Elsevier

Journal of Surgical Education

Volume 71, Issue 5, September–October 2014, Pages 756-761
Journal of Surgical Education

Original reports
Troublesome Knowledge in Pediatric Surgical Trainees: A Qualitative Study

https://doi.org/10.1016/j.jsurg.2014.03.004Get rights and content

Background

Meyer and Land (2003) describe threshold concepts as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. The successful completion of pediatric surgical training in the United Kingdom is a lengthy and complex professional journey in which trainees emerge as consultants with a professional identity. We sought to explore how “threshold concepts” applied to pediatric surgical training with a view to identifying elements that were “troublesome.”

Methods

Semistructured interviews were conducted. Transcripts were generated from audio recordings and thematically analyzed by the authors. Constant comparison was used to refine themes. Participants were purposively recruited across all years of training. A total of 8 pediatric surgical trainees participated in the study. Approval from obtained from the Human Research Ethics committee.

Results

Although there is overlap between themes, analysis revealed “troublesome” areas of training related to knowledge (breadth and rarity of some conditions), clinical judgment (shifting expectation of independence), technical skills (accessing opportunities), transitions between roles (increasing responsibility and remoteness of support), relationships with trainers, and the effect of negative experiences.

Conclusions

Viewing trainees’ experiences of surgical training through the lens of “threshold concepts” provides insight to the importance of viewing the curriculum in a holistic way. Negative experiences in training were an important catalyst for development, inducing a fundamental change in perception, which might be characterized as a rupture of a “meaning frame.” Trainees in pediatric surgery can be viewed as moving to a mature specialist identity via a transitional state—liminality, from entry into specialist training.

Introduction

Pediatric surgery in the United Kingdom (UK) involves the delivery of specialist surgical care to patients under the age of 16 years. As a consequence of this, the specialty encompasses specialist gastrointestinal surgery, thoracic surgery, urology, surgical oncology, and neonatal surgery. Pediatric surgeons, therefore, encounter a wide range of pathology and a wide range of sizes of patient. Pediatric surgical training consists of a 6-year higher surgical training program, which follows a period of core surgical training.

Higher training is governed by the curriculum laid down in the Intercollegiate Surgical Curriculum Project (ISCP).1 Within the 5-year training program, trainees have to gain experience and expertise across the wide range of subspecialties already described. The training system requires regular workplace-based assessments (approximately 40 per year), including an annual 360° appraisal. Trainees’ progress is reviewed at a formal meeting at least annually. Knowledge is assessed summatively at the end of training by the intercollegiate Fellowship of the Royal College of Surgeons examination. Within the training period, therefore, trainees must make the transition from a core surgical trainee to consultant, competent and confident in dealing with a wide range of types of patient and clinical problems. Knowledge of the specific difficulties faced by trainees during the process may enhance the training system.

To identify these difficulties, we decided to approach this study from the perspective of the trainee. This has the advantage of avoiding approaching difficulty from the perspective of the trainer, whose perception might be significantly different; it has been argued that “an expert’s perception may be radically different from a novice’s, and a novice may struggle with difficulties that the expert can no longer see.”2

To approach the issue of difficulty, we chose the framework of threshold concepts described by Meyer and Land3 as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. Meyer and Land further characterized the crossing of a threshold as being irreversible, integrative, and troublesome. As Schwartzman4 points out, “all defining characteristics, except for troublesome, describe the aftermath—not the experience—of student’s successful acquisition of troublesome material.” Therefore, to identify threshold concepts in current trainees, we needed to identify areas of learning where learners report experiencing “troublesomeness.”

Therefore, the research question for this study was as follows, “what knowledge and skills do pediatric surgical trainees find most troublesome to acquire?”

Section snippets

Method

To seek examples of troublesome knowledge in pediatric surgical trainees, individual semistructured depth interviews were conducted by the lead author (S.B.). Depth interviews were selected to ensure confidentiality because of the potential sensitivity of the topic.

Interviews were conducted off hospital premises in a quiet location. An interview guide was developed based on the ISCP,1 the theoretical framework of threshold concepts, and participants were encouraged to identify areas of

Results

Overall, 8 of 10 interviewees accepted the invitation to participate in the study. Participants were from all 6 years of higher training in pediatric surgery; 2 of them were women. Detailed participant characteristics have been omitted to preserve anonymity. All participants in the study engaged well with the interview process and seemed to give their views freely.

Discussion

This study’s importance is in illuminating broader elements of trainees’ development.

Several facts were thought by participants to be important components of successful learning, and consequently their absence led to difficulties. The most prominent example of this was the relationship with their training consultant, which was thought to govern access to opportunities to develop operative skills. The decision about whether an operation is performed by a trainee or their trainer is complex and

Acknowledgments

The authors would like to gratefully acknowledge Dr Eleanor Bond’s helpful comments on the manuscript.

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