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Year : 2014  |  Volume : 1  |  Issue : 4  |  Page : 213-214

Reflections on teaching in the outpatient surgical clinics: The summarize, narrow down, analyze, probe, plan, select model

Department of Surgery, Division of Burns and Plastic Surgery, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication14-Nov-2014

Correspondence Address:
Abdul Rasheed Ibrahim
Department of Surgery, Division of Burns and Plastic Surgery, Ahmadu Bello University, Zaria
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DOI: 10.4103/2384-5147.144746

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How to cite this article:
Ibrahim AR. Reflections on teaching in the outpatient surgical clinics: The summarize, narrow down, analyze, probe, plan, select model. Sub-Saharan Afr J Med 2014;1:213-4

How to cite this URL:
Ibrahim AR. Reflections on teaching in the outpatient surgical clinics: The summarize, narrow down, analyze, probe, plan, select model. Sub-Saharan Afr J Med [serial online] 2014 [cited 2020 May 28];1:213-4. Available from: http://www.ssajm.org/text.asp?2014/1/4/213/144746


The surgical out-patient clinic is a unique platform for teaching a variety of clinical presentations in surgical practice. It is patient focused with emphasis on the process of decision making for the surgical patient with specific clinical symptoms. The teaching process is considered as a privileged apprenticeship and trainees learn both technical aspects of surgical practice and professional attributes. [1]

However, this time-honored educational tool is being threatened in most surgical out-patient clinics. The clinics are often under-resourced, chaotic and over-stretched, with limited time available for consultation. [1] Trainers have to tandem teaching responsibilities with an overwhelming demand for clinical services. Faced with continuing pressure to reduce waiting times anything which affects output in clinical services has to come second. [2]

Inevitably, teaching is put at risk as the consequences are considered less than those for not fulfilling service commitments. [3] Thus, the utopian vision of an enthusiastic trainer with ample time set aside for a pedagogic, "spoon-feeding" approach to learning, and a receptive trainee keen to develop new skills and thoughts, is not always the reality in most tertiary institutions. [1]

In response to the challenge of balancing teaching and clinical productivity, the summarize, narrow down, analyze, probe, plan, select (SNAPPS) model was developed for more efficient and effective teaching and learning. [2],[4],[5] It is different from the traditional or patient centered model, in which the case is presented by the trainee in a standardized format. The trainer then asks several directed questions to clarify the history and physical examination findings, in order to establish a differential diagnosis and a treatment plan. This process may take place during or after the presentation and is sometimes followed by a brief mini-lecture, which occasionally contains a feedback. [5]

The SNAPPS model is a trainee centered model that includes six steps that the trainee controls. [Table 1] the model encourages a presentation that is intended to redirect the learning encounter by condensing the reporting of clinical facts and encouraging the expression of thinking and reasoning. [4] The challenges of teaching in a surgical out-patient setting are quite different from those in inpatient settings. The focus is often on management, and the trainee can end up observing rather than doing or being asked only questions of factual recall. [4] Furthermore, a defining feature of surgical training is the acquisition of procedural skills. Planning for clinical teaching also involves planning for out-patient encounters e.g., instructions in surgical procedures commonly done in the clinic. [3] The SNAPPS model encourages trainees to justify their assessment of the patient, articulate questions and explore uncertainties that arise in the process of care. [2],[4] It underscores the need for three factors to enhance teaching and learning. Firstly, trainees need to become more concerned with their own learning, which should be trainee centered. Secondly, trainees must also own the curriculum, collaborate with trainers in how and what they learn, and focus on personal growth throughout their training. Third, the role of the trainer needs to change from one of supervisor to one of facilitator of learning, who works in harmony with the trainee to identify and enhance learning. [1]

Surgical trainees, having declared themselves' to be self-motivated learners by subscribing to a surgical residency, are excellent candidates for education through the SNAPPS model. Transfer of learning is not automatic and must be facilitated. Follow-up support is provided (step 6) to enable transfer of learning into daily practice with open discussion and debate encouraged. The SNAPPS model may require the training of both trainers and trainees to be highly successful, and needs to be bought into by both parties. Trainers may be uncomfortable with the change in their role from that of "expert" to that of "facilitator", and trainees may feel equally uncomfortable being forced to take the lead. [5] SNAPPS represents a paradigm shift in surgical out-patient education that engages the trainee and creates a collaborative learning conversation in the context of quality patient care.
Table 1: SNAPPS, a six-step mnemonic for trainee centered learning in the surgical outpatient clinic

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  References Top

Williamson J. Teaching and learning in out-patient clinics. Clin Teach 2012;9:304-7.  Back to cited text no. 1
Irby DM, Wilkerson L Teaching when time is limited. BMJ 2008;336:384-7.  Back to cited text no. 2
Skeff KM, Bowen JL, Irby DM. Protecting time for teaching in the ambulatory care setting. Acad Med 1997;72:694-7.  Back to cited text no. 3
Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A learner-centered model for outpatient education. Acad Med 2003;78:893-8.  Back to cited text no. 4
Chacko KM, Aagard E, Irby D. Teaching models for outpatient medicine. Clin Teach 2007;4:82.  Back to cited text no. 5


  [Table 1]

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1 Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity
Navdeep S. Sidhu,Morgan Edwards
Medical Teacher. 2018; : 1
[Pubmed] | [DOI]


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