Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
What are threshold concepts and how can they inform medical education? Hilary Neve, Andy Wearn & Tracey Collett To cite this article: Hilary Neve, Andy Wearn & Tracey Collett (2016) What are threshold concepts and how can they inform medical education?, Medical Teacher, 38:8, 850-853, DOI: 10.3109/0142159X.2015.1112889 To link to this article: http://dx.doi.org/10.3109/0142159X.2015.1112889
Published online: 26 Nov 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Weill Cornell Medical College]
Date: 02 August 2016, At: 01:06
2016, 38: 850–853
What are threshold concepts and how can they inform medical education? HILARY NEVE1, ANDY WEARN2 & TRACEY COLLETT1 1
Plymouth University Peninsula Schools of Medicine and Dentistry, UK, 2The University of Auckland, New Zealand
Abstract
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
The notion of ‘‘threshold concepts’’ is being widely applied and researched in many disciplines but is rarely discussed within medical education. This article is written by three medical educators who regularly draw on threshold concept theory in their work. They explore here the nature of threshold concepts and describe how the theory can offer medical educators new perspectives in terms of how they design curricula, approach teaching and support learners.
Background
Practice points
Consider the following situation. You have been Kate’s academic tutor since she started at medical school 18 months ago. One of your roles is to support her to develop her reflective writing, a requirement of the programme’s professionalism module. Kate has been resistant to the idea of reflective practice and you are not hopeful about your meeting this afternoon. She says that she cannot see the point of reflection and that the task is just ‘‘a hoop to jump through’’. You have spent time explaining the importance of reflection and suggesting ways she might develop her skills, but she tends to divert the conversation or disengage. Her writing, meanwhile, continues to be formulaic and feel inauthentic. There have, however, been some glimmers of thoughtfulness, particularly when she has written about her clinical experiences. When Kate arrives today, things are different. ‘‘I’ve got it!’’ she says ‘‘I finally get reflection!’’ Sure enough, her latest piece is insightful and analytical — she has written about her feelings and assumptions, explored dilemmas and considered others’ perspectives. You discuss what she has learnt about being a patient and the kind of doctor she hopes to become. She shows you an App that she has downloaded to record future reflections on her smartphone. After 18 months, her view of reflective practice has, it seems, been transformed; she has crossed a threshold and navigated a troublesome concept in learning. Reflective practice has been identified as a likely threshold concept (Joyce 2012). First described by Meyer and Land (2003) following extensive research into higher education, threshold concepts have been embraced by educators in many and diverse disciplines, leading to a growing body of research. While rarely discussed in medical education, they have the potential to offer medical educators important new perspectives. The threshold concepts framework can, for example, throw new light on Kate’s learning journey,
The notion of threshold concepts has been embraced in many disciplines, but little studied in medical education. Threshold concepts are key to achieving mastery of a subject. They are usually transformative, integrative, irreversible, bounded and often troublesome. A range of qualitative and quantitative methods have been used to identify threshold concepts. Identifying threshold concepts can help educators understand which concepts are fundamental to grasping their discipline and which might be particularly troublesome for learners. ‘‘Homeostasis’’, ‘‘the nature of evidence’’, ‘‘uncertainty’’, ‘‘empathy’’ and ‘‘embodied shared care’’ are concepts in medicine which appear to meet the criteria of a threshold concept.
helping us understand her ‘‘stuckness’’ and how to work with and support her while she lets go of her previous views, enabling her understanding of reflection to be transformed.
Aims In this paper, we draw on literature from other disciplines, including the health professions, to define threshold concepts and to consider which concepts, already identified as threshold, might be relevant to medicine and medical education. We discuss ways the threshold concept framework can influence how we design curricula, approach teaching and support learners. We also acknowledge some of the criticisms of the threshold concept framework.
