Making Clinical Teaching a “SNAPP”

I’m always on the lookout for new tools to try to improve my clinical teaching. I’ve been a fan of the “one-minute preceptor” for a while. One tool I’ve been very interested in but only recently begun to use is called SNAPPS.  Like the one-minute preceptor, SNAPPS is another tool that was developed for the ambulatory setting. What I really like about SNAPPS is that it forces some role reversal between the teacher and the learner. This allows the learner to be more active in their education and can also promote higher order thinking. No longer does the teacher have to worry about what they are going to teach, they can simply respond to the learner’s needs.

So how does this work?

SNAPPS is actually a mnemonic:

  1. Summarize briefly the history and findings
  2. Narrow the differential to two or three relevant possibilities
  3. Analyze the differential by comparing and contrasting the possibilities
  4. Probe the preceptor by asking questions about uncertainties, difficulties or alternative approaches
  5. Plan management for the patient’s medical issues
  6. Select the case-related issue for self-directed learning

Step-by-Step:

Learners will require a little bit of coaching as you get used to using this method. You may wish to hand them a card with the steps listed on it. As you both get used to using this, you will find it becomes more intuitive.

Summarizing the case:

Similar to any interaction, the learner will go to the patient’s bedside and evaluate the patient, obtaining a history and performing an examination. Afterwards they present the case. Hopefully, you’ve already taught them the three-minute medical student presentation.

Narrowing and analyzing the differential:

I combine these two steps together. I want the student to present their top suspected diagnoses and why they included them in the differential. If they’re having difficulty, I play SPIT.

Probing the preceptor

This isn’t as painful as it sounds!  At this point in the discussion, the learner takes control and is rewarded for doing so. They should be open about their uncertainties and knowledge deficits. Once they reveal these, the teachable moment magically appears. They may reveal these deficits by asking good questions of the preceptor. The level of questions that they ask can also give insights into their level of knowledge, somewhat akin to RIME.

Planning management

Here, the learner or the preceptor may be in control. More advanced learners will suggest a plan of evaluation. Similar to probing above, the learner should be encouraged to utilize the teacher as a resource.

Selecting a case for self-directed learning

As the case wraps up, the learner should be encouraged to create a focused question for further study. A newer method of making this a reality is to use the Population-Intervention-Comparison-Outcome framework utilized by evidence-based medicine experts. This operationalizes the task and teaches the learner to ask a much more focused question. For this step, I often give my learners a stack of 3 x 5 cards to record their questions. At the end of the shift, we can record these and select the highest yield questions for them to review before the next shift.

So what you think? Have you used SNAPPS before? Let me know your experience and if you’re trying it out for the first time, share your pearls and pitfalls!

References:

Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step “microskills” model of clinical teaching. The Journal of the American Board of Family Practice, 5(4), 419-424.

Wolpaw, T. M., Wolpaw, D. R., & Papp, K. K. (2003). SNAPPS: a learner-centered model for outpatient education. Academic Medicine, 78(9), 893-898.

Nixon, J., Wolpaw, T., Schwartz, A., Duffy, B., Menk, J., & Bordage, G. (2014). SNAPPS-Plus: An Educational Prescription for Students to Facilitate Formulating and Answering Clinical Questions. Academic Medicine, 89(8), 1174-1179.

Tolsgaard, M. G., Arendrup, H., Lindhardt, B. O., Hillingsø, J. G., Stoltenberg, M., & Ringsted, C. (2012). Construct validity of the reporter-interpreter-manager-educator structure for assessing students’ patient encounter skills.Academic Medicine, 87(6), 799-806.

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