SNAPPS Case Presentations in a Thai Internal Medicine Ambulatory Care Rotation
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Purpose: SNAPPS is a learner-centered approach to clinical case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting. The purpose of this study was to replicate these studies in an Asian medical school. Methods: We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations (usual) for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. The experimental time was 3 weeks; one week shorter than the US study. There were 12 outcomes measured at the end of the rotation including, the number of basic attributes, completeness of summary thoroughness, number of differential diagnoses, number of justifications in the differential diagnoses, expression of uncertainties, student-initiated management discussion, student-initiated reading selections, total presentation time, summary time, discussion time, number of supportive evidence, and student-initiated diagnosis discussion. The last three outcomes were new for this study. Results: SNAPPS users (90 case presentations), compared with the usual group (93 presentations), had more diagnoses in their differentials (1.81 vs. 1.42) and more differential justifications (0.90 vs. 0.78), more student-initiated diagnosis discussions (76.7% vs. 59.1%) and student-initiated reading selections (6.67% vs. 0%), and included more supportive attributes for the differential (2.39 vs. 1.22). Thai students expressed fewer uncertainties and selected fewer readings than in the American study. Conclusions: The use of the SNAPPS technique among fifth-year Thai medical students during their internal medicine ambulatory care rotation did facilitate the expression of their clinical reasoning. While the SNAPPS technique was applicable across cultures with regards to expressing clinical reasoning, the Thai students were still reluctant to express their uncertainties, likely because of different procedural and Thai cultural barriers.