Correspondence: Hilary Neve, Plymouth University Peninsula Schools of Medicine and Dentistry, Portland Square, Plymouth, PL4 8AA, UK. Tel: +44 (0)1752 586802; E-mail: [email protected]
850
ISSN 0142-159X print/ISSN 1466-187X online/15/080850–4 ß 2015 Taylor & Francis DOI: 10.3109/0142159X.2015.1112889
What are threshold concepts?
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
What is a threshold concept? Learning is often thought of in terms of building blocks of core concepts, which are often encapsulated in our learning outcomes. Core concepts have to be understood for learning to progress and must be correctly constructed. For example, to understand the disease of diabetes, students will need to understand concepts such as hormones, the role of the pancreas and receptors. Threshold concepts, it is proposed, do much more. They lead to a qualitatively different view of subject matter and are central to achieving mastery [sic] of a subject. Importantly, they have been described as being like a portal: ‘‘opening up a new and previously inaccessible way of thinking about something’’ (Meyer & Land 2003). According to Meyer and Land (2003), threshold concepts have certain characteristics in common, which Kate’s story illustrates. They are transformative, in that once understood, they can result in a significant shift in a learner’ perception of a subject or how they see the world. They are integrative inasmuch as connections that were previously hidden come into view (integration is often associated with an ‘‘Aha!’’ moment for learners). Moreover, as students journey towards the portal, they are said to pass through a liminal phase, (Cousin 2006), literally standing on the threshold (limina meaning threshold in Latin). This liminality is frequently troublesome (Perkins 2006) as students wrestle cognitively and/or emotionally with their emerging knowledge. New understandings, once learned, are usually irreversible and unlikely to be forgotten. It is noted that each threshold concept is bounded, demarcated from other conceptual areas (Meyer & Land 2003). Considerable work has been undertaken to define threshold concepts in different disciplines, using a range of qualitative and quantitative research methods including interviews, focus groups, document reviews, Delphi cycles and mixed ethnographic approaches (Barradell 2013). Researchers seek descriptions of learning experiences, promote debate between students and teachers and draw on the taxonomy of threshold concepts to capture them in a particular setting. Some of the first threshold concepts were identified in science subjects. For example, gravity in physics (Meyer & Land 2003) and evolution in biology (Ross et al. 2010) (Clouder 2005) discusses and proposes care as a threshold concept for health professionals. She argues that students need to develop a new, complex and professional understanding of what care means; once grasped, they can develop as practitioners. Yet all too often care is something that we assume students easily learn.
Threshold concepts in medicine Within medical education, researchers have used semistructured interviews with Problem Based Learning staff (Meek & Jamieson 2012), audiodiaries with medical students (Collett et al. In press) and focus groups with registrars in palliative care (Wearn et al. In press) to identify threshold concepts. These studies suggest the nature of evidence, population perspectives (Meek & Jamieson 2012), embodied shared care and active inaction (Wearn et al. In press) are
likely threshold concepts for learners. The relationship between inequalities and health (Chittleborough 2013), empathy and ethical challenges (Ryan 2012) may also be threshold concepts in undergraduate medicine. Medical educators’ may themselves have to grapple with threshold concepts related to teaching and learning. Representing and valuing the voice of service users (Kirwan 2014), sustaining student engagement in learning (Noonan 2012) and thinking processes are more important than correct answers (Mills & Wilson 2014) have been proposed as threshold concepts for teachers in other disciplines. In the context of surgical training, Kneebone (2009) has suggested authenticity is important for learning threshold concepts through simulation.
