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J Surg Educ. 2014 Sep-Oct;71(5):756-61. doi: 10.1016/j.jsurg.2014.03.004. Epub 2014 Apr 24.

Troublesome knowledge in pediatric surgical trainees: a qualitative study.

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Imperial College, London, United Kingdom. Electronic address:
School of Rural Health, Health PEER, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia.



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."


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.


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.


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.


Interpersonal and Communication Skills; Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Professionalism; paediatric surgery; qualitative study; specialist identity; threshold concepts; troublesome knowledge

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