Home Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials
Article
Licensed
Unlicensed Requires Authentication

Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials

  • Javier A. Flores-Cohaila ORCID logo EMAIL logo , Sonia F. Vizcarra-Jiménez ORCID logo , Milagros F. Bermúdez-Peláez ORCID logo , Fritz Fidel Vascones-Román ORCID logo , Marco Rivarola-Hidalgo ORCID logo and Alvaro Taype-Rondan ORCID logo
Published/Copyright: March 7, 2024
Diagnosis
From the journal Diagnosis Volume 11 Issue 3

Abstract

Introduction

Clinical reasoning is crucial in medical practice, yet its teaching faces challenges due to varied clinical experiences, limited time, and absence from competency frameworks. Despite efforts, effective teaching methodologies remain elusive. Strategies like the One Minute Preceptor (OMP) and SNAPPS are proposed as solutions, particularly in workplace settings. SNAPPS, introduced in 2003, offers a structured approach but lacks comprehensive evidence of its effectiveness. Methodological shortcomings hinder discerning its specific effects. Therefore, a systematic review is proposed to evaluate SNAPPS' impact on clinical reasoning teaching.

Content

We searched PubMed, EMBASE, and CINAHL for randomized controlled trials (RCTs) comparing SNAPPS against other methods. Data selection and extraction were performed in duplicate. Bias and certainty of evidence were evaluated using Cochrane RoB-2 and GRADE approach.

Summary

We identified five RCTs performed on medical students and residents. Two compared SNAPPS with an active control such as One Minute Preceptor or training with feedback. None reported the effects of SNAPPS in workplace settings (Kirkpatrick Level 3) or patients (Kirkpatrick Level 4). Low to moderate certainty of evidence suggests that SNAPPS increases the total presentation length by increasing discussion length. Low to moderate certainty of evidence may increase the number of differential diagnoses and the expression of uncertainties. Low certainty of evidence suggests that SNAPPS may increase the odds of trainees initiating a management plan and seeking clarification.

Outlook

Evidence from this systematic review suggests that SNAPPS has some advantages in terms of clinical reasoning, self-directed learning outcomes, and cost-effectiveness. Furthermore, it appears more beneficial when used by residents than medical students. However, future research should explore outcomes outside SNAPPS-related outcomes, such as workplace or patient-related outcomes.

Keywords: SNAPPS; medical education; clinical reasoning
Corresponding author: Javier A. Flores-Cohaila, Medical Doctor, Escuela de Medicina, Universidad Científica del Sur, UCSUR Campus Villa II, Ctra. Panamericana S 19, Villa EL Salvador 15067, Lima 15067, Peru, Phone: +51 924 341 073, E-mail:

  1. Research ethics: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing interests: Authors state no conflict of interest.

  5. Research funding: None declared.

  6. Data availability: The raw data can be obtained on request from the corresponding author.

References

1. Gruppen, L. Clinical reasoning: defining it, teaching it, assessing it, studying it. West J Emerg Med 2017;18:4–7. https://doi.org/10.5811/westjem.2016.11.33191.Search in Google Scholar PubMed PubMed Central

2. Vally, ZI, Khammissa, RAG, Feller, G, Ballyram, R, Beetge, M, Feller, L. Errors in clinical diagnosis: a narrative review. J Int Med Res 2023;51:1–10. https://doi.org/10.1177/03000605231162798.Search in Google Scholar PubMed PubMed Central

3. Young, M, Szulewski, A, Anderson, R, Gomez-Garibello, C, Thoma, B, Monteiro, S. Clinical reasoning in CanMEDS 2025. Can Med Educ J 2023;14:58. https://doi.org/10.36834/cmej.75843.Search in Google Scholar PubMed PubMed Central

4. Connor, DM, Durning, SJ, Rencic, JJ. Clinical reasoning as a core competency. Acad Med 2020;95:1166. https://doi.org/10.1097/acm.0000000000003027.Search in Google Scholar

5. Schmidt, HG, Mamede, S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ 2015;49:961–73. https://doi.org/10.1111/medu.12775.Search in Google Scholar PubMed

