What trainees grapple with: a study of threshold concepts on the medicine ward

Abstract

The identified TCs offer important insights into the relationship between trainee actions and how they conceptualise practice. At their heart, many appeared to represent ideals of practice that trainees should incorporate into their developing identities as they explore what it means to be a physician. Future research should explore how to incorporate TCs into assessment and the support of trainee development.

Grappling with troublesome knowledge

“…By contrast, some of the categories in the present study seem more akin to skills or skill sets than to concepts. For example, Bhat et al.…”

“…Troublesome knowledge, in the lexicon of threshold concepts, is not simply knowledge that is difficult to understand, but knowledge that drastically alters one's perception of how that ‘piece of the world’ works. For example, ‘uncertainty in medicine’ emerges as a troublesome and transformative concept in the present study, as well as in other studies of medical students and palliative care physicians . Tolerance for ambiguity is considered essential for medical competence and yet some trainees enter medicine with the assumption that it is an exact science.…”

“…In this issue of Medical Education , Bhat et al. report a qualitative study of what residents grapple with on an internal medicine rotation using threshold concepts as a sensitising analytical tool . Their report sheds light on poorly understood processes of identity and skill development by describing nine threshold concepts.…”

“…Their report sheds light on poorly understood processes of identity and skill development by describing nine threshold concepts. These include ‘contextual care’, wherein a holistic understanding of a patient's context and complexity is needed to provide an appropriate care plan, and ‘plurality of role’, which requires trainees to recognise and enact their status as not just learners, but also health care providers and educators …”

“…Discovering that physicians must often work with diagnostic and therapeutic uncertainty is unsettling and, for some, insurmountable (‘If I am wrong about this, what else am I wrong about?’ ‘If medicine is uncertain, what is a doctor anyway?’). Linking threshold concepts such as this to identity formation as Bhat et al . have done is apt because crossing such a conceptual threshold transforms not only how we see the world around us, but how we see ourselves as well.…”