ICE: ideas, concerns and expectations in PLAB 2
ICE - the patient's ideas, concerns and expectations - is the highest-yield habit in the entire exam. It appears in the mark scheme of virtually every history and counselling station, it takes under a minute, and it is the difference between a consultation and an interrogation. Candidates rarely fail because they asked ICE badly; they fail because under time pressure they never asked at all.
Step by step, with exam phrasing
| Step | What it means in the cubicle | |
|---|---|---|
| I | Ideas | What does the patient think is going on? Their theory changes what you must address: a patient convinced it is cancer needs that answered whatever the diagnosis. "Have you had any thoughts yourself about what might be causing this?" |
| C | Concerns | What are they most worried about? Often different from their idea, and often the real reason they came. Name it and address it explicitly before the end. "Is there anything in particular that's been worrying you about it?" |
| E | Expectations | What are they hoping happens today? Antibiotics, a scan, a sick note, reassurance. If you cannot give it, say so and explain why - unmet, unspoken expectations read as a failed consultation. "Was there anything you were hoping we would do today?" |
When it carries the marks
Every history-taking and counselling station, usually after the presenting complaint is explored and before examination or explanation. In counselling stations, ICE up front is what stops you explaining the wrong thing: check what they know and fear before you teach.
Where candidates lose the marks
- Skipping it entirely under time pressure - the single most common interpersonal-skills deduction in the exam.
- Firing all three questions in a row like a checklist. Space them through the history where they fit naturally.
- Asking and not using the answer. If she says she is terrified of MS, your explanation must return to MS by name.
- The robotic script: 'Do you have any ideas, concerns or expectations?' asked verbatim signals memorisation, not curiosity.
- Dismissing the idea: 'No, it won't be cancer' without exploring why they fear it.
- Leaving expectations unaddressed: if they wanted antibiotics and you are not prescribing, close that loop explicitly.
Apply it in a real station
These station guides use this framework directly:
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Frequently asked questions
What does ICE stand for in medicine?
Ideas, concerns and expectations: what the patient thinks is going on, what worries them most, and what they hope will happen. It comes from the Calgary-Cambridge consultation model and is a core marked behaviour in PLAB 2 and UK OSCEs.
When should I ask ICE in a PLAB 2 station?
Weave it into the history rather than bolting it on: ideas often fit after the presenting complaint, concerns when the patient hints at worry, expectations before you move to explanation. Asking all three as one block sounds scripted and scores worse than three well-placed single questions.
How do I ask about ideas without sounding scripted?
Use natural variants: 'Have you had any thoughts about what this might be?', 'Was there something you were worried this could be?', 'What was going through your mind when it started?'. The examiner is listening for genuine curiosity, not a formula.
Is ICE really marked in PLAB 2?
Yes. Exploring the patient's perspective is an explicit interpersonal-skills criterion in most history and counselling mark schemes, and addressing the stated concern is frequently a separate mark. In our own rubric-marked practice data, missed ICE is among the most repeated criterion failures.
Frameworks stick when you say them out loud.
Sit a free timed station and practise the phrasing against a patient who answers back.
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