Problems Versus Systems: How Does the Internal Medicine Clerkship Influence Medical Students' Note Writing?

1Brigham and Women's Hospital, Boston, MA
2Brigham and Women's Hospital, Boston, MA
3Brigham and Women's Hospital, Boston, MA

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 44

Background:

Learning to write inpatient notes is an integral part of the internal medicine (IM) clerkship. Anecdotal evidence suggests variation in students' assessment/plan (A/P) sections; students tend to follow either a system‐based or problem‐based A/P format. Educational commentators have written about the value of writing notes in a problem‐based format as a tool for teaching clinical reasoning. Little is known about the influences on, preferences for, and perceived value of a particular A/P section format. We sought to determine how students wrote notes prior to and during the IM rotation, the influenoes on format choice, and which format students find most valuable.

Methods:

We conducted a pre‐ and postclerkship survey of third‐year medical students entering the IM clerkship. Notes written by students on these patients were reviewed by investigators; the A/P section was classified as problem based, systems based, or mixed. The study was approved by both the HMS and Partners Institutional Review Boards.

Results:

Thirty‐one of 38 eligible students participated in the study (82%). In the prederkship survey, 40% of students preferred a problem‐based format, 25% preferred a system‐based format, 15% specified their own unique format, and 20% had no preference. Former preceptors (48%) and prior clerkships (42%) were the strongest influences on format. Prior pediatrics (29%) and surgery (26%) clerkships were the strongest clerkship influences, with neurology (13%) and obstetrics/gynecology (3%) clerkships showing less influence on format. Of 125 notes reviewed, 12%, 63.2%, and 24.8% were classified as systems‐based, problem‐based, and mixed problem‐systems A/P, respectively. In the postclerkship survey, 52% and 97% of students reported being instructed to write a system‐based and problem‐based A/P, respectively, at some point during the clerkship Residents, followed by attending physicians, were identified as the supervisors most influential in determining A/P format. Students who wrote systems based notes more frequently reported trouble determining where to place particular elements of the assessment and plan compared with students who wrote problem‐based notes (23% vs. 6%). At the end of the IM clerkship, 75% of students preferred a problem‐based format; 0% preferred a system‐based format, 10% preferred a mixed problems‐systems format, and 5% specified another approach.

Conclusions:

Students enter the internal medicine clerkship with a variety of preferences for note format. The majority exit the clerkship with a preference for a problem‐based format. This occurs despite conflicting instruction from supervisors about note format. More studies need to be done to evaluate the impact of A/P format on clinical reasoning.

Author Disclosure:

A. Dalal, none; M. Thorndike, none; J. Schnipper, none.

To cite this abstract:

Dalal A, Thorndike M, Schnipper J. Problems Versus Systems: How Does the Internal Medicine Clerkship Influence Medical Students' Note Writing?. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 44. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/problems-versus-systems-how-does-the-internal-medicine-clerkship-influence-medical-students-note-writing/. Accessed September 18, 2019.

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