Purpose: Little is known about how often residents encounter unanswered clinical questions in their training. This knowledge would facilitate the development of curricula to help residents practice evidence-based medicine. This study was conducted to determine the frequency, characteristics, and pursuit of residents' clinical questions.

Subjects and methods: Residents in a university-based primary care internal medicine program were observed in two hospital-based teaching clinics. Residents were interviewed after each patient encounter to determine whether they had any remaining clinical questions. At the end of each clinic session, they recorded their level of agreement with a series of statements about factors that were expected to motivate residents to seek the answers to each question. One week later, residents were contacted to determine if they had pursued these questions.

Results: Sixty-four residents were interviewed after 401 (99%) of 404 patient encounters. They identified 280 new questions, approximately 2 questions for every 3 patients. The most common types of questions were related to therapy (38%) or diagnosis (27%). The residents were subsequently contacted about 277 (99%) of their questions. Of these, only 80 (29%) were pursued, most commonly by consulting textbooks (31%), original articles (21%), or attending physicians (17%). In a multivariable analysis, belief that the patient expected the answer (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.3 to 4.0, P = 0.004) and fear of malpractice exposure (OR = 2.1, 95% CI: 1.0 to 4.3, P = 0.05) were associated with information pursuit. Lack of time (60%) and forgetting the question (29%) were the most frequent reasons for failing to pursue a question.

Conclusion: Residents frequently encountered new clinical questions in the outpatient clinic, but infrequently answered them. Efforts to demonstrate the feasibility of timely searches, remind them of their questions, and reinforce the exigency (educational if not clinical) of all questions may reclaim missed opportunities for self-directed learning.