Challenges in the Commencement of Consultant Surgical Practice: A Study of Threshold Concepts in Junior Cardiothoracic Surgeons

Authors

  • Julian A. Smith Monash University http://orcid.org/0000-0003-1244-4277
  • Simon Blackburn Great Ormond Street Hospital for Children NHS Foundation Trust, London
  • Debra Nestel Monash University, Australia and University of Melbourne

DOI:

https://doi.org/10.18552/ijpblhsc.v6i1.435

Keywords:

cardiothoracic surgery, junior consultant surgeon, liminality, threshold concepts, uncertainty

Abstract

The transition from trainee to consultant cardiothoracic surgeon may be challenging. Curricula for cardiothoracic surgical training and for the professional development of cardiothoracic surgeons need to address the issues in transition that are the most difficult. This research used threshold concepts to identify the areas within this transition that are the most problematic. Semi-structured, in-depth, face-to-face, individual interviews were conducted with 13 junior cardiothoracic surgeons (in practice for ten years or less) who were purposively recruited. Transcripts were generated from the interviews and subjected to thematic analysis. Data was independently analysed by three researchers. Problematic areas in the transition to consultant practice included: (1) taking ultimate responsibility for patient care including clinical judgment, decision-making and unsupervised operating; (2) designing a career; (3) navigating new work environments; (4) managing relationships with colleagues, trainees and other team members; (5) managing technical challenges; (6) managing the previously unseen or unexpected; and (7) coping with adverse events. Uncertainty associated with each of these challenges was the most prominent threshold concept. Successfully addressing some or all of these problematic areas resulted in (8) change as a person or surgeon that positively influenced each individual’s sense of worth and identity as a cardiothoracic surgeon. Despite the completion of surgical education and training, time and the passing of the Fellowship examination, significant challenges remain for individuals commencing cardiothoracic surgical practice. There exist further curricular opportunities for the education of senior trainees and for the professional development of junior consultant surgeons to assist in the negotiation of these challenges.

References

Baillie, C., Bowden, J., and Meyer, J. (2013) 'Threshold capabilities: Threshold concepts and knowledge capability linked through variation theory'. Higher Education, 65, 227–246 https://doi.org/10.1007/s10734-012-9540-5

Blackburn, S., and Nestel, D. (2014) 'Troublesome knowledge in paediatric surgical trainees: A qualitative study'. Journal of Surgical Education, 71, 756–761 https://doi.org/10.1016/j.jsurg.2014.03.004

Braun, V and Clarke, V. (2006) 'Using thematic analysis in psychology'. Qualitative Research in Psychology, 3 (2), 77–101 https://doi.org/10.1191/1478088706qp063oa

Cristancho, S., Apramian, T., Vanstone, M., Lingard, L., Ott, M., and Novick, R. (2013) 'Understanding clinical uncertainty: What Is going on when experienced surgeons are not sure what to do?'. Academic Medicine, 88 https://doi.org/10.1097/ACM.0b013e3182a3116f

Cristancho, S.M., Bidinosti, S.J., Lingard, L.A., Novick, R.J., Ott, M.C., and Forbes, T.L. (2014) 'What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations'. Academic Medicine, 89, 1540–1547 https://doi.org/10.1097/ACM.0000000000000478

Cristancho, S.M., Vanstone, M., Lingard, L., LeBel, M.-E., and Ott, M. (2013) 'When surgeons face intraoperative challenges: A naturalistic model of surgical decision making'. American Journal of Surgery, 205, 156–162 https://doi.org/10.1016/j.amjsurg.2012.10.005

Evgeniou, E. and Loizou, P. (2012) 'The theoretical base of e-learning and its role in surgical education'. Journal of Surgical Education, 69, 665–669 https://doi.org/10.1016/j.jsurg.2012.06.005

Flanagan, M. (2018) Threshold Concepts: Undergraduate Teaching, Postgraduate Training and Professional Development: a short introduction and bibliography. https://www.ee.ucl.ac.uk/~mflanaga/thresholds.html

Goethe, R. (2003) 'Ritual and liminality (NCSS Theme: Culture) - Purpose, background, and context'. cited in Meyer, J.H.F., and Land, R. (2005) 'Threshold concepts and troublesome knowledge (2): Epistemological considerations and a conceptual framework for teaching and learning'. Higher Education, 49, 373–388, p.376 https://doi.org/10.1097/SLA.0b013e3182583135

Guba, E. (1981) 'Criteria for assessing the trustworthiness of naturalistic inquiries'. Educational Communication and Technology Journal, 29, 75–91

Jin, C.J., Martimianakis, M.A., Kitto, S., and Moulton, C.A. (2012) 'Pressures to "measure up" in surgery: Managing your image and managing your patient', Ann Surg, 256, 989–993 https://doi.org/10.1097/SLA.0b013e3182583135

Kneebone, R.L. (2009) 'Practice, rehearsal, and performance: An approach for simulation-based surgical and procedure training', JAMA, 302, 1336–1338 https://doi.org/10.1001/jama.2009.1392

Land, R. and Meyer, J.H.F. (2011) 'The scalpel and the "mask": Threshold concepts and surgical education.' in Fry, H. and Kneebone, R. (eds.), Surgical Education: Theorising an Emerging Domain. London: Springer, 91–106

Meyer, J.H.F. and Land, R. (2003) Threshold Concepts and Troublesome Knowledge: Linkages to Ways of Thinking and Practising within the Disciplines. Occasional Report 4. [online] available from http://www.etl.tla.ed.ac.uk/docs/ETLreport4.pdf

Meyer, J.H.F. and Land, R. (2005) 'Threshold concepts and troublesome knowledge (2): Epistemological considerations and a conceptual framework for teaching and learning', Higher Education, 49, 373–388 https://doi.org/10.1007/s10734-004-6779-5

Mitchell, E., Lee, D., Liem, T., Landry, G., and Moneta, G. (2011) 'A fresh cadaver lab to conceptualize troublesome anatomical relationships in vascular surgery'. Society for Clinical Vascular Surgery (SCVS) 39th Annual Symposium. Orlando, Florida, USA

Morrison, J., Clement, T., Nestel, D., and Brown, J. (2016) '"Underdiscussed, underused and underreported": Pilot work in team-based qualitative research'. Qualitative Research Journal, 16, 314–330

Moulton, C., Regehr, G., Mylopoulos, M., and MacRae, H. (2007) 'Slowing when you should: A new model of expert judgement'. Academic Medicine, 82, S109–116

Rees-Lee, J.E. and O’Donoghue, J.M. (2009) 'Inspirational surgical education: The way to a mature specialist identity'. Journal of Plastic, Reconstructive & Aesthetic Surgery, 62, 564–567 https://doi.org/10.1016/j.bjps.2009.03.003

Schwartzman, L. (2010) ‘Transcending disciplinary boundaries: A proposed framework for threshold concepts’ in Threshold Concepts and Transformational Learning: Educational Futures, Rethinking Theory and Practice. ed. by Meyer J.H.F., Land, R, and Baillie, C. Rotterdam: Sense, 21–44

Shenton, A. (2004) 'Strategies for ensuring trustworthiness in qualitative research projects', Education for Information, 22, 63–75 https://doi.org/10.3233/EFI-2004-22201

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Published

2018-07-31

How to Cite

Smith, J. A., Blackburn, S., & Nestel, D. (2018). Challenges in the Commencement of Consultant Surgical Practice: A Study of Threshold Concepts in Junior Cardiothoracic Surgeons. International Journal of Practice-Based Learning in Health and Social Care, 6(1), 78–95. https://doi.org/10.18552/ijpblhsc.v6i1.435