How might threshold concepts assist medical educators – and learners? Threshold concepts may help us with curriculum design. How often, when we plan curricula do we consider which elements are fundamental to understanding and which may need more time, because they are troublesome to learn? And what evidence can we draw on to inform this categorisation? By identifying threshold concepts, we can better focus and structure student learning around these transformative and conceptually difficult ideas. For example, homoeostasis has been identified as a threshold concept (Meek & Jamieson 2012) and is likely to be problematic to teach and learn. Unless adequate time is provided and unless teachers engage students in thinking with, rather than about, the concept, how will students properly comprehend subjects, such as physiology, biochemistry or the many clinical disorders, that are underpinned by disrupted homoeostasis? Threshold concepts and the associated idea of troublesome knowledge (Meyer & Land 2003; Perkins 2006) can offer new perspectives for teachers, particularly in relation to the barriers and enablers to effective learning. Teachers need to understand that learners, like Kate, can take time to get to grips with new and important concepts. While in the liminal phase, learners ‘‘may oscillate between old and emergent understandings’’ (Cousin 2006). In this stage, students may pass assessments, while only having a partial understanding of a subject. Teachers can learn to distinguish superficial understanding and mimicry from mastery, noticing where students are stuck, uncertain or confused. Teachers can then support students by providing a safe ‘‘holding environment’’ and encouraging recursiveness: revisiting ideas in different ways (Cousin 2006). Medical students often have fragmentary learning experiences and consequently struggle to make meaningful connections between concepts and disciplines. Teachers can help students integrate and connect different elements of learning, looking out for ‘‘Aha!’’ moments as these come together. Threshold concepts may also help us understand some of the role confusion encountered during professional identity formation. For example, students often express anxiety about working with uncertainty and struggle to accept that this is
851
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
H. Neve et al.
integral to clinical practice. Uncertainty has been identified as a threshold concept in many disciplines, including medicine (Collett et al. In press). The ideas of troublesome knowledge, liminality and transformation can provide a framework for understanding and supporting students as they make the ontological shift towards embracing uncertainty, necessary to work effectively as a clinician. The process of decoding the disciplines (Middendorf & Pace 2004) can help teachers identify crucial bottlenecks in student understanding of troublesome concepts and break these down into explicit steps. These bottlenecks sometimes relate to teachers’ own assumptions and tacit knowledge: expert teachers may skip over steps that have become so innate and obvious that they are unaware of their existence. Reflective practice is one such example; it may be a tacit process for experienced practitioners, but its nature and its role in learning may not be apparent to learners (Mann et al. 2009). Do threshold concepts exist? Criticism focuses on the tentative nature of Meyer and Land’s original description and the difficulties of empirically isolating threshold concepts (Rowbottom 2007). Identification is not always a straightforward process. However, some threshold concepts have been identified independently by teachers and learners, using different research methods and some, such as complexity and sustainability, feature across a range of disciplines. In addition, the framework clearly resonates with many educators as a heuristic tool which offers insights into features of learning, previously unarticulated.
Conclusions Threshold concepts were recently identified by the Open University, UK, as one of 10 new pedagogies with the potential to provoke major shifts in educational practice (Sharples et al. 2014). The threshold concept framework challenges us to question some of our traditional ideas about education. For example, the complexity and variation in each learner’s transformation (multiple attempts at understanding, experimentation and reflection on integration) challenges the linear learning outcome model (Land et al. 2005) and requires us to look more critically at what we mean by a spiral curriculum (Kinchin & Cabot 2012). Threshold concepts may be particularly valuable for exploring how we teach ways of thinking and practising (Cousin 2008), for understanding the interaction of the formal and hidden curriculum (Neve & Collett 2014) and for offering students new insights into the nature of learning. It can also be a tool for facilitating dialogue and ‘‘transactional curriculum inquiry’’ between teachers and learners (Cousin 2008). It may be that threshold concepts are themselves a threshold concept! Our own experience is that getting to grips with the theory can be troublesome: the notion of threshold concepts can initially seem abstract and hard to understand. Yet it has transformed the way we see and practice our educational work. As the literature continues to expand and develop in other disciplines, we would encourage medical educators to explore the value of applying and 852
researching the threshold concept framework within their own contexts.
