Join us with our guests Alaka Ray (@AlakaRay) and Ryan Nall (@nallryan) as we discuss different precepting models for the outpatient setting. Dr. Ray and Dr. Nall review the pros and cons of the traditional, the one-minute preceptor (OMP), SNAPPS, and precepting in the presence of the patient (PIPP) models of precepting. Learn about the various precepting models for teaching all levels of learners!
Teaching in the outpatient setting can be challenging due to the fixed schedule and limited time. Once behind, a learner can feel stressed and the patients can get upset creating barriers to learning. Focus on the Goldilocks principle of ambulatory teaching: not too much or too little, but just the right amount. The preceptors role is to help the learner take great care of patients while growing their ambulatory medicine knowledge base.
Oftentimes giving student learners fewer patients to see can allow the learners the time needed to orient themselves to the patients, reflect afterwards, and effectively learn. More is less in this setting.
When time-crunched, resident preceptors often jump to the plan during a presentation. This practice takes away the opportunity for the resident to independently develop the care plan.
Focuses on clinical supervision. The traditional model is about safely taking care of the patient. The learner presents information to the preceptor. The preceptor asks for additional details and then gives the plan to the learner to implement. Often, there is no deliberate teaching. If teaching does occur it is usually specific to a patient case and not always generalizable to future patient care. Typically there is no direct feedback given to the learner. Indirect feedback is provided as the preceptor or attending makes changes to a care plan. This model is typically time-efficient for patient care. However, this model does not allow the preceptor to assess the learner’s knowledge or clinical reasoning skills.
Focus on Five Microskills
The One Minute Preceptor is a good default strategy, especially for early learners and new attendings. This is a preceptor-driven strategy that encourages independent thinking and helps the preceptor assess knowledge gaps and diagnostic reasoning (Neher 1992).
SNAPPS is learner-driven and best for more advanced learners who can self-assess knowledge gaps.
Having the learner identify a knowledge gap for self directed study is a key component of this preceptor strategy (Wolpaw 2003).
PIPP is the outpatient equivalent of inpatient bedside presentations. The learner sees and examines the patient like normal and then when the learner is ready the preceptor joins in the exam room. The presentation occurs in front of the patient at which time the preceptor can ask clarifying questions, perform any additional exam maneuvers, and review the plan with the patient and learner. The preceptor can add teaching pearls in the exam room and if necessary, debrief with the learner after the encounter.
This model is efficient and patient-centered. PIPP increases time spent face to face with the patient and can reduce the patient’s length of time in the office. This model works for early and advanced learners. PIPP allows for the preceptor more time to observe the learner and to provide feedback on communication style, body language, use of the electronic health record, and other aspects of doctoring that are not seen if receiving a presentation out of the exam room (Madson 2014, Power 2017). Challenges include making learners comfortable presenting in front of the patient and ensuring patients allow the learner to direct and lead the encounter (i.e. making sure the patient does not just direct all attention to the preceptor).
Each of the above precepting models (OMP, SNAPP, and PIPP) allows the preceptor to assess the learner’s thought process and clinical reasoning. Dr. Nall points out that it is perfectly acceptable to be fluid in the precepting approach and utilize all of the precepting models (traditional, OMP, SNAPP, and PIPP) in the outpatient setting.
In What Makes a Leader, Daniel Goleman discusses different types of leadership including both positive and negative leadership styles. Goleman points out all types of leadership have a place depending on the circumstance. Similarly, all precepting models or parts of them can be useful and necessary in our clinical teaching.
Dr. Ray recommends that no matter what precepting model you choose, always try to ask the learner for their plan.
One thing that OMP, SNAPP, and PIPP all have in common is deliberate practice and intention. As long as you are deliberate and intentional. you can choose any preceptor model or aspect of a preceptor model to make it work for you.
These models have been studied. OMP seems more focused on differentials and diagnostic evaluations versus the traditional model, which is much more focused on the history taking, risk factors, and presentation skills (Irby 2004). SNAPPS is much more likely to explore differentials and justification than the traditional model (Wolpaw 2012).
We often teach around differentials and medical knowledge , but you can also go into other areas of management reasoning. Teach about processes. Some residents are medically competent but don’t know how to get things done. It can be generalizable and will empower residents to take better care of their patients. “Getting stuff done” Reasoning is part of being a physician and systems-based practice.
With advanced learners, it can be helpful to push their thinking with hypotheticals. If someone is hitting the nail right on the head in the presentation, that’s when hypotheticals like “what if,” “when would you,” and “why” can work well.
Create a learning climate- set expectations, be kind, give and ask for feedback.
Be deliberate and intentional about your approaches- use what parts of precepting models work.
Have fun! Create a positive learning environment and welcome learner’s thoughts and expertise in the care of patients.
Listeners will develop precepting strategies to employ in their next ambulatory teaching experience.
After listening to this episode listeners will…
Drs Alaka Ray and Ryan Nall report no relevant financial disclosures. The Curbsiders Teach team reports no relevant financial disclosures.
Nall R, Ray A, Heublein M, Kryzhanovskaya E. “#12 Teaching in the Ambulatory World: precepting model potpourri (PIPP, SNAPPS, OMP)”. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach. August 2, 2022.
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