Scripts for Ideas, Concerns and Expectations

Key points

Always explore ALL THREE components ideas, concerns and expectations

Usually, you can explore these three things in that order: ideas concerns
expectations (ICE for short).
But sometimes, the patient might start off with a concern: I came in because I am
worried that these headaches might be a sign of brain cancer. In that case, as
the patient has started with the concern, explore the concerns further and then
go onto the ideas and the expectations i.e. CIE.
If a patient brings in a third party into the conversation like my wife made me
come in to see you, then explore what her ideas, concerns and expectations are
as well as that of the patient.
Some trainees get confused over what patients ideas actually means. It refers
to their health belief system. In other words, what model do they have in their
head that makes them think (for instance) that this headache is a brain cancer.
In other words, WHY do they think it is that?
Exploring ICE makes the rest of the consultation (like explanation and
management) so much easier. In the CSA, the art is to do it quickly but to do it
well.
So, if a patients initial response to your question is nothing really, dont just
simply accept this and move on. All patients have some sort of ideas, concerns
and expectations otherwise THEY WOULD NOT COME TO SEE YOU! So, if they
respond in the negative, think about phrasing your question in a different way.
The scripts on the next page give you some examples (or scripts) of first and
second level questions. To get to the heart of the matter sometimes you have
to dig deep: but you cant do that unless you have supplementary questions up
your sleeve.

Look at the next page for the scripts.

Learn these scripts off by heart. Practise saying them with patients. You will eventually add your
own flavour to them in time.

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

2nd level script

1st level script

IDEAS

CONCERNS

EXPECTATIONS

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Scripts for Psychological, Social and Occupational

Key points

Always explore the effect of the problem in ALL of these THREE contexts the
psychological, social and occupational (PSO).
Sometimes, the exploration of ideas, concerns and expectations (ICE) will give you
some idea of where to explore deeper in PSO terms.
Exploring the PSO helps BOTH YOU and the PATIENT.
It will make your
consultation loads easier. It helps in the following ways:
1. Exploring PSO helps you get a better understanding of the significance or
severity of the problem. For instance, someone might come in and say
theyve got backache and you might be thinking Oh no, not another one. But
if you went onto a PSO exploration and the patient then said I cant even get
up the stairs; Ive had to start sleeping downstairs. Ive even had to buy a bed
pan as I cant even walk to the toilet, hopefully you would sit up, be more
alert, ask deeper questions and do a more thorough back examination.
2. And in this way, exploring PSO protects you: making you sit up and do a more
thorough job of history and examination when necessary.
3. And by exploring the PSO, you enable the patient to truly express what they
want to say and get things off their chest. In that way, they feel theyve been
properly listened to; they now believe you got a good understanding of their
problem. As a result, they have trust and confidence in you. Exploring PSO
can be a powerful way of building instantaneous rapport.
4. Exploring the PSO also helps with other parts of the consultation, making
consulting life a lot easier for you. The most obvious three are: explanation
and management plan. Rather than giving a generic explanation of the
problem or the management. By incorporating the patients ICE and PSO into
the explanation and management plan makes it more interactive and tailored
to the patient. You can start giving specific advice on things that might make a
difference. I know you said that your work involved quite a bit of lifting and
bending, but are there any lighter duties that work could give you over the next
two weeks to help your back settle?
The scripts on the next page give you some scripts of first and second level
questions. To get to the heart of the matter sometimes you have to dig deep:
but you cant do that unless you have supplementary questions up your sleeve.

Look at the next page for the scripts.

Learn these scripts off by heart. Practise saying them with patients. You will eventually add your
own flavour to them in time.
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

2nd level script

1st level script

PSYCHOLOGICAL

SOCIAL

OCCUPATIONAL

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Scripts for Explanation of Diagnosis

Key points

Explanation is not simply you telling the patient about whats going on and
expecting them to be quiet and to listen. It is not unidirectional but Bidirectional.
That means it is a two way process. What you say and they say depends on what
each of you has said prior to that.
Avoid any medical jargon. Think of the patient as a family member or friend. What
would you say to them? It really is as simple as that. But somehow, trainees often
think they have to dress up explanations and the reality is that you simply dont.
Your job is to explain things adequately, cover anything else the patient wants to
know AND check theyve understood everything.
Below are some scripts that you can use for explanation the diagnosis. The second
level questions give you an alternative way of asking the first question.
Explanation is difficult to summarise in 2 pages. The least I could get it down to is 4,
but whats in these 4 pages is like gold dust!
We will look at checking understanding in another document.

Look at the next page for the scripts.

Learn these scripts off by heart. Practise saying them with patients. You will eventually add your
own flavour to them in time.

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

1. Explanation - Signposting
Signpost that youre going onto the explanation and state your diagnosis briefly.

2. Explanation identifying the patients starting point

3. Explanation building on what the patient already knows

What you do here depends on what the patient has told you. Confirm anything which
they've said which is right and correct anything which isn't. Try and weave in what they
have told you so far into your explanation as much as possible.
You will need to put flexibility in your explanation to keep checking what the patient already
knows so that you can then continue to build on that.

