Teaching medical students and residents in ambulatory settings/Out-patient Department (OPD) is an integral part of medical education. However, it has been found to be unsatisfactory and characterized by variability, unpredictability, immediacy, and lack of continuity [1,2]. Passive role of learners, and exchange of factual information without much clinical reasoning have also been identified [3,4]. SNAPPS (Summarize history and findings; Narrow differentials; Analyze differentials; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study), a learner-centered model, modifies the learning encounter by condensing the reporting of facts while encouraging clinical reasoning [5].

Four residents (2nd and 3rd year) and three faculty members participated in case discussions. Each resident had five encounters in both the groups. Data were analyzed on six outcome categories, further subdivided into 11 variables (Table I). Though total case discussion time was more in SNAPPS as compared to traditional method, time taken for case summarization was almost equal in both; extra time was spent in active discussion with SNAPPS. Evaluations regarding completeness of history and completeness of relevant physical examination revealed better results with SNAPPS method (P=0.008 and 0.025, respectively).

TABLE I Comparison of  Case Presentations with Traditional and SNAPPS Methods 

Residents initiated making differentials in all (20/20) SNAPPS presentations compared to only two (2/20) in traditional method. Of the remaining 18 traditional case presentations, preceptor elicited the differentials in 17 and no diagnosis was made in one case. In addition, the preceptors also raised more uncertainties in traditional than SNAPPS presentations (11 vs 8), supporting preceptor’s dominance in traditional case presentations. Topics for self-study were selected only with SNAPPS model, though only in 60% cases.

Residents perceived that SNAPPS model was more structured, stimulating, relevant to teaching in the OPD, and easy to follow. They felt confident in making differentials with clinical reasoning, and motivated for self-directed learning. They read most, though not all, selected topics for self-study. One resident found the encounters to be stressful initially.

In this comparative study of SNAPPS model and traditional teaching of four residents in the OPD setting, we observed that SNAPPS model motivated pediatric residents to think actively, reason out more differentials, raise their uncertainties, and select case-related issues for self-study. Our study found case presentations to be more complete with SNAPPS.

Limitations of present study include small number of residents and few training sessions. We did not check how much learning occurred on topics selected for self-study, which can be an area of future research.

The results in present study are in accordance with the original study by Wolpaw, et al. [6]. In their follow-up study, they demonstrated that students in SNAPPS group raised more uncertainties about diagnostic reasoning and received more preceptors’ feedback [7]. Our residents agreed that the corrective feedback from faculty improved their reasoning skills; similar result has been reported previously [8]. Stress among residents during SNAPPS presentations was also reported in a previous study [9]. SNAPPS has also been adapted for indoor-teaching as a whole or in components [10], and in different cultural settings [9]. SNAPPS, ensures explicit analysis of the differentials, and adds two more steps to traditional teaching – probing the preceptor for uncertainties and selecting case related topics for self-study. These experiences provide experiential learning to be applied in future [11]. When preceptors seek their students’ thought process, learners increase their own expression of clinical thinking and reasoning [4].

To conclude, the present study suggests that SNAPPS model is an efficient teaching-learning tool to promote clinical reasoning. It can be used effectively in a busy OPD where preceptor gets multiple, short-duration teaching-opportunities between patient care. It allows a paradigm shift of teacher-centered precepting to learner-centered learning.