Clinical teachers are frequently pressed for time, living with the tension between efficiently caring for patients and making time for teaching in the context of a busy clinical practice (1). In recent years, the pace of psychiatry training (e.g., brief medication visits and one-session intake/evaluations) has increased. In order to expedite treatment decision-making and satisfy billing requirements, increasingly, supervision must occur simultaneous with or soon after the visit (2). As clinical teachers continue to struggle to balance teaching and patient care, research highlights the importance of clinical teaching: clinical teaching affects learner achievement over and above clinical experiences such as the number of patients seen (3, 4).
During the past two decades, models for effective teaching in clinical settings have been introduced (5–8). Clinical teaching models have been developed in specialties other than psychiatry, primarily to provide practical guidance. Recently, researchers have begun to examine outcomes associated with various teaching models. Because of the similarities between clinical teaching in psychiatry and other specialties, models developed within other specialties may be relevant to psychiatric teaching. This mini-review introduces psychiatric educators to research-informed clinical teaching models and encourages their regular use. We describe and review the literature on two clinical teaching models, both selected because they were the only models with research supporting their effectiveness. We explain the applicability of these models to psychiatry by providing psychiatry-based examples. This review will provide clinical teachers in psychiatry with a research-informed presentation that can guide clinical teaching practice and faculty development.
Two clinical teaching models, the One-Minute Preceptor (OMP) and SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, Select) are described here (7, 9). Clinical educators developed both the OMP and SNAPPS in response to a shift in clinical teaching from inpatient to outpatient settings, and, thus, they are primarily geared to ambulatory-care settings. Nonetheless, both models rely on steps that may be applicable across inpatient and outpatient settings.
For this review, we extracted 29 articles published between 1970 and 2011 via PubMed in English using the search terms “clinical teaching,” “models,” or “methods,” with Boolean operators in medical education. Among those, we searched each model further in PubMed and Web of Science to determine which models had been studied empirically. Descriptions of teaching models without supporting research on their effectiveness, individual instructional strategies (e.g., provision of feedback to learners), and teaching models that were part of larger interventions were not included in this review. Examples of the articles not included in this review were “the Aunt Minnie Model” (5) (the learner presents the main complaint and probable diagnosis to the teacher, and the case discussion occurs after the clinical teacher has independently seen the patient) and time-saving instructional strategies (10) (teaching strategy in which demonstration is balanced with supervision). We extracted 10 articles that were empirical and focused on direct outcomes of the clinical teaching models. Those 10 articles focused on research outcomes of the OMP, which was developed in 1992 (8 articles), and SNAPPS, which was developed in 2003 (2 articles). For the purpose of this paper, we summarize the findings from those studies relevant to teaching practice.
The OMP, also referred to as the “microskills” of clinical teaching, was developed by Neher and colleagues (7). It is the most researched clinical teaching model (11–16). Neher and colleagues posited that clinical teachers in ambulatory settings needed to find ways to integrate trainees into patient care without disrupting it. The model was built on research about clinical teaching. The research demonstrated that, in traditional clinical teaching encounters, a trainee’s presentation of a patient was often followed by the teacher’s questions, focused primarily on diagnosing the patient and questions about factual information (e.g., “Does the patient have a history of suicide attempts?” “What risk factors for violence does the patient have?”) (17). Clinical teachers often asked for more details about the patient, but rarely asked trainees for their own impressions of the patient. Although asking about the patient helped the clinical teacher efficiently determine what was going on with the patient and prioritized patient care, it did not directly assess the learner’s level of knowledge. Accordingly, there was often little-or-no teaching or feedback to the learner (12). The goal of the OMP was to diagnose the patient, as well as the learner’s knowledge, in a time-efficient manner (7). We list each step of the OMP, including relevant examples from two teaching settings in psychiatry (pharmacotherapy and psychotherapy), in Table 1.
