ArticlePDF Available

Insights into teaching a complex skill: Threshold concepts and troublesome knowledge in electroencephalography (EEG)

Authors:
Article

Insights into teaching a complex skill: Threshold concepts and troublesome knowledge in electroencephalography (EEG)

Abstract and Figures

Threshold concepts (TCs) are defined as ideas within a discipline that are often conceptually difficult (“troublesome”), but when learned, transform a learner’s understanding. Electroencephalography (EEG) has been recognized as a conceptually difficult field in neurology, and a study of threshold concepts in EEG may provide insights into how it is taught and learned. Methods: Semi-structured interviews were performed with 12 EEG experts in the US and Canada. Experts identified potential TCs and troublesome knowledge, and explored how these concepts were taught and learned. Interview transcripts were coded and analyzed using a general thematic analysis approach, based on the core elements of the threshold concepts framework. Results: One concept (polarity) emerged most clearly as a threshold concept. Other troublesome areas included pattern interpretation and clinical significance, but these lacked some of the characteristics of TCs. Several themes emerged, including the role of TCs and troublesome knowledge in determining expertise and the role of prior experience. Conclusions: We have used the threshold concepts framework to explore potential barriers to learning, suggest ways to support learners, and identify potential points of emphasis for teaching and learning EEG. A similar approach could be applied to the study of teaching and learning in other conceptually difficult areas of medical education. Find it here: http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902 (or contact me for a free ePrint)
Content may be subject to copyright.
This is an Accepted Manuscript of an article published by Taylor & Francis in MEDICAL
TEACHER on 07 Dec 2017, available online:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Insights into teaching a complex skill:
Threshold concepts and troublesome knowledge in
electroencephalography (EEG)
Jeremy J. Moeller, MD, MSc, FRCPC1 and Tim Fawns, PhD2
Affiliations
1. Department of Neurology, Yale School of Medicine
2. College of Medicine and Veterinary Medicine, University of Edinburgh
Short Title: Threshold Concepts in EEG
Corresponding Author:
Jeremy Moeller, MD, MSc, FRCPC
Key Words: Threshold concepts, troublesome knowledge, expertise, graduate
medical education, learning theory
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
2
Abstract
Background: Threshold concepts (TCs) are defined as ideas within a discipline that
are often conceptually difficult (“troublesome”), but when learned, transform a
learner’s understanding. Electroencephalography (EEG) has been recognized as a
conceptually difficult field in neurology, and a study of threshold concepts in EEG
may provide insights into how it is taught and learned.
Methods: Semi-structured interviews were performed with 12 EEG experts in the
US and Canada. Experts identified potential TCs and troublesome knowledge, and
explored how these concepts were taught and learned. Interview transcripts were
coded and analyzed using a general thematic analysis approach, based on the core
elements of the threshold concepts framework.
Results: One concept (polarity) emerged most clearly as a threshold concept. Other
troublesome areas included pattern interpretation and clinical significance, but
these lacked some of the characteristics of TCs. Several themes emerged, including
the role of TCs and troublesome knowledge in determining expertise and the role of
prior experience.
Conclusions: We have used the threshold concepts framework to explore potential
barriers to learning, suggest ways to support learners, and identify potential points
of emphasis for teaching and learning EEG. A similar approach could be applied to
the study of teaching and learning in other conceptually difficult areas of medical
education.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
3
Acknowledgements
The authors wish to acknowledge the EEG experts who were interviewed for the
purposes of this work. Dr. Moeller would also like to thank the faculty and staff in
the MSc Clinical Education Programme at the University of Edinburgh.
Declaration of Interest
The authors report no declarations of interest.
Glossary
Threshold concepts: Concepts within a discipline that are conceptually difficult
(“troublesome”), but when learned, transform a learner’s understanding of the field,
opening up new ways of thinking (Meyer, J. H. F., & Land, R. 2003. Threshold
Concepts and Troublesome Knowledge: linkages to ways of thinking and practising
within the disciplines. In C. Rust (Ed.), Improving Student Learning - Ten Years On.
Oxford: Oxford Centre for Staff and Learning Development).
Practice Points
Threshold concepts are areas within a discipline that are often conceptually
difficult (“troublesome”) but when learned, transform a learner’s
understanding of the field.
In EEG education, polarity is the clearest example of a threshold concept.
The process of identifying threshold concepts can also reveal other types of
troublesome knowledge. In EEG, pattern interpretation and clinical
significance were identified as troublesome.
Exploring how threshold concepts and troublesome knowledge integrate
with each other can allow the formulation of a “threshold conception” of
learning within a field, which may guide curriculum design.
The learner’s background plays a role in their ability to understand threshold
concepts, and should also be considered in curriculum design.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
4
Introduction
The framework for threshold concepts (TCs) was first proposed in 2003 by Meyer
and Land, and was first tested in a study of higher education in economics. Since
then, there have been studies of threshold concepts in a broad range of disciplines,
at all levels of education. In their original article, Meyer and Land (2003) described
threshold concepts as “akin to a portal, opening up a new and previously
inaccessible way of thinking about something . . . without which the learner cannot
progress (p. 1).” They propose that the framework can be used as a method of
understanding how learners obtain expertise in conceptually difficult fields. The key
elements of threshold concepts are outlined in Box 1. Much has been written about
the “troublesome” nature of TCs, and about troublesome knowledge in general, and
the main types of troublesome knowledge are also outlined in Box 1
During the process of learning TCs, students occupy a “liminal space, described by
Meyer and Land (2006) as a state of inauthentic understanding. While in the liminal
space, students may resort to mimicry to approximate a deeper understanding. This
can be “compensatory” (e.g. the student defers understanding and opts for a
superficial approach in order to pass an examination) or “conscious” (the student
uses a superficial approach to survive day-to-day activities while working toward
genuine understanding) (Meyer and Land 2006). As learners progress through the
liminal space, they not only internalize TCs, but also become more engaged in the
discourse of their discipline, learning to think like an expert.
Meyer and Land (2006) suggest that understanding exactly why and how some
concepts are troublesome may be critical in understanding how they are learned,
and how teachers and curricula can support students to move beyond the liminal
space. Among other things, this involves an understanding of the students’ “pre-
liminal variation” or the different understandings with which students enter the
liminal state (Meyer and Land 2006).
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
5
Threshold Concepts in Health Professions Education
In the years since their introduction, there has been research into TCs in many
disciplines, at all levels of educational practice (Flanagan 2016). Compared to some
other fields, there has been relatively little published in the medical education
literature on TCs, despite the call from some authors for more research in this area
(Neve et al. 2016). Threshold concepts could be a particularly useful approach to
understanding the transformation of learners as they engage with complex skills
and troublesome ideas in medicine, and anticipating areas where learners might get
“stuck” in the learning process. As Neve et al. (2016) argue, the threshold concepts
framework also encourages a non-linear and individualized approach to learning, an
approach that fits well with current trends of integrated medical school curricula
and competency-based assessment. The small number of studies involving medical
trainees (Blackburn and Nestel 2014; Wearn et al. 2016; Collett et al. 2017) focused
mainly on the non-technical aspects of healthcare (e.g. psychology and ethics,
emotional engagement, communication management), and we did not find studies
in medical education with a focus on more technical cognitive tasks like EEG
interpretation.
Threshold concepts have been studied more extensively in other health professions,
including nursing (Levett-Jones et al. 2015; McAllister et al. 2015), occupational
therapy (Clouder 2005; Rodger et al. 2015) and physiotherapy (Barradell 2013;
Barradell and Kennedy-Jones 2015; Barradell and Peseta 2016). Barradell and
Peseta (2016) in particular have written about the challenges in identifying
threshold concepts, and distinguishing them from key concepts, competencies or
learning outcomes.