6. Sudacka, M, Adler, M, Durning, SJ, Edelbring, S, Frankowska, A, Hartmann, D, et al.. Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators. BMC Med Educ 2021;21:575. https://doi.org/10.1186/s12909-021-02960-w.Search in Google Scholar PubMed PubMed Central

7. Parodis, I, Andersson, L, Durning, SJ, Durning, SJ, Hege, I, Knez, J, et al.. Clinical reasoning needs to be explicitly addressed in health professions curricula: recommendations from a European consortium. Int J Environ Res Public Health 2021;18:11202. https://doi.org/10.3390/ijerph182111202.Search in Google Scholar PubMed PubMed Central

8. Rencic, J, Trowbridge, RL, Fagan, M, Szauter, K, Durning, S. Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. J Gen Intern Med 2017;32:1242–6. https://doi.org/10.1007/s11606-017-4159-y.Search in Google Scholar PubMed PubMed Central

9. Pierce, C, Corral, J, Aagaard, E, Harnke, B, Irby, DM, Stickrath, C. A BEME realist synthesis review of the effectiveness of teaching strategies used in the clinical setting on the development of clinical skills among health professionals: BEME Guide No. 61. Med Teach 2020;42:604–15. https://doi.org/10.1080/0142159x.2019.1708294.Search in Google Scholar

10. Wolpaw, TM, Wolpaw, DR, Papp, KK. SNAPPS: a learner-centered model for outpatient education. Acad Med 2003;78:893–8. https://doi.org/10.1097/00001888-200309000-00010.Search in Google Scholar PubMed

11. Wolpaw, T, Papp, KK, Bordage, G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med 2009;84:517–24. https://doi.org/10.1097/acm.0b013e31819a8cbf.Search in Google Scholar PubMed

12. Fagundes, EDT, Ibiapina, CC, Alvim, CG, Fernandes, FRA, Carvalho-Filho, MA, Brand, PLP. Case presentation methods: a randomized controlled trial of the one-minute preceptor versus SNAPPS in a controlled setting. Perspect Med Educ 2020;9:245–50. https://doi.org/10.1007/s40037-020-00588-y.Search in Google Scholar PubMed PubMed Central

13. Nixon, J, Wolpaw, T, Schwartz, A, Duffy, B, Menk, J, Bordage, G. SNAPPS-Plus: an educational prescription for students to facilitate formulating and answering clinical questions. Acad Med 2014;89:1174–9. https://doi.org/10.1097/acm.0000000000000362.Search in Google Scholar

14. Teixeira Ferraz Grünewald, S, Grünewald, T, Ezequiel, OS, Granero, AL, Lucchetti, G. One-minute preceptor and SNAPPS for clinical reasoning: a systematic review and meta-analysis. Intern Med J 2023;53:680–9. https://doi.org/10.1111/imj.16005.Search in Google Scholar PubMed

15. Page, MJ, McKenzie, JE, Bossuyt, PM, Boutron, I, Hoffmann, TC, Mulrow, CD, et al.. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71.Search in Google Scholar PubMed PubMed Central

16. Gordon, M, Gibbs, T. STORIES statement: publication standards for healthcare education evidence synthesis. BMC Med 2014;12:143. https://doi.org/10.1186/s12916-014-0143-0.Search in Google Scholar PubMed PubMed Central

17. Ouzzani, M, Hammady, H, Fedorowicz, Z, Elmagarmid, A. Rayyan – a web and mobile app for systematic reviews. Syst Rev 2016;5:1–10. https://doi.org/10.1186/s13643-016-0384-4.Search in Google Scholar PubMed PubMed Central

18. Yardley, S, Dornan, T. Kirkpatrick’s levels and education ‘evidence’. Med Educ 2012;46:97–106. https://doi.org/10.1111/j.1365-2923.2011.04076.x.Search in Google Scholar PubMed

19. Sterne, JAC, Savović, J, Page, MJ, Elbers, RG, Blencowe, NS, Boutron, I, et al.. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019:l4898. https://doi.org/10.1136/bmj.l4898.Search in Google Scholar PubMed

20. Reed, DA, Cook, DA, Beckman, TJ, Levine, RB, Kern, DE, Wright, SM. Association between funding and quality of published medical education research. JAMA 2007;298:1002–9. https://doi.org/10.1001/jama.298.9.1002.Search in Google Scholar PubMed

