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.

More than three fourths of the total resident-attending physician interactions involved presentation of the case by the resident and information gathering through direct questions by the attending physician. Thus, in an average interaction of a little more than 4 minutes, the demands of data gathering to assure good patient care left very little time for teaching. Additional study is needed to determine whether scheduling patients to allow for more teaching time would be justified educationally and financially. Even more basic, it should be determined whether attending physicians would use additional time for teaching if it were available.

The authors were puzzled by the similarity in residents' verbal behaviors regardless of postgraduate year, and the variations in the behaviors of the attending physicians (although only one was statistically significant) when interacting with residents at different levels. Thus, the attending physicians taught differently at the postgraduate year levels, but the residents interacted in much the same manner. This finding seemed to be contrary to the findings of Williamson et al, [3] which showed increasing independence with resident level.

Of the six most common resident verbal behaviors, only exploration and open discussion is a teaching-learning behavior and accounted for 10% or less of the residents' part of the interaction. The other resident behaviors were more specific to patient care issues, although it is difficult to discriminate between patient care and teaching behaviors. Attending physician behaviors were also more specific to patient care, and about 35% of the attending physicians' time related to teaching and learning.

Facilitating the development of residents' clinical problem-solving skills through the use of questioning and discussion strategies by attending physicians is encouraged during faculty development teaching skills seminars. Direct questions are suggested as a means of completing the clinical picture of the patient being presented and to narrow or focus the residents' problem-solving. In contrast, inquiry or open-ended questions are suggested to redirect or widen the residents' thinking. It may be that while teaching through questioning, the Socratic method, is preferred, it is also the most time-consuming and inefficient method of attending physician teaching.

The total time for resident-attending physician interactions is relatively short when compared with other teaching-learning experiences such as grand rounds or morning report. How much the resident-attending physician interaction contributes to learning is unknown. In practice, this interaction may have more of a supervision or quality control function than an educational function. If the residents' presentation is the only source of information about the patient for the attending physician, it is appropriate that a substantial portion of the interaction focuses on gathering information. Thus, actual teaching by the attending physician is limited by the nature of the interaction, and scheduling of patients to allow time for teaching may be necessary.