EEG as a focus of threshold concepts research
The electroencephalogram (EEG) is one of the central diagnostic tests in neurology,
and is a central aspect of neurological graduate medical education. Basic proficiency
in EEG is required by most groups that provide accreditation for neurologists
(ACGME 2013). In spite of these requirements, misinterpretation of EEG has been
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
6
identified as a major problem (Klass and Westmoreland 1985; Williams et al. 1985;
Benbadis and Lin 2008; Tatum 2013). Several explanations for EEG
misinterpretation have been proposed, and the problem may relate to the
complexity of EEG interpretation as a clinical skill or to deficiencies in how this
clinical skill is taught. Little has been written about EEG education, and in particular,
there is little insight to be gained from the existing literature into how or why EEG
might be difficult, where learners run into difficulty, or what should be emphasized
in EEG teaching. The identification and exploration of threshold concepts could
provide some of these insights and could serve as a starting point in curriculum
design.
Aims of our research
Our goal was to identify and explore potential threshold concepts and other
troublesome knowledge in EEG learning. Further, we aimed to understand teachers’
perspectives on barriers to learning and ways in which students could be supported
as they engage with TCs and troublesome knowledge in EEG. Although our primary
aims were to explore TCs and troublesome knowledge in EEG learning, we hoped
that our findings could provide insights into teaching and learning of other
conceptually difficult topics in the health sciences.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
7
Methods
Study Setting and Design
Between August 2015 and February 2016, one of the authors (JJM) conducted
interviews with 12 neurologists in US and Canadian academic medical centres who
have expertise in EEG interpretation and teaching. The semi-structured interview
with experts was chosen as a form of what Cousin describes as the “elite” interview,
in which the participant provides expertise and authority on a specialized subject
(Cousin 2009). These interviews have the potential to harness experts’ passion for
teaching in order to generate deeper understandings of threshold concepts (Cousin
2009). The individual expert interview is a method that has been used in several
studies of threshold concepts, either alone or in combination with other methods
(Jordan et al. 2011; Barradell 2013; Quinlan et al. 2013).
Although focus groups have been used in many studies of TCs (Cousin 2009), this
method would have imposed limits on our results. Our aim was to obtain a broad
perspective on EEG education, from multiple centres, and from people with a range
of teaching and learning experiences. As a starting point, it was much more feasible
to get such a broad sample of perspectives with individual interviews. In addition,
although focus groups may have been helpful in providing consensus, they can also
lead to convergence of an opinion that might not accurately reflect the opinions or
experiences of all the members (Cousin 2009).
Participants
For the purposes of this study, we generated an operational definition of expertise
in EEG interpretation and teaching, as no recognized formal definition was available.
We considered those to have expertise in EEG interpretation if they had post-
residency training in EEG and certification through a national subspecialty body. We
considered subjects to have expertise in EEG teaching if they had at least 2 years of
EEG teaching experience and a leadership role in EEG education or had produced
scholarly work in EEG.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
8
Within these parameters, we recruited a convenience sample of experts, taking
several steps to gather diverse perspectives. Both junior and senior faculty
members were interviewed, in order to account for changes in learning and practice
that may have arisen from technological changes over the last 25 years, including
the advent of digital EEG and continuous EEG monitoring (Collura 1993; Gavvala et
al. 2014). We invited interviewees who trained, practice and teach in different
institutions, in order to avoid interviewing only members of a particular “school” of
EEG interpretation. We interviewed both Canadian and US experts in order to
broaden the perspectives on learning beyond a single health care system or culture.
In order to enrich the sample and invite a range of perspectives, we specifically
asked early interviewees to identify experts who might have a different perspective
or opinion (Lingard and Kennedy 2010).
Interview Process
Semi-structured interviews were conducted using a standardized interview script,
based on the 5 original features of threshold concepts (Box 1). Our interview script
was developed around some of the early work in threshold concepts, and we chose
not to include the three additional elements in Box 1, which we thought were more
conceptually complex and difficult to explain to those without prior knowledge of
TCs. However, these elements were evident in the interviewee’s responses, and have
been included in the analysis and discussion. The interviews started with a brief
outline of the TC framework, followed by an explanation that the purpose of the
interview was to address two questions: what are some threshold concepts in EEG
interpretations; and how might we (as EEG educators) design curricula and teaching
strategies to help learners understand these threshold concepts? The initial
questions focused on experts perceptions of the areas of EEG that are fundamental
to the grasp of the topic, and areas that are perceived as most troublesome to
learners. Follow-up questions about each concept explored the process of acquiring
troublesome knowledge and helpful ways of supporting learning. The goal was to
understand not only what the threshold concepts are, but how they are learned, why
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
9
they might be troublesome, and what role the teacher and/or curriculum might play
in facilitating learning.
All interviews were conducted either in person or by video chat, with the exception
of one interview that was conducted by telephone because of technical limitations.
Data Analysis
One author (JJM) coded and analyzed the interview transcripts using a general
thematic analysis approach (Lingard and Kennedy 2010) in NVivo. Initial units of
analysis included examples of potential threshold concepts and the five original
characteristics of threshold concepts, as outlined in our interview script (Meyer and
Land 2003). Other units of analysis were terms that are linked to threshold concepts
such as different types of troublesome knowledge and the liminal state. The
discursive nature of threshold concepts was also explored (Meyer and Land 2006).
We also included specific topics within EEG learning, as outlined in the interview
script. After the first three transcripts were coded, a preliminary analysis was
performed which was reviewed by the second author (TF), and the approach to
analysis was refined as a result of review and discussion between the authors.
Subsequent coding and analysis was performed iteratively, 2-3 interview transcripts
were analyzed at a time, and at each stage, the coding framework was modified as
needed. When possible, new nodes were reviewed, merged or connected, with
constant return to the 5 core elements of threshold concepts.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
10
Results
Through the iterative recruitment process described above, 12 EEG experts were
invited to participate, and all agreed to be interviewed. Selected characteristics of
the interviewees are contained in Table 1. Polarity emerged as a threshold concept
that was identified in every expert interview, usually as the first concept that was
discussed. Two other themes of troublesome knowledge - pattern interpretation and
clinical significance - contained some features of threshold concepts, but we felt that
they did not clearly satisfy all criteria. Experts discussed the role that TCs and
troublesome knowledge might play in the learning process and barriers to learning,
such as variability in learners’ experiences prior to first engaging in EEG
interpretation (pre-liminal variation) and the discursive nature of TC learning.
Polarity as a threshold concept
Broadly defined, polarity refers to the direction and extent of an electrical field
generated by the brain, and this can be determined by visual analysis of EEG signals.
This is important clinically because an understanding of the polarity and electrical
field of an abnormality can provide specific insights into the location and potential
etiology of an epileptic focus within the brain. Polarity contained the essential
elements of threshold concepts, as outlined by the original work of Meyer and Land
(2003), and examples of these elements are shown in Table 2. Experts identified
that there was some troublesome language related to polarity. Terminology like
“sharply contoured” or “phase reversals” are used to describe EEG findings most
commonly associated with epilepsy, and many experts observed that EEG learners
look for these findings without really understanding why. Several experts suggested
that the use of these terms and especially an inability to elaborate on their
physiological relevance revealed a superficial, incomplete understanding of
polarity.
“I think that for many of the newbies, they’re looking for sharply contoured waves. That’s the
only thing that they’ve heard about or phase reversals or something and that’s what they’re
looking for without any concept of what it really is that we’re looking at” (Expert #3).
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
11
Other experts suggested that while the term was problematic, it was possible to find
evidence of deeper understanding by probing the student.
“… it's a very superficial term. …You have to ask them, okay, what's the concept behind that
phase reversal. If they can understand polarity, they'll tell me. If they don't understand polarity,
they can't tell me.” (Expert #8)
This expert suggested it is not necessarily the term “phase reversal” that is
troublesome, but whether or not the term is used to compensate for a lack of
understanding.