TABLE 1.The Steps of the One-Minute Preceptor (OMP) and Summarize, Narrow, Analyze, Probe, Plan, Select (SNAPPS) Clinical Teaching Models with Relevant Examples From Pharmacotherapy and Psychotherapy Teaching Settings
| Add to My POL
|Clinical Teaching Model Steps||Examples From Pharmacotherapy Settings||Examples From Psychotherapy Settings|
|Model: One-Minute Preceptor|
|1. Obtain a Commitment from the learner about what he or she thinks is going on with the case.||“What do you think is going on with the patient?”“How concerned are you about the patient’s suicidal ideation today?”||“What is your psychodynamic formulation for the patient?”|
|2. Probe for underlying reasoning to explore the learner’s understanding.||“What are the major findings that led to your conclusion?”“What other DSM-based differential diagnoses might you consider?”“How did you rule those diagnoses out?”||“What is the evidence that led to your formulation?”|
|3. Teach one-to-two general rules pertaining to the case.||“In cases like this following an acute stroke, the prevalence of depression ranges from 20% to 50%.”||“Adding relaxation training to your cognitive-behavioral therapy may be particularly important for helping this patient manage his anger.”|
|4. Provide positive feedback for what the learner did well.||“You did a good job asking sensitive and non-judgmental questions about suicide.”||“You did a good job helping the patient understand how showing up late for the appointment might be worth examining without making [her] feel judged?”|
|5. Correct learner’s errors and make recommendations for improvement.||“Next time, be sure to also screen for homicidal ideation and psychotic symptoms in patients with depression.”||“Next time, consider delving deeper into the patient’s “forgetfulness” about paying his bill for the psychotherapy.”|
|1. Summarize briefly the history and findings.|
|2. Narrow the differential to two or three relevant possibilities.||“What are highest in your differential for understanding the patient’s history of aggressive behavior?”||“How might you understand the patient’s history of aggressive behavior using an interpersonal psychotherapy model?”|
|3. Analyze the differential by comparing and contrasting the possibilities.||“What else might you consider, and why?”||“What else might you consider, and why?”|
|4. Probe the preceptor: student asks questions about uncertainties, challenges, or alternative approaches.||Trainee: “I have never prescribed a tricyclic before and am unsure of the side effects.”||Trainee: “I feel uncomfortable talking to the patient about his bill for the psychotherapy. Isn’t that up to the billing office?”|
|5. Plan management for the patient’s medical/psychiatric issues.||“What treatment changes would you consider?”||“How might you address the patient’s resistance in the next session?”|
|6. Select a case-related issue for self-directed learning.||Trainee: “I would like to read more about the treatment options for bipolar depression before our next clinic.”||Trainee: “I would like to read more about the meanings of payment in psychotherapy before our next supervision.”|
The OMP begins after the trainee presents the case; it consists of five steps. In the Commitment and Probing steps, the clinical teacher gains an understanding of the learner’s knowledge, reasoning, and learning needs, while simultaneously learning more about the patient. Obtaining a Commitment and Probing underlying reasoning inform the teacher’s direction for the next step: Teaching is targeted specifically to the trainee’s learning needs and therefore is more likely to be retained. Finally, during the Feedback and Correcting Errors steps, trainees receive directly relevant feedback about their knowledge and performance.
Researchers have primarily studied teacher and learner perceptions of the OMP, including both medical students and residents. After participation in OMP workshops, clinical teachers have described the OMP as useful and time-efficient, improving the perceived success of their teaching encounters, and improving their ability to evaluate learners and help learners reach their own conclusions (11, 14–16). After observing both traditional and OMP teaching encounters, students expressed preference for the OMP format (13). Clinical teachers trained in the OMP reported improved ability to “obtain a commitment” and “probe for supporting evidence” with their learners (16). Clinical teachers also reported more confidence in their ratings using OMP, as compared with traditional teaching interactions (11).
Other studies demonstrated improved clinical teaching skills and feedback behaviors for clinical teachers after OMP training (15). Learners rated residents trained in the OMP higher than control residents on getting a commitment, providing feedback, and motivating learners to do outside reading (14). Students reported that faculty who used the OMP provided improved quality of feedback and involved students more actively in the decision-making process (13). These studies found no differences in certain outcomes: overall teaching effectiveness or overall pre- and post- student satisfaction between teachers who use the OMP and those who did not were similar (14–16).
Researchers comparing teaching points after traditional or OMP teaching found mixed results. Medical students randomized to either OMP or traditional teaching expressed greatest interest in learning about the natural progression of disease. The top three teaching points preferred by students were the same for both groups (13). Medical students viewing OMP teaching scenarios expressed greater interest in learning about the natural progression of disease compared to students viewing traditional teaching scenarios (12). Teaching about disease and disease-processes focuses the teaching encounter on higher-order thinking, suggesting a potential benefit of the OMP model (12).
