OBJECTIVE: To determine if fourth-year medical students can learn the high-level cognitive skills needed to manage critically ill patients during a critical care medicine elective designed in accordance with established educational principles. DESIGN: Students were randomly assigned to take one of two examinations with ten short essay questions to complete on the initial day. After the elective, students completed the other examination in a crossover design. SETTING: Five surgical intensive care units (ICUs) in a tertiary care university teaching hospital. PARTICIPANTS: Fourth-year medical students enrolled in the critical care medicine elective. INTERVENTIONS: All students were enrolled in a critical care medicine elective consisting of an orientation, interactive conferences, technical skills laboratories, daily rounds, and patient-care experience. These components were designed to encourage problem-solving, improve analytical skills, and minimize the deterrents to education in the ICU. MEASUREMENTS: The primary outcome measure was the difference in examination scores before and after the rotation. Examinations were designed to test the student's skills in application, analysis, synthesis and evaluation. Specific questions concerning hemodynamic assessment were compared. MAIN RESULTS: The students' mean pre-elective scores were 58.8 +/- 10.8%, compared with 85.5 +/- 9.4% after the elective (p < .0001). CONCLUSION: Students can learn cognitive components of patient management skills using a format that encourages judgment, decision-making, and analytical skills, despite the liabilities inherent to education in an ICU.