Notes on contributors HILARY NEVE, MBChB MRCGP MEd PFHEA, is a General Practitioner, Associate Professor and Director of Small Group Learning, Professionalism and Social Engagement at Plymouth University Peninsula Medical School, UK. ANDY WEARN, MBChB, MMedSc, MRCG, is a General Practitioner, Associate Professor and Director of the Clinical Skills Centre, at the Faculty of Medical and Health Sciences, University of Auckland, New Zealand. TRACEY COLLETT, BEd MSc PhD SFHEA, is Associate Professor in the Sociology of Health and Illness at Plymouth University Peninsula Medical School, UK.
Declaration of interest: The authors report no conflicts of interest.
References Barradell S. 2013. The identification of threshold concepts: A review of theoretical complexities and methodological challenges. High Educ 65: 265–276. Chittleborough C. 2013. Threshold concepts in a flipped classroom to facilitate learning about health inequalities. In: Bricks to Bytes, Higher Educational Research Group Adelaide (HERGA) Conference, Adelaide, Australia. [Accessed 10 November 2015] Available from http:// www.herga.com.au/herga-2013.html. Clouder L. 2005. Caring as a ‘threshold concept’: Transforming students in higher education into health(care) professionals. Teach High Educ 10(4):505–517. Collett T, Neve H, Stephen N. In press. Using audio diaries to identify threshold concepts in "softer" disciplines: a focus on medical education. Practice and Evidence of the Scholarship of Teaching and Learning in Higher Education. Vol 10 Special Issue: Threshold Concepts and Conceptual Difficulty. Cousin G. 2006. An introduction to threshold concepts. Planet 17:4–5. [Accessed 10 November 2015] Available from http://journals.heacademy.ac.uk/doi/abs/10.11120/plan.2006.00170004. Cousin G. 2008. Threshold concepts: Old wine in new bottles or new forms of transactional inquiry? In: Land R, Meyer JHF, Smith J, editors. Threshold concepts within the disciplines. Rotterdam: Sense Publishers. pp 261–272. Joyce P. 2012. Crossing the threshold into reflective practice. In: From personal practice to communities of practice. Fourth Bienniel Conference on Threshold Concepts, Dublin: Ireland. [Accessed 10 November 2015] Available from http://www.nairtl.ie/documents/ BookofAbstracts_ONLINE.pdf. pp 119–120. Kinchin I, Cabot L. 2012. Threshold concepts and the spiral curriculum: Complementary or conflicting ideas? In: From personal practice to communities of practice, Fourth Bienniel Conference on Threshold Concepts, pp 98–99. Dublin: Ireland. [Accessed 10 November 2015] Available from http://www.nairtl.ie/documents/ BookofAbstracts_ONLINE.pdf. Kirwan G. 2014. Up close and personal: Engaging learners with serviceuser perspectives. From personal practice to communities of practice. In: O’Mahony C, Buchanan A, O’Rourke M, Higgs B, editors. Proceedings of the national academy’s sixth annual conference and the fourth biennial threshold concepts conference. NAIRTL: Ireland. pp 143–147. [Accessed 10 November 2015] Available from: http:// www.nairtl.ie/documents/EPub_2012Proceedings.pdf. Kneebone R. 2009. Simulation and transformational change: The paradox of expertise. Acad Med 84(7):954–957.
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What are threshold concepts?
