LAUSR

BACKGROUND Despite the growing role of simulation in procedural teaching, bronchoscopy training is largely experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education (ACGME) sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Little data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy is currently supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellows' autonomy with patient safety? STUDY DESIGN and Methods: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interview of fellows were also recorded. Interviews were transcribed verbatim prior to analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which were then grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may serve to create well-rounded bronchoscopists by the end of fellowship training and should be further studied.