The unique character of medical education in the outpatient setting has created challenges in teaching and learning that cannot be solved by the adaptation of traditional inpatient approaches. Previous work and the authors' own observational study describe a relatively passive learner focused on reporting history and physical examination data to the preceptor. Based on the work of Bordage in cognitive learning, and that of Osterman and Kottkamp on reflective practice for educators, the authors have developed a collaborative model for case presentations in the outpatient setting that links learner initiation and preceptor facilitation in an active learning conversation. This learner-centered model for case presentations to the preceptor follows a mnemonic called SNAPPS consisting of six steps: (1) Summarize briefly the history and findings; (2) Narrow the differential to two or three relevant possibilities; (3) Analyze the differential by comparing and contrasting the possibilities; (4) Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; (5) Plan management for the patient's medical issues; and (6) Select a case-related issue for self-directed learning. The authors conducted a pilot study of SNAPPS, introducing the model to both third-year medical students and their preceptors. Feedback was enthusiastic and underscored the importance of the paired approach. SNAPPS represents a paradigm shift in ambulatory education that engages the learner and creates a collaborative learning conversation in the context of patient care.
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