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Wolpaw T, Papp KK, Bordage G. Using SNAPPS to Facilitate the Expression of Clinical Reasoning and Uncertainties: A Randomized Comparison Group Trial. Acad Med. 2009; 84:517-524.

Wolpaw T, Papp KK, Bordage G. Using SNAPPS to Facilitate the Expression of Clinical Reasoning and Uncertainties: A Randomized Comparison Group Trial. Acad Med. 2009; 84:517-524.

Reviewer: Bill Varade University of Rochester

What is the problem and what is known about it so far?
To foster the growth of students' clinical reasoning skills preceptors need to gain insight into their clinical thinking. Traditional case presentations provide mainly factual information with little revelation of students' clinical reasoning.

Why did the researchers do this particular study?
Given the time constraints on practitioners, an efficient learner-centered tool to allow reflection on students' knowledge base and reasoning skills in the outpatient setting is needed. The SNAPPS technique for case presentations (Summarize history and findings; Narrow the differential; Analyze the differential; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study) was studied.

Who was studied?
108 of 162 eligible 3rd year medical students in a required 4-week family medicine clerkship were recruited over a 1 Yl year period. 64 completed the study. 42 family medicine preceptors at 30 sites were recruited and randomly assigned to three study groups. Students were placed into study groups based on their preceptor's assignment.

How was the study done?
Preceptors and students in the SNAPPS group were trained in this presentation technique. The 2nd group was trained in the importance of providing and SOliciting regular feedback. The 3rd group was provided no particular training and was told to use their preferred case presentation method. All students were asked to audiotape their presentations to their preceptors at the end of the clerkship. Two of the authors listened to all the tapes and coded the content according to whether it contained eight elements identified as being related to clinical reasoning and case-based uncertainties, as well as presentation length and conciseness.

What did the researchers find?
The SNAPPS students' presentations tended to be longer but were more concise than the other groups. All three groups' presentations were thorough and complete. The SNAPPS students provided twice as many diagnostic possibilities, justified these five times more often, and compared and contrasted two hypotheses more often than the other groups. SNAPPS students formulated more questions and uncertainties and initiated management discussions 30% more often than the other groups. Student• initiated selection of reading material occurred only in the SNAPPS group.

What were the limitations of the study?
Though participants were asked not to discuss the method they used with members of the other groups, it is unlikely that the student body would remain blinded for long. The study was performed in a single institution, during a Family Medicine clerkship, and in an outpatient setting. Application to other settings might not give the same results. Retention and continued use of the SNAPPS technique by students beyond the FM clerkship (an indication of the perceived value of the process) was not addressed.

What are the implications of the study?
This study showed that the SNAPPS presentation technique provided preceptors with more insight into indicators of students' clinical reasoning allowing for more precise and effective teaching without a significant increase in time commitment. The technique places responsibility for its use on the learner rather than the preceptor, thus potentially allowing for the early training of medical students in SNAPPS which they could then apply in a variety of clinical situations. This learner-implemented approach could avoid the long-standing faculty development problem of trying to instruct preceptors from a wide variety of disciplines, both within and outside the medical center, in the consistent application of effective teaching techniques.

Ed note: I cringe when I hear the students on rounds say, "in summary this is a ... (recapitulating the chief complaint) and our pian will be (followed by drivel on several well functioning organ systems}." Any tool that enhances student commitment, decision making, and problem solving is a winner. (WVR)

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