Analysis of resident and attending physician interactions in family medicine

Journal of Family Practice, June, 1989 by Mark P. Knudson, Frank H. Lawler, Steven C. Zweig, Carlos A. Moreno, Michael C. Hosokawa, Robert L. Blake, Jr.

Analysis of Resident and Attending Physician Interactions in Family Medicine

There has been increasing interest in defining, describing, and analyzing clinical teaching, particularly in the ambulatory setting. Most clinical teaching does not fit neatly into traditional teaching or learning models; however, the interaction between a resident and an attending physician is of particular interest because of the broad range of behaviors that come into play. This one-to-one interaction has several functions, including education, supervision, socialization, and quality control.

Traditionally, in the ambulatory setting the resident-attending physician interaction follows the completion of a history and physical examination by the resident. The resident presents the findings to the attending physician, and the ensuing dialogue becomes a teaching-learning experience focused on the care of the patient. Teaching and learning may be categorized as instruction, question-and-answer, inquiry-problem solving, modeling, consultation, demonstration, clarification, or seeking information from such outside resources as texts or consultants. When a diagnosis and a management plan have been developed that are acceptable to the resident and to the attending physician, the resident returns to the examination room to discuss the findings and the plan with the patient.

There are many variations to this basic scenario. In some training programs, all residents present all patients to the attending physicians, and in others, the interns present all patients, but second- and third-year residents present a proportion of their patients or present only at the residents' discretion. The resident and the attending physician may see the patient together, the resident may be viewed from an observation room or by video, or the entire interaction may be centered on the resident's presentation of a patient whom the attending physician never sees.

Few observational studies of one-to-ne clinical teaching have been published. Foley and others[1] videoptaped 17 randomly selected clinical teaching sessions in a core medical school clerkship and analyzed the verbal behavior and the level of verbal interaction. Foley defined low-level information and low-level questions as reporting, reading, summarizing, giving or asking directions, giving information, or asking about procedures of facts. High-level information and questions included comparing, contrasting, evaluating, synthesizing, predicting, and hypothesizing. The 17 observations included teaching rounds, working rounds, morning reports, lectures, patient management conferences, grand rounds, and journal clubs. Low-level information and questions accounted for 78% of instructor talk and ranged from 69% in morning reports to 86% in lectures.

Glenn and others [2] observed 949 interactions between residents and attending physicians in a family medicine ambulatory care center. Teaching behaviors were placed in ten categories on an interaction analysis recording form. Clarifying information and concluding statements were observed in 90% of the interactions; statements that recalled didactic information or involved analysis of information and options were observed in two of every three interactions. Multiple recurrence of clarifying, recalling, analytical, and concluding behaviors occurred in the same teaching interaction, and Glenn et al concluded that resident-attending physician teaching was best described as team problem solving.

Williamson and others [3] observed resident-attending physician interactions to determine clinical independence and assertiveness. First-year residents consulted the attending physician in 48% of the visits compared with 28% and 26% for second- and third-year residents, respectively (P [is less than].005). The mean duration of the interactions decreased from 7.7 minutes for first-year residents to 6.9 and 6.1 minutes for second- and third-year residents, respectively (P [is less than].05]). More senior residents engaged in more focused interactions and demonstrated clinical independence and educational assertiveness.

The authors of this study were interested in developing an observationabl model to better describe the resident--attending physician interaction. The purpose of this study was to observe, classify, and record verbal teaching-learning behaviors in the resident-atteding physician interaction.

METHODS

Family medicine residents at the University of Missouri-Columbia present patients to the attending physician in a conference room adjacent to the examining rooms. Interns are expected to present all patients to the attending physician. Second- and third-year residents present their patients or cases at their discretion; all encounters are reviewed by the attending physician, but not necessarily at the time the patient is in the clinic. Following the case presentation and discussion of a patient, the resident returns to the patient in the examining room; in some cases the attending physician accompanies the resident to see the patient. Most teaching or learning occurs during the case presentation and discussion of the patient. Attending physicians use this opportunity differently depending on their attending style, the number of patients to be seen by the resident, the chielf complaint, and the skills of the resident.