Patient Perspectives: Exploring Ideas, Concerns & Expectations
This article explores the reasons why exploring patient perspectives during a medical consultation is not only important but essential to delivering empathic and patient-centred care.
As a communication skills tutor and OSCE clinical examiner, I have observed hundreds of students, over the years, attempt to explore patient perspectives. This is frequently an area of the consultation that can either make or break rapport. So, I've written this article to give my top tips on how and when to ask about patient perspectives; I also explore common pitfalls when asking these types of questions.
The patient perspective includes areas such as the patient's ideas, concerns and expectations (endearingly referred to as ICE by many students). ICE can and should be integrated into all consultations, be it when taking a history, giving information to a patient or within the context of shared decision-making. In addition, it is always worth exploring the impact of symptoms or management plans on a patient's life. This holistic approach not only enhances the clinician-patient relationship but also contributes to improved patient outcomes. For example, patients are more likely to take their prescribed medication when their views and concerns have been explored and discussed. Patients are also more likely to develop trust in their healthcare provider when they feel they have been listened to.
How NOT to ask about Ideas, Concerns and Expectations...
Over the years, I've observed that most students do attempt to explore the patient's perspective. Hence, the component itself is not generally missing from the consultation, but the problem, in my opinion, is that many students, especially in the early years of training, treat ICE as a tick-box exercise.
The commonest place I've seen students ask these questions is at the very end of the consultation (I think in the hope this gains them a few extra marks in their exams). It is often an afterthought and done in a matter-of-fact, cold (ironically, ICY) manner. This completely defeats the objective of asking these questions (remember, the aim here is to build rapport and better understand the patient).
As an examiner, observing when a student asks three questions in quick succession to explore ICE can become an awkward moment; this never lands well with the patient. My tip is to AVOID asking like this:
1. "What are your ideas about this?"
Quickly followed by...
2. "What are your concerns?"
Quickly followed by...
3. "What are your expectations from the consultation?"
There are several reasons why this approach does not work well:
- This questioning style feels like a checklist and focuses too heavily on the clinician's agenda.
☐ Ideas
☐ Concerns
☐ Expectations
- The number of questions in close succession feels rushed and abrupt.
- There seems to be little thought put into these questions; they appear formulaic rather than conversational.
- There is not enough time and space for the patient to answer and to further explore the answers given with follow-up questions.
- The position of the questions does not flow naturally in the consultation.
- Sometimes, students are not really listening to the answers (frequently, they are focusing too much on the next question), and hence, they miss important patient cues (both verbal and non-verbal).
How can I ask about ICE authentically?
Remember that a holistic consultation should feel like a dialogue between a patient and their clinician. Many years ago, whilst a medical student, I also pondered how to ask these questions naturally. I wanted to find a way to ask that did not break the flow of the consultation. Here are some ideas on how to integrate ICE effortlessly into your consultations:
- Come up with questions that feel natural to you and your consultation style.
- Try out different phrases when practising with peers. Where possible, try to avoid using the word expectation. There are many more authentic ways to ask (I will give a few examples later!)
- Look for opportunities in the consultation where the questions naturally flow into the conversation.
- Pick up on patient cues to sensitively explore their perspective.
- Ask with a caring intent and tone (not just to gain marks in an exam!).
When is the best time for ICE in a consultation?
- Try to discuss some elements of ICE early during a consultation, this generally helps to build rapport (however, there is always a balance to be struck, so equally, it is not necessarily the 1st thing to ask!).
- Be flexible with where you ask these questions. Find areas of the consultation or patient cues that naturally lend themselves to exploring these areas.
- Avoid asking all ICE questions at the END of a consultation.
My Analogy of ICE in Consultations and Icing on a Cake
If you made a three-tiered cake and put all the icing right at the bottom, it would be sickly sweet at the bottom, and the rest of the cake would lack the sweetness the cake required.
In a consultation, if you ask ICE only at the end of a consultation (at the bottom of the cake), without incorporating it into other elements of the history (the rest of the cake), the consultation can feel unbalanced. Instead, try balancing the ICE questions throughout the consultation (adding icing to each layer of the cake). This means asking when opportunities naturally occur during different parts of the consultation (i.e not all in one go and not all at the end of the consultation).
Exploring Ideas
Patient Ideas About their Symptoms
Patients might formulate their ideas about their symptoms from various sources, e.g. personal experiences, friends, family and commonly "Dr Google". Having an endless sea of online information can be overwhelming, factually incorrect and often difficult for patients to interpret. For example, a patient experiencing a headache might be led to believe they have a brain tumour, and whilst this is possible, the likelihood is low. Despite this, the patient may be convinced and understandably anxious if this is what they believe. In other cases, a patient may have a clear idea of what triggers their headaches, and we might encourage them to create a headache diary to explore their hypothesis further. In all cases, regardless of what the patient's ideas are, understanding them will help build rapport, may assist with differentials or could potentially be an area that requires reassurance following a full history and examination. It is useful to understand why the patient has the ideas they have.
Ways to Ask About Ideas
Asking about ideas can be as simple as saying:
“What do you think might be causing this?”
“Do you have any thoughts about what could be going on?”
These questions can be followed up with why the patient has these thoughts to gain a deeper understanding, e.g.
"What makes you think that?"