There was extensive discussion of the role that prior educational experiences might
have in understanding polarity. Many experts observed that polarity might be
troublesome because of its foundation in physics and electronics: topics that may be
intimidating to some learners, and may prevent full engagement in the learning
process.
“I think there's a certain bit of technophobia … they automatically think because there are
pictures of resistors and capacitors in the textbook chapter, that they're not going to get it”
(Expert #10)
A few experts suggested that a strong knowledge of physics and electronics was
essential for mastery of the concept of polarity, but others disagreed. Experts
discussed their own discomfort with the technical side of EEG, and reflected on how
the EEG teaching community may be missing opportunities to make these concepts
relevant to students who don’t have a strong background in the physical sciences or
engineering:
“… I think it's frankly dry for many people or most people. I think we don't necessarily as a
whole make it that exciting … We give the same dry lectures about positive and negative
charges. It's very easy to fall asleep.” (Expert #12)
Thus, experts did not all agree about why polarity (and the underpinning physical
and technological principles and knowledge) was troublesome. Views about the
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
12
role of physics might have depended upon the expert’s personal experience. Many
experts who felt strongly that students should have a deep understanding of the
physics and technology talked about how their own approach was rooted heavily in
the fundamentals of physics, and some spoke of having some training in physics
before entering medicine. Those who felt that it was possible to have some level of
expertise without a deep understanding of physics emphasized that it is important
to make physics relevant to the task at hand.
“I always struggled with [physics] when I was in high school, and undergrad, so I'd always shied
away from it. Then just trying to understand more about the basics of the electricity behind
EEG led me to read more about the polarity itself” (Expert #9).
Emphasizing the relevance of the underlying principles may have the effect of
encouraging the learner to return to the foundational principles with renewed
interest. Some experts suggested that initial engagement with polarity might not
require mastery of physics or electronics, but as students advance, and begin to
understand more about why the physics is important, they may return to the
foundational principles.
Pattern interpretation
Many experts used the term “pattern recognition” in the interviews, but then talked
about a process that was more than simple recognition, and for this reason, we have
applied the term “pattern interpretation” to this process. This process includes
interpretation of the polarity of an electrical field, combined with visual recognition
of a pattern and classification of the pattern so that it can be put into clinical context.
Pattern interpretation was thought to be troublesome in several ways: it can be
tacit, conceptually difficult or alien. Examples of these aspects are shown in Table 3.
Clinical significance
Experts also discussed the troublesome nature of determining the clinical
significance of an EEG pattern. This process involves pattern interpretation (and,
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
13
thus, an understanding of polarity), but also involves an understanding of the
clinical context, disease processes, and the ability to communicate the meaning of
the EEG findings to non-experts. Some examples of the troublesome nature of
clinical significance are shown in Table 3.
One expert (Expert #10) discussed how it can be particularly difficult for learners to
take into account the “audience and the implications” when generating an
impression of EEG findings: that is, an EEG report should be modified depending
upon who is receiving it, in order to ensure that the findings are not taken out of
context or over-interpreted. While many experts observed the tendency of
inexperienced EEGers to overstate the significance of EEG findings, almost all
expressed a desire that the least skilled EEGers should do the exact opposite. Most
experts expressed the opinion that a patient was much more likely to come to harm
with over-interpretation of findings. This is troublesome because it is counter-
intuitive: in many diagnostic testing modalities, greater harm occurs when a finding
is missed, while in EEG, there may be greater harm with over-interpretation. As
such, many experts discussed a situation in which they would ensure, at the very
least, that learners who did not develop a deep understanding of clinical
significance, could remain “safe” by limiting their clinical conclusions.
A “threshold conception” of EEG interpretation
While not necessarily fitting the description of TCs, the themes of pattern
interpretation and clinical significance emerged from many of the expert interviews
as areas that were troublesome to learners. To varying degrees, both of these
activities were rooted in an understanding of polarity, and each of these concepts
built on each other. Figure 1 illustrates how polarity was identified as the core
threshold concept: a fundamental understanding of polarity is necessary for
expertise in EEG interpretation, and learners need to understand pattern
interpretation in order to understand clinical significance. Pattern interpretation
incorporated an understanding of polarity, but also incorporated other knowledge
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
14
and skills. An understanding of clinical significance was seen to build upon
knowledge of polarity and pattern interpretation.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
15
Discussion
As we related our results to the existing knowledge and understanding of threshold
concepts and troublesome knowledge, several themes emerged. We believe that
these themes could provide useful insights to support teaching and learning in EEG
interpretation.
Troublesome knowledge and learning as discourse
Experts acknowledged that some EEG concepts and terminology can be tacit,
counter-intuitive or conceptually difficult, and this can impose barriers in EEG
learning. Some of the terminology used in EEG interpretation is subject to
disagreement, and there is a lack of agreed-upon definitions for some EEG findings.
For learners, this can be frustrating, and they may struggle to understand how an
expert makes decisions. Learners may oscillate between periods of apparent
understanding and moments of frustration when faced with a particularly
ambiguous pattern or troublesome terminology (Meyer and Land 2006). Developers
of curricula could acknowledge that this oscillation will be a normal part of learning,
and should provide maximal opportunities for discourse between expert/teacher
and student. In this way, the learner will have the opportunity to move beyond
memorizing rules and begin to understand what it is to think and communicate like
an expert (Land et al. 2005).
When a learner is not functioning at the level that the teacher expects, there could
be many different explanations. By probing for understanding of troublesome
knowledge, the teacher may be able to “diagnose” difficulties and thus provide more
specific support. Is the problem that the learner is not grasping polarity, for
example? Or if the learner does grasp polarity, is the problem related to the
student’s inability to understand the ambiguities of pattern interpretation?
Depending upon the problem, the teacher may be able to recommend readings,
resources and exercises, and may choose to focus on the problematic concept in
subsequent teaching.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
16
Addressing variation in learners’ prior experiences
In order to support learners as they wrestle with threshold concepts and
troublesome knowledge, some acknowledgement of pre-liminal variation can be
built into the curriculum. For example, it may be useful to inform learners a priori
that some of them will grasp some concepts quickly, while others may take longer.
Learners who do not grasp the concepts as quickly should be reassured that with
time, they can eventually get it; their difficulty is not necessarily related to a lack of
ability, but also to differences in background and prior knowledge. While lack of
prior experience can be seen as a barrier to learning, because TCs involve
transformation and reconstitution, learners should also be advised that
understanding these concepts may require abandoning or reshaping their
preconceptions about the topic. Learners can be further encouraged by being
reminded that the process of understanding TCs is often non-linear, with repetition
as part of the learning process.
Threshold capabilities
Ultimately, expertise may be determined not only by whether the concepts are
understood, but also how that knowledge is applied in practice. Baillie et al. (2013)
have proposed combining elements of the TC framework with capability theory to
focus on applications of threshold concepts to novel situations, within a framework
of “threshold capabilities.” Within this framework, the focus is on what the learner
should be capable of doing in a novel situation, and then determining what
threshold concepts are central to these capabilities. In much the same way as we
outline above, educators and curriculum developers can focus on these capabilities
to inform all aspects of curriculum design, from learning objectives to the teacher’s
role, to assessment. In our work, it may be possible to consider some aspects of
pattern interpretation and determination of clinical significance as capabilities,
rooted in the threshold concept of polarity, as outlined in our threshold conception
of EEG teaching and learning.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
17
Implications for further research
The framework of threshold concepts may be particularly useful for understanding
how conceptually difficult or “troublesome” knowledge and skills are learned.
Ultimately, the goal is to ensure that students understand difficult concepts on an
“expert” level, and refrain from either giving up or resorting to superficial
understanding. Too often, curricula are filled with educational objectives that are
either vague or very specific, and the overall “conception” of the field remains
obscure to new learners, until they have gained specific knowledge and experience.
