Doctor, listen...

Some might describe the doctor-patient visit as a transaction: the patient comes with a problem and the physician gives her an answer. But does this fulfil the patient’s needs? Not always.

Asking the ICE (ideas, concerns, expectations) questions can help the doctor understand the patient’s point of view: ‘What do you think is going on?’ (ideas), ‘What are you most worried about?’ (concerns) and ‘What do you think I can do?’ (expectations)

Tapping collaboration
Mostly, the patient wants a two-way relationship with her physician. She wants to work with the doctor and actively contribute to her care.

The patient is not always forthcoming though, and sometimes the physician wishes she could tell her to be more clear. The doctor is not a mind reader. The patient is supposed to prepare, be concise and accurate. The physician expects her to describe the nature of her problem: When did it start? What makes it better or worse? What contributes to it?

But where does the responsibility lie?

Sometimes, the patient is reluctant to share information: she does not want to interrupt, she might defer to the doctor’s expertise, or she might not be asked.

The physician plays a critical role as an educator, but the patient can also inform the doctor by asking direct questions. These can be a starting point for informed collaboration on diagnosis, treatment and prognosis.

Empathy’s weight
The patient’s health problem is the fact. The rest are her feelings. Those feelings need to be explored and acknowledged: What keeps her awake at night? What is she angry about? What does she fear? What is the best way to support her?

The physician ought to address these concerns because they are legitimate and must be recognized whether or not they are justified (in the doctor’s opinion).

Empathy is the physician’s ability to understand the patient’s experience and supportively communicate this to her.

A 2011 analysis of empathy published in The Canadian Medical Association Journal cited a study of oncologists who were filmed speaking with their patients. Moments when the patient expressed an emotion like, ‘I’ve got nothing to look forward to,’ were tracked. The oncologists responded in an empathetic way only 22 per cent of the time during these “empathic opportunities”.

Empathy is a clinical skill. It gives the doctor the information she needs to provide AND show care.

Attunement or agreement?
Expectations are complex because they differ depending on the patient. Each person’s unique makeup affects her attitudes around every aspect of her life, including health care.

Some expectations concern treatment and prognosis: ‘What will happen to me next?’ Others relate to what the patient hopes will happen. Still others revolve around how the patient wants to be involved in decisions about her care.

Asking the patient, ‘What are your expectations of me as your physician?’ is a valuable starting point. By listening to the answers, the doctor can confirm that she is on the same page as the patient. The physician provides the best care when she understands, respects and helps manage these expectations.

A lot has been written about the patient’s ideas, concerns and expectations. A 2009 study in The British Journal of General Practice looked at 36 family doctors in Belgium. It aimed to discover how often ideas, concerns and expectations came up at the physician-patient encounter, and to determine any correlation between these questions and prescriptions.

When ideas, concerns and expectations were addressed, medication was prescribed less frequently. As the authors write, “Identifying and eliciting ICE components are key competencies related to shared decision-making”.

Understanding the patient’s responses to ideas, concerns and expectations facilitates attunement over agreement. Asking these questions says, ‘I hear you, I understand you and I respect what you are saying.’

The doctor will not always agree with the patient’s ideas, share her concerns or meet her expectations, but these questions help the physician and the patient understand each other.