MRCGP SCA: Shared Decisions, ICE, and Relating to Others

In the MRCGP SCA, shared decision making and ICE only score well when they change what you do next. If a patient tells you she is frightened her cough is cancer because a neighbour was diagnosed recently, examiners want that fear to shape your explanation, options and safety net — not sit as a token line in minute 4. The current exam uses twelve 12-minute simulated consultations with 3 minutes' reading time, and RCGP is clear that there is no single preferred consultation model or script.

Why this matters

Relating to Others is one of the three marked domains, alongside Data gathering and diagnosis and Clinical management and medical complexity. At passing level, RCGP says you need ethical awareness, person-centred communication, and enough flexibility to overcome communication barriers and reach shared understanding with the patient.

That is why candidates can look clinically sensible and still lose marks. Official feedback statements repeatedly describe problems such as formulaic listening, weak response to cues, poor exploration of agenda or preferences, explanations not adapted to the person, judgemental language, inadequate sensitivity, weak ownership, poor teamwork, and missed safeguarding.

What examiners are really scoring

Think of this domain as what the patient experiences during the consultation. In practice, examiners are listening for whether you:

notice and follow cues rather than marching on with a checklist
explore ideas, concerns, expectations and impact in a natural way
adapt explanations to the person's language, culture, disability or situation
use the patient's preferences in the plan, instead of parking them and returning to your own agenda
stay respectful, non-judgemental and appropriately sensitive
show you know when to act independently, when to involve the wider team, and when safeguarding changes the consultation

A useful way to frame it in your own head is this: data gathering tells the examiner what you know; Relating to Others shows how safely and humanly you use it. If the management plan feels generic, the communication marks usually fall with it.

ICE that changes the plan

RCGP is explicit here. Discovering ICE is not a hoop to jump through; without it, it is hard to reach a well-informed working diagnosis or involve the patient in management, safety netting and follow-up. The toolkit also warns against asking about ICE in a clunky, jarring or insensitive way.

A simple way to make ICE exam-useful is to move through three steps:

Find it naturally. Start open, listen, and follow the cue before you drop in a stock phrase.
Name why it matters. If the patient is worried about cancer, addiction, infertility, or losing their job, say that you can see why that changes the conversation.
Use it visibly. Let it alter your explanation, your options, your follow-up, or your safety net.

Worked example

A weaker answer sounds like this: you ask about ideas, concerns and expectations, get an answer, then continue as if nothing was said.

A stronger answer sounds like this: a 67-year-old with a cough says his neighbour died of lung cancer. You reply, 'That helps me understand why this feels bigger than just a cough. From what you've told me, infection or irritation still sounds more likely, but let me explain what would make me think about something more serious, and what review would be sensible for you.' That is person-centred ICE because you have used the fear to shape the explanation and the plan.

The same applies to expectations. If a patient hopes for antibiotics, a scan, a fit note, or referral, do not treat that as an awkward obstacle. Bring it into the negotiation early enough that the final plan still feels shared.

MRCGP SCA shared decision making that scores well

In the toolkit, shared decision making is more than offering a menu. You should share options at the patient's pace, in understandable language, using the ICE and psychosocial information you have already discovered. The process should feel interactive — more chunks and checks than lecture. RCGP also warns that candidates lose marks when they simply list options and push the decision back onto the patient without support.

A practical structure is:

State your working diagnosis or analysis clearly.
Offer the realistic options only.
Give a recommendation when one option is clearly safer or more appropriate.
Relate the options to the patient's life. Think work, caring responsibilities, access, beliefs, past experience, and tolerance of risk.
Check understanding selectively. Do it when the decision is complex, the patient seems uncertain, or communication needs make it important.
Agree the plan out loud. Finish with follow-up and safety netting that the patient can actually support.

Shared decision making is not passive

Candidates sometimes become so determined to sound collaborative that they stop being doctors. That is not what examiners want. Support in decision-making means helping the patient settle on a sensible plan, not shrugging and saying, 'Which one do you want?'

Take a 45-year-old with mechanical back pain who wants strong opioids because he still has to drive for work. A good answer is not to recite every analgesic on the shelf. It is to explain why strong opioids are a poor fit here, outline the safer options, relate them to driving and work, and then agree a plan the patient can realistically follow. The toolkit specifically highlights negotiation when patients ask for unsafe or unhelpful treatment.

Relating to Others in professionalism-heavy stations

Some stations are lost not through missing medicine, but through the tone of the medicine. Official feedback statements flag judgemental language, poor respect or consent, weak ownership, failure to recognise team roles, and missed safeguarding as Relating to Others problems.