As others have written, students may be more comfortable with struggle and
ambiguity and may be less likely to give up if they are aware of the existence of
an overall “conception” of the topic, and if they are reassured that they will
eventually understand it (Land et al. 2005). Perhaps the most important next step
will be to investigate how to operationalize threshold concepts and troublesome
knowledge in curriculum design in medical education, to determine how this
approach can inform approaches to teaching complex skills. In our specific area of
EEG, the topic of pattern interpretation could be explored further, possibly by
comparing and contrasting approaches in EEG with other fields where pattern
interpretation is a central element (e.g. radiology or pathology).
Limitations of this study
There may be limitations in including only experts in our analysis. Several authors
(Davies and Mangan 2007; Loertscher et al. 2014) have emphasized the importance
of confirming the validity of threshold concepts by engaging students in the process.
It may not be possible for experts to remember or fully understand why a concept is
troublesome, or how it felt to exist in a liminal space (Barradell and Peseta 2016).
While we did not include students, we made efforts to include subjects who included
EEG teaching as a major component of their professional roles. These subjects were
able to reflect on years of experiences with students’ struggles, and we believe we
obtained some on the challenges that students face in learning EEG.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
18
Barradell & Peseta (2016) have described some of the methodological challenges in
engaging content experts in the identification of threshold concepts. The TC
framework is complex, and arguably troublesome in itself. In our study, we were
less focused on creating a definitive list of TCs in EEG, and more focused on using a
unique approach to understanding how EEG could be taught and learned. Therefore,
the TC framework functioned to set the stage of the subsequent interview, and
arguably a full understanding of TCs was not necessary to generate useful insights.
It is also important to address some of the criticisms of the threshold concepts
framework itself. Importantly, the original 5 “defining” characteristics of TCs include
several qualifiers, including the words “probably,” “often” and “potentially”
(Wilkinson 2014). As a result, critics argue, it is difficult to know what are the
essential features of a threshold concept (Rowbottom 2007), and how such a
concept might differ from similar terms like “core,” “fundamental” or “key” concepts
(O'Donnell 2010). In addition, even if we accept that threshold concepts exist as
distinct entities, they are “agent-relative:” the definition of a threshold concept
(particularly the transformative, irreversible, and troublesome aspects) depends
upon the experience of the learner (Rowbottom 2007; O'Donnell 2010). Thus, what
might be a threshold concept for one learner might not be for another. In our
research, there was disagreement between experts about how troublesome certain
EEG concepts were, which may provide support for the “agent-relative” argument.
However, we do not think that these criticisms detract from our findings or insights.
While much of the debate in the literature centres on how a list of threshold
concepts is derived, in our research, TCs were not the end itself. Rather, they served
as a foundation of an exploration of the teaching and learning of a complex skill.
Reflexivity
We considered several issues raised by the fact that the interviewer and primary
author (JM) was both a content expert and a member of the EEG community from
which participants were recruited. We addressed recruitment bias by approaching
interviewees in an iterative fashion, specifically asking each interviewee to identify
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
19
other experts who might have divergent perspectives. We also recruited
participants who were both known and unknown by the interviewer, as well as
participants who were both junior and senior in academic rank. We hoped that by
ensuring a range of relationships between interviewer and interviewees, we would
get a broader range of responses. We also acknowledge that the primary author’s
position as a content expert could also affect data analysis, which could be biased by
the author’s preconceptions about EEG teaching and learning. To address this, we
ensured that both authors (one a content expert and one not) were involved in data
analysis and interpretation. We also considered a potential advantage to the
position of interviewer as content expert: in a field as technically complex as EEG, if
the interviewer was not an expert, much of the interview time may have been
consumed by explanations of the technical aspects of the field. This could have
limited the depth of discussion, and even prevented the emergence of the themes
outlined in our work above.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
20
Conclusion
We identified one potential threshold concept in EEG education (polarity), and also
explored two major troublesome themes: pattern interpretation and clinical
significance. We have shown how each of these concepts may relate to each other as
a threshold conception of EEG learning: polarity forms the core of EEG
understanding, and needs to be understood before learners can understand pattern
interpretation or determine clinical significance. Our hope is that these findings
have clarified potential barriers to learning EEG, ways in which learners can be
supported, and potential areas of emphasis in curriculum design. Learners may
oscillate between mimicry and genuine understanding, and the learning process
requires an acknowledgment of this, with frequent opportunities for repetition and
discussions with experts. An acknowledgement of the variability in experiences that
students bring to the learning process (pre-liminal variation) can go a long way to
supporting students in overcoming barriers to learning. In addition, these TCs and
troublesome knowledge may get to the root of expertise; determining whether a
student has truly understood a threshold concept may be a useful foundation for
assessment of the very highest levels of knowledge and skills in EEG interpretation.
The threshold conception of EEG learning should be considered a starting point:
both for novel approaches to teaching, curriculum design and assessment, but also
for further validation with future research. A similar approach could be applied to
other areas of medical education where identifying and engaging with TCs may
provide focus to a curriculum, allowing teachers and curriculum designers to better
understand what students need to learn in order to progress and how to determine
the extent to which they understand it.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
21
References
ACGME. 2013. The Neurology Milestone Project. [accessed February 4, 2015].
http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/NeurologyMilesto
nes.pdf.
Baillie C, Bowden JA, Meyer JHF. 2013. Threshold capabilities: threshold concepts
and knowledge capability linked through variation theory. Higher Education.
65(2):227-246. English.
Barradell S. 2013. The identification of threshold concepts: a review of theoretical
complexities and methodological challenges. Higher Education. 65(2):265-276.
English.
Barradell S, Kennedy-Jones M. 2015. Threshold concepts, student learning and
curriculum: making connections between theory and practice. Innovations in
Education and Teaching International. 52(5):536-545.
Barradell S, Peseta T. 2016. Promise and challenge of identifying threshold concepts:
a cautionary account of transactional curriculum inquiry. Journal of Further and
Higher Education. 40(2):262-275.
Benbadis SR, Lin K. 2008. Errors in EEG interpretation and misdiagnosis of epilepsy.
Which EEG patterns are overread? Eur Neurol. 59(5):267-271.
Blackburn SC, Nestel D. 2014. Troublesome knowledge in pediatric surgical
trainees: a qualitative study. J Surg Educ. 71(5):756-761. English.
Clouder L. 2005. Caring as a 'threshold concept': Transforming students in higher
education into health (care) professionals. Teach High Educ. 10(4):505-517. English.
Collett T, Neve H, Stephen N. 2017. Using audio diaries to identify threshold
concepts in "softer" disciplines: a focus on medical education. Practical and Evidence
of Scholarship of Teaching and Learning in Higher Education. 12(2):99-117.
Collura TF. 1993. History and evolution of electroencephalographic instruments and
techniques. Journal of clinical neurophysiology : official publication of the American
Electroencephalographic Society. 10(4):476-504.
Cousin G. 2009. Researching Learning in Higher Education: An Introduction to
Contemporary Methods and Approaches. New York: Routledge.
Davies P, Mangan J. 2007. Threshold concepts and the integration of understanding
of economics. Studies in Higher Education. 32:711-726.
Flanagan M. 2016. Threshold Concepts: Undergraduate Teaching, Postgraduate
Training, Professional Development and School Education: A Short Bibliography.
[accessed June 3, 2016]. http://www.ee.ucl.ac.uk/~mflanaga/thresholds.html.
Gavvala J, Abend N, LaRoche S, Hahn C, Herman ST, Claassen J, Macken M, Schuele S,
Gerard E, Critical Care EEGMRC. 2014. Continuous EEG monitoring: a survey of
neurophysiologists and neurointensivists. Epilepsia. 55(11):1864-1871.
