Mastering Clinical Reasoning: Building Confidence on Medical Rotations

Maya Brooks

Hello everyone, and welcome back to the AI Med Tutor Podcast. I’m your co-host, Maya Brooks, your AI-generated fourth-year medical student here to help make sense of the clinical year. Today’s episode focuses on clinical reasoning — one of the most important skills you’re expected to develop on clerkships, and one of the least explicitly taught.

Dr. Randy Clinch

And I’m Dr. Randy Clinch, a DO family medicine physician and medical educator. Clinical reasoning is one of the most common sources of anxiety I hear about from students. They’ll say things like, “I know the facts, but I don’t know how to think like my attending,” or “I freeze when I’m asked what I think is going on.” That’s not because they’re behind. It’s because clinical reasoning develops differently than factual knowledge.

Maya Brooks

Exactly. In the preclinical years, success often means knowing the right answer. In clerkships, success means explaining why you think something is happening, even when you’re not completely sure. And that transition can feel uncomfortable.

Dr. Randy Clinch

The good news is that clinical reasoning is a skill you can practice intentionally. It’s not magic, and it’s not something you either have or don’t have. Today we’re going to show you how to build it deliberately during your clerkships, using real patient encounters as your training ground.

Maya Brooks

Let’s start by clarifying what we mean by clinical reasoning. It’s not memorizing differential diagnoses. It’s not reciting guidelines. Clinical reasoning is the process of connecting patient information into a coherent story and using that story to make decisions.

Dr. Randy Clinch

It’s about pattern recognition and interpretation. It’s noticing which details matter and which ones don’t. It’s asking yourself, “What is the most likely explanation for what I’m seeing?” and then being able to defend that thinking when someone asks.

Maya Brooks

Here’s a simple example. A patient presents with shortness of breath. You could list pulmonary, cardiac, metabolic, and hematologic causes. But if that patient also has orthopnea, bilateral leg edema, crackles, and an S3, your thinking starts to narrow toward heart failure. That narrowing is clinical reasoning.

Dr. Randy Clinch

That’s clinical reasoning in action. You’re building an illness script — a mental pattern that links findings to a diagnosis. And clerkships are where those scripts get built, one patient at a time.

Maya Brooks

One of the most powerful ways to build clinical reasoning is to intentionally reflect on the patients you see each day. After a shift, instead of asking, “What did I do today?” ask, “What problems did I see today?”

Dr. Randy Clinch

For example, let’s say you cared for a patient admitted with pneumonia. Don’t just remember that they had pneumonia. Ask yourself what made it pneumonia. Was it fever, focal crackles, hypoxia, leukocytosis, an infiltrate on imaging? Those features become the anchors of the pattern.

Maya Brooks

Then imagine how that same pattern might show up slightly differently. What if the patient were elderly and afebrile? What if they were immunocompromised? That mental comparison strengthens your reasoning far more than rereading a textbook paragraph.

Dr. Randy Clinch

Another example might be chest pain. If you saw a patient with crushing substernal pain radiating to the arm, diaphoresis, and nausea, that builds a myocardial infarction script. But if you saw pleuritic pain that worsens with inspiration and improves when leaning forward, now you’re building a pericarditis script. Each patient refines your diagnostic instincts.

Maya Brooks

This is where we want to slow down and talk clearly about Pattern Cards, because they’re one of the most effective tools students can use to build clinical reasoning during clerkships. A Pattern Card is not a flashcard and it’s not a page of notes. It’s a way to capture how a disease shows up in real life so your brain can recognize it again. Instead of memorizing lists, you’re training yourself to see patterns.

Dr. Randy Clinch

When a student builds a Pattern Card, they’re answering three questions. First, how does this condition usually present? Second, what are the key clues that help you recognize it? And third, what underlying mechanism explains why those clues occur together? That structure keeps the card focused and clinically meaningful.

Maya Brooks

Let’s walk through an example. Imagine you cared for a patient with acute decompensated heart failure. A Pattern Card for that patient might sound like this: the presentation is shortness of breath and fatigue; the key clues are orthopnea, bilateral leg edema, crackles, and an S3; and the explanation is impaired ventricular function leading to fluid overload and pulmonary congestion.