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

A bit more about weaving: try and incorporate the patients health belief system in your
explanation. By patients health belief system I mean their ideas, concerns & expectations. Patients
are experts in their own lives and if you want them to accept your diagnosis/explanation of what is
going on (especially when it is at variance with theirs), then you need to start off with their
perceptions/thoughts. If those perceptions and thoughts are on a different track to yours, you need
to explain why you dont subscribe to their view and then go on to modify their thinking so that it
aligns with yours. To be able to do all of this, you need to go back and start from what they told you
when you explored their ideas, concerns and expectations. If you do this, the patient is more likely
to engage with you and the consultation becomes easy as they understand where you are coming
from and start having faith in you.
Examples:

You mentioned earlier that you were concerned that you might have angina. I can see why
you might have thought that, but in fact I think it is more likely to be muscular pain. Let me
explain why I don't think it is angina.
This rash is called psoriasis, and is caused by overactive cells in the skin, but it is probably not
affected by what you eat (having elicited food concerns earlier).
Yeah, I think your right: your irritable bowel syndrome is very likely to be related to the stress
you were telling me about earlier.

4. Explanation helping the patient to remember what is being said

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

5. Explanation at appropriate times & the non-verbals

Give explanation at appropriate times
Explanation happens at various points in the consultation (usually during the middle and the last bit).
It doesnt just happen the once. Therefore, give explanation at the appropriate times youll know
when because the patient will say something that tells you more explanation is needed.

Patient: so you dont think I need antibiotics?

Doctor: In your particular case, having listened to your chest, I dont. Let me explain why

Read the patients non verbals

People might be able to lie or cover up things with their mouths but their non-verbals always give
the game away; the non verbals display the truth. Read the non-verbals and respond to them. So,
if a patient looks confused during your explanation, STOP and say what you see: Mmm Am I right
in saying that I think Ive confused you a bit?

Am I right in sensing that youre still worried about something?

If you dont mind me saying, it looks like theres still something bothering you

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Scripts for Formulating a Management Plan

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Key points

There are six parts to formulating a management plan and we will look at these in turn.
1. Signpost
2. Discuss treatment package or treatment options
3. Involve the patient
4. Facilitate decision making/the process
5. Reassure where necessary
6. Summarise periodically
In general, seek permission rather than being directive e.g. Is it okay if we... or How would you feel if I suggested xxxx? rather than You
must do xxx and yyy and zzz.
Reassure where necessary (and sometimes you might need to do this several times): I know you're worried about the chest pains coming
from your heart but let me reassure you again that.... or I sense that youre still worried about the pains coming from your heart. Can you
give me an idea of what would reassure you?
Remember, as the patient is the main one affected by the management plan, you must share, discuss and negotiate it with them. Otherwise
they won't engage. Clearly, sometime you, as the doctor, do need to take charge (e.g. Medical emgencies) but other than that, most
situations and their management plans should be done jointly with the patient.
Look at the next page for the scripts.
Learn these scripts off by heart. Practise saying them with patients. You will eventually add your own flavour to them in time.

1. Signpost: that you're going to move onto this stage.

Use words like shall we, can we or is it okay if we....

2a. When there is a treatment package

If youve said there are three things which can be done to make your
(headaches) better but then remember a fourth, simply say 'Actually, I've just
thought of another thing we/you can do.

3a. Involve the patient

What you say next depends on how they respond.

2b. When there are treatment options

3b. Involve the patient

5. Facilitate decision making process

Help the patient by facilitating decision making especially if there is some difficulty coming to a decision.
First, detail each option
Then discuss the pros and cons of each
Now see what they prefer and don't prefer
Offer your professional opinion e.g. 'In my professional opinion, I think it would be best if...'

6. Reassure where necessary

And that doesn't just mean doing it once. If the patient still seems worried, you need to do it again at the point where you spot that anxiety (i.e.
through their verbals and non-verbals).
e.g. Let me reassure you that I don't think your chest pains are a heart attack because...

7. Summarise periodically

Especially if you end up having a long discussion.

Okay, just to recap, what we've agreed to do is.... Are you still happy with that?

Key points

Scripts for Checking Understanding

After you have explained things adequately and covered anything else the patient
wants to know, you then need to check theyve understood everything.
When you are checking understanding, you are checking understanding for TWO
things:
A) that they have understood the diagnosis/explanation
B) that they have understood the treatment or management plan
And when you are checking the understanding of diagnosis and treatment, there are
TWO key elements involved if you want to do it successfully:
A) Exploring the patients understanding of the diagnosis or treatment
B) Giving a reactive explanation of the diagnosis or treatment in light of (A)
Below are some scripts that you can use for checking understanding.

Look at the next page for the scripts.

Learn these scripts off by heart. Practise saying them with patients. You will eventually add your
own flavour to them in time.

Checking understanding

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Dont forget to check understanding of both DIAGNOSIS and MANAGEMENT/TREATMENT.

Alternative more specific questions for the treatment/management plan:
How do you feel about that plan?... What questions does it leave you with? Is there
anything I havent covered or explained?
Im not sure how that plan has left you feeling. You still seem a bit anxious over what Ive
said
And when youre checking the understanding, dont forget about the patients non verbals
People might be able to lie or cover up things with their mouths but their non-verbals always give
the game away; the non verbals display the truth. Read the non-verbals and respond to them. So,
if a patient looks confused during your explanation, STOP and say what you see:

Am I right in sensing that youre still worried about something?

If you dont mind me saying, it looks like theres still something bothering you
Mmm you look a bit confused to me. What would help to get rid of the confusion?

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010