Jordan K, Tracy F, Johnstone K. 2011. Threshold concepts as focal points for
supporting student learning. Bioscience Education. 18(1):1-7.
Klass DW, Westmoreland BF. 1985. Nonepileptogenic epileptiform
electroencephalographic activity. Annals of neurology. 18(6):627-635.
Land R, Cousin G, Meyer JHF. 2005. Threshold concepts and troublesome knowledge
(3): Implications for course design and evaluation. In: Rust C, editor. Improving
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
22
Student Learning. Oxford: Oxford Centre for Staff and Learning Development; p. 53-
64.
Levett-Jones T, Bowen L, Morris A. 2015. Enhancing nursing students'
understanding of threshold concepts through the use of digital stories and a virtual
community called 'Wiimali'. Nurse Educ Pract. 15(2):91-96.
Lingard L, Kennedy TJ. 2010. Qualitative research methods in medical education. In:
Swanwick T, editor. Understanding Medical Education: Evidency, Theory and
Practice. Chichester, West Sussex: Wiley-Blackwell; p. 323-335.
Loertscher J, Green D, Lewis JE, Lin S, Minderhout V. 2014. Identification of
threshold concepts for biochemistry. CBE - Life Sciences Education. 13:516-528.
McAllister M, Lasater K, Stone TE, Levett-Jones T. 2015. The reading room:
Exploring the use of literature as a strategy for integrating threshold concepts into
nursing curricula. Nurse Educ Pract. 15(6):549-555.
Meyer JHF, Land R. 2003. Threshold Concepts and Troublesome Knowledge:
linkages to ways of thinking and practising within the disciplines. In: Rust C, editor.
Improving Student Learning - Ten Years On. Oxford: Oxford Centre for Staff and
Learning Development.
Meyer JHF, Land R. 2006. Threshold concepts and troublesome knowledge: Issues of
liminality. In: Meyer JHF, Land R, editors. Overcoming Barriers to Student
Understanding: Threshold concepts and troublesome knowledge. London:
Routledge; p. 19-32.
Neve H, Wearn A, Collett T. 2016. What are threshold concepts and how can they
inform medical education? Med Teach. 38(8):850-853.
O'Donnell R. 2010. A Critique of the Threshold Concepts Hypothesis and an
Application in Economics. Working Paper No 164. [accessed July 18, 2016]:[1-18 p.].
http://www.finance.uts.edu.au/research/wpapers/wp164.pdf.
Quinlan KM, Male S, Baillie C, Stamboulis A, Fill J, Jaffer Z. 2013. Methodological
challenges in researching threshold concepts: a comparative analysis of three
projects. Higher Education. 66(5):585-601. English.
Rodger S, Turpin M, O'Brien M. 2015. Experiences of academic staff in using
threshold concepts within a reformed curriculum. Studies in Higher Education.
40(4):545-560. English.
Rowbottom DP. 2007. Demystifying threshold concepts. J Philos Educ. 41(2):263-
270. English.
Tatum WO. 2013. How not to read an EEG: introductory statements. Neurology.
80(1 Suppl 1):S1-3.
Wearn A, O'Callaghan A, Barrow M. 2016. 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 M, editors. Threshold
Concepts in Practice. Rotterdam: Sense Publishers; p. 223-238.
Wilkinson L. 2014. The problem with threshold concepts. Sense and Reference: A
philosophical library blog. [accessed 2016 June 19, 2014].
https://senseandreference.wordpress.com/2014/06/19/the-problem-with-
threshold-concepts/.
Williams GW, Luders HO, Brickner A, Goormastic M, Klass DW. 1985. Interobserver
variability in EEG interpretation. Neurology. 35(12):1714-1719.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
23
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
24
Box 1. Threshold Concepts and Troublesome Knowledge
Characteristics of Threshold Concepts (Meyer and Land 2003, 2006; Baillie,
Bowden and Meyer 2013)
Transformative: The understanding of threshold concepts leads to a shift in the
student’s perception of the subject area.
Probably irreversible: Once they are learned, threshold concepts change
perspective so that learners are unlikely to forget them.
Integrative: They will show the “hidden interrelatedness” of a subject.
Often bounded: These concepts may form a boundary or demarcation in levels of
expertise, and understanding these concepts may serve as a portal to open up
new areas of intellectual exploration.
Potentially troublesome: Troublesome knowledge is “‘alien,’ counter-intuitive or
even intellectually absurd at face value.”
Discursive*: Learning threshold concepts involves enhanced use of language.
Liminality*: During the learning process, learners occupy a “liminal space”
characterized by incomplete or fragile understanding.
Reconstitutive*: Related to both the transformative and discursive
characteristics, learning threshold concepts involves discarding prior conceptual
stances regarding the topic.
Types of Troublesome Knowledge (Perkins 1998, 2006)
Ritual knowledge: A type of routine knowledge used for a specific task or social
ritual.
Inert knowledge: Knowledge that is known or understood on some level, but
rarely used out of a specific context.
Conceptually difficult knowledge: Knowledge that is difficult to understand at
face value.
Foreign or alien knowledge: Knowledge arising from a foreign or conflicting
perspective.
Tacit knowledge: Knowledge that is acted upon every day, but about which we
may not be entirely conscious or aware.
* The last 3 characteristics were added to the original 5 elements of the threshold concepts
framework based on further work by Meyer & Land (2006).
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
25
Table 1. Selected characteristics of EEG experts interviewed.
Gender
Years of
teaching
Experience
Location of
EEG
training
Location of
practice
Number of
residents
taught
Number of
fellows
taught
F
5-10
USA
USA
40-50
10-20
M
20-25
USA
USA
>100
70-80
M
30-35
Canada
Canada
20-30
1-5
M
30-35
USA
USA
0
>100
M
30-35
USA
USA
>200
10-20
M
15-20
USA
USA
>100
>100
F
5-10
USA
USA
20-30
10-20
M
35-40
Canada
Canada
>100
40-50
M
5-10
USA
USA
40-50
20-30
M
1-5
USA
USA
30-40
0
M
10-15
Canada
Canada
20-30
0
F
15-20
USA
USA
70-80
10-20
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
26
Table 2. Polarity as a threshold concept.
Transformative
They might say they understand it, but then you ask them a question about
it and they clearly do not. Then, one day after the right picture on the screen,
all of a sudden everything clicks, and your life is beautiful.” (Expert #10)
(Probably) Irreversible
“[polarity] seems to be a very hard concept to get through, but it always
seems like once they get it, they just got it.” (Expert #9)
Integrative
“how to transform [EEG] into the idea of a three dimensional electrical field
like a topographic map of contours and that’s not something that comes
immediately to mind.” (Expert #3)
Bounded
Once they can understand dipoles and where things are coming from, I think
that opens up the field of localization for them as well.” (Expert #9)
Troublesome
“I think that's why EEG is even more difficult to conceptualize [than
radiology]… I mean, not to sound too philosophical but we kind of made this
up and decided that there's certain conventions and you have to just learn
this and there are rules. That absolutely does not apply in radiology.” (Expert
#12)
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
27
Table 3. Examples of troublesome aspects of pattern interpretation and clinical
significance.
