01Principles and purposeThe professional or clinical skill and the decisions it supports.
Explanation begins with listening. A technically accurate monologue can fail if it answers a question the patient did not ask or ignores a feared meaning. Start by checking what the person has been told, what words they use and whether they want a broad overview or detailed discussion. Identify communication needs, distress, language support and whether they want another person involved. Use plain language without being patronising, and introduce necessary clinical terms with an immediate explanation. Chunk information and pause because emotional responses reduce how much new detail can be processed.
Diagnostic certainty exists on a spectrum. A clinician may have a confirmed finding, a working diagnosis, several similarly plausible explanations or an important condition still being excluded. State the level explicitly and say what evidence supports it. Avoid precise percentages unless they are well founded and useful. Uncertainty does not mean there is no plan: explain the test, observation period, treatment trial or review that will reduce it, plus what could happen before then. A patient may reasonably value avoiding a serious missed diagnosis differently from avoiding an invasive test, so consequence belongs in the dialogue.
Treatment choice is a comparison, not a catalogue. Describe options relevant to this patient's condition and values, including the purpose, expected benefit, material risks, practical burden and uncertainties. Discuss doing nothing now or monitoring when it is a reasonable choice. Elicit what matters—symptom relief, function, fertility, caring responsibilities, work, longevity, treatment burden or avoiding a particular adverse effect. Offer a professional recommendation with reasons, then check how it fits those priorities. Shared decision making does not require neutrality about unsafe choices or abandonment of clinical judgement.
Closure converts conversation into care. Invite questions, ask the patient to explain the main points and next step in their own words, and correct misunderstandings without blame. Record information discussed, the patient's priorities, the agreed or deferred decision and any information materials supplied. If more time or specialist input is needed, name the interim safety plan. In an SCA-style encounter, assessment includes data gathering, clinical management and interpersonal skills; a rehearsed consent speech that does not respond to the individual is weak. Feedback should examine accuracy, responsiveness, risk framing and usable closure.
Key points
- Ask what the patient already understands, what they want to know and which outcome or concern matters most before delivering a prepared explanation.
- Give information in short chunks: name the problem, connect it to the person's symptoms or findings, pause, and invite correction or questions.
- Calibrate language to evidence by distinguishing confirmed diagnosis, most likely explanation, important alternative and residual uncertainty.
- Compare reasonable options using benefits, burdens, material risks, alternatives and the option of no immediate treatment where clinically relevant.
- Make a recommendation transparently while preserving choice; avoid presenting the preferred option as inevitable or transferring the entire decision without support.
- Close with teach-back, a documented decision, actions, result ownership, review time and specific advice if symptoms change.
02Situations and prioritiesThe context, relevant information and actions that matter most.
The patient's existing beliefs, previous explanations and desired level of detail determine where a useful explanation begins and reveal misconceptions needing attention.
Words such as confirmed, likely, possible and not yet excluded should match the evidence and be paired with the action that follows from that level.
A risk or burden may matter because of its likelihood, seriousness or relevance to this person's circumstances, even when it is not the statistically commonest outcome.
When more than one reasonable route exists, differences in benefit, burden and uncertainty require explicit exploration of what the patient values.
Distress, time pressure, authority gradients and leading language can create apparent agreement without a genuinely voluntary and informed choice.
Silence, nodding or signing a form does not demonstrate comprehension; teach-back can reveal where the explanation or plan needs revision.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Ask-tell-ask dialogue - Why
- Anchor information to the patient's knowledge and check its meaning as the explanation develops.
- Interpretation and limitations
- Ask what is understood, tell one relevant chunk, then ask for reaction or restatement; correction is information about communication, not patient failure.
- 02
Uncertainty statement - Why
- Make the evidential status and next discriminating step explicit.
- Interpretation and limitations
- Name what is known, the leading explanation, important unresolved alternative and how or when the uncertainty will be reviewed.
- 03
Option comparison - Why
- Lay out reasonable choices using consistent dimensions.
- Interpretation and limitations
- Compare purpose, likely benefit, important risks, burdens, alternatives and no immediate treatment when relevant; uneven framing can steer the decision covertly.