Patient Ideas About Medications and Treatment Plans
Before discussing treatment plans, it is important to check a patient's understanding and ideas about this. This enables us to tailor our explanations to the patient's needs. For example, if a patient has based their ideas about receiving a vaccine on something they have read in the media, there may potentially be a lack of scientific evidence to back up the ideas, and in this case, we can utilise patient education to challenge the ideas.
A patient might have certain ideas or preferences for their treatment. For example, a patient may prefer to address lifestyle factors rather than take medications in the early stages of hypertension. In this case, the risks and benefits of taking antihypertensive medications versus lifestyle changes must be clearly discussed to enable the patient to make an informed decision.
"What do you know so far about your condition/treatment plan?"
Exploring Concerns and Worries
- Patient concerns are as individual as the patient themselves. However, here are a few common areas of concern that you may wish to explore depending on the context of the consultation:
- Work and financial concerns
- Impact on family life/relationships
- Fear of sinister cause of symptoms or disease progression
- Side effects and effectiveness of treatment
- Concerns often link to the patient's social history, so when we explore this part of the history, it is often a good time to also explore the concerns.
- Patient concerns may be realistic to their problem or, on the other hand, completely unfounded, in which case we can provide reassurance.
- Patients may give nonverbal cues about their concerns, such as appearing worried in their facial expressions or tone, although they may not necessarily verbalise their concerns. Hence, when we see a cue about concerns, we should acknowledge and explore the concern/s.
- If we don't specifically ask about concerns, the patient may not share them, and we miss this important opportunity to address them.
Ways to Ask About Concerns
“Do you have any specific worries?”
“Is there anything in particular that you are concerned about regarding your symptoms/ treatment?”
"How have you felt since receiving the diagnosis/ treatment?"
"I can see you look worried. Can you tell me what your main worries are at the moment?"
Exploring Expectations
When asked formulaically about expectations, most patients do not understand why you are asking about what they are expecting. For most people attending a healthcare setting, it is generally apparent that they want a diagnosis/appropriate management initiated or possibly reassurance.
However, it is essential to understand the patient's expectations because their expectations and reality might be very different. Perhaps the patient wants a referral, a sick note, some tests or antibiotics and the list goes on. It may not always be appropriate to give the patient what they want.
Let's say, for example, a mother has come into the GP surgery with her unwell child. The clinician has taken a history, examined the child and diagnosed a viral throat infection. The mother and child are sent home with advice and safety netting. If the clinician didn’t recognise that the mother’s main expectation was that their child would receive antibiotics, the mother might leave feeling dissatisfied with the consultation. However, if their expectations have been explored, this provides an opportunity to delicately manage the expectations and provide education about the use of antibiotics.
Ways to Ask About Expectations
“Was there something in particular you were hoping I could do for you today?”
“How do you think we should proceed?”
"If there is one thing I can do for you today, what would you want that to be?"
NB. My suggestions illustrate that there are many different ways to ask questions relating to patient perspectives. They are not intended to be used verbatim as the "best way to ask" but rather to help you start pondering your own ways to ask these types of questions.
My Personal Example
I've written this section to help you contextualise what I have gone through so far.
A few years ago, I had a telephone appointment with a doctor because I had been feeling tired all the time. This had been fluctuating on and off for several years but had gotten to a point that it was affecting every aspect of my life. I‘d had a standard set of blood tests the year before, but all these had returned normal. This time, I had gotten to a point where I really needed some answers and a solution.
My Ideas
"Did I have vitamin D deficiency?"
My Concerns
"Was the doctor going to test my vitamin D, as I knew this is not routinely tested?"
"The tiredness was really affecting my work and home life. Was anything sinister going on?"
My Hopes/ Expectations
I had hoped the doctor would listen to my concerns and request the vitamin D test, but on the other hand, I was anticipating/expecting he would tell me to carry on with supplements and that the test was not required.
What Happened During the Appointment
The doctor took a thorough history, and at some point, he asked me what I hoped for from the consultation. I discussed that I wanted my vitamin D level to be checked. I explained that I wanted to understand my baseline level due to a complex endocrine medical condition that had been diagnosed in a relative. In addition to the standard 1st line blood tests (and going along with my request!), the doctor added vitamin D to the blood tests. Lo and behold, the levels came back in the severely deficient range. Despite already taking supplements, my body required a higher dose. Now, if it wasn’t for this doctor enquiring about my ideas, concerns and expectations, the likelihood is I would still be suffering from chronic tiredness, being told that my blood tests were all normal, and not be able to live my life to the full. A simple tablet in my life has made all the difference 😊.
Summary
- Exploring patient perspectives can help build rapport and foster empathy (but only if done in a patient-centred way!).
- There are many ways to explore ICE, try to avoid stock phrases and instead use authentic questions to explore these areas.
- Utilise natural opportunities in the consultation to explore ICE (e.g., where each element naturally falls in the consultation).
- Make use of patient cues (verbal and nonverbal) to explore ICE.
- Always consider the patient's perspective as a meaningful part of the consultation, not a tick-box exercise.
OSCE Course
If you liked this article, take a look at my OSCE course. I have broken down how to tackle different types of OSCE stations and included all my top examiner tips and advice. This is what I cover in the course:
- How to Prepare for OSCEs
- History Taking
- Information Giving
- Clinical Examinations
- Procedural Skills
- How to Effectively Summarise
- How to Answer Examiner Questions
- Worked Examples
