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.
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.
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.
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.
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 April 6, 2020.