- 04
Values elicitation - Why
- Discover outcomes and burdens that should influence recommendation.
- Interpretation and limitations
- Use open questions and concrete trade-offs; do not infer preferences from age, disability, culture or a relative's opinion.
- 05
Teach-back - Why
- Check the usability of the explanation and agreed plan.
- Interpretation and limitations
- Ask the patient to describe key points in their own words and re-explain gaps; it tests the communication, not the person's intelligence.
- 06
Decision record - Why
- Preserve continuity and show how the plan was reached.
- Interpretation and limitations
- Document material information, questions, priorities, decision or deferral, review arrangement and any new concern rather than relying on a form alone.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseExplain an uncertain pulmonary noduleA fictional case supplies an incidental small lung nodule on imaging, no diagnosis yet, a planned interval scan, low immediate clinical concern and a patient who believes the word nodule means cancer.+
- 1Ask what the patient understood from the report and acknowledge the fear attached to the word before adding technical information.
- 2Explain that a nodule describes a small imaging finding with several possible causes, that the current scan does not establish cancer, and that its features support planned surveillance rather than a definitive label.
- 3Describe why interval imaging is proposed, what change would prompt further assessment and the limits of what a single scan can determine; avoid invented numerical risk.
- 4Explore how waiting affects the patient and agree practical support, result communication, timing and symptom-based reasons to seek earlier review.
- 5Verify with teach-back that the patient distinguishes finding from diagnosis and knows the plan; document questions and seek feedback on whether reassurance remained evidence-based.
02Choice discussionCompare two reasonable treatmentsTwo options have different recovery burdens and similar overall suitability for the clinical problem.+
- 1Establish the decision to be made and invite the patient to name the outcomes and burdens most relevant to daily life.
- 2Describe both options in the same order—purpose, expected benefit, material risk, recovery and uncertainty—plus any reasonable monitoring route.
- 3Offer a recommendation linked openly to clinical evidence and the patient's stated priorities.
- 4Allow questions or time where safe, agree the decision or deferral and record the follow-up needed.
03Uncertainty closurePlan while the diagnosis remains openInvestigation has narrowed the differential but has not confirmed one cause.+
- 1State the leading explanation and the main alternative that still matters, along with evidence for and against each.
- 2Explain the next test or observation and how each possible result would change action.
- 3Address current symptoms and concerns rather than making the patient wait without support.
- 4Agree review timing, result ownership and concrete worsening triggers, then check understanding.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Review whether the patient's later account matches the intended explanation, especially the distinction between a finding, a working diagnosis and confirmation.
- Check that consent and decision records capture material concerns and alternatives rather than only a signed form or selected option.
- Use feedback from observed consultations to identify jargon, unequal option framing, missed emotional cues and untested assumptions about values.
- Confirm that deferred decisions have a safe interim plan, a time for return and a named route for questions or deterioration.
- Update the explanation when evidence changes and explicitly correct earlier working assumptions so that stale labels do not persist.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Reassurance needs evidence
Useful reassurance states what lowers concern and what remains planned; absolute promises can damage trust when uncertainty is real.
Recommendation can support choice
Patients often want professional guidance. Explain the reasons and how their priorities shaped it, while leaving room to question or decline.
Numbers need a reference frame
When reliable numerical risks are used, give a consistent time period and denominator and include both event and non-event framing when helpful.
Emotion changes information capacity
A pause, acknowledgement and second conversation may improve decision quality more than continuing a dense explanation after distress appears.
Teach-back tests the clinician
A misunderstanding usually signals that wording, sequencing or volume should change; it is not a pass-fail test for the patient.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using certainty language that exceeds the evidence because a decisive explanation feels more reassuring.
- 02
Presenting the favoured treatment in detail while describing alternatives briefly or negatively.
- 03
Listing rare complications without first explaining purpose, likely benefit and the risks most relevant to the patient's priorities.
- 04
Asking 'Do you understand?' and treating a yes as proof that the plan can be followed.
- 05
Leaving result communication and review timing unspecified after a careful discussion of uncertainty.