21. West, SL, Gartlehner, G, Mansfield, AJ, Poole, C, Tant, E, Lenfestey, N, et al.. Comparative effectiveness review methods: clinical heterogeneity [Internet]. Agency for Healthcare Research and Quality (US); 2010. https://www.ncbi.nlm.nih.gov/books/NBK53317/ [Accessed 24 Sep 2023].Search in Google Scholar

22. Guyatt, G, Oxman, AD, Akl, EA, Kunz, R, Vist, G, Brozek, J, et al.. GRADE guidelines: 1. Introduction – GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:383–94. https://doi.org/10.1016/j.jclinepi.2010.04.026.Search in Google Scholar PubMed

23. Santesso, N, Glenton, C, Dahm, P, Garner, P, Akl, EA, Alper, B, et al.. GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. J Clin Epidemiol 2020;119:126–35. https://doi.org/10.1016/j.jclinepi.2019.10.014.Search in Google Scholar PubMed

24. Murad, MH, Mustafa, RA, Schünemann, HJ, Sultan, S, Santesso, N. Rating the certainty in evidence in the absence of a single estimate of effect. Evid Based Med 2017;22:85–7. https://doi.org/10.1136/ebmed-2017-110668.Search in Google Scholar PubMed PubMed Central

25. Mahakalkar, CC, Srivastava, T, Vagha, S, Waghmare, L, Kaple, M, Shrivastava, S. SNAPPS as a method of case presentation for inpatient setting: a randomized controlled trial. J Res Med Educ Ethics 2019;9:59. https://doi.org/10.5958/2231-6728.2019.00012.x.Search in Google Scholar

26. Young, ME, Thomas, A, Lubarsky, S, Gordon, D, Gruppen, LD, Rencic, J, et al.. Mapping clinical reasoning literature across the health professions: a scoping review. BMC Med Educ 2020;20:107. https://doi.org/10.1186/s12909-020-02012-9.Search in Google Scholar PubMed PubMed Central

27. Carpenter, CJ. Meta-analyzing apples and oranges: how to make applesauce instead of fruit salad. Hum Commun Res 2020;46:322–33. https://doi.org/10.1093/hcr/hqz018.Search in Google Scholar

28. Cook, DA. Randomized controlled trials and meta-analysis in medical education: what role do they play? Med Teach 2012;34:468–73. https://doi.org/10.3109/0142159x.2012.671978.Search in Google Scholar

29. Thammasitboon, S, Rencic, JJ, Trowbridge, RL, Olson, APJ, Sur, M, Dhaliwal, G. The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners. Diagnosis 2018;5:197–203. https://doi.org/10.1515/dx-2018-0052.Search in Google Scholar PubMed

30. Park, YS, Lineberry, M, Hyderi, A, Bordage, G, Riddle, J, Yudkowsky, R. Validity evidence for a patient note scoring rubric based on the new patient note format of the United States Medical Licensing Examination. Acad Med 2013;88:1552. https://doi.org/10.1097/acm.0b013e3182a34b1e.Search in Google Scholar

31. O’Dowd, E, Lydon, S, O’Connor, P, Madden, C, Byrne, D. A systematic review of 7 years of research on entrustable professional activities in graduate medical education, 2011–2018. Med Educ 2019;53:234–49. https://doi.org/10.1111/medu.13792.Search in Google Scholar PubMed

32. Singh, M, Collins, L, Farrington, R, Jones, M, Thampy, H, Watson, P, et al.. From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. Diagnosis 2022;9:184–94. https://doi.org/10.1515/dx-2021-0031.Search in Google Scholar PubMed

33. Torre, D, German, D, Daley, B, Taylor, D. Concept mapping: an aid to teaching and learning: AMEE Guide No. 157. Med Teach 2023;45:455–63. https://doi.org/10.1080/0142159x.2023.2182176.Search in Google Scholar PubMed

34. Cook, DA. If you teach them, they will learn: why medical education needs comparative effectiveness research. Adv Health Sci Educ 2012;17:305–10. https://doi.org/10.1007/s10459-012-9381-0.Search in Google Scholar PubMed

35. Jain, V, Waghmare, L, Shrivastav, T, Mahakalkar, C. SNAPPS facilitates clinical reasoning in outpatient settings. Educ Health 2018;31:59–60. https://doi.org/10.4103/1357-6283.239052.Search in Google Scholar PubMed

36. Jain, V, Rao, S, Jinadani, M. Effectiveness of SNAPPS for improving clinical reasoning in postgraduates: randomized controlled trial. BMC Med Educ 2019;19:224. https://doi.org/10.1186/s12909-019-1670-3.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2023-0149).

