Threshold concepts in medical education: A scoping review

Abstract

Introduction The threshold concept framework (TCF) was first described nearly 20 years ago, but its application in the field of medical education has recently seen a significant growth of interest with a diverse range of literature published on the subject. The transformative nature of threshold concepts (TCs) offers potential for the design of learning experiences and curricula across the medical education continuum. A scoping review was conducted to map the extent of the current literature regarding TCs in medical education—to describe the types of available evidence and its focus—and identify research gaps. Methods The review followed the JBI Manual for Evidence Synthesis approach for scoping reviews. Four databases and two additional websites were searched for articles exploring TCs in medical education. Data were analysed using quantitative and qualitative thematic approaches. A framework of conceptual change was used to synthesise the TCs identified. Results Thirty‐six papers, spanning undergraduate, postgraduate and continuing medical education, were included in the final analysis. The most frequent application of the TCF was in the identification of TCs, which related to basic scientific knowledge, ways of thinking and ways of practising in medicine. Uncertainty, patient care, clinical reasoning and professional identify formation were themes that emerged at multiple stages of training. Several papers evaluated the use of the TCF in teaching. Conclusion The understanding and embodiment of TCs increases in complexity across the medical education continuum, with TCs recurring with changes in clinical environment and responsibilities. This lends support to a holistic approach to curriculum design spanning all stages of training. Further research is needed to develop a consistent approach for describing and applying the TCF in medical education and to address how the TCF can be used in teaching and how threshold crossing can be measured.

The journey not the destination: Liminality and lifelong learning

“… 1 Similarly, Kua et al described how ‘through the iterative process of problem solving and guided successful transfer experiences expertise can be continuously refined and expanded’. 2 These observations are consistent with many of the TCs identified in our recent scoping review of the threshold concept framework (TCF) in medical education, 3 which involve an ongoing series of ontological shifts and nuanced refinements in understandings as new, increasingly complex experiences and learning transformations are encountered through clinical practice. By considering TCs through the lens of lifelong learning, we conceptualise some TCs as recursive, located in an ongoing state of liminality; they are an ongoing journey rather than a destination to be reached .…”

“…If creative problem solving is required to address the uncertainty of complex clinical situations, then it follows that recognising, accepting and embodying uncertainty as a feature of clinical practice is first required. Uncertainty is a key TC found at all stages of the medical education continuum and underlies aspects of clinical reasoning and decision making 3 . Therefore, a better understanding of connections between concepts in the health professions is needed to distinguish what concepts are strands, steps or TCs in themselves and how they influence one another.…”

“…For learners, this recursivity may align with changing environments or responsibilities, requiring them to develop a more advanced understanding or embodiment of a TC. 3 With adaptive expertise, this transition point appears to occur when graduates gained individual responsibility for patient care, and they demonstrated a developing awareness of adaptive perspectives. 1 However, they did not yet appreciate the importance of balancing both routine (efficient) and adaptive (innovative) approaches in their practice.…”

“…Uncertainty is a key TC found at all stages of the medical education continuum and underlies aspects of clinical reasoning and decision making. 3 Therefore, a better understanding of connections between concepts in the health professions is needed to distinguish what concepts are strands, steps or TCs in themselves and how they influence one another. Concept mapping has been used in engineering to express the interrelationship and contingencies between the most integrative TCs, where integrative is taken to mean connecting all disciplines.…”

A Reflection On: Integrating Threshold Concepts and Ways of Think and Practising: Supporting Physiotherapy Students to Develop a Holistic View of the Profession through Concept Mapping

“…Unsurprisingly, there is an abundance of literature about threshold concepts and it continues to grow even as its original researchers have now retired from higher education. The international Threshold Concepts conference continues, as recently as July 2023 in Australia, and the field (particularly health professional education) is at a point where more scholars are conducting syntheses and reviews of threshold concepts research (Amin, 2019;Jones & Hammond, 2022;Liljedahl et al, 2022;Nicola-Richmond et al, 2018). To the best of our knowledge, we were the first to undertake such an analysis and it is perhaps half-surprising that these reviews, and other conceptual work in this space (i.e., Brown et al, 2022;Crookes et al, 2020) have reached similar conclusions: that researchers are still mainly in the business of identifying threshold concepts; that new additions to the threshold concepts terminology adds to its slipperiness; and that these different understandings have implications for research and the utility of threshold concepts.…”