SNAPPS for busy clinics

The 90-second summary

The S is a summary, and its whole discipline is length. Two or three sentences: who the patient is, what brought her in, and the findings that bear on the decision. Not the full history in the order it was collected. A student summarising a fatigue visit gives the age, the duration, two positives and two relevant negatives, and then stops. If she runs past four sentences, hold up a hand and ask for the short version.

You will hear the difference between a student who has thought and one who has transcribed. The transcriber narrates: the whole review of systems, every negative, a cousin's family history. The thinker selects. Selection is the skill you are building, and the summary is where it first becomes visible, which is why you can judge a presentation in its opening fifteen seconds and know what the rest of it will need from you.

Narrow, then analyse

N is narrowing: two or three possibilities said out loud, not a list of nine. A is analysing: she weighs them against her own findings and says which way each finding points. Ask for that explicitly. Fatigue in a 34-year-old could be anaemia, thyroid disease or depression, and the analysis is the sentence where she says the heavy periods pull her toward the first while the flat affect keeps the third in play.

This is the pair students dodge, because it is where being wrong becomes visible. A summary is safe and a plan is safe, but narrowing commits her to something. Expect hedging in week two and ask for a number: give me two, and tell me which one you would treat today. Once she does that reliably, most of what you were teaching in the corridor she has started teaching herself.

Probe with her question, not your quiz

P is the probe, and the direction of traffic reverses here. She asks you about what she could not work out alone. Not a question with an obvious answer, and not a request for the answer to the case. Something closer to whether the pattern in a set of thyroid results changes the interval before repeating them. Her question shows you exactly where her knowledge stops, which you would otherwise spend a fortnight guessing at.

Insist on a real question. New students ask nothing, either because they think the question exposes them or because they have rehearsed something safe. Say plainly that you expect one uncertainty per presentation and that it costs her nothing with you. Then answer briefly: two sentences and a rule of thumb, not the lecture the question deserves, because there is another patient waiting and she can read the rest this evening.

Plan, then select

The second P is her plan, said in the order she would carry it out: what she orders, what she prescribes, what she tells the patient, and when she wants the patient back. Concrete enough that you can agree with it or change it. 'A CBC and a TSH, talk about her sleep, back in three weeks' is a plan. 'Some labs and reassurance' is not a plan, and you should hand that one back.

S is select: she picks one issue out of the case to read about and names it before she walks away. That is the entire step, and it does two useful things. It closes the encounter with her own learning question instead of homework you assigned, and it hands you an opening line for Thursday. Ask her what she found. A student who knows the question is coming actually does the reading.

When it beats the one-minute preceptor

The two methods answer different problems. The corridor method is yours to drive: you ask, she answers, and the exchange stays on rails you are holding. SNAPPS hands her the rails. That is better once she can structure a case, because you see her reasoning without your own questions shaping it. It is worse in week one, when an unstructured student handed the floor will talk for four minutes and arrive nowhere in particular.

Read the day as well as the student. SNAPPS suits the visit with five minutes of slack in it: follow-ups, chronic care, the back half of a rotation. The five microskills suit the walk-in you are already late for. Most preceptors use both in one afternoon, and the students who do best are simply told which is happening. Say 'give me the full version on this one' and she will.

Teaching it in week two

Introduce it as a format, on paper, at the start of week two. Write the six steps on an index card and give her the card. Tell her that from Monday you want the first patient of each session presented this way, then the first two, then every follow-up. Starting with one patient a session is deliberate. A student practising a new structure on every case will drop it by Wednesday.

Then coach the format rather than the medicine for a fortnight. If she skips the analysis, name the step and ask her to take it again from there. If she asks you nothing, wait her out. By week four the shape is habit and you can go back to teaching clinically. If her presentations are not improving and you cannot see the reason, your coordinator has watched this go sideways before and support is one call.

Questions

Sources: AANP: Precepting With Purpose

Written by

Tamsin R., DNP, FNP-BC

Reads every application and every midpoint evaluation. Has precepted FNP students in a rural family practice since 2014 and still takes one a term. Writes the teaching-method pieces in Off the Clock.