Clinical Teaching Tools: OMP and SNAPPS

Rationale: This step forms the basis for your assessment of their level of understanding of the case, and gets the learner personally invested in the learning process

Tips:

• Get them to commit to something, even amid uncertainty.
• Reassure timid learners they aren’t being judged for being wrong.
• Offer a brief didactic if knowledge gaps prevent commitment.
• With advanced learners, focus on management, systems, equity, self-improvement, evidence-based medicine, etc.
• If too quick to commit, ask them to expand; if too broad, help them focus. 

Example prompts:

• What do you think is going on? What do you want to do next?
• What is the most important thing to address for this patient today? Why?
• How sick is this patient? Do they need to be admitted?
• What additional information do you need to come to a decision?
• If you were alone, what would you do next?
• If this patient had a fever, how would your differential change?
• Is this most likely infectious, allergic, or rheumatologic?
• If you could only do one test to confirm your diagnosis, what would it be?
• Have you seen a similar patient before? Do you think this patient has the same thing?
• What will you do to assure adherence with treatment?
• What opportunities for advancing health equity or advocacy did this case bring up for you?
• What did you do to increase efficiency with this patient?
• What would you teach a junior learner about this case?

Rationale: This step allows you to assess their diagnostic reasoning, and identify possible gaps to guide your teaching

Tips:

• Ask about thinking process rather than knowledge
• If the learner seems intimidated, you may need to clarify that you are asking questions so that you can target your reaching, rather than to test their knowledge
• For the advanced learner, consider asking about their rationale for their next step or for systems change

Example prompts:

• Tell me how you arrived at your diagnosis (rather than “why do you think the patient has X”)
• Which specific aspects of the history and physical support your diagnosis?
• Is there anything about this patient that is not consistent with your diagnosis?
• What else did you consider in your differential? 
• Convince me why this patient needs a stat head CT
• What are some more common conditions that might present this way? 
• What’s making you uncomfortable/uncertain about this patient?
• How did the test/xray/exam results help you arrive at your diagnosis?
• How did you interpret test result Y?
• Since you haven’t seen “X” before, what do you know about general causes of shortness of breath?
• Where might you go to find evidence for the most effective treatment for this condition?
   

Rationale: Teaching that is individualized to the learner’s level, and generalizable to future encounters is highly valued by learners. 

Tips:

• Using what you have learned in steps 1 and 2, pick 1-2 general rules, max, per teaching encounter. 
• Take the learner’s knowledge one step further: (if they know diagnosis, focus on management. If they know exam findings focus on lab findings, etc)
• Sometimes this is just a summary or rephrasing of something the learner already knows, to reinforce it.
• Consider your learner’s level (appropriate learning issues for med student, fellow, etc) and interests (ER resident on peds rotation, med student going into radiology but on surgery rotation)
• Basics are always worth revisiting (anatomy, lab interpretation, exam techniques, medical terminology, organization of presentation)
• Consider the longitudinal relationship you have with the learner: build on general rules over time
• Think beyond medical knowledge: 
  • Consider teaching principles of equity, communication and value-based care
  • For advanced learners, can teach about health systems, compliance, efficiency, etc
  • Consider teaching “how to learn”: use of references, how to find information, etc

Example prompts:

• When I see a rash that is dry and itchy, I am usually thinking of some sort of allergic process
• When I am faced with a disease I don’t see very often, the first thing I do is see if there is a review article on the subject in “Journal of X”.
• I learned once that patients remember the first and last things they hear best, so I try to make sure that my most important teaching points are at the beginning and at the end of patient counseling
• Assessing pain in a patient who has cognitive impairment can be challenging. Could I share some tips with you?
• Since the physical exam findings were critical to your diagnosis, when we go back in, I’d like to show you my favorite technique for eliciting wheeze

Rationale: Reinforcing correct behavior helps the behavior become firmly established.  

