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Using SNAPPS to Facilitate the Expression of Clinical Reasoning and Uncertainties: A Randomized Comparison Group Trial

Wolpaw, Terry MD, MHPE; Papp, Klara K. PhD; Bordage, Georges MD, PhD

doi: 10.1097/ACM.0b013e31819a8cbf
Clinical Reasoning

Purpose When medical students present cases to preceptors, they focus mainly on factual information and reveal little about their diagnostic reasoning or uncertainties. Do third-year students using the six-step, learner-centered SNAPPS technique (Summarize history and findings, Narrow the differential; Analyze the differential; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study) for case presentations to family medicine ambulatory care preceptors express clinical reasoning and learning issues more than students not trained in the technique?

Method The authors conducted a posttest-only, comparison groups, randomized trial in 2004–2005 with 64 students in three groups: SNAPPS training, feedback training (controlling for training time), and usual-and-customary instruction. SNAPPS training combined brief faculty development with more extensive learner development followed by practice during a four-week family medicine rotation. During the last week, students audiotaped case presentations, which the authors coded for 10 dependent variables organized into six outcome categories that measure expression of clinical diagnostic reasoning and learning issues.

Results The authors coded 66 SNAPPS, 67 comparison, and 82 usual-and-customary case presentations. Students in the SNAPPS group outperformed students in comparison and usual-and-customary groups for each outcome category. SNAPPS presentations were no longer than usual presentations but were one minute longer than those of the comparison group.

Conclusions SNAPPS greatly facilitates and enhances expression of diagnostic reasoning and uncertainties during case presentations to ambulatory care preceptors. Students can conduct case presentations using a technique that makes each step explicit and gives learners, rather than preceptors, the responsibility for expressing their clinical reasoning and uncertainties.

Dr. Wolpaw is associate dean, Curricular Affairs, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Dr. Papp is director, Center for the Advancement of Medical Learning, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Dr. Bordage is professor, Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois.

Correspondence should be addressed to Dr. Wolpaw, Case Western Reserve University School of Medicine, Office of Curricular Affairs, 10900 Euclid Avenue, T402, Cleveland, OH 44106-4924; telephone: (216) 368-6986; fax: (216) 368-5125; e-mail: (

© 2009 Association of American Medical Colleges