Dr. Randy Clinch

Notice what’s not there. There’s no long paragraph. No guideline table. No medication list. The goal isn’t completeness. The goal is recognizability. When you later see a patient or a board question with those same features, your brain retrieves the pattern, not isolated facts.

Maya Brooks

Here’s another example. You see a patient with nephrotic syndrome. A Pattern Card might include generalized edema as the presentation, heavy proteinuria and hypoalbuminemia as the key clues, and podocyte injury leading to increased glomerular permeability as the explanation.

Dr. Randy Clinch

Students often ask how many Pattern Cards they should make. The answer is fewer than you think. Pattern Cards work best when they’re built from real patients or missed questions — moments where the pattern truly mattered.

Maya Brooks

At the end of a shift, instead of reviewing everything you saw, ask yourself, “What was the main clinical problem today?” Then build one Pattern Card from that case. Over time, those cards stack into a mental library you can draw from on rounds and on exams.

Maya Brooks

There’s another critical step that connects your day on rotations directly to board prep. After seeing a patient, ask yourself, “If this showed up on a board exam, how would it be tested?”

Dr. Randy Clinch

That question changes how you learn. Instead of separating clinical work from studying, you let your patients drive your board preparation. Clinical reasoning and exam reasoning begin reinforcing each other.

Maya Brooks

Let’s use pneumonia again. After seeing that patient, you might ask what a question writer would focus on. They could test distinguishing bacterial from viral pneumonia. They could test lab trends, oxygen requirements, complications, or scoring systems. Suddenly, one patient generates multiple board-style questions.

Dr. Randy Clinch

Or take nephrotic syndrome. After caring for a patient with edema and proteinuria, you might anticipate questions about hyperlipidemia, thrombotic risk, or how nephrotic differs from nephritic syndromes. You can then do a short, focused question set that reinforces that exact pattern.

Maya Brooks

This is where Pattern Cards and question banks work together. You see the patient, identify the pattern, anticipate how it would be tested, and then apply that knowledge through questions. Even ten focused minutes makes a difference.

Dr. Randy Clinch

This approach also helps you analyze why you miss questions. Sometimes it’s a knowledge gap. Sometimes it’s anchoring too early or misreading a stem. That insight strengthens both clinical reasoning and test-taking.

Maya Brooks

Instead of dividing your day into “clinical work” and “studying,” you create a loop. Patients inform your studying. Studying sharpens how you see patients.

Maya Brooks

OK, now let's shift to when you're asked to demonstrate your clinical reasoning. One of the hardest parts of clinical reasoning for students is speaking their thoughts out loud. There’s fear around being wrong. But reasoning isn’t about certainty. It’s about plausibility.

Dr. Randy Clinch

Attendings don’t expect perfection. They want to hear how you’re thinking. A student who says, “I’m not sure, but given the fever, productive cough, and focal findings, I’m concerned about pneumonia,” is demonstrating far more reasoning than a student who stays silent.

Maya Brooks

Here’s a real scenario. You’re asked what you think is going on, and you freeze. Instead of searching for the perfect answer, try framing your response as a working hypothesis. Say something like, “Based on the vitals and exam, my leading thought is X, but I’d like to see the labs to confirm.” That shows reasoning without overconfidence.

Dr. Randy Clinch

Clinical reasoning grows when you allow yourself to be provisional. You’re allowed to revise your thinking as new data comes in. That flexibility is a strength, not a weakness.

Maya Brooks

Let’s recap. Clinical reasoning isn’t something you wait to magically develop. It’s something you build. You build it by paying attention to patterns in real patients, reflecting on why diagnoses fit, using Pattern Cards to capture illness scripts, and pairing patient encounters with board-style questions.

Dr. Randy Clinch

Over time, these habits change how you think. You move from memorizing facts to recognizing stories. From feeling uncertain to feeling curious. And from separating clinical work and studying to letting them reinforce each other.

Maya Brooks

You don’t need to be perfect. You just need to be intentional. That’s how clinical reasoning grows during clerkships.

Maya Brooks

OK that's it for today's episode! Thank you for joining us on the AI Med Tutor Podcast. We’ll see you next week and, in the meantime, remember, stay curious and keep learning!