Clinical teaching is complicated by the requirement for clinicians to provide excellent clinical service while permitting students to practice clinical skills including history-taking, physical examinations, and clinical reasoning. Posted below are a number of manuscripts describing various aspects of clinical teaching. The manuscript by Pascoe et al describes a couple of specific techniques to advance clinical reasoning in students, including the SNAPPS model that was described by Dr. James Nixon on Education Day 2016.
The One-Minute Preceptor model
The One-Minute Preceptor model consists of five steps.
- Get a commitment - This is not about gathering more information and instead is about asking the student what they think is happening. Example questions might include, "what do you think are the most likely diagnoses", "what laboratory tests do you think we should ask for", and "how do you think we should treat this patient?"
- Probe for supporting evidence - This is about asking the student why they made their specific choices in the first step. Example questions might include, "what factors in the history and physical examination support that diagnosis", or "why would you choose that particular medication"?
- Teach general rules - This is about providing the learner with relevant information about the diagnosis and management of this kind of case.
- Reinforce what was done correctly - This should be specific feedback describing their behavior. An example might include, "it was very good that you took time to talk to the client about lifestyle factors that might make tick exposure more likely for this cat."
- Correct mistakes - This again should be specific feedback, such as, "I agree that we likely could get some great information from an MRI but with this dog's acute collapse and newly identified significant cardiac murmur, general anesthesia probably is contraindicated at this time." This technique permits the clinician to learn much about the knowledge and thought processes of the learner, encourages teaching to the appropriate level, and is well-studied.
It requires some practice for clinicians to use the model consistently and may be difficult if students have not collected enough information during their initial examination to readily permit an in-depth discussion.
The SNAPPS model
The SNAPPS model consists of six steps.
- Summarize - Students are expected to create a concise summary statement that includes key demographics, a temporal pattern for the presentation, and clinical manifestations. An example might be, "Captain is a 3 year old castrated male Australian Shepherd who lives on a farm and has, for the last 5 days, had intermittent episodes of gagging up thick phlegm and wheezing."
- Narrow - The student lists their 2-3 top differentials or diagnostic plans.
- Analyze - In this step, the learner explicitly discussed their rationale and the clinician questions them to determine their clinical reasoning process.
- Probe - This is a chance for the student to ask questions of the clinician. It is an opportunity for the student to consider their own needs as a learner and to use the clinician as an expert resource.
- Plan - The student suggests next steps and works with the clinician to come up with a specific plan.
- Select - The student chooses a topic for self-directed learning about the case. This model is learner-centered and gives faculty members insight into student's knowledge and clinical decision making abilities. Training is required for both students and clinicians and learners must feel comfortable admitting what they don't know.
The Aunt Minnie model
The Aunt Minnie model is an official name for the kind of clinical teaching that has been done for many years. It is called Aunt Minnie because it is about pattern recognition - if you see someone who dresses like your Aunt Minnie, sounds like your Aunt Minnie, and looks like your Aunt Minnie, she probably is your Aunt Minnie. Students state the main problem for which the patient was brought in, their initial impression, and their first thoughts about diagnostic and treatment plans. The clinician then sees the patient without the student, and discusses the case with the student afterward. The primary advantage to this model is that experts rely heavily on pattern recognition for diagnosis and this pushes students toward building their own body of experience about common disorders. It is also quick. Research suggests that learners usually are right in their first impressions when seeing common disorders. The primary disadvantage of this model is that it promotes snap judgments and may promote other errors in clinical diagnosis. For example, a learner may make assumptions that all Cocker Spaniels have ear infections and not do an examination sufficient to identify other causes of the dog leaning its head to one side. Another error is premature closure, where students fail to perform diagnostics beyond those needed to verify their first impression, potentially missing the correct diagnosis. It is also ineffective for very novice or struggling students.
Clinical Teaching Paradigms at the University of Minnesota College of Veterinary Medicine
Drs. Robert Washabau and Peggy Root identified clinical teaching paradigms used at the College; that manuscript is below and the abstract is included here for your convenience.
Course coordinators were surveyed and course syllabi reviewed at the University of Minnesota College of Veterinary Medicine for types of teaching paradigms used for clinical training and extent of those varying types of teaching in large animal, small animal, and non-species-based rotations. Show-and-tell, or apprenticeship, was the most commonly used teaching paradigm. Other teaching paradigms, in decreasing order, included topic rounds, case rounds, critical scientific reading / evidence-based medicine, assignments and other assessments, games, and discussion of roles in society / ethics. Apprenticeship teaching was more common in small animal rotations and topic rounds was more common in large animal rotations; this may be a reflection of caseload. Specific teaching methods, tools, and unique learning opportunities are described.