Expressing clinical reasoning and uncertainties during a Thai internal medicine ambulatory care rotation: Does the SNAPPS technique generalize?

Abstract

Background: SNAPPS is a learner-centered approach to case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting.

Aim: To evaluate the SNAPPS technique in an Asian setting.

Methods: We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. We created four experimental groups to test main and maturation effects. We measured 12 outcomes at the end of the rotations: total, summary, and discussion presentation times, number of basic clinical findings, summary thoroughness, number of diagnoses in the differential, number of justified diagnoses, number of basic attributes supporting the differential, number of student-initiated questions or discussions about uncertainties, diagnosis, management, and reading selections.

Results: SNAPPS users (90 case presentations), compared with the usual group (93 presentations), had more diagnoses in their differentials (1.81 vs. 1.42), more basic attributes to support the differential (2.39 vs. 1.22), more expression of uncertainties (6.67% vs. 1.08%), and more student-initiated reading selections (6.67% vs. 0%). Presentation times did not differ between groups (12 vs. 11.2 min). There were no maturation effects detected.

Conclusions: The use of the SNAPPS technique among Thai medical students during their internal medicine ambulatory care clerkship rotation did facilitate the expression of their clinical reasoning and uncertainties. More intense student–preceptor training is needed to better foster the expression of uncertainties.

Declaration of interest: We wish to express our gratitude to the Khon Kaen University Faculty of Medicine for their financial support and to the students and preceptors for their participation in the study. Funds were provided to support this project in part by an invitational research grant, Khon Kaen University Faculty of Medicine and TRF grants from the Senior Research Scholar Grant, Thailand Research Fund (RTA5580004), and the Higher Education Research Promotion and National Research University Project of Thailand, Office of the Higher Education Commission, Thailand, through the Health Cluster (SHeP-GMS) at Khon Kaen University.

Ethical approval: The ethics committees from Khon Kaen University and the University of Illinois at Chicago approved this study.

Previous presentations: Preliminary results at the Association for Medical Education in Europe (AMEE) Conference 2013, 24–28 August 2013, Prague, Czech Republic.