Land R, Cousin G, Meyer JHF, Davies P. 2005. Threshold concepts and troublesome knowledge (3): Implications for course design and evaluation. In: Rust C, editor. Improving student learning – Diversity and inclusivity. Oxford: OCSLD. pp 53–64. Mann K, Gordon J, MacLeod A. 2009. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ Theory Pract 14(4):595–621. Meek S, Jamieson S. 2012. Threshold concepts and troublesome knowledge in the first year curriculum at a UK medical school. In: From personal practice to communities of practice. Fourth Bienniel Conference on Threshold Concepts pp 122–123. Dublin: Ireland. [Accessed 10 November 2015] Available from http://www.nairtl.ie/ documents/BookofAbstracts_ONLINE.pdf. Meyer JHF, Land R. 2003. Threshold concepts and troublesome knowledge (1) – Linkages to ways of thinking and practising. In: Rust C, editor. Improving student learning – Ten years on. Oxford: OCSLD. Middendorf J, Pace D. 2004. Decoding the disciplines: A model for helping students learn disciplinary ways of thinking. New Dir Teach Learn 98: 1–12. Mills R, Wilson A. 2014. There’s a right answer but only some students can get it: Threshold concepts in the professional development of physics demonstrators. In: O’Mahony C, Buchanan A, O’Rourke M, Higgs B, editors. Proceedings of the national academy’s sixth annual conference and the fourth biennial threshold concepts conference, pp 148–153. NAIRTL: Ireland. [Accessed 10 November 2015] Available from: http:// www.nairtl.ie/documents/EPub_2012Proceedings.pdf. Neve H, Collett T. 2014. Revealing the hidden curriculum to medical students: insights from threshold concept theory. Fifth International Biennial Threshold Concepts Conference, Threshold Concepts in
Practice, Durham: UK. [Accessed 10 November 2015] Available from http://www.ee.ucl.ac.uk/mflanaga/abstracts/TC14Abstract32.pdf. Noonan S. 2012. Threshold crossings and concepts in teaching: An exploration. In: From personal practice to communities of practice. Fourth Bienniel Conference on Threshold Concepts, pp 99–100. Dublin, Ireland. [Accessed 10 November 2015] Available from http:// www.nairtl.ie/documents/BookofAbstracts_ONLINE.pdf. Perkins D. 2006. Constructivism and troublesome knowledge. Overcoming barriers to student understanding: Threshold concepts and troublesome knowledge. In: Meyer J, Land R, editors. Overcoming barriers to student understanding: Threshold concepts and troublesome knowledge. pp 33–47. London & New York: Routledge. Ross P, Taylor CE, Hughes C, Whitaker N, Lutze-Mann L, Kofod M, Tzioumis V. 2010. Threshold concepts in learning biology and evolution. Biol Int 47:47–54. Rowbottom DP. 2007. Demystifying threshold concepts. J Philos Educ 41(2):263–270. Ryan T. 2012. Medical student reflections of newborn medicine: Looking back for threshold concepts. In: From personal practice to communities of practice. Fourth Bienniel Conference on Threshold Concepts. pp 26– 27. Dublin, Ireland. [Accessed 10 November 2015] Available from http://www.nairtl.ie/documents/BookofAbstracts_ONLINE.pdf. Sharples M, Adams A, Ferguson R, Gaved M, McAndrew P, Rienties B, Weller M, Whitelock D. 2014. Innovating pedagogy 2014: Open university innovation report 3. Milton Keynes: The Open University. Wearn A, O’Callaghan A, Barrow M. In press. Becoming a different doctor: Identifying threshold concepts when doctors in training spend six months with a hospital palliative care team. In: Land R, Meyer JHF, Flanagan MT, editors. Threshold concepts in practice. Rotterdam, Boston and Taipei: Sense Publishers.
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ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
What are threshold concepts and how can they inform medical education? Hilary Neve, Andy Wearn & Tracey Collett To cite this article: Hilary Neve, Andy Wearn & Tracey Collett (2016) What are threshold concepts and how can they inform medical education?, Medical Teacher, 38:8, 850-853, DOI: 10.3109/0142159X.2015.1112889 To link to this article: http://dx.doi.org/10.3109/0142159X.2015.1112889
Published online: 26 Nov 2015.