Received: 2023-10-17
Accepted: 2024-02-09
Published Online: 2024-03-07

© 2024 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. The growing threat of hijacked journals
  4. Review
  5. Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials
  6. Mini Review
  7. Diagnostic value of D-dimer in differentiating multisystem inflammatory syndrome in Children (MIS-C) from Kawasaki disease: systematic literature review and meta-analysis
  8. Opinion Papers
  9. Masquerade of authority: hijacked journals are gaining more credibility than original ones
  10. FRAMED: a framework facilitating insight problem solving
  11. Algorithms in medical decision-making and in everyday life: what’s the difference?
  12. Original Articles
  13. Computerized diagnostic decision support systems – a comparative performance study of Isabel Pro vs. ChatGPT4
  14. Comparative analysis of diagnostic accuracy in endodontic assessments: dental students vs. artificial intelligence
  15. Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics
  16. The Big Three diagnostic errors through reflections of Japanese internists
  17. SASAN: ground truth for the effective segmentation and classification of skin cancer using biopsy images
  18. Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE)
  19. Development of a disease-based hospital-level diagnostic intensity index
  20. HbA1c and fasting plasma glucose levels are equally related to incident cardiovascular risk in a high CVD risk population without known diabetes
  21. Short Communications
  22. Can ChatGPT-4 evaluate whether a differential diagnosis list contains the correct diagnosis as accurately as a physician?
  23. Analysis of thicknesses of blood collection needle by scanning electron microscopy reveals wide heterogeneity
  24. Letters to the Editor
  25. For any disease a human can imagine, ChatGPT can generate a fake report
  26. The dilemma of epilepsy diagnosis in Pakistan
  27. The Japanese universal health insurance system in the context of diagnostic equity
  28. Case Report – Lessons in Clinical Reasoning
  29. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst
https://doi.org/10.1515/dx-2023-0149
Keywords for this article
SNAPPS; medical education; clinical reasoning

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. The growing threat of hijacked journals
  4. Review
  5. Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials
  6. Mini Review
  7. Diagnostic value of D-dimer in differentiating multisystem inflammatory syndrome in Children (MIS-C) from Kawasaki disease: systematic literature review and meta-analysis
  8. Opinion Papers
  9. Masquerade of authority: hijacked journals are gaining more credibility than original ones
  10. FRAMED: a framework facilitating insight problem solving
  11. Algorithms in medical decision-making and in everyday life: what’s the difference?
  12. Original Articles
  13. Computerized diagnostic decision support systems – a comparative performance study of Isabel Pro vs. ChatGPT4
  14. Comparative analysis of diagnostic accuracy in endodontic assessments: dental students vs. artificial intelligence
  15. Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics
  16. The Big Three diagnostic errors through reflections of Japanese internists
  17. SASAN: ground truth for the effective segmentation and classification of skin cancer using biopsy images
  18. Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE)
  19. Development of a disease-based hospital-level diagnostic intensity index
  20. HbA1c and fasting plasma glucose levels are equally related to incident cardiovascular risk in a high CVD risk population without known diabetes
  21. Short Communications
  22. Can ChatGPT-4 evaluate whether a differential diagnosis list contains the correct diagnosis as accurately as a physician?
  23. Analysis of thicknesses of blood collection needle by scanning electron microscopy reveals wide heterogeneity
  24. Letters to the Editor
  25. For any disease a human can imagine, ChatGPT can generate a fake report
  26. The dilemma of epilepsy diagnosis in Pakistan
  27. The Japanese universal health insurance system in the context of diagnostic equity
  28. Case Report – Lessons in Clinical Reasoning
  29. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 8.9.2025 from https://www.degruyterbrill.com/document/doi/10.1515/dx-2023-0149/html
Scroll to top button