What this sounds like in practice

A vaccine-hesitant patient does not need a debate you are trying to win. They need curiosity about beliefs, clear risk explanation, and a non-pressurising plan.
A patient disclosing partner abuse needs acknowledgement, sensitive questions about immediate safety, and careful explanation of what help is available.
A consultation involving a child, frail adult, or cognitively impaired patient needs visible respect, appropriate consent language, and attention to safeguarding.
A patient whose background triggers your assumptions — obesity, addiction, prison history, immigration status, poor adherence — still needs the same warmth, clarity and partnership.

Ownership matters as well. In a straightforward case, hiding behind 'I'll ask someone else just in case' can sound less professional, not more. RCGP's feedback notes make the point that involving others is often right, but sometimes the safe and defensible answer is a clear GP decision, explained calmly and owned properly.

Sound natural under time pressure

The consultation overview places Relating to Others across the whole encounter, with data gathering ideally largely complete by 6 to 7 minutes so there is time for explanation, negotiation and planning. If you spend 10 minutes collecting facts, shared decision making will sound rushed and bolted on.

A few habits help:

start broad, then narrow
when you hear emotion, slow down for one line before moving on
use plain words first, technical words second
summarise before planning
in telephone stations, make the conversation even more explicitly interactive, because you lose visual cues and it is easier to become didactic

Short, natural phrases are usually enough:

'You seem worried this is something serious.'
'Tell me what you were hoping we'd sort out today.'
'There are two sensible ways we could go here.'
'Given your shift work, that option may be harder to stick to.'
'My advice would be this, and let me explain why.'

Natural flow beats a memorised acronym. Examiners are alert to consultations that sound rigid or scripted.

Common mistakes

asking ICE as a bolt-on and never using the answer
repeating empathy phrases until they sound mechanical
listing every possible option instead of the relevant options
saying 'What do you want to do?' before the patient understands the choices
missing the cue because you are busy finishing your checklist
explaining in GP jargon
becoming judgemental when discussing smoking, weight, sex, addiction or adherence
over-referring a simple problem to sound safe
forgetting team roles or safeguarding when the case clearly demands them

Practice workflow

RCGP's consultation toolkit is built for this kind of preparation. Use the consultation overview and RAG self-assessment with your trainer or educational supervisor, compare your own rating with theirs, and start with the red items. Because the SCA samples capability areas across the whole exam and cases come from a large bank mapped to the curriculum, your practice should be broad rather than diagnosis-by-diagnosis.

A sensible weekly rehearsal loop looks like this:

run two or three 12-minute mocks under proper timing
force yourself to verbalise a working diagnosis or analysis by around the 6 to 7 minute mark
debrief one communication skill at a time: cues, ICE, shared plan, clear language, professionalism, safeguarding
repeat one case in telephone format, because many candidates become more prescriptive on audio
keep a short error log of repeated habits, not just repeated cases

If you use peer practice, trainer practice, or AI rehearsal, make the feedback specific. 'Be more empathetic' is too vague to help. 'You ignored the cue about childcare, so your management plan sounded generic' is the sort of debrief that changes scores.

If your formal feedback shows one repeated statement, fix the consultation habit behind it rather than bolting on a phrase. RCGP specifically warns against over-correcting one feedback point so hard that the consultation becomes formulaic or wastes time.

Summary

In this exam, ICE scores when it changes the explanation, plan and safety net.
Shared decision making means supported decisions, not passive option-dumping.
Relating to Others includes professionalism: respect, non-judgement, ownership, teamwork and safeguarding.
Clear language and natural flow matter as much as sounding empathetic.
Practise with timed mocks, case-specific debrief, and repeated review of the same consultation habits.

MRCGP SCA: Shared Decisions, ICE, and Relating to Others

Why this matters

What examiners are really scoring

ICE that changes the plan

Worked example

MRCGP SCA shared decision making that scores well

Shared decision making is not passive

Relating to Others in professionalism-heavy stations

What this sounds like in practice

Sound natural under time pressure

Common mistakes

Practice workflow

Summary

References

Practice Family Medicine with a live AI examiner

Why this matters

What examiners are really scoring

ICE that changes the plan

Worked example

MRCGP SCA shared decision making that scores well

Shared decision making is not passive

Relating to Others in professionalism-heavy stations

What this sounds like in practice

Sound natural under time pressure

Common mistakes

Practice workflow

Summary

References

Related guides

Practice Family Medicine with a live AI examiner