Submit your article to this journal
Article views: 374
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Weill Cornell Medical College]
Date: 02 August 2016, At: 01:06
2016, 38: 850–853
What are threshold concepts and how can they inform medical education? HILARY NEVE1, ANDY WEARN2 & TRACEY COLLETT1 1
Plymouth University Peninsula Schools of Medicine and Dentistry, UK, 2The University of Auckland, New Zealand
Abstract
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
The notion of ‘‘threshold concepts’’ is being widely applied and researched in many disciplines but is rarely discussed within medical education. This article is written by three medical educators who regularly draw on threshold concept theory in their work. They explore here the nature of threshold concepts and describe how the theory can offer medical educators new perspectives in terms of how they design curricula, approach teaching and support learners.
Background
Practice points
Consider the following situation. You have been Kate’s academic tutor since she started at medical school 18 months ago. One of your roles is to support her to develop her reflective writing, a requirement of the programme’s professionalism module. Kate has been resistant to the idea of reflective practice and you are not hopeful about your meeting this afternoon. She says that she cannot see the point of reflection and that the task is just ‘‘a hoop to jump through’’. You have spent time explaining the importance of reflection and suggesting ways she might develop her skills, but she tends to divert the conversation or disengage. Her writing, meanwhile, continues to be formulaic and feel inauthentic. There have, however, been some glimmers of thoughtfulness, particularly when she has written about her clinical experiences. When Kate arrives today, things are different. ‘‘I’ve got it!’’ she says ‘‘I finally get reflection!’’ Sure enough, her latest piece is insightful and analytical — she has written about her feelings and assumptions, explored dilemmas and considered others’ perspectives. You discuss what she has learnt about being a patient and the kind of doctor she hopes to become. She shows you an App that she has downloaded to record future reflections on her smartphone. After 18 months, her view of reflective practice has, it seems, been transformed; she has crossed a threshold and navigated a troublesome concept in learning. Reflective practice has been identified as a likely threshold concept (Joyce 2012). First described by Meyer and Land (2003) following extensive research into higher education, threshold concepts have been embraced by educators in many and diverse disciplines, leading to a growing body of research. While rarely discussed in medical education, they have the potential to offer medical educators important new perspectives. The threshold concepts framework can, for example, throw new light on Kate’s learning journey,
The notion of threshold concepts has been embraced in many disciplines, but little studied in medical education. Threshold concepts are key to achieving mastery of a subject. They are usually transformative, integrative, irreversible, bounded and often troublesome. A range of qualitative and quantitative methods have been used to identify threshold concepts. Identifying threshold concepts can help educators understand which concepts are fundamental to grasping their discipline and which might be particularly troublesome for learners. ‘‘Homeostasis’’, ‘‘the nature of evidence’’, ‘‘uncertainty’’, ‘‘empathy’’ and ‘‘embodied shared care’’ are concepts in medicine which appear to meet the criteria of a threshold concept.
helping us understand her ‘‘stuckness’’ and how to work with and support her while she lets go of her previous views, enabling her understanding of reflection to be transformed.
Aims In this paper, we draw on literature from other disciplines, including the health professions, to define threshold concepts and to consider which concepts, already identified as threshold, might be relevant to medicine and medical education. We discuss ways the threshold concept framework can influence how we design curricula, approach teaching and support learners. We also acknowledge some of the criticisms of the threshold concept framework.
Correspondence: Hilary Neve, Plymouth University Peninsula Schools of Medicine and Dentistry, Portland Square, Plymouth, PL4 8AA, UK. Tel: +44 (0)1752 586802; E-mail: [email protected]
850
ISSN 0142-159X print/ISSN 1466-187X online/15/080850–4 ß 2015 Taylor & Francis DOI: 10.3109/0142159X.2015.1112889
What are threshold concepts?
