Transcript The One Minute Preceptor and SNAPPS

“To teach is to learn twice.”
– Joseph Joubert
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The One-MinutePreceptor Model and
SNAPPS
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Objectives
As a result of this session participants will be able
to:
 Develop
an organized approach to teaching clerks
and residents:
 Using the “One-Minute-Preceptor” model
 Using the SNAPPS model
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The Five Steps

Get a commitment

Probe for understanding

Reinforce what was done well

Correct mistakes

Teach a general rule
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Step #1 Get a Commitment - “What do you think is
going on?”
NB: The learner must feel safe enough to risk a
commitment – even if it is wrong.
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Get a Commitment – Alternative
Questions
The Issue
How to Ask for a Commitment
Differential
diagnosis
What....? (do you think is going on or is most likely?)
Diagnostic
strategy
What....? (investigations should be ordered?)
Selection of
therapy
What....? (is your first choice of medication?)
Prognosis
What....? (do you think is probably going to happen?)
Management
issue
Why....? (do you think this patient is non-adherent?)
What....? (would you like to achieve this visit)
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Step #2 Probe for underlying reasoning or
supportive evidence.
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Probe for underlying reasoning Additional questions

What......( factors make this diagnosis likely)?

Why...... (do you suggest getting this test first?)

Which......(medications are available for this condition?)

How...... (did this prognosis emerge as the most probable?)

What if……(the patient were 30 instead of 60?)

Others…
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More on questioning…
What makes a question helpful vs. not
helpful?
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Two Main Types of Questions
 To
clarify the clinical story:
 To
fill in gaps in the case presentation
 To understand the case presentation
 To
facilitate learning:
 Ongoing
needs assessment
 Help students retrieve related knowledge & integrate it
with new knowledge
 Practice retrieval
 Get them to think deeper
 Stimulate wonder
 Explore attitudes & feelings
 Get students into the habit of asking their own questions
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Open vs. Closed Questions
Closed-ended:
is the usual
starting dose for
simvastatin?”
 “What
are the names
of the 12 cranial
nerves?”
 “What
is the target BP
for a patient with
diabetes and
hypertension?”
Open ended:

“What diagnoses are
you considering?”

Why do you think that?

“What might be some
contributors to Mr. Jones
heart attack?”

“How would you justify
the use of test X in this
case?”
 “What
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Questioning Tips cont’d.
 Include
questions that help students explore
their attitudes and feelings e.g. “How would
you describe that patient’s impact on you?
Your internal reaction, how you felt.”in
addition to questions on clinical content.
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Questioning Tips…
Avoid

playing “Guess what I’m thinking.”
E.g. “What do you think is the key to success in managing
hypertension?”
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Step #3 Reinforce what was done well
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Reinforce What was Done Well
Some examples: Be specific!

"You did a good job of… considering multiple possibilities
and prioritizing the most probable diagnoses"

"I noticed how well you… considered the patient’s age and
concerns about cost in selecting medications"
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Step #4 Correct mistakes
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 "I
agree this patient’s headache is worrying him,
but from the history and in the absence of
neurological signs, CT is more likely to distract us
with false positive findings than change the
diagnosis or management plan.”
 "That
drug is often a good first choice for this
condition, but she is also taking warfarin (or has
an elevated creatinine) and the interaction would
be dangerous.”
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Use the Field Note as a Guide:
Continue (strength to reinforce): Comment on aspects of
performance that were effective.
Identify behaviour the
Consider (for development) a. Identifylearner
a behaviour
the to
learner
knows how
do,
knows how to do and encourage to do more
often,
and could
do,or
or b.
do more
often.a doable challenge
Highlight a point of growth for the learner,
(aka. SMART goal) for future interactions.
Stop or do less (correct mistakes): Describe actions that were
not helpful, or could be harmful.
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Feedback: How to be specific

Focus on observations, not inferences
“You did such and such vs. you are…”

Focus on descriptions, not judgments
“What I observed was… vs. that was
inadequate.”

Focus on specific details, not generalities
“At the start of the interview with Mrs.
Jones, I noticed…vs. your
introductions are all…”
Correct Mistakes…

Elicit or suggest alternative behaviours.

Address realistic changes in doable steps
(SMART goal).

Provide an opportunity to try again (with real
patient, simulated patient or role play).

Establish clear follow-up plans.
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Step #5
Teach general rules
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General Rules - Examples
 "In
(certain population) with
(specific diagnosis), it is important to
consider
(general rule).”
 Even
better…ask the learner about
his/her take home message
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The One Minute Preceptor Model

Get a commitment

Probe for understanding

Reinforce what

Correct mistakes

Teach a general rule
Field Notes
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SNAPPS
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Application Points:
 Good
for providing resident or senior
student with framework for case
presentation and expectations
 Student/resident
led – At the beginning the
student or resident may need prompting
but should quickly learn acronym and lead
the discussion.
 Does
not include a feedback component so
ideal for using with field notes.
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic
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S
– Summarize the case
N
– Narrow the differential
A
– Analyze the evidence
P
– Probe the preceptor
P
– Plan the management and follow-up
S
– Self-directed study topic*
* Instead of self-directed study I use self reflection and
have the resident complete their own field note.
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Use the Field Note as a SelfDirected Learning Guide:
Tell me what you thought went well (strength): Comment
on aspects of performance that were effective and good to
continue.
Identify behaviour the
Identify something that you would like learner
to workknows
on orhow
tryto(for
do,
development) a. Identify a behaviour the
how to
andlearner
could do,knows
or do more
do and encourage to do more often, or often.
b. Highlight a point of
growth for the learner, a doable challenge (aka. SMART goal)
for future interactions.
Describe something that you were not happy with (correct
mistakes): Describe actions that were not helpful, or could be
harmful and should be stopped.
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Role Play Try to guide your neighbour through either
one of these teaching models. Then switch
roles.
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Questions?