The development of clinical independence: resident-attending physician interactions in an ambulatory setting

Interactional analysis data from 949 resident-attending physician interactions about the care of 2,975 ambulatory patients were analyzed to test the hypothesis that consultation rates and behaviors would demonstrate a progressive increase in clinical independence and assertiveness. Consultation rates for first-, second-, and third-year residents were 48, 28, and 26 percent, respectively. The mean durations of consultations were 7.7, 6.9, and 6.1 minutes, respectively. Attending physicians visited 20, 12, and 13 percent of the patients of first-year, second-year, and third-year residents. The more senior residents displayed fewer of most types of interactional behaviors, suggesting a more focused discussion. Senior residents showed a progressive increase in initiating interactions of all types, demonstrating a kind of clinical independence and educational assertiveness that progressed through three years. There is a growing consensus that teaching in ambulatory medical practices will become widespread, but little information directs educational efforts in these settings. The findings suggest that clinical independence in the ambulatory setting is progressive and that measurements of consultation rates and behaviors expand knowledge about education in ambulatory care.