Terrific T6 talks – Teaching Clinical Reasoning

In Education & Quality Improvement by Nadim Lalani2 Comments

from http://www.learningrxblog.com/

The SNAPPS approach

Unsatisfied with teaching historically “passive” learners in the outpatient context, Wopaw and co[ Link ] created this paradigm. They believed that it would allow more engagement during case presentations – linking learner initiation and preceptor facilitation in an “active learning conversation“.SNAPPS stands for:

(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.

(6) Select a case-related issue for self-directed learning.

One Minute Preceptor – Six Steps

Another popular and widely used method for improving teaching skills created by Neher et al. Originally designed for use by faculty in busy ambulatory practices, it facilitates efficient clinical teaching with the use of 5 “microskills” to help the mentor guide the teaching interaction. The 5 microskills are:

  1. Present Summary
  2. Get a commitment
  3. Probe for supporting evidence
  4. Teach general rules
  5. Reinforce what was done correctly
  6. Correct mistakes

Both ask for the commitment up front – this makes the presentation concise. Both also probe for supporting evidence. SNAPPS is more learner-driven and OMP is more preceptor-driven. SNAPPS is more for the junior learner. Use either – just use them and teach learners to do the same. [Here’s how to use it]

The RAPID Checklist

Invented by my brilliant colleague Dr. Rob Woods, it’s a memory aid that allows learners in the ED to focus in on ALL the important aspects of patient care.  It comprises five key areas:

  1. Resuscitation [ABC’s  & SAMPLE hx]
  2. Analgesia/Assessment [Attention to Pain and Nausea, Ancillary information]
  3. Patient needs [Addresses non-medical needs that are often forgotten]
  4. Interventions
  5. Disposition

Teaching how to avoid Cognitive Errors

There’s still many practising physicians that don’t know about Croskerry’s work. In this article he talks about the need to educate health care workers at all levels about diagnostic errors and how they come about. If you haven’t read his stuff – you should. Here’s a couple of snippets:

Confirmation Bias [justifying your diagnosis and ignoring conflicting information]

  • ddx – needs to include both non and life-threatening things
  • probe for evidence [challenge the learner by asking questions that get them to work it out for themselves e.g. “does asthma usually present with a fever?”]

Attribution error [stereotypes/blaming the patient]

Commission bias and Omission Bias [doing too much/not enough]

  • If one had to pay for the test yourself  [“trauma protocol”] would you do it?
  • 2 marbles in your pocket for consults / CT’s /Admits – once you’ve used them up … no more.
  • would it change management?
  • “what if the case was different this way?”
Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.