me there's something you're a bit worried about?"
Later still: doctor says "We've a couple of options here — what feels right for you given everything you've said?"
What Genuine Curiosity Looks and Sounds Like
- You ask follow-up questions about the answer you just received — not a new item on your list
- You use the patient's own words back to them: "You said you were 'terrified' — tell me more about that."
- You look surprised, curious, or moved by what the patient says — genuine reactions, not neutral nodding
- Your management plan directly references something the patient told you about their ICE or PSO
- When addressing a concern, you name it explicitly: "You mentioned you were worried it might be something like what happened to your dad — let me address that directly."
- Your safety-netting is tailored to their specific concern, not generic
When to Explore Each Component — Rough Timing
Common Mistakes That Cost Marks
Asking all three ICE questions back-to-back, unprompted, in the first two minutes of the consultation.
Eliciting a concern — then never addressing it. The patient mentioned fearing cancer. You gave them a prescription. Never mentioned cancer. Zero marks.
Asking about ICE early but failing to return to it during the explanation and management plan. Gathering ICE is half the job. Using it is the other half.
Only exploring Concerns (everyone practises this one) and forgetting Ideas and Expectations — especially Expectations. Only 3.3% of UK GPs directly ask about Expectations in routine consultations. Don't be that GP.
PSO exploration done without follow-up. You ask "has this affected your work?" and the patient says "yes, massively." You don't follow up. Wasted opportunity — and a missed mark.
Exploring the psychological aspect of PSO as a standalone mood question with PHQ-2 rather than letting it emerge naturally from what the patient has already told you about their experience.
- Summarise the patient's ICE back to them before moving to management: "So, if I've understood right — you've thought this might be a migraine, you're not terrified it's serious, but you really want to know definitively. Have I got that right?"
- Reference ICE explicitly in your management plan: "Given that you're worried about long-term use, let's go with the lowest dose and review in four weeks."
- Tailor your safety-netting to their concern: not generic "come back if worse," but "If you notice any of the features we talked about — the ones that worried you — please don't wait, come back or call 111 straight away."
- Use PSO to bridge into mental health screening naturally rather than abruptly.
ICE on the Phone — Why It's Harder and How to Do It Better
The SCA includes three telephone (audio-only) consultations. In these, there are no visual cues — no hesitation you can see, no expression that tells you something is being held back. Research and RCGP toolkit guidance both confirm that cue detection is harder in audio consultations, and trainees are less likely to identify and follow up on non-verbal cues when those cues are only auditory.
There is also a natural tendency in audio consultations to become more directive and less collaborative — the absence of visual contact can push doctors back into a hospital-style, question-and-answer mode. The RCGP toolkit explicitly warns against this.
What Changes — and What Doesn't
| Aspect | Face-to-Face / Video | Audio (Telephone) |
|---|---|---|
| Cue detection | Visual + verbal cues available | Verbal and vocal cues only — requires more active listening |
| Rapport building | Eye contact, body language help | Must be built entirely through voice, pacing, and warmth |
| ICE timing | Visual cues guide when to ask | Must listen for vocal hesitations, pauses, changes in tone |
| PSO exploration | Easier to see emotional response | Must ask more explicitly — reactions aren't visible |
| Checking understanding | Expression confirms comprehension | Must verbalise checks: "Does that make sense?" |
| Shared decision-making | Nods, expressions guide the discussion | More important to explicitly invite patient's voice: "What are your thoughts on that?" |
Practical Adaptations for Telephone ICE
🔊 Listening for Vocal Cues
🔊 Making ICE Explicit on the Phone
Interestingly, some patients find it easier to disclose their ideas and concerns on the phone than face-to-face — particularly sensitive topics like mental health, sexual health, or fears they feel embarrassed to say out loud in person. The reduced visual contact can lower the barrier. If you create the right opening on the phone, you may get richer ICE than you would have expected.
