#12 Teaching in the Ambulatory World: Precepting Model Potpourri (PIPP, SNAPPS, OMP)

August 2, 2022 | By Molly Heublein

With Dr. Alaka Ray and Dr. Ryan Nall

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! 

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Credits

• Producers, hosts: Era Kryzhanovskaya MD,  Molly Heublein MD
• Cover Art/Infographic: Charlotte Chaiklin MD
• Show Notes: John Ong DO
• Audio Editor: Clair Morgan of Nodderly
• Guest:  Alaka Ray MD,  Ryan Nall MD

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Time management
• Traditional approach to precepting
• The One Minute Preceptor (OMP)
• SNAPPS
• Precepting in the presence of the patient (PIPP)
• How to set up a particular topic or teaching pearl
• Self-improvement
• Outro

Precepting Models Pearls

1. Creating the learning climate is foundational! Set expectations, be kind, and give and ask for feedback
2. Be deliberate and intentional.  You don’t have to use any particular model, just use the parts of each that you think will work and keep getting feedback.
3. The traditional model of precepting is about taking care of the patient- the preceptor provides the supervision necessary to take care of the patient safely.  This may be a good choice when you are very time crunched/behind.
4. The One Minute Preceptor is focused on 5 microskills: 1. Get a commitment 2. Probe for supporting evidence. 3. Teach general rules  4. Reinforce what was done right.  5. Correct mistakes.  A good fall back approach, especially with early learners.
5. SNAPPS is a learner driven precepting model that is great for more advanced trainees.  Summarize the history and findings.  Narrow the differential to 2 or 3 possibilities. Analyze the differential by comparing and contrasting the possibilities. Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches.  Plan management for the patient’s medical issues
6. Precepting in the Presence of the Patient – PIPP- is a new model that can save time and improve patient experience.

Teaching in the Ambulatory World: Precepting Model Potpourri (OMP, SNAPPS, PIPP)

Biggest challenge to effective precepting: TIME 

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. 

Precepting Models

Traditional Model

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.   

The One Minute Preceptor (OMP)

Focus on Five Microskills

1. Get a commitment (to a diagnosis or next step in management) 

• What is the working diagnosis? If the diagnosis is established, what is the next step in treatment? 

2. Probe for supporting evidence

• Ask the learner questions about the evidence supporting the commitment
  • The goal is to understand the learner’s thought process and clinical reasoning

3. Teach a general principle 

• A short succinct teaching pearl that the learner can apply to future patient care

4. Reinforce what went well 
5. Correct errors and omissions 

•  Be mindful of the space in which you provide critical feedback 
  • It may be best to save critical feedback for an one-on-one session (not in a crowded room)  
• For more advanced learners without errors in their presentations, ask for other differential diagnoses as a thought exercise to avoid anchoring 

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 

• Summarize the patient case 
• Narrow the differential to two or three possibilities 
• Analyze the differential by comparing and contrasting the different possibilities 
• Probe the preceptor about uncertainties, difficulties, or challenges with the patient case 
• Plan management 
• Select a case-related issue for self-directed learning

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).

Precepting in the Presence of the Patient – PIPP

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). 

Choosing a Precepting Approach

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).

Choosing a Teaching Pearl

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. 

Tips for Continuous Improvement

• Getting candid feedback from learners can be difficult sometimes, especially in a 1 on 1 setting with the attending. The attending can help with the feedback process by starting off with something they say they didn’t do well, or are trying to improve upon, and getting feedback specifically on that. By doing this, it can help give the learner somewhere to start and feel more comfortable with giving feedback. 
• Getting feedback from peer observers, and observing others to take the best practices and good habits from someone else can be very valuable. In this way, feedback isn’t being used as an evaluative process, but more of a community building and learning exercise. 
• There are faculty development resources on a local or national level like through SGIM workshops, APDIM (Association of Program Directors in Internal Medicine), and podcasts
• Identifying a goal and work toward that- gather focused feedback from a peer and/or your learners
• Listen to other preceptors to try and learn from, and see how others handle situations
• Be honest with yourself
• Having a structure and a model can be helpful, especially with reflection and celebration
• Try other models of precepting

Take home points

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.

Other Stuff

Links

1. Alaka’s book recommendation, All the Light We Cannot See – Anthony Doerr and Cloud Cuckoo Land – Anthony Doerr
2. Ryan’s book recommendation: The Secret Life of Bees – Sue Monk Kidd
3. Levels of Listening
4. Era’s Pick of the Week: Pop-Up Magazine
5. Molly’s Pick of the Week: This Podcast Will Kill You
6. Join national organizations!  SGIM  APDIM SHM are great resources for learning and growth

Goal

Listeners will develop precepting strategies to employ in their next ambulatory teaching experience.  

Learning objectives

After listening to this episode listeners will…

1. Recognize the challenges and opportunities around precepting in the ambulatory world. 
2. Describe the advantages and disadvantages of different precepting models in the outpatient setting.
3. Distinguish opportunities to apply various precepting strategies based on the level of the learner and the teaching points to be made.

Disclosures

Drs Alaka Ray and Ryan Nall report no relevant financial disclosures. The Curbsiders Teach team reports no relevant financial disclosures. 

Citation

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.