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

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.