Although no formal studies have assessed the use of the OMP in psychiatry, in a recent letter, Tsao reflected on the usefulness and relevance of the OMP to psychiatry teaching (18). The OMP has been used as one of several instructional methods in psychiatry residents-as-teachers programs (19, 20) and for teaching of evidence-based medicine curricula to psychiatry residents (21). Residents experienced positive outcomes from the programs overall (19–21).
Ottolini and colleagues (8) recently extended the OMP to include steps to promote a safe learning climate and self-directed learning. The model, referred to as the eight-step preceptor model (ESP), includes the five steps of the OMP plus three additional steps. In one of these additional steps, teachers are encouraged to listen to the learner without interruption, to help create a safe learning climate. Teachers promote self-directed learning in two subsequent steps. This includes assessing the level of the learner by discussing the learner's experiences with previous patients and ensuring that learners identify their own learning needs by developing learning objectives at the end of each encounter. Clinical teachers who use more of the ESP steps received higher teacher ratings, but did not necessarily have longer teaching sessions. However, with the exception of teaching a general point and providing feedback, clinical teachers trained in the ESP model did not consistently incorporate all of the model's steps. This finding highlights the need for ongoing reinforcement of the steps after the initial training.
In summary, the OMP is consistently well received by teachers and learners. Most evidence suggests that the OMP model is efficient and has improved teacher skills for obtaining a commitment from the learner, probing for supporting evidence, and providing detailed feedback. Finally, the OMP appears to focus clinical teachers’ teaching-points on higher-order thinking skills of the disease and disease processes.
The SNAPPS teaching method was developed by Wolpaw and colleagues, based on the premise that the learner should prepare for and direct the outpatient learning encounter (9). The premise of their argument was that the learner has made a commitment to education, whereas the teacher has committed primarily to the care of patients. Thus, although both the teacher and learner are responsible for the success of the learning encounter, the individual who has committed time to education (i.e., the learner) should actively structure and direct that interaction. SNAPPS was developed to empower learners by emphasizing the collaborative relationship between the learner and the teacher. Both must be familiar with the steps of SNAPPS, with the teacher taking an initial coaching role until the learner begins to lead the encounter. Table 1 lists the steps of the SNAPPS model as well as relevant examples from pharmacotherapy and psychotherapy.
In the SNAPPS model, the Summarize step (Step 1) is the case presentation by the student. Narrowing (Steps 2) and Analyze (Step 3) are similar to the Commitment and Probing steps of the OMP. During these steps, the process of narrowing and analyzing the differential reveals the clinical reasoning skills of the learner. The Probe step (Step 4) is novel in that it requires learners to identify their own learning deficiencies and areas warranting additional study. Similar to the Teaching a General Rule step of the OMP, the Probe step in SNAPPS elicits the general rule to be taught to the student. To the degree that time permits, the preceptor addresses the student's specific questions during Step 4, but, unlike the OMP, the content of that discussion is learner-driven. Planning (Step 5) pushes the learner to consider a management or intervention plan in consultation with the preceptor and re-focuses the interaction onto the patient's care. Finally, in Select (Step 6), the student creates a plan with the preceptor for achieving the student's specific learning goals.
Research on SNAPPS has assessed the perceptions of medical students and teachers utilizing the model. Those studies demonstrated that SNAPPS fosters a collaborative relationship between learner and teacher (9). Learners utilizing SNAPPS described improved ability to assume an active role in identifying their own learning needs. Learners found SNAPPS easy to learn, and they appreciate being allowed to question their teacher and select their own self-directed learning issues. Clinical teachers reported that SNAPPS helped students generate questions relevant to the case and the learners’ level of knowledge. Clinical teachers enjoyed SNAPPS-based encounters with students. Teachers felt relieved that, instead of generating teaching-points that may not be of interest to the student, they could direct their teaching to students' self-identified learning needs. Clinical teachers must guide the interaction. Therefore, key to the success of SNAPPS are orienting faculty to its steps, encouraging students to use the model, and faculty’s assuming the role of an expert facilitator.
