One of the most useful teaching techniques I have used as a preceptor is also one of the simplest: I think out loud. Experienced clinicians make hundreds of small decisions throughout the day. We know which questions to ask, which findings matter, and what needs to be addressed today.
Much of that thinking becomes so automatic that we may not realize our students cannot see it. They can watch us conduct an exam, review laboratory results, and make a treatment decision, but they cannot see how we connected the pieces. Thinking out loud makes that invisible process visible.
Narrating the physical exam
I have found it especially helpful to narrate parts of the physical exam when precepting newer students. For example, I might tell the patient, “I’m looking in your ears to check for wax, redness, fluid, and to see how your eardrums look.” Then I explain what I find: “Your ears look great. I don’t see any signs of infection or other concerns.”
When examining the neck, I may explain that I am checking for tenderness, swollen lymph nodes, and unusual lumps or bumps. During an abdominal exam, I let the patient know I am listening for bowel sounds and checking for tenderness or swelling.
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For patients, this takes some of the mystery out of the exam and helps them feel involved in their care. For students, it adds another layer of learning. They hear what I am assessing while also seeing how to communicate clearly with the patient.
When it is the student’s turn to perform the exam, I encourage them to do the same. Students can become so focused on remembering each step that they forget the patient may be wondering what is happening.
Knowing when not to narrate everything
Thinking out loud does not mean describing every detail of every examination. We still need to consider what will make the patient feel informed rather than uncomfortable. During a pelvic exam, for example, I explain what the patient needs to know and warn them when they may feel cold, pressure, or discomfort. I do not usually provide a detailed play-by-play. Instead, I often talk with the patient about something else to help them relax and feel a little distracted.
Explaining the “why” behind clinical decisions
Thinking out loud becomes even more valuable when I explain my clinical reasoning to the patient while the student listens. The patient better understands my decisions, and the student hears how I gather information and put the pieces together.
Suppose a patient has an elevated blood pressure. A student may expect me to increase the medication immediately. Instead, I might tell the patient, “Before I adjust anything, I want to confirm a few things.” I then ask whether they are taking the medication consistently, checking their blood pressure at home, or experiencing side effects. I may explain, “I don’t want to increase your medication based on one reading without looking at the bigger picture. If your blood pressure is lower at home, or if you are already feeling dizzy when you stand up, increasing the dose could create another problem.”
If a patient’s creatinine has increased, I might say, “Your kidney function looks a little different from the last time we checked it. I want to look at the trend, review your medications, ask about medications such as ibuprofen or naproxen, and find out whether you may have been dehydrated when the blood was drawn.”
The patient understands why I am asking these questions and why I may not make an immediate treatment change. At the same time, the student hears that clinical care is rarely about reacting to one isolated number. We are considering the patient’s history, examination findings, medications, test results, symptoms, risks, preferences, and ability to follow up.
I also want students to see how I talk with patients when the answer is not immediately clear. I might say, “This symptom does not fit neatly with what we were originally considering, so I want to take another look and ask you a few more questions.”
Admitting that the answer is not obvious does not undermine our expertise. It shows the patient and student that good clinicians remain curious, reconsider their assumptions, and change direction when the information does not fit. The student also learns how to bring patients into the reasoning without overwhelming or alarming them.
Choosing the right time and place
Not every clinical thought should be discussed in front of the patient. We do not want to create unnecessary worry, undermine the student, or introduce alarming possibilities before we have evaluated them. Some thinking can be shared appropriately during the visit. For example, I might tell the patient, “Because this cough has lasted several weeks, I want to listen carefully to your lungs and ask a few more questions before deciding whether you need imaging.”
A complicated differential diagnosis, uncertainty about the treatment plan, or correction of a student’s mistaken assumption may be better discussed before entering the room or during a brief debrief afterward. Patient-centered communication and student-centered teaching should support each other, but they are not always the same conversation. An effective preceptor knows what to say, when to say it, and who needs to hear it.
A small habit with meaningful benefits
Thinking out loud does not require a lengthy lecture. Often, one or two sentences are enough to turn routine patient care into a practical teaching opportunity. The student hears how an experienced clinician sorts through information and communicates decisions, while the patient better understands what is happening and why.
The goal is not to fill every quiet moment. It is to recognize which thoughts will help the student learn, which explanations will help the patient understand, and which conversations are better saved for outside the room. Preceptors, do you think out loud when you have students? Do you have any stories to share from your experience?
Lynn McComas is the chief nursing officer at AMOpportunities and the founder of PreceptorLink. She is a recognized expert in precepting nurse practitioners and advanced practice provider students and has been matching preceptors since 2014. With over two decades in primary care, McComas has served as a coach, advisor, mentor, and preceptor for countless healthcare professionals, including NPs, nurses, and medical assistants. She co-founded a successful skills and procedures business and speaks nationwide on NP-related issues.
McComas is also a regular contributor on LinkedIn, KevinMD, Facebook, YouTube, Instagram @preceptorlink, X @LynnMcComas, and her blog, where she addresses the growing NP and PA professions and the urgent need for preceptor sites.
Her unique perspective, shaped by her business, clinical, and educational experiences, positions her as a key voice in tackling preceptor shortages. McComas is committed to driving change through a paradigm shift in NP education, reducing barriers, offering preceptor incentives, and advocating for reforms within the profession.
