(And what examiners are actually looking for)
One of the most frustrating experiences for GP trainees preparing for the MRCGP SCA is this:
I asked about Ideas, Concerns and Expectations… so why did I still fail?
Here’s the short answer:
Most GP trainees elicit ICE.
But not everyone ask ICE in context and integrate it in their plan.
Let’s unpack what that really means.
What you need to understand about ICE
In the SCA, ICE is not a checklist.
Examiners are not awarding marks because you asked:
- “Any ideas?”
- “Any concerns?”
- “What were you expecting?”
They are assessing whether:
- You showed curiosity
- You picked up and explored cues
- You understood the patient’s health beliefs
- Whether you linked ICE back in your explanation and management
If ICE doesn’t influence what you say next, it doesn’t score well.
Six mistakes that most often cost marks in the SCA
1. Treating ICE like a formula
Running through ICE mechanically feels safe but it looks doctor-centred.
Examiners see:
- Low curiosity
- Limited partnership
- Minimal adaptability
2. Missing patient cues
When a patient says:
My dad had heart problems…
That’s not background detail.
That’s a cue and a test of curiosity.
Ignoring it suggests shallow data gathering.
3. Chasing symptoms too early
Jumping straight to diagnosis and management without addressing the patient’s belief turns the consultation into a monologue.
Patients feel unheard.
Examiners mark this down.
4. Eliciting ICE but not re-addressing it
This is the most common trap.
Eliciting ICE without revisiting it later is like opening a door and walking away.
Patients leave with unanswered fears.
Examiners notice immediately.
5. Assuming instead of checking
Guessing what the patient is worried about is not shared understanding.
ICE must be explored, not assumed.
6. Rushing ICE at the end
ICE left until the last minute looks like an afterthought.
Strong candidates surface ICE early and return to it intentionally before management.
How high-scoring candidates incorporate ICE in the SCA
A simple structure:
1. Elicit ICE early (around minutes 2–3)
Naturally. With curiosity.
2. Note the patient’s health agenda
What do they think is happening?
What worries them most?
What outcome are they hoping for?
3. Take a focused history
Your questions now have direction.
4. Re-address ICE before management
This is where marks are gained.
Examples:
- “You were worried this could be cancer from what you’ve told me, there’s nothing to suggest that.”
- “You were hoping for a scan. Let me explain why that wouldn’t help here and what would.”
5. Check reassurance has landed
If it hasn’t, adapt your explanation.
One language change that improves scoring
Avoid:
❌ “What were you expecting?”
Use:
✅ “What were you hoping we could achieve today?”
“Hope” signals partnership.
“Expect” can sound confrontational.
Examiners pick up on this.
The key takeaway for SCA candidates
ICE is not complete when it’s elicited.
ICE is complete when it’s addressed.
If you don’t close the loop:
- Shared understanding is missed
- Shared decision-making becomes difficult
- Marks are lost
If you’ve ever left a mock or the real SCA thinking:
I covered everything so why didn’t it land?
This is usually why.
👉 Next step:
Review a recent roleplay and ask yourself:
Did ICE genuinely change what I said or recommended?
That reflection alone can shift your score.
Frequently Asked Questions
Why do candidates fail the SCA despite covering ICE?
Candidates often fail because ICE is treated as a checklist rather than a meaningful conversation. Common issues include eliciting ICE without linking it back, missing cues, rushing ICE at the end, or assuming patient concerns instead of checking them explicitly.
What does “addressing ICE” mean in the MRCGP SCA?
Addressing ICE means explicitly responding to the patient’s ideas, concerns and expectations after history-taking and before management. This may involve explaining why a feared diagnosis is unlikely or why a requested test is not needed. This step is essential for reassurance and shared understanding.
When should ICE be explored during an SCA consultation?
ICE should be explored early, usually within the first 2–3 minutes of the consultation. Doing this early helps you understand the patient’s agenda, guides focused history-taking, and allows you to revisit ICE later with clarity. Leaving ICE until the final minute often scores poorly.
Does ICE affect shared decision-making?
Yes. Without addressing ICE, shared understanding is incomplete. Without shared understanding, shared decision-making becomes difficult. This directly affects management scores in the MRCGP SCA.
How did this IMG pass MRCGP SCA?
After a failed SCA attempt with a score of 69, Dr Lawrence’s confidence was crushed. Check out how Dr Lawrence conquered SCA after this major setback.