The authors of the interesting Debate & Analysis article1 mention that the application of five cards might show — verbally and non-verbally — that the doctor has recognised and understands what he has heard: when the three patient’s cards of Ideas, Concerns, and Expectations (ICE) have been played, the doctor may have a better understanding of the patient’s illness experience; and the two other Receipt and Summary cards seem to be a response as a receipt in confirmation.
Although the application of the aforementioned ‘cards’ seems justified, and most of us have the impression that the ICE acronym works,2 until now there is a scarcity of studies on ICE: there are no (efficacy) randomised trials on ICE and no patient satisfaction studies on this acronym. As far as we know there is only one cross-sectional study with students in educational training which showed that the mean number of ICE components per doctor and per contact was 1.54 (SD 0.54); one, two, or three of the ICE components were expressed in 38.5%, 24.4%, and 20.1% of contacts, respectively. On the other hand, in 22% (77 out of 350) of the new contact reasons, no ICE was voiced, and the GPs operated without knowing this information about the patients.3
In our contact with students and their video consultations of patients, we perceive some recurring facts:
Students are ‘conditioned’ and tempted to concentrate on the detail of the symptoms instead of what the presenting problem means for the patient with its current and future implications. They find it sometimes difficult to explore the ICE components and to clarify and play all (unexpressed) ICE cards; because expectations are often difficult to explore for students, we suggest alternatives for example: ‘Mr X, you expect an X-ray or you want medication now?’; or ‘What do you prefer: a painkiller or had you thought about a blood analysis first?’. Indeed, there is the need to develop a personal repertoire of questions and answers which sound fresh and ‘tailored’ to the particular patient, rather than formulaic and unnatural phrases about ICE.
It is a learning process to structure the consultation and to learn the interplay between the five cards and to give clear and unambiguous receipts. For example, it is often easier to nod or to mumble agreement rather than (dare) to show real empathy and interest in the story of the patient.
The five cards seem a simple guide for the experienced practitioner but are they for the beginning practitioner? This is not a criticism of the article but a request for more evidence on ICE and more evidence on the reciprocal relationship of the five cards and in that way we congratulate the authors for their refreshing debate and analysis.
- © British Journal of General Practice 2014
