As a physician-educator, I prepare the next generation of healthcare professionals. Talk about a big responsibility; one of these kids may be my doctor someday!

Medical students and residents generally have great fact-learning skills. To get this far in life they have learned volumes of information and successfully regurgitated it on multiple-choice exams. During the clinical years of medical school and residency, we really try to hone analytic and critical thinking skills. Many of my colleagues feel we do an inadequate job in this arena. When I received an invitation to view a video on teaching critical thinking today, I jumped at the chance!

First, what is critical thinking? We all know it when we see it, but what skills make it happen? We can all agree that analysis, evaluation, and problem-solving are part of the picture. Self-reflection often goes along with the process. The hot skill in education circles is metacognition, or thinking about thinking. This boils down to making the learner address what they know and do not know, as well as the quality of their information, assumptions, and reasoning. Critical thinking can best be triggered via collaborative settings with high levels of learner engagement. Early feedback also helps drive this skill set.

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Writing assignments are ideal for critical thinking because writing open-ended answers forces engagement with a topic. Interaction and early feedback further drive interaction and reflection, either via peer or supervisor review. One speaker in the video session discusses successful use of a model in which students prepare a draft of an assignment, they undergo peer review, and then they turn in a final product. The quality of these assignments increased dramatically with this model when compared to making an assignment without the peer-review step.

The most writing in clinical courses involves structured clinical documentation, often in the inpatient setting. The nature of these notes has changed a lot since my days as a resident. Back then (1985-88), our notes followed the SOAP format- Subjective, Objective, Assessment, and Plan. We organized the assessment section by problems, either as an established diagnosis (Meningitis) or symptom (Acute Febrile Illness).  Plans for each problem could be organized as diagnostic, therapeutic, or educational (discussing exacerbating factors or importance of immunization with parents). In our assessment, we had to discuss the diagnostic possibilities for a symptom complex or other issues for an established diagnosis (for acute asthma exacerbations, we had to identify possible factors that provoked the episode). If we saw something new or unusual, we had to read something about the condition to provide an adequate discussion or we got it at rounds.

Sometime in the past decade, inpatient notes switched to a systems-based format for the assessment, listing the status of the cardiovascular, respiratory, and all other systems. I first saw this in intensive care settings; now all residents seem to use this format in all settings. I can see why intensivists love this method. It provides a very clear snapshot of how all body systems are supported and the progress they are making. The goal of ICU care is to get the patient out of the ICU alive, not necessarily to solve the overall issues. When no systems require intensive care, the patient can go to the floor whether or not the overall problem has been diagnosed.

This form of note does not force or promote the sort of critical thinking of the original SOAP format. Can we do the same thing verbally on rounds? Possible, but as the video points out, writing is still the best way to engage trainees.

I wonder if other academic physicians feel the same way about "systems-based assessments?" Has anyone tried a hybrid format with an assessment section like the old days followed by systems-based assessments and plans?

My other question is how this shift happened? I have been unable to find publications to support the superiority of the systems-based approach. Does it exist?