LESSON 7.2: Verbalising Your Clinical Reasoning

Synthesized clinical reasoning framework with practical examples

LESSON 7.2: Verbalising Your Clinical Reasoning

This is one of the most important lessons in this course. Many candidates have excellent clinical reasoning — they know exactly what is going on, what the differential is, and what they would do. But they keep it in their head. In the SCA, this means they get zero marks for it. The examiner is watching a recording. They cannot read your mind. They can only mark what they see and hear.

If you suspect a migraine but never say the word "migraine," the examiner cannot give you credit for reaching the right diagnosis. If you rule out meningitis in your head but never mention that you screened for red flags, the examiner sees a doctor who forgot to check. If you prescribe a statin because the evidence supports it but never explain why, the examiner sees a doctor handing out a prescription without reasoning.

Why Candidates Don't Verbalise

1. It feels unnatural — in real practice, you do not narrate your thinking to the patient
2. They worry it will sound condescending or overly medical
3. They are so focused on the next question that they skip the reasoning step
4. They assume the examiner will infer their thinking from the questions they ask — they won't

What to Verbalise — and When

There are four key moments in every consultation where you should make your thinking audible:

1. When You Are Forming a Differential

As you gather data, share your developing picture with the patient. This scores on Data Gathering and builds patient trust.

1. "From what you've described, there are a few things this could be. The most likely is X, but I'd also like to make sure it's not Y or Z — so let me ask you a few more questions."
2. "This sounds very much like it could be a tension headache, but because you mentioned it came on suddenly, I want to rule out anything more serious."

2. When You Are Screening for Red Flags

Do not just ask red flag questions silently. Tell the patient why you are asking. This scores on Data Gathering and reassures the patient.

1. "I'm going to ask you a few specific questions now — not because I think anything is seriously wrong, but because it's important to rule certain things out."
2. "I'm reassured that you haven't had any weight loss, night sweats, or blood in your stools. That makes me much less worried about anything sinister."
3. "The fact that you haven't had any weakness in your legs or problems with your bladder is really reassuring and helps me rule out a condition called cauda equina."

3. When You Share Your Working Diagnosis

This is the transition from data gathering to management. Name your diagnosis and explain how you arrived at it — connecting it to what the patient told you.

1. "Based on everything you've told me — the location of the pain, the fact that it's worse with stress, and that there are no red flag symptoms — I think this is most likely a tension headache."
2. "Putting this all together — your tiredness, the weight gain, and the fact that you've been feeling cold — I'd like to check your thyroid function, because this pattern fits with an underactive thyroid."
3. "I don't think we're dealing with anything dangerous here, and I'll explain why. Your symptoms started gradually, they're worse with movement, and your examination was normal — this points towards a muscular cause rather than anything structural."

4. When You Explain Your Management Decision

Do not just prescribe or refer — explain the reasoning behind your choice. This scores heavily on Clinical Management.

1. "I'd like to start you on amitriptyline. The reason I'm choosing this over regular painkillers is that it works on the nerve signals that are driving your pain, rather than just masking the symptoms."
2. "I'm not going to prescribe antibiotics today, and I want to explain why. This looks like a viral infection, and antibiotics won't help with that — but they could cause side effects. What I'd like to do instead is..."
3. "I think we should refer you to the two-week wait pathway. I want to be upfront — this doesn't necessarily mean I think it's cancer, but the guidelines recommend urgent investigation for symptoms like yours, and I'd rather we have the answer quickly."
4. "Rather than ordering a scan straight away, I'd like to try a course of physiotherapy first. The evidence shows that for this type of back pain, imaging often doesn't change the management and can sometimes cause more worry than it resolves."

The Phrases That Make Reasoning Visible

Keep these in your back pocket. They work in almost any case:

1. "Based on what you've told me..." — signals you are using the patient's information
2. "I'm reassured that..." — shows you screened for red flags and interpreted the findings
3. "The reason I'm suggesting this is..." — links your management to evidence
4. "I want to rule out..." — shows you are thinking about differential diagnosis
5. "The most likely explanation is... because..." — names the diagnosis and justifies it
6. "I'd rather be safe and check, because..." — shows appropriate caution without over-investigating
7. 
   

A Common Trap: The Silent Consultation

Some candidates ask all the right questions, reach the right diagnosis, and prescribe the right treatment — but do it almost silently. The consultation sounds like: question, answer, question, answer, question, answer, "I'll prescribe X, here's your safety net, goodbye." The examiner sees a doctor who gathered data mechanically and prescribed without reasoning. The marks for clinical thinking are lost entirely.

The fix is simple: after every 3–4 questions, summarise briefly what you are thinking and why. After reaching your diagnosis, say it out loud and explain how you got there. After choosing a management plan, explain why this option over others.