Troublesome
concept
Example
Type of troublesome
knowledge
Pattern
interpretation
“I remember my first day trying to read EEG,
someone pointed out an artifact, or I asked,
‘What is that?’ And they said it was an
artifact, and I asked, ‘Why?’ They said it looks
‘artifact-y.’ That sums up most of my hatred
of trying to learn EEG from that first day, is if
you can't explain why something is the way it
is, it makes it very hard for someone to learn
why it is that.” (Expert #9)
Tacit
"…when I first started it was all a big
jumbled mess, I had no idea what I was doing
…" (Expert #7)
Conceptually difficult
"I think people come and their only prior
experience with anything that remotely
resembles this is an electrocardiogram and
they try and apply some of the same
inspection of these waves that they learned
from fundamental [ECG] ... and it really isn’t
the same at all." (Expert #3)
Foreign or alien
Clinical
significance
"… actually writing an impression is quite
difficult: knowing how to make something
sound either important or not important … "
(Expert #2)
Tacit
"making the distinction between the
summary of findings and your impression, is
one of the things that I try to stress ...Your
impression is your impression, but always
keep in mind the audience and the
implications." (Expert #10)
Conceptually difficult
“I always say … leniency comes with
experience. The more you see, the more you
tolerate normal variants. In addition, the
other factor is, the legal environments in
which we here in the United States practice,
people are so afraid of missing something
that they would rather over-diagnose.”
(Expert #6)
Foreign or alien
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
28
Figure 1. “Threshold conception” of EEG interpretation.
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
29
Appendix 1: Interview Script for Threshold Concepts in EEG
Intro:
Threshold concepts are “akin to a portal, opening up a new and previously
inaccessible way of thinking about something . . . without which the learner cannot
progress”
They are:
1. Transformative: Once understood, their potential effect on student learning
and behavior is to occasion a significant shift in the perception of a subject
2. Probably irreversible: The understanding of threshold concepts changes
perspective to a point that they are unlikely to be forgotten.
3. Integrative: They will show the “interrelatedness” of a subject.
4. Often bounded: They are a portal through the boundaries or demarcations in
levels of understanding of a subject.
5. Potentially troublesome: Troublesome knowledge is “alien” or
counterintuitive or even intellectually absurd at face value.
Think about your career as an EEG teacher, and your experiences with students in the
context of these ideas as we discuss teaching and learning EEG.
Baseline Data
1. How long have you been involved in the teaching of EEG (including
fellowship).
2. How many students have you trained (approximately)?
a. Residents
b. Fellows
c. Others
3. What are the contexts and venues in which you teach (or have taught) EEG
interpretation?
Questions about EEG learning
1. What concepts in EEG are fundamental to the grasp of this topic?
2. Of these areas, which have been most “troublesome” to learners, in your
experience?
a. To fellows?
b. To residents?
c. To both?
3. [for each concept] Specific to these areas that you have identified, how have
you seen learners progress to truly understand these troublesome concepts?
a. How has the process taken place (gradually or all of a sudden)?
b. What role have you played as a teacher in facilitating this?
c. What else has been helpful in getting them to understand troublesome
concepts?
Accepted Manuscript. Published version available at:
http://www.tandfonline.com/doi/full/10.1080/0142159X.2017.1408902
Moeller & Fawns Threshold Concepts in EEG
30
d. What are barriers to them understanding troublesome concepts?
4. [for each concept] Specific to each of these areas, have they been, and if so
how:
a. Transformative
b. Irreversible
c. Bounded (portals)
d. Integrative
5. What are some overall aspects of the learning environment, teaching
strategies, curriculum that are most helpful in allowing learners to truly
understand EEG interpretation?
6. What are some general barriers to EEG learning?
Would you like to make any additional comments about EEG learning, troublesome
concepts, etc.?
Specific categories [use only if not addressed with answers to questions
above]
Please consider troublesome concepts and teaching strategies in the following
areas:
Technical aspects of EEG (montages, polarity rules, filters, etc)
Normal awake and asleep recordings
Artifacts
Normal variants
Epileptiform discharges
Seizures
EEG in critically ill patients.
Terminology, writing reports
... 5 Most of the studies targeting threshold concepts in medical education have been done in Europe, the United States and Australia, focussing on identifying threshold concepts in either clinical subjects or soft disciplines, including ethics, professionalism and professional identity formation. 3,7,8 Several studies are carried out without direct student involvement in identifying the threshold concepts. 9 Robust curricular reforms are under way in Pakistan with an obvious drive to adopt and implement an integrated curriculum in Basic Health Sciences. ...
... The questions were developed after literature search and all questions of the interview were open-ended. 7 Seven questions were designed for the students, and nine for the faculty. Interviews were conducted after the conclusion of the GIT module. ...
... Moeller and Fawns explored threshold concepts in learning electroencephalography (EEG), and acknowledged that taking experts only as participants was a limitation to their study because experts may not be able to comprehend why a concept is troublesome for the students. 7 Evgeniou and Loizou had similar suggestion that experts might differ in their opinion of troublesome concepts they faced as beginners. 16 In contrast, most of our students were of the view that they had limited previous knowledge of the concepts they found troublesome. ...
Article
Full-text available
Objective: To explore threshold concepts in a Basic Health Sciences module. Methods: The qualitative study was conducted at the Islamabad Medical and Dental College, Islamabad, Pakistan, in March 2019, and comprised students and faculty members in the gastrointestinal tract module of spiral I of the integrated modular curriculum in Basic Health Sciences. Data on student experiences was collected using semi-structured interviews with open-ended questions. The data was coded and themes were identified by the researchers independently. A thematic matrix was produced, cross-referencing data relating to troublesome areas identified by the students against the threshold concept criteria. The identified themes were discussed among the researchers to reach consensus. Only the identified themes were taken as the expected threshold concepts in the gastrointestinal tract module. Results: Of the 18 subjects, 14(77.8%) were students and 4(22.2%) were facilitators. There were 8 areas identified by the students as troublesome in the module; development of gastrointestinal tract, anatomical relations, electron transport chain, histology of gastrointestinal tract mucosa, peritoneal disposition, anal canal and ischioanal fossae, peristalsis, and absorption across gastrointestinal tract mucosa. Only development of gastrointestinal tract appeared to cross-match with all the criteria outlined for threshold concepts. The troublesome areas identified by the teachers were development of gastrointestinal tract, peritoneal disposition, anatomical relations, absorption across gastrointestinal tract and peristalsis. Conclusions: Development of gastrointestinal tract was found to be the threshold concept in the system-based integrated module of gastrointestinal tract. Most of the students found their previous knowledge inadequate in learning concepts of the module.
... Two articles identified TCs based on literature reviews (Khurshid et al., 2020;Wearn et al., 2020). Some articles focused on a specific concept or area within a professional field, e.g., microsurgery (Evgeniou et al., 2015), EEG (Moeller & Fawns, 2018), prosthetics (Hill, 2017), palliative medicine (O'Callaghan et al., 2020), prescription writing (Khurshid et al., 2020) and self-directed learning (Bowman, 2017). Other articles identified TCs in a specific area within professions, such as mental health within nursing (Leidl, 2018;Stacey & Stickley, 2012), professionalism among medical students (Neve et al., 2017), internal medicine for residents (Bhat et al., 2018), psychiatry (Khatri et al., 2020), paediatric surgical training (Blackburn & Nestel, 2014), practice education for occupational students (Tanner, 2011), or population health . ...
... Others used clinical educators or educationalists e.g., (Barradell & Peseta, 2016;Tanner, 2011) and some combined several stakeholders as respondents, such as students, educationalists and professionals (Hill, 2017;Khatri et al., 2020) or students, educationalists, and professionals (Nicola-Richmond et al., 2016). In some studies, informants were introduced to TC and then asked to identify potential TCs in their own practice (Barradell & Peseta, 2016;Moeller & Fawns, 2018;Neve et al., 2020). Others did not mention TCs to their informants and instead asked them to describe, for example, difficult concepts, troublesome knowledge or crucial learning experiences (Bhat et al., 2018;Hill, 2017;Leidl, 2018). ...
... As in the theme TCs influencing curriculum design there were articles mainly focusing on identifying TCs that also discussed their nature and how one should go about investigating them (Fortune & Kennedy-Jones, 2014;Hyde et al., 2018;Moeller & Fawns, 2018;Neve et al., 2017Neve et al., , 2020Nicola-Richmond et al., 2016). Many found the task of identifying TCs to be challenging, which was related to Meyer and Land's notion that a TC does not necessarily need to fulfil all predefined criteria (Meyer & Land, 2003). ...
