BMJ Open. 2026 Jul 9;16(7):e115534. doi: 10.1136/bmjopen-2025-115534.
ABSTRACT
OBJECTIVES: (1) To compare the effectiveness of guided group reflection (GGR) versus SNAPPS (Summarise history and physical examination, Narrow differentials, Analyse the differentials, Probe the preceptor, Plan of patient management, Self-directed learning), as a teaching intervention in improving clinical reasoning (CR) skills of final-year MBBS (Bachelor of Medicine, Bachelor of Surgery) students. (2) To determine which teaching intervention is more effective in improving specific components of CR (data acquisition, problem presentation, hypothesis generation, illness script comparison and diagnosis) among final-year MBBS students.
DESIGN: Quasi-experimental study involving two parallel intervention groups with pretest and post-test research design.
SETTING: The study was conducted from March to June 2025 at the medical department of Holy Family Hospital, affiliated with Rawalpindi Medical University.
PARTICIPANTS: A total of 128 final-year Bachelor of Medicine, Bachelor of Surgery students participated over three consecutive internal medicine clinical rotations, each rotation lasting four weeks and involving approximately 45 students.
INTERVENTION: After the informed consent, the participants were randomly allocated into two groups using a lottery method: one receiving GGR intervention and the other receiving SNAPPS intervention. Four clinical cases: chronic dyspnoea, anaemia, chronic liver disease and chronic diarrhoea were addressed during the teaching sessions in both groups. To maintain ethical fairness, students were offered crossover exposure to the alternate teaching method after a 4-week gap.
OUTCOMES: A pretest comprised of 15 extended matching questions (EMQs) was used to assess baseline CR skills of the students. Post-tests using blueprint-aligned EMQs were administered after each session, with cumulative scoring at the end of each rotation. The primary outcome was overall improvement in CR, whereas the secondary outcome was improvement in performance of specific CR components.
RESULTS: Both groups showed significant improvement in overall CR scores (p<0.001). The GGR group achieved higher postintervention scores compared with SNAPPS (32.25±6.2 vs 28.89±9.0; p=0.016), with a moderate effect size favouring GGR (Cohen’s d=0.43). Domain-level analysis showed greater gains with GGR in data acquisition, problem presentation and hypothesis generation, while no significant differences were observed for illness script comparison or final diagnosis.
CONCLUSION: Both GGR and SNAPPS teaching methods effectively enhance CR skills among undergraduate medical students. However, GGR demonstrated greater effectiveness in CR domains requiring deeper analytical thinking and collaborative reflection, especially when managing complex cases. Incorporating GGR within undergraduate clinical clerkships may strengthen diagnostic reasoning, particularly in settings with limited faculty-student teaching opportunities.
PMID:42425559 | DOI:10.1136/bmjopen-2025-115534