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
What is a threshold concept? Learning is often thought of in terms of building blocks of core concepts, which are often encapsulated in our learning outcomes. Core concepts have to be understood for learning to progress and must be correctly constructed. For example, to understand the disease of diabetes, students will need to understand concepts such as hormones, the role of the pancreas and receptors. Threshold concepts, it is proposed, do much more. They lead to a qualitatively different view of subject matter and are central to achieving mastery [sic] of a subject. Importantly, they have been described as being like a portal: ‘‘opening up a new and previously inaccessible way of thinking about something’’ (Meyer & Land 2003). According to Meyer and Land (2003), threshold concepts have certain characteristics in common, which Kate’s story illustrates. They are transformative, in that once understood, they can result in a significant shift in a learner’ perception of a subject or how they see the world. They are integrative inasmuch as connections that were previously hidden come into view (integration is often associated with an ‘‘Aha!’’ moment for learners). Moreover, as students journey towards the portal, they are said to pass through a liminal phase, (Cousin 2006), literally standing on the threshold (limina meaning threshold in Latin). This liminality is frequently troublesome (Perkins 2006) as students wrestle cognitively and/or emotionally with their emerging knowledge. New understandings, once learned, are usually irreversible and unlikely to be forgotten. It is noted that each threshold concept is bounded, demarcated from other conceptual areas (Meyer & Land 2003). Considerable work has been undertaken to define threshold concepts in different disciplines, using a range of qualitative and quantitative research methods including interviews, focus groups, document reviews, Delphi cycles and mixed ethnographic approaches (Barradell 2013). Researchers seek descriptions of learning experiences, promote debate between students and teachers and draw on the taxonomy of threshold concepts to capture them in a particular setting. Some of the first threshold concepts were identified in science subjects. For example, gravity in physics (Meyer & Land 2003) and evolution in biology (Ross et al. 2010) (Clouder 2005) discusses and proposes care as a threshold concept for health professionals. She argues that students need to develop a new, complex and professional understanding of what care means; once grasped, they can develop as practitioners. Yet all too often care is something that we assume students easily learn.
Threshold concepts in medicine Within medical education, researchers have used semistructured interviews with Problem Based Learning staff (Meek & Jamieson 2012), audiodiaries with medical students (Collett et al. In press) and focus groups with registrars in palliative care (Wearn et al. In press) to identify threshold concepts. These studies suggest the nature of evidence, population perspectives (Meek & Jamieson 2012), embodied shared care and active inaction (Wearn et al. In press) are
likely threshold concepts for learners. The relationship between inequalities and health (Chittleborough 2013), empathy and ethical challenges (Ryan 2012) may also be threshold concepts in undergraduate medicine. Medical educators’ may themselves have to grapple with threshold concepts related to teaching and learning. Representing and valuing the voice of service users (Kirwan 2014), sustaining student engagement in learning (Noonan 2012) and thinking processes are more important than correct answers (Mills & Wilson 2014) have been proposed as threshold concepts for teachers in other disciplines. In the context of surgical training, Kneebone (2009) has suggested authenticity is important for learning threshold concepts through simulation.
How might threshold concepts assist medical educators – and learners? Threshold concepts may help us with curriculum design. How often, when we plan curricula do we consider which elements are fundamental to understanding and which may need more time, because they are troublesome to learn? And what evidence can we draw on to inform this categorisation? By identifying threshold concepts, we can better focus and structure student learning around these transformative and conceptually difficult ideas. For example, homoeostasis has been identified as a threshold concept (Meek & Jamieson 2012) and is likely to be problematic to teach and learn. Unless adequate time is provided and unless teachers engage students in thinking with, rather than about, the concept, how will students properly comprehend subjects, such as physiology, biochemistry or the many clinical disorders, that are underpinned by disrupted homoeostasis? Threshold concepts and the associated idea of troublesome knowledge (Meyer & Land 2003; Perkins 2006) can offer new perspectives for teachers, particularly in relation to the barriers and enablers to effective learning. Teachers need to understand that learners, like Kate, can take time to get to grips with new and important concepts. While in the liminal phase, learners ‘‘may oscillate between old and emergent understandings’’ (Cousin 2006). In this stage, students may pass assessments, while only having a partial understanding of a subject. Teachers can learn to distinguish superficial understanding and mimicry from mastery, noticing where students are stuck, uncertain or confused. Teachers can then support students by providing a safe ‘‘holding environment’’ and encouraging recursiveness: revisiting ideas in different ways (Cousin 2006). Medical students often have fragmentary learning experiences and consequently struggle to make meaningful connections between concepts and disciplines. Teachers can help students integrate and connect different elements of learning, looking out for ‘‘Aha!’’ moments as these come together. Threshold concepts may also help us understand some of the role confusion encountered during professional identity formation. For example, students often express anxiety about working with uncertainty and struggle to accept that this is