Article
Full-text available
Threshold concepts (TCs) are increasingly used in health professions education (HPE) research. TCs are claimed to be conceptual gateways which are often traversed with substantial difficulty. In this paper, we report on a scoping review investigating the following research question: What is the scope and nature of the currently available research on threshold concepts in health professions education literature? We employed Arksey and O’Malley’s model for scoping reviews. A search for literature on TCs in HPE research between 2003 and 2020 yielded 999 records of which 59 were included in the review. The data set was subject to quantitative descriptive analysis of article characteristics as well as qualitative thematic analysis of the scope of research on TCs. Among the 59 articles selected for review, there were 30 empirical, 26 conceptual and three reviews. A majority were published in 2015 or later. Almost half of the included articles attempted to identify possible TCs within HPE. Others investigated how TCs can be traversed or suggested how TCs could influence curriculum design. Some critically appraised the framework of TC. Although TCs are increasingly utilised in HPE, the present review identified how researchers came across methodological challenges related to identifying possible TCs and definitional challenges around identifying the essential characteristics of TCs. Before embracing TCs as the next go-to theory for learning in HPE, we acknowledge the need for methodological stringeny and rigour as well as more data to support TCs. Until then, any implementation of TCs in HPE curricula should be done cautiously.
... 9,32 At a postgraduate level, TCs have been identified among doctors, [33][34][35][36][37] nurses, 29,30 pharmacists, 38 and occupational therapists. [39][40][41] Within these contexts, TCs have been referenced as knowledge one must acquire, 40,42 skills, 43,44 or as part of professional identity development. 45,46 Specific TCs identified include, but are not limited to, "uncertainty within medicine," 22,45,46 "caring, " 47 "documentation as essential practice, " 34 "professional touch," 48 "one concept [polarity] of electroencephalography," 44 and "recovery." ...
... 45,46 Specific TCs identified include, but are not limited to, "uncertainty within medicine," 22,45,46 "caring, " 47 "documentation as essential practice, " 34 "professional touch," 48 "one concept [polarity] of electroencephalography," 44 and "recovery." 29,30 Some studies identify TCs in regard to their "transformative" and/or "troublesome" nature 37,[49][50][51] or other characteristics, 34,44,52 but few have screened for all proposed components. 53 Meyer and Land themselves, when analyzing surgical education, only identified TCs on the basis of whether or not they were transformative, 22 paying only "passing reference" to liminality and troublesome-ness. ...
Article
Full-text available
Issue Threshold Concepts are increasingly used and researched within health professions education. First proposed by Meyer and Land in 2003, they can be defined as ways of knowing central to the mastery of a subject. They are framed as profoundly transformative, impacting the identity of those who encounter them through irreversible shifts in an individual’s outlook. Although Threshold Concepts have been identified in a multitude of educational settings across the continuum of health professions education, there has been little critique of Threshold Concepts as a theory of health professions education. Within adjacent fields critical discourse is also underdeveloped, perhaps given the educational resonance of the theory, or the way in which the theory encourages subject specialists to discuss their area of interest in depth. This commentary critically examines how Threshold Concepts have been used and researched within health professions education, applying critiques from other educational fields, to assist scholars in thinking critically regarding their application. Evidence Three significant critiques are outlined: 1) ‘The floating signifier problem’; 2) ‘The body of knowledge problem’; and 3) ‘The professional identity problem.’ Critique 1, the floating signifier problem, outlines how Threshold Concept theory lacks articulation and has been inconsistently operationalized. Critique 2, the body of knowledge problem, outlines the issues associated with attempting to identify a singular body of knowledge, particularly in regard to the reinforcement of entrenched power dynamics. Critique 3, the professional identity problem, argues that the way in which Threshold Concepts conceptualize identity formation is problematic, inadequately grounded in wider academic debate, and at odds with increasingly constructionist conceptualizations of identity within health professions education. Implications These critiques have implications for both educators and researchers. Educators using Threshold Concepts theory must think carefully about the tacit messages their use communicates, consider how the use of Threshold Concepts could reinforce entrenched power dynamics, and reflect on how their use may make material less accessible to some learners. Further, given that Threshold Concept theory lacks articulation, using the theory to structure curricula or educational sessions is problematic. Threshold Concepts are not synonymous with course learning outcomes and so, While considering Threshold Concepts may enable pedagogical discussion, the theory cannot help educators decide which concepts it applies to; this requires careful planning which extends beyond the bounds of this theory. For researchers, there are issues too with power and inconsistent theoretical operationalization, but also with the way in which Threshold Concepts theory conceptualizes identity formation, which cast doubt on its use as a theory of identity development. On balance, we believe Threshold Concept theory suffers a number of fundamental flaws that necessitate a shift from the positioning of Threshold Concepts as a theory, toward the use of Threshold Concepts as a less prescriptive reflective prompt to stimulate pedagogical discussion.
... Open access identified in pathology, 25 anaesthetics, 26 cardiothoracic surgery, 27 geriatrics, 28 29 neurology, 30 palliative care 31 and psychiatry. 32 Neve 20 explored the potential for identifying TCs in postgraduate primary care, and Gupta and Howden 23 described TCs identified in undergraduate primary care teaching. ...
Article
Full-text available
Objective To identify threshold concepts (TCs) for physicians undergoing postgraduate medical education (PGME) in general practice. Design An explorative, qualitative study with 65 min focus group interviews and thematic analysis was used. Participants were asked to describe their most transformative learning experiences. Heuristical TCs were identified from the thematic analysis. Setting Aotearoa/New Zealand (A/NZ). Participants Fifty participants, mostly comprising current trainees and educators from urban centres, and of NZ/European ethnicity. Results Twenty TCs covering many aspects of postgraduate general practice experience were derived from themes identified in the data. Presented in medical proverbial form for ease of recollection, these included: Money makes the practice go round; Be a legal eagle; Manage time or it will manage you; Guidelines, GPs’ little helpers; Right tool, right word, right place; The whole of the practice is greater than the sum of the parts; The personal enhances the professional; Beat biases by reflection; Chew the Complexity, Unpredictability, Diversity; Embrace the uncertainty; Not knowing is knowing; Seek and you shall find; Waiting and seeing, waiting and being; Look, listen, think between the lines; Treat the patient beyond the disease; No patient is an island; Words work wonders; Hearing is healing; Being you and being there; and; The relationship is worth a thousand consults. These TCs mapped onto core competencies in A/NZ’s PGME in general practice curriculum. Conclusions Participants readily identified transformative and troublesome moments in their PGME in general practice. These findings confirmed evidence for a wide range of TCs with many newly identified in this study. All TCs were fundamentally based on the doctor–patient relationship, although often involving the context and culture of general practice. Actively incorporating and teaching these identified TCs in PGME in general practice may enable trainees to grasp these important learning thresholds earlier and more easily and aid in identity and role formation.
... Furthermore, the prospective chemistry teachers are asked about concepts on chemical equilibrium that are considered difficult or troublesome according to their learning experiences. Troublesome knowledge identified based on the analysis of misconceptions findings [11] and prospective chemistry teachers' responses about the concept that considered troublesome [12]. ...
Article
Full-text available
This research aims to find out misconceptions and troublesome knowledge on chemical equilibrium. The qualitative method used in this study is conducting a semi-structured interview with prospective chemistry teachers. The interview consists of investigating the prospective chemistry teachers’ understanding using CaCO 3 equilibrium system, NO 2 -N 2 O 4 equilibrium system, and FeSCN ²⁺ equilibrium system and asking about concepts that are considered troublesome according to their learning experiences. The common misconceptions on chemical equilibrium revealed by this study are about the dynamic nature of chemical equilibrium, the constancy of equilibrium constant, and the shift of equilibrium. Meanwhile, the dynamic equilibrium, the equilibrium constant, and Le Chatelier’s principle are considered troublesome knowledge because they can be alien, conceptually difficult, and troublesome language.
