SNAPPS Letz 4/2014

Background SNAPPS A collaborative model for case presentations in outpatient setting Well recognized Simple format Promotes active learning Learner directed A fundamental distinction exists between inpatient versus outpatient educational time commitments whereas often in the inpatient setting the educator or preceptor blocks off time to go where the learners are working. In the office setting the student goes to where the preceptor is working and does not block off time. You will often find that your preceptors are immersed in the day to day work and will have limited time to address your individual learning needs. Learning moments in the office setting are frequently less than 5 minutes. Thus our expectation is that you as students will be prepared for clinical, present in a succinct manner and provide direction to your own learning. In experiential learning, where actual experience and learning are integrated, the learner takes on a central role and the instructor’s role as expert changes to one of facilitator. Based on the work of Bordage in cognitive learning, and that of Osterman and Kottkamp on reflective practice for educators, the authors (Wolpaw, Wolpaw, and Papp) developed a collaborative model for case presentations in the outpatient setting that links learner initiation and preceptor facilitation in an active learning conversation. The learner centered model for case presentations to the preceptor follows the mnemonic called SNAPPS consisting of six steps. The model encourages a presentation that is intended to redirect (but not lengthen) the learning encounter by condensing the reporting of facts and encouraging an expression of thinking and reasoning. Case presentations should generally not exceed 5 minutes.

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select S: The S stands for summarize. Summarize briefly the history and findings. The learner obtain a history, performs an appropriate examination and presents a concise summary to the preceptor. This should generally be less than 50% of the presentation as a whole. The summary should be condensed to relevant information as the preceptor can elicit further details from the student.

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select N: Narrow the differential diagnosis to two or three relevant possibilities The learner verbalizes what he or she thinks is going on in the case focusing on the most likely possibilities rather than on “zebras.” For follow up or sick visits the differential may focus on why the patient’s disease is active. The learner must present an initial differential to the preceptor before engaging the preceptor to expand or revise the differential.

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select Analyze the differential diagnosis by comparing and contrasting the possibilities. Example: “I think angina is a concern because the pain is in his anterior chest. At the same time I think that a pulmonary cause is more likely because the pain is worse with inspiration, and I heard crackles when I examined the lungs.”

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select P: Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches The learner is expected to reveal areas of confusion and knowledge deficits. The step is the most unique of the learner-driven model because the learner initiates an educational discussion by probing the preceptor with questions rather than waiting for the preceptor to questions the student. The learner is taught to utilize the preceptor as a knowledge resource that can be readily accessed. Example “We could taper his steroids since his Crohn’s flare is nearly resolved, but what protocols can be used to avoid problems with steroid withdrawl?”

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select P: Plan management for the patient’s medical and other issues

S: Summarize N: Narrow A: Analyze P: Probe P: Plan S: Select S: The S stands for select. Select a case-related issue for self-directed learning. The learner should devote time to reading soon after the office encounter as possible. We encourage learners to read nightly in a regular, disciplined, and patient-based manner rather than in long, unfocused bursts. Example: “What is the rationale for the use of ace inhibitors in CHF?” Rather then read the entire chapter on CHF.

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