Learning<->teaching moments in the ambulatory setting are seldom longer than five minutes. This time constraint can negatively impact case presentations, resulting in a passive learning experience. This post shares about the SNAPPS Clinical Model a learner-focused model, in which medical students and residents take greater initiative in the conversation and accept more responsibility for their learning, and preceptors change from their usual teacher-as-expert to teacher-as-facilitator role.
1. Summarize Briefly the History and Physical Findings.
The difference here is that the learner presents a concise summary of relevant information to the attending based on the learner’s history and clinical findings. This should take no longer than three minutes (no more than 50% of the learning encounter). If needed, the preceptor then elicits further details from the learner.
2. Narrow the Differential to Two or Three Relevant Possibilities.
The learner presents an initial differential to the preceptor, focusing on two or three of the most likely possibilities before engaging the preceptor to expand or revise the differential.
3. Analyze the Differential by Comparing and Contrasting the Possibilities.
In this step the learner initiates a case-focused discussion by comparing and contrasting relevant diagnostic possibilities, demonstrating his/her clinical reasoning and fund of knowledge.
4. Probe the Attending / Preceptor by Asking Questions about Uncertainties, Difficulties, or alternative Approaches.
This step is unique because the learner acknowledges areas of confusion and knowledge gaps and initiates a learning interaction with the preceptor, engaging the preceptor with questions and statements. The preceptor in turn can identify knowledge or skill deficits in the resident and provide information or resources for additional learning.
5. Plan Management for the Patients Medical Issues.
Again, the learner initiates a discussion for managing the patient with the preceptor and must attempt either a brief management plan or suggest specific interventions. The learner is encouraged to ask questions of the preceptor.
6. Select a Case-related Issue for Self-directed Learning.
Learners are encouraged to: a) read nightly and focus their learning on patient-based questions; b) check with their preceptor to focus their reading and frame relevant questions; c) read as soon after the patient encounter as possible; d) document learning issues on cards or personal digital assistants; e) further probe the attending with questions based on the readings at the next patient visit.
What is different about the SNAPPS model?
This model requires a bit of orientation and training for preceptors and learners before they enter the outpatient setting. The roles of the learner and the preceptor differ dramatically from the traditional case presentation.
In this approach medical students or residents do most of the work, by elaborating and justifying their thinking and intentionally expressing what they do not know. The learner organizes a six-step case presentation to the attending / preceptor and is expected to take the lead role in moving through the steps. Learners need to collect their thoughts prior to going to the attending, so they can ask questions.
The preceptor’s role changes from the usual ‘teacher-as-expert’ to ‘teacher-as-facilitator’. Using facilitation skills, the preceptor guides the learning process rather than dominates the case discussion. Preceptors talk less and provide responses to the questions posed by the learner. Initially, the preceptor may need to coach but should rapidly transfer the lead role to the learner. A pilot study based on the SNAPPS model with third-year medical students demonstrated that learners were more actively involved and readily came up with questions, whereas in more traditional interactions they rarely did.
Wolpaw, T., Wolpaw, D., & Papp, K. (2003). SNAPPS: A Learner-centered Model for Outpatient Education, Academic Medicine 78(9), 893-898. Get the full story on this model of case presentation that engages the learner and creates a collaborative learning environment in the context of patient care.
Bowen, J. (2006). Educational Strategies to Promote Clinical Diagnostic Reasoning, The New England Journal of Medicine, 355, 2217-25. Learn how your case presentations can be improved by comparing a novice resident’s presentation vs. an expert resident’s presentation and discover how preceptors can address problems in clinical reasoning of housestaff.