Phrases That Truly Show Intent to Understand
The phrases below are designed to sound like something a kind, thoughtful person would say — not a textbook question read aloud. The best phrases share three qualities: they normalise the patient's experience, they explain why you're asking, and they leave room for the patient's own words. Read them once and try to understand the structure, not memorise them verbatim — then adapt them naturally.
🌱 Exploring Ideas
😟 Exploring Concerns
🤝 Exploring Expectations
🔺 Exploring PSO
🔁 Using ICE in the Explanation
💫 When ICE Leads to Shared Decision-Making
Rather than memorising fixed phrases, internalize the structure behind them. These templates work for almost any presentation:
| Purpose | Template Structure |
|---|---|
| Exploring Ideas | "You've been dealing with [this] for [some time]. I'd be interested to know — in that time, have you had any thoughts about [what it might be / what's going on]?" |
| Normalising before asking | "A lot of people in your situation [worry about X / want to know Y / hope for Z]. Have you had similar thoughts?" |
| Exploring Concerns | "Often when people have [this problem] for [this long], they start to worry about [it / what it might mean / what comes next]. Have you had any worries like that?" |
| Exploring Expectations (collaborative) | "I've got my own thoughts about where we go from here. But before I share them — did you have any thoughts about what you were hoping we might [do / try / organise]?" |
| Using PSO in management | "You mentioned earlier that [PSO finding]. I was thinking — would [management option] help with that specifically?" |
💎 Insider Pearls — What Trainees Wish They'd Known Earlier
Trainees who do best in SCA report that they stopped trying to "fit ICE in" and started listening specifically for patient cues. Once you realise every patient drops hints, the whole consultation changes. You're no longer inserting questions — you're responding to them.
Almost every experienced trainee reaches the same conclusion: when a patient says "not really" to an ICE question, there is almost always something there. The quiet echo — "Not really? Sounds like there might be something?" — opens the door almost every time.
Research shows that in only 3.3% of UK GP consultations did the GP directly ask about expectations. Yet expectations are often the entire hidden agenda of the consultation. The patient who seemed fine with your plan — but left quietly unsatisfied — usually had an unspoken expectation you never uncovered.
Trainees find it hard to ask about depression or anxiety without it feeling abrupt. PSO solves this. If you've already established that the condition has made someone cry and stopped them leaving the house, asking "how have your spirits been?" doesn't feel like a PHQ-2. It feels like continuation of the same caring conversation.
One of the highest-yield consultation habits in the SCA is explicitly checking whether you've addressed the patient's original concern before closing. "Before we finish — do you feel like we've properly addressed what was worrying you when you came in?" This one question can rescue an otherwise incomplete consultation.
Counterintuitively, trainees who invest the first few minutes in genuine ICE and PSO exploration often finish faster — because they're solving the right problem, not the apparent problem. The patient who "just wants a prescription" and returns four times might need one honest conversation about their fear, not four prescriptions.
✅ Final Take-Home Points
The bits to carry with you into tomorrow's clinic.
- Practising holistically means understanding the impact of illness on a patient's whole life — not just treating the diagnosis.
- ICE (Ideas, Concerns, Expectations) and PSO (Psycho, Social, Occupational) are lenses, not checklists. Use them with curiosity, not compliance.
- Patients do not always share their ICE straight away. Rapport comes first. The cues come next. The questions follow the cues.
- The phrase "not really" almost always means "yes, but I need a moment." A gentle echo almost always opens the door.
- The same disease can produce radically different illnesses. PSO turns the disease into a person's story — and transforms how you manage them.
- In the SCA, what distinguishes good candidates is not whether they ask about ICE — it is whether the patient's answers visibly change what the doctor does next.
- Expectations are the most neglected component of ICE. Ask about them. They are often the entire hidden agenda of the consultation.
- Always close the ICE loop before you close the consultation: "Do you feel like we've addressed what was really worrying you today?"
- Holistic consulting is not the opposite of efficient consulting. Done well, it makes consultations faster — because you solve the right problem first time.
- The goal is not to ask the right questions. The goal is to be genuinely curious about the human sitting in front of you. The right questions will follow naturally from that.