851
Downloaded by [Weill Cornell Medical College] at 01:06 02 August 2016
H. Neve et al.
integral to clinical practice. Uncertainty has been identified as a threshold concept in many disciplines, including medicine (Collett et al. In press). The ideas of troublesome knowledge, liminality and transformation can provide a framework for understanding and supporting students as they make the ontological shift towards embracing uncertainty, necessary to work effectively as a clinician. The process of decoding the disciplines (Middendorf & Pace 2004) can help teachers identify crucial bottlenecks in student understanding of troublesome concepts and break these down into explicit steps. These bottlenecks sometimes relate to teachers’ own assumptions and tacit knowledge: expert teachers may skip over steps that have become so innate and obvious that they are unaware of their existence. Reflective practice is one such example; it may be a tacit process for experienced practitioners, but its nature and its role in learning may not be apparent to learners (Mann et al. 2009). Do threshold concepts exist? Criticism focuses on the tentative nature of Meyer and Land’s original description and the difficulties of empirically isolating threshold concepts (Rowbottom 2007). Identification is not always a straightforward process. However, some threshold concepts have been identified independently by teachers and learners, using different research methods and some, such as complexity and sustainability, feature across a range of disciplines. In addition, the framework clearly resonates with many educators as a heuristic tool which offers insights into features of learning, previously unarticulated.
Conclusions Threshold concepts were recently identified by the Open University, UK, as one of 10 new pedagogies with the potential to provoke major shifts in educational practice (Sharples et al. 2014). The threshold concept framework challenges us to question some of our traditional ideas about education. For example, the complexity and variation in each learner’s transformation (multiple attempts at understanding, experimentation and reflection on integration) challenges the linear learning outcome model (Land et al. 2005) and requires us to look more critically at what we mean by a spiral curriculum (Kinchin & Cabot 2012). Threshold concepts may be particularly valuable for exploring how we teach ways of thinking and practising (Cousin 2008), for understanding the interaction of the formal and hidden curriculum (Neve & Collett 2014) and for offering students new insights into the nature of learning. It can also be a tool for facilitating dialogue and ‘‘transactional curriculum inquiry’’ between teachers and learners (Cousin 2008). It may be that threshold concepts are themselves a threshold concept! Our own experience is that getting to grips with the theory can be troublesome: the notion of threshold concepts can initially seem abstract and hard to understand. Yet it has transformed the way we see and practice our educational work. As the literature continues to expand and develop in other disciplines, we would encourage medical educators to explore the value of applying and 852
researching the threshold concept framework within their own contexts.
Notes on contributors HILARY NEVE, MBChB MRCGP MEd PFHEA, is a General Practitioner, Associate Professor and Director of Small Group Learning, Professionalism and Social Engagement at Plymouth University Peninsula Medical School, UK. ANDY WEARN, MBChB, MMedSc, MRCG, is a General Practitioner, Associate Professor and Director of the Clinical Skills Centre, at the Faculty of Medical and Health Sciences, University of Auckland, New Zealand. TRACEY COLLETT, BEd MSc PhD SFHEA, is Associate Professor in the Sociology of Health and Illness at Plymouth University Peninsula Medical School, UK.
Declaration of interest: The authors report no conflicts of interest.
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