Understanding the patient’s perspective (ICE)

Ideas, concerns and expectations

  • A concept developed initially from cross-cultural work (Kleinman etc.) The way into the patient’s lifeworld, into the patient’s true agenda (Mischler)
  • Very good evidence that eliciting affects outcome

ICE will often appear in the attentive listening stage as cues that need to be picked up rather than clear statements and that this can be even better than direct questions re ICE – easier and more natural.

But doctors have been shown to repeatedly fail to pick up patient’s cues. Why?

This may be due to control issues – we control via direct questions and this limits patient and renders them more passive -we don’t know where patient cues will take us but paradoxically they may be a shortcut to the most important areas.

Note the central importance of accepting and acknowledging the legitimacy of patient’s having views:

Handling the patient’s ideas, concerns and expectations is a three-stage process—

  • identify
  • acknowledge
  • build into explanation

Asking how illness is affecting patient’s life is a good way into ICE

The specific phrasing of ideas and concern questions


  • What do you think is causing it?
  • Why do you think that is happening?
  • Have you any ideas about it yourself about what might be causing it?
  • Have you got any clues, have you any theories?
  • Tell me in your own words
  • You obviously given this some thought
  • Some people….
  • Did you think it might be….?

Explain why you are asking and why it is helpful to you (especially to counter the “you’re the doctor” comment)


  • “What are you concerned that it might be?” has been shown to be a more acceptable phrase than “what are you worried that it might be?”
  • Is there anything particular or specific that….?
  • What was the worst thing you were thinking it might be?


  • What do you think we might….?
  • What were you hoping we might be able to do for this?
  • How were you hoping I might help you with this?
  • How best might I help you with this?
  • Were you hoping that I might be able to do something in particular?
  • Describe the range of options first and then ask for theirs
  • You’ve obviously given this some thought


An area which, at medical school, we were taught to avoid, yet the area that counsellors are taught most how to explore!

We all need to practice phrases which allow the patient to express their feelings:

  • repetition of cues e.g. “upset..?”
  • picking up and checking out e.g. “you seem to be upset”. Also, use direct questions e.g. “did that leave you feeling?”
  • early use of questions about feelings will establish your interest in the subject
  • permission asking to enter this realm e.g. could you bear to tell me just how you have been feeling?
  • how to end and not sink into a downward spiral with the patient e.g. “Thank you for telling me how you have been feeling, that helps me to understand the situation much better. Do you think you’ve told me enough about how you are feeling to help me understand things?”
  • “I think I understand now a little of what you have been thinking – let’s look at the practical things that we can do together to help.”
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