... (Mayer and Land 2003). In medical education, threshold concepts have been used to define areas of practice and define strategies for teaching (Neve et al. 2016, Delaney et al. 2017, Kempenaar and Shanmugam 2017, Ma et al. 2017, Moeller and Fawns 2017. To our knowledge, there have been relatively few studies of threshold concepts in clinical settings. ...
Article
Background: Threshold skills are defined as new ways of thinking about and performing in a discipline. They represent transformed ways of thinking and doing that are pivotal to learners’ progress. Our aim was to establish whether clinical reasoning exhibited features of a threshold skill. Methods: Twenty-five final-year medical students were interviewed with a five-question protocol about how they were learning clinical reasoning. Students’ responses were analyzed using a deductive method to identify features of threshold skills. Results: Students’ descriptions of learning clinical reasoning exhibited five features: transformation, troublesomeness, integration, association with practice, and issues with transferability. Conclusions: Viewing clinical reasoning as a threshold skill is a novel interpretation of its nature and has implications for learning, teaching, and research. Students can be reassured that, although initially troublesome, with practice, they will not only learn the skill but also how to use it more effectively. Teachers can help students to understand that clinical reasoning is difficult to learn and will require time and repeated practice under supervision to develop.
... One of the largest "spikes" in audience retention was to a segment on polarity rules in EEG ( Fig. 1). In separate qualitative research, polarity was identified by experts as a "threshold concept," a concept that was necessary to understand in order to progress to expertise in EEG interpretation [27]. In this way, learning technology can be useful not only as a teaching tool, but as a research tool that augments our understanding of how complicated concepts (including many of the concepts in epilepsy and EEG) are learned. ...
Article
Full-text available
Purpose of Review The goal of this review is to survey the current literature on education in epilepsy and provide the most up-to-date information for physicians involved in the training of future doctors on this topic. We intended to review what opportunities exist to enhance our current teaching practices that may not be well-known or widely used, but may be adapted to a broader audience. Recent Findings Many new techniques adopting principles of education (e.g., retrieval practice and spaced learning) or new technologies (e.g., pre-recorded lectures, computer-enhanced modules, and simulation practice) have been trialled to enhance medical education in epilepsy with some success. Many of these techniques are currently adaptable to a wider audience or may soon be available. Summary The use of these opportunities more broadly may allow expansion of educational research opportunities as well as enhancing our ability to pass on information. As the knowledge base in epilepsy continues to dramatically expand, we need to keep evaluating our teaching techniques to ensure we are able to pass along this knowledge to our future providers.
Article
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.
Chapter
paper available at https://link.springer.com/referenceworkentry/10.1007/978-981-13-6106-7_25-1
Article
Within Medical Education students more readily engage with the ‘hard’ sciences seeing sociology, psychology and ethics as ‘nice’ rather than ‘need’ to know. Yet within the published literature, there has been little research into students’ experiences of these subjects. In this paper we discuss a research method that allows the application of threshold concept theory to the exploration of the process of ‘non-biomedical science learning in medical education’. 16 students from a UK medical school were asked to record on their smart phones, their experiences of ‘doctor facilitated’ small group sessions. The students uploaded their recordings to a secure drop box facility and recordings were removed daily and transcribed. 68 transcripts were analysed for both substantive concepts and exemplars (within students’ language) of threshold concept criteria. Concepts were then crossreferenced against threshold criteria. Where concepts appeared to meet the criteria of transformation, liminality, integration and troublesomeness we speculated that these might be ‘threshold’. Audio diaries appear to be a promising methodology for applying threshold concept theory to understanding learning. The study provided an insight into students’ experiences. We learned that our students currently re-appropriate sociological ideas to the medical setting often finding new terminologies situated in their own ‘student speak’. We were able to spot gaps in their learning and notice how and where students get ‘stuck’. A resolvable limitation is we were unable to test for irreversibility. We also found little evidence of boundedness leading us to speculate about the nature of threshold concepts in the non-biomedical sciences.
Chapter
This work arose from some early conversations around a related PhD thesis and a sharing of some concurrent interest in Meyer and Land’s theoretical framework of threshold concepts (Meyer & Land, 2006; Meyer & Land, 2005). We talked widely about clinical communication skills, the processes of change in learning, and the clinical setting of palliative care where Anne worked. In many ways this was the perfect storm of serendipity, a clearly transformative learning setting and a desire to explore Threshold Concepts in a practice context.
Article
This paper arises from ongoing research undertaken by the Economics team of the ESRC/ TLRP Project 'Enhancing Teaching and Learning Environments' (ETL) 1 . This forms part of the large scale ESRC Teaching and Learning Research Programme Phase 2. ETL is seeking to identify factors leading to high quality learning environments within five disciplinary contexts across a range of HE institutions. Meyer's notion of a threshold concept was introduced into project discussions on learning outcomes as a particular basis for differentiating between core learning outcomes that represent 'seeing things in a new way' and those that do not. A threshold concept is thus seen as something distinct within what university teachers would typically describe as 'core concepts'. Furthermore, threshold concepts may represent, or lead to, what Perkins (1999) describes as 'troublesome knowledge' — knowledge that is conceptually difficult, counter-intuitive or 'alien'. The paper attempts to define characteristics of threshold concepts and, in the light of Perkins' work, to indicate correspondences between the notion of threshold concepts and that of 'troublesome knowledge.'
Article
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.
Article
In addition to acquiring a solid foundation of clinical knowledge and skills, nursing students making the transition from lay person to health professional must adopt new conceptual understandings and values, while at the same time reflecting on and relinquishing ill-fitting attitudes and biases. This paper presents creative teaching ideas that utilise published narratives and explores the place of these narratives in teaching threshold concepts to nursing students. Appreciating nuance, symbolism and deeper layers of meaning in a well-drawn story can promote emotional engagement and cause learners to care deeply about an issue. Moreover, aesthetic learning, through the use of novels, memoirs and picture books, invites learners to enter into imagined worlds and can stimulate creative and critical thinking. This approach can also be a vehicle for transformative learning and for enhancing students' understanding and internalisation of threshold concepts that are integral to nursing. Guided engagement with the story by an effective educator can help learners to examine taken-for-granted assumptions, differentiate personal from professional values, remember the link between the story and the threshold concept and re-examine their own perspectives; this can result in transformative learning. In this paper, we show how threshold concepts can be introduced and discussed with nursing students via guided engagement with specific literature, so as to prompt meaningful internalised learning. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
The original work on threshold concepts arose from a project designed to improve students’ learning experiences by taking seriously the features of disciplinary knowledge as its starting point. The conceptual and empirical work on threshold concepts has since developed and matured. While many disciplines have engaged enthusiastically with the identification of threshold concepts, healthcare has not been well represented. Drawing on Cousin’s (2007, 2009) notion of transactional curriculum inquiry, the study explores the identification of threshold concepts in a physiotherapy subject, with a sample of physiotherapy clinical educators, using nominal group technique (NGT). While the article presents a set of concepts from the pilot study, this is not its key contribution. Instead, three novel insights are offered for future threshold concepts research. First, there is a need to extend the stakeholders involved in curriculum reform and renewal beyond the university (particularly, for professions). Second, there must be ongoing opportunities for these external stakeholders to engage with and reflect on the distinct features of threshold concepts if the context and authenticity of practice is to be taken seriously for enhancing student learning. Third, the problem of identification is beset with conceptual challenges that remain unresolved for researchers.