Bruce Peyser, MD, FACP
Professor of Medicine, Duke University School of Medicine
Director of Education and Teaching, Duke Primary and Urgent Care
Provider, Duke Primary Care Pickett Road
Have you ever thought your teaching routine may have become a little monotonous, either for you or your learner? If we structure patient interactions with learners to be the same each time, there is a chance that, after a while, boredom can detract from the learning experience. A technique called SNAPPS can be a great “cure” and keep both the teacher and learner engaged!
SNAPPS is a technique that was created by Terry Wolpaw, MD, and her husband, and published in Academic Medicine in 2004. Dr. Wolpaw came to Duke about 10 years ago to teach us this technique, and for several years, SNAPPS was a standard part of the curriculum for medical students. It turns out that this technique is probably better utilized in the outpatient and urgent care worlds, and so it’s been taken out of the regular course curriculum. But some stubborn educators still find this technique to be very helpful at times.
The mnemonic SNAPPS stands for
- S: Summarize, in a succinct fashion, the history, and physical findings, using perhaps two to four abbreviated sentences.
- N: Narrow the differential to a couple of possibilities.
- A: Analyze the differential. What’s the most likely diagnosis? Why are other choices are less likely?
- P: Probe the preceptor. Learners love this. They get to ask the teacher a question relevant to the case at hand. Note, it is fine, and it can often occur, that the preceptor does not know the answer. Make a plan to look it up!
- P: Discuss the plan for evaluation and management of the patient’s care.
- S: Select an issue or item for the student to read about that night after the patient has left.
Many students know how to present within a SNAPPS outline. In particular, students in the Primary Care Leadership Track program have practiced the technique and have handheld cards that explain how to present in a SNAPPS outline.
I find the SNAPPS technique is best used if the patient being evaluated has a symptom complex, such as shortness of breath or abdominal pain. The approach works best when presented outside the patient’s exam room. Also, the technique is not so helpful to evaluate or hear about patients returning with chronic, multiple problems. I often encourage the student to pick one case in a half-day to present using SNAPPS. Also, when they do this, the student doesn’t typically write up the case; I usually write the note. Finally, the technique is helpful to evaluate the clinical reasoning of the learner.
Sometimes preceptors are reluctant to utilize SNAPPS because they don’t like the sensation of being questioned. (Who likes to be probed?!) What I find, though, is that it can be fun to be asked a question about your clinical experience, and most of the time, preceptors actually can answer the questions at hand. But remember it is perfectly fine to say, “I don’t know the answer to that, and let’s look that up together.”
The Physician Assistant Education Association has a wonderful one page work-up of SNAPPS; and for those of you who are especially interested in teaching, PAEA offers several other one-page summaries linked in this article entitled “Tips for Making Precepting Painless.”
One last resource in case you or your learner never learned SNAPPS: This YouTube video demonstrates how it’s done.
I am a big SNAPPS fan and would love to come to teach your clinic group how to utilize SNAPPS in your daily routine. Just give a shout, and we can set up a time to review.