Despite the growing use of simulators in medicine and other disciplines, researchers say bronchoscopy remains a field where learning is largely hands-on, experienced through taking care of real patients.

Attending physicians must balance the autonomy of teaching fellows with patient safety during these clinical teaching experiences, Dr. Anna K. Brady and others write in their research, entitled “Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists’ Assessment of Learners, Supervisory Styles and Variation In Practice.”

Students are given a target of performing 100 bronchoscopies during their pulmonary fellowship — a goal set by the Accreditation Council for Graduate Medical Education. Little data, however, is available on best bronchoscopy teaching practices, according to the research.

A better understanding of how bronchoscopy is supervised could enable improvements to how bronchoscopy is taught, the authors write.

The researchers set out to answer a primary question: “How do attending bronchoscopists supervise bronchoscopy, and, in particular, how do they balance fellow autonomy with patient safety?”

Their study was conducted at a single center as a focused ethnography, which used audio recordings of the conversations between attendings and fellows during the procedures. That was supplemented with  observations of nonverbal teaching that occurred during the bronchoscopies.

In addition, there were some supplemental interviews conducted with the attendings and fellows.

The study, which observed seven attending bronchoscopists overseeing eight bronchoscopies, identified four supervisory styles:

• Modelling
• Coaching
• Scaffolding, which helps students build on prior knowledge
• Fading, where the teacher gradually decreases the level of assistance needed to complete the procedure

Attendings chose a style based on their assessment of the skill of those they were overseeing and moved between teaching styles as needed. Further study is needed, the researchers wrote, to determine whether the combination of teaching modes helped produce well-rounded bronchoscopists.

More than five years ago, a CHEST Expert Panel Report raised concerns about the variability in bronchoscopy training programs and recommended that bronchoscopy training incorporate multiple tools, including e-learning, lectures, books, case-based reviews and simulation.

That research — entitled “Adult Bronchoscopy Training, Current State and Suggestions for the Future: CHEST Expert Panel Report” — also recommended that certifying agencies move to standardized skill acquisition and knowledge-based competency assessment for both pulmonary and thoracic surgery trainees.

The training styles documented in that research were didactic lectures with hands-on supervision, a checklist approach, and some use of advanced simulation centers.

A “volume-based criteria” for competency assessment, the authors wrote, doesn’t serve patients well and “leaves well-meaning training programs to their own devices on how to best ensure training and competency assessment of their residents and fellows.”