This article resumes the series by the Council on Medical Student Education in Pediatrics (COMSEP) examining the skills and strategies of great clinical teachers.
So far we have reviewed what makes a clinical teacher great1 and the importance of orientation,2 observation,3 and feedback.4 In this article we discuss how best to use the time during or after a student case presentation to assess and strengthen student diagnostic reasoning skills. The development of good clinical reasoning skills is an essential component of medical school training and remains critical to clinical practice.
Each of us has heard lengthy presentations from medical students on patients they have seen. The presentations tend to emphasize the facts of the case (the history and what others have done) but often do not include an assessment or any explanation of why the student has come to a particular conclusion. Using case presentations as a platform, we present 2 models for assessing diagnostic reasoning skills: one in which the student presents the case and drives the learning (SNAPPS)5 and one in which the preceptor directs the learning by asking 5 types of questions after listening to the case presentation (One-Minute Preceptor [OMP]).6 Both models are designed for use in a busy office setting with minimal time commitment by the preceptor.
THE SNAPPS MODEL
SNAPPS is a learner-driven model in which the student articulates both his or her diagnostic reasoning processes and uncertainties about the clinical case.7 SNAPPS stands for “summarize the history and physical findings,” “narrow down the differential diagnosis,” “analyze the differential,” “probe the preceptor about uncertainties,” “plan management for the patient,” and “select case-related issues for self-study”5 (see Table 1).
In the SNAPPS model, the student first summarizes the salient features of the case. The summary should be short and directed and should not exceed 50% of the time allotted to the total presentation. The next step for the student is to narrow the differential diagnosis to the 2 or 3 most likely possibilities. This is not an exercise to generate an exhaustive differential, most of which is unlikely. For example, for an 8-year-old with a remote history of asthma and a cough for 1 week, the differential could include asthma exacerbation, viral lower respiratory tract illness, and bacterial pneumonia. The student next analyzes his or her own differential by comparing and contrasting the possibilities or justifying selection of the most likely possibility. In this case, viral illness may be likely, because the student heard no wheezing and there was no environmental trigger. The student next asks the preceptor questions about any uncertainties or difficulties he or she may have experienced. Going back to our example, the student might ask the preceptor whether children with asthma exacerbations always present with wheezing. The SNAPPS model differs from most other models used in medical student education, because it specifically supports students in their expression of uncertainty or diagnostic confusion.
Once the student has identified areas of uncertainty, he or she begins a discussion about how to manage the patient. Because this is in the context of direct patient care, the student cannot waffle using words such as “might” and “could.” Finally, the student identifies, with the help of the preceptor, case-related topics for further study. Importantly, the student commits to a plan to remediate gaps in knowledge or reasoning skills identified during the patient encounter.7 Because this process is student-directed and built on self-reflection, it is likely to be more powerful than teacher-directed reading.8
The SNAPPS model assumes that the primary role of the preceptor is that of coach or facilitator. The preceptor may teach the model on the first day but thereafter listens to the case presentation, encourages students to complete all components of the process, answers questions, assists in selecting areas for further development, and provides feedback. Videos at www.practicalprof.ab.ca (“teaching nuts and bolts”) demonstrate how to use SNAPPS in the office setting.9
Although quite different from traditional presentation models, faculty preceptors have required little training in the use of SNAPPS. In a pilot study, the preceptors were merely reminded by telephone that the students would be using the SNAPPS methodology and to encourage its continued use.5 In another study the preceptors were given a 20-minute orientation on SNAPPS.7 SNAPPS remains an efficient way to learn about both the patient and the student. The length of the student presentations using SNAPPS, approximately 5 minutes, did not differ significantly from the length of traditional presentations.7
Compared with students using a traditional presentation model, students using SNAPPS were more likely to include a differential diagnosis, compare and contrast diagnoses, formulate a management plan, and identify topics for further discussion.7 Also, students enjoy the active learning inherent in the SNAPPS model.7 SNAPPS allows students to move beyond simple reporting to actively managing patients.
THE OMP MODEL
Similar to the SNAPPS model, the OMP uses the student case presentation as a springboard for assessing and remediating student diagnostic reasoning. However, in contrast to SNAPPS, the OMP model is a 5-step preceptor-driven model6 (Table 1).
The student begins by presenting the salient features of the case. Once the student has finished the presentation, the first task of the preceptor is to ask the student to commit to a diagnosis or management plan. Once the student has committed, the preceptor probes the student for the supporting evidence used to make the diagnosis or management plan. These 2 steps are key to evaluating student knowledge and reasoning. A practical way to remember the first 2 steps is to ask students “what” is going on and “why.” Using our example, the student may state that he or she thinks the patient has a bacterial rather than a viral lung infection because the patient has a fever. Armed with information about both the patient and the student, the preceptor can then teach to general points that can be used in future patient encounters. In this example, the preceptor could briefly state that both viral and bacterial lung infections can lead to fever and that a better finding suggesting a bacterial infection would be the presence of localized crackles. The final steps in the OMP model involve reinforcing what the student has done well, correcting errors, and making recommendations for improvement. Videos that demonstrate effective questions and the OMP model can be viewed at www.practicalprof.ab.ca (“teaching nuts and bolts”).9
The OMP model has been incorporated successfully into a variety of clinical venues10,11 and has been shown to improve key teaching behaviors.10,12,13 The model is not intended to be prescriptive but, rather, a set of guidelines that can be altered to fit the clinical and teaching situation.14
Both SNAPPS and the OMP allow preceptors to assess the diagnostic reasoning skills of learners. Their use can be facilitated by orientation of the student, use of laminated pocket cards to help remember the steps, posters on the wall, and both students and preceptors keeping track of student self-study topics.15 Using these models allows preceptors to diagnose 2 things: the patient's problem and the student's understanding of the patient's problem. Understanding both of these things is crucial for effective patient care and great clinical teaching.
- Accepted May 19, 2011.
- Address correspondence to Susan L. Bannister, MD, Department of Pediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail NW, Calgary, Alberta, Canada T3B 6A8. E-mail:
The views expressed in this article are those of the authors and not necessarily those of the Uniformed Services University of the Health Sciences or the US Department of Defense.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- OMP —
- One-Minute Preceptor
- Bannister SL,
- Raszka WV Jr.,
- Maloney CG
- Raszka WV Jr.,
- Maloney CG,
- Hanson JL
- Hanson JL,
- Bannister SL,
- Clark A,
- Raszka WV Jr.
- Gigante J,
- Dell M,
- Sharkey A
- Neher JO,
- Gordon KC,
- Meyer B,
- Stevens N
Alberta Rural Physician Action Plan. Key features of great clinical teachers. Available at: www.practicalprof.ab.ca/teaching_nuts_bolts/key_features.html. Accessed May 16, 2011
Centre for Evidence-Based Medicine Toronto. Educational prescriptions. Available at: www.cebm.utoronto.ca/practise/formulate/eduprescript.htm. Accessed May 16, 2011
- Copyright © 2011 by the American Academy of Pediatrics