Tips: See tips above

​​​​Example prompts:

• I liked how you emphasized the key points of the past history, such as the recent antibiotic course and history of multiple UTI’s, early on in your presentation. This made the presentation easier to follow, and showed that you were aware of which pieces of information were most important.
• Despite the challenges with the interpreter phone, I appreciated how you remained focused on the patient, and continued to express empathy and concern throughout.
• I am glad you brought me in right away to evaluate this patient when you were concerned about her breathing. That way we could stabilize the child while also directly observing and examining her together
• I really liked how you patiently explained the procedure and assured that the patient understood before moving forward. This creates a partnership and trust that will make them more relaxed during the procedure 
• I’m glad you were honest about not being able to do the ear exam. That helps me to keep otitis media on my differential, and to know what we can focus on when we go back into the room
• You quickly zeroed in on the patient’s main concern, and negotiated an agenda for addressing her more chronic concerns later. This builds trust with the patient, and sets us up for a long-term therapeutic relationship

Rationale:  

• Correcting mistakes in a specific, constructive and timely manner is appreciated and valued by learners
• Incorporating corrective feedback into every teaching encounter normalizes it and makes it feel less evaluative. 

Tips: See tips above

​​​​​Example prompts:

• While viral exanthems are common, most are only mildly pruritic, or totally asymptomatic. This patient has intense pruritus, which is why I am less concerned about a viral cause for her rash
• The pediatric ear exam is something that takes years to master. Next time I’d like you to try a different way of holding the otoscope against the child’s face, so that you have more control. Let’s go practice that. 
• Next time I’d like you to start your physical exam with a description of the patient’s general appearance. This shows me that you have assessed the patient’s level of illness, and also helps me gauge how ill the patient is.
• You’re right that most acute low-back pain is musculoskeletal in nature, but in order to rule out more serious etiologies like cord compression, I’d recommend asking about focal neurologic symptoms such as numbness, bowel or bladder incontinence.
• If you have trouble with part of the exam, I’d actually prefer that you tell me that up front rather than stating that it is “normal”. This allows me to know what to focus on when I go in to see the patient, and also allows me to identify what areas of the exam we need to work on. 
• This patient’s strong family history of asthma is so essential to the diagnosis, it would have been more helpful to me to hear about it earlier in the presentation. That’s an example of something I might include in your initial “ID” sentence.”
• Your assessment and plan was spot-on, so I’d like to focus on judicious use of testing. For example, the CBC in this case was not really necessary, as we already knew that the patient had an infection from her exam and history. Next time, try asking yourself “how will this test change what I already know about this patient?”  before you order it. 
   

• The learner performs an appropriate H and P of the patient and presents a concise summary to the preceptor.  
• The summary should occupy < 50% of the learning encounter and generally should be < 3 minutes.  
• The “problem representation” format, which includes the patient’s demographics, risk factors, time course and descriptions of symptoms and key objective findings, is ideal for this step.

• The learner verbalizes what he/she thinks is going on in the case.  
• Focus on the most likely or most important to rule out possibilities, avoiding “zebras”.  
• This requires a commitment from the learner.  
• Examples: 
  • “I think the most likely diagnosis is a bacterial pneumonia, but I am also considering a viral LTRI or exacerbation of her underlying asthma.”  

• The learner initiates a discussion of the differential by comparing/contrasting the top items on the differential.  
• This allows the learner to verbalize their thinking process, and stimulates active discussion between learner and preceptor that is targeted to the learner’s level
• Example: 
  • “I think his chest pain is most likely anginal because of his description of the pain, and the accompanying shortness of breath and fatigue. However, he doesn’t have any cardiac risk factors, so I am also considering that it could be from non-cardiac causes such as pulmonary disease”.   
     

• The learner reveals areas of confusion or knowledge deficits, helping guide the preceptor to relevant and individualized teaching
• Examples: 
  • “I feel like I’m missing something – is there anything else I should include in the differential?” 
  • “I’m not sure how to examine the thyroid for nodules. Would you be able to go over that with me?”

• The learner initiates a discussion of patient management with the preceptor 
• Ideally the learner should commit to either a brief management plan or suggest future interventions.  
• (This could also be included in step 1, or be an identified uncertainty in step 4)
• Example: 
  • “I would like to treat his asthma flare with steroids, as it has failed home treatment, but I can’t remember how many days we normally treat with a steroid burst”.  
  • I would like to get a CT scan for appendicitis. In the meantime, I would like to treat her pain, and start IV fluids for dehydration. Should we call surgery now, or wait for the results of the CT scan? 

• The final step encourages the learner to read about focused, patient-based questions. 
• The learner should check with the preceptor to focus the reading and frame relevant questions.  
• At the next teaching interaction, the learner can then ask the preceptor any questions that arose from the reading.  
• Examples:
  • “Based on this case, I’d like to read more about the evidence for using ‘asthma action plans’ with patients.  What do you think?”
  • “I was hoping to learn more about the differential for headaches in young children. Do you have any suggested resources on this topic?”