Compared with traditional clinical teaching, SNAPPS facilitated the expression of clinical diagnostic reasoning in the ambulatory setting (22). Students using SNAPPS have more concise summaries of patient findings, communicated more diagnoses, and compared diagnostic possibilities and justification for diagnoses more frequently than students taught with traditional methods (22). Also, SNAPPS did not create longer-than-usual student case presentations than traditional teaching encounters.
In brief, SNAPPS is a well-received and time-efficient teaching method that assesses learners' clinical knowledge and reasoning and engages them actively in their own learning while alleviating some of the teaching burden from the preceptor.
The OMP and SNAPPS clinical teaching models provide helpful frameworks for approaching teaching with psychiatry trainees and provide a general framework (e.g., asking for a commitment, discussing alternative hypotheses, focusing teaching on the learning needs of the trainee, providing feedback) that may be very useful for supervision in psychiatry settings. Clinical teachers can select the model that works best for them. In doing so, teachers should keep in mind that that the OMP is teacher-centered and requires that the teacher recall the steps of the model and use those steps to guide the discussion. Hence, the onus of directing the teaching encounter during the OMP falls upon the teacher. SNAPPS, on the other hand, requires that students use the steps of the model to guide the discussion and their learning with the teacher. Thus, SNAPPS is student-centered and places responsibility for the structure and direction of the encounter on the learner.
The OMP and SNAPPS were designed for settings that utilize a medical model and may be readily applied to psychiatry settings that use a similar model (e.g., psychopharmacology clinics, inpatient psychiatry wards). The steps of both models may also be applicable to psychotherapy supervision. Psychotherapy supervision differs from most other clinical teaching settings in a number of ways (23, 24): In psychotherapy supervision, there is typically a delay between the time of the clinical encounter and discussion of the case with a supervisor. The psychotherapy supervisor may not directly examine the patient or observe the trainee–patient interaction. In many circumstances, the psychotherapy supervisor's role may focus exclusively on teaching, and may not include the role of attending-of-record. Finally, the relationship between the trainee and psychotherapy supervisor and the pace of their work may be unlike those of other settings because of the intense focus on a small number of patients seen over an extended period of time. Acknowledging these differences, we believe that the core steps of the OMP and SNAPPS can apply to psychotherapy supervision as well as teaching in other psychiatry settings (see examples in Table 1). Time available for each step may be extended in many psychiatry settings, but much of the basic structure and process of preceptor–learner interactions may be the same as in non-psychiatry settings. The OMP and SNAPPS create a structure for the teacher–learner dyad that would likely apply regardless of the content or setting of the teaching encounter.
Both OMP and SNAPPS models require feedback skills to encourage and reinforce learning for the student. However, neither model describes specific feedback techniques that teachers might utilize. Literature on the provision of feedback in medical education dates back 50 years, with significant focus on the lack of feedback for learners in medical education (25). Learners identify the ability to give feedback as one of the most vital qualities of a good teacher (26). Yet, concerns with providing feedback have been similar to clinical teaching: lack of time precludes the provision of quality feedback. Feedback is also laden with another challenge: it is often a difficult and uncomfortable task for the teacher and the learner (27). Ultimately, incorporating research-based methods for providing optimal feedback will augment the success of the OMP and SNAPPS models.
These models maximize teaching during the clinical encounter by actively engaging learners and facilitating efficiency in the teaching process. The effectiveness of the clinical teaching models described here has not been studied among learners who have difficulty with self-reflection or identifying and monitoring their own learning needs. We would expect that those learners would struggle during Step 4 of the SNAPPS model. Similarly, the effectiveness of these models is less clear when learners are insufficiently responsive to feedback. Moreover, the differences between supervision in psychiatric settings and non-psychiatric settings limit the applicability of the research findings. The OMP, for example, was designed to be extremely brief and narrowly focused, neither of which are typical of many psychotherapy supervision settings. Each of the steps of the OMP or SNAPPS models could be covered more extensively in psychotherapy supervision than in faster-paced clinical teaching settings. Acknowledging these differences, these models provide an approach that may be applicable across most clinical teaching settings.
Teaching is a fundamental academic practice, and the impact of teaching on learning is far-reaching. The landscape of teaching continues to evolve. During the past two decades, demands have increased for accountability and documentation of teaching for academic promotion and self-improvement (28). Also, duty-hour changes have increased and will continue to increase faculty teaching responsibilities (29). The models described here provide teachers with a beneficial framework and requisite skills to teach in ways that promote and maximize learning.