ORIGINAL REPORTS
Troublesome Knowledge in Pediatric Surgical Trainees: A Qualitative Study Simon C. Blackburn, BSc, MBBS, MEd, FRCS(Eng),* and Debra Nestel, PhD, CHSE-A FAcadMEd† Imperial College, London, UK; and †School of Rural Health, Health PEER, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia *
BACKGROUND: Meyer and Land (2003) describe thresh-
old concepts as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. The successful completion of pediatric surgical training in the United Kingdom is a lengthy and complex professional journey in which trainees emerge as consultants with a professional identity. We sought to explore how “threshold concepts” applied to pediatric surgical training with a view to identifying elements that were “troublesome.”
METHODS: Semistructured interviews were conducted. Transcripts were generated from audio recordings and thematically analyzed by the authors. Constant comparison was used to refine themes. Participants were purposively recruited across all years of training. A total of 8 pediatric surgical trainees participated in the study. Approval from obtained from the Human Research Ethics committee. RESULTS: Although there is overlap between themes, analysis revealed “troublesome” areas of training related to knowledge (breadth and rarity of some conditions), clinical judgment (shifting expectation of independence), technical skills (accessing opportunities), transitions between roles (increasing responsibility and remoteness of support), relationships with trainers, and the effect of negative experiences. CONCLUSIONS: Viewing trainees’ experiences of surgical
training through the lens of “threshold concepts” provides insight to the importance of viewing the curriculum in a holistic way. Negative experiences in training were an important catalyst for development, inducing a fundamental change in perception, which might be characterized as a rupture of a “meaning frame.” Trainees in pediatric surgery can be viewed as moving to a mature specialist identity via a transitional state—liminality, from entry into specialist C 2014 Association of Program training. ( J Surg ]:]]]-]]]. J Correspondence: Inquiries to Simon Blackburn, BSc, MBBS, MEd, FRCS(Eng), Department of Paediatric Surgery, St George’s Hospital, Blackshaw Road, London, SW13 0QT; fax: (207) 813-8260; e-mail: [email protected]
Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: troublesome knowledge, paediatric surgery,
threshold concepts, specialist identity, qualitative study COMPETENCIES: Patient Care, Practice Based Learning
and Improvement, Interpersonal Skills and Communications, Professionalism
INTRODUCTION Pediatric surgery in the United Kingdom (UK) involves the delivery of specialist surgical care to patients under the age of 16 years. As a consequence of this, the specialty encompasses specialist gastrointestinal surgery, thoracic surgery, urology, surgical oncology, and neonatal surgery. Pediatric surgeons, therefore, encounter a wide range of pathology and a wide range of sizes of patient. Pediatric surgical training consists of a 6-year higher surgical training program, which follows a period of core surgical training. Higher training is governed by the curriculum laid down in the Intercollegiate Surgical Curriculum Project (ISCP).1 Within the 5-year training program, trainees have to gain experience and expertise across the wide range of subspecialties already described. The training system requires regular workplace-based assessments (approximately 40 per year), including an annual 3601 appraisal. Trainees’ progress is reviewed at a formal meeting at least annually. Knowledge is assessed summatively at the end of training by the intercollegiate Fellowship of the Royal College of Surgeons examination. Within the training period, therefore, trainees must make the transition from a core surgical trainee to consultant, competent and confident in dealing with a wide range of types of patient and clinical problems. Knowledge of the specific difficulties faced by trainees during the process may enhance the training system. To identify these difficulties, we decided to approach this study from the perspective of the trainee. This has the advantage of avoiding approaching difficulty from the
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.03.004
1
perspective of the trainer, whose perception might be significantly different; it has been argued that “an expert’s perception may be radically different from a novice’s, and a novice may struggle with difficulties that the expert can no longer see.”2 Threshold Concepts To approach the issue of difficulty, we chose the framework of threshold concepts described by Meyer and Land3 as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. Meyer and Land further characterized the crossing of a threshold as being irreversible, integrative, and troublesome. As Schwartzman4 points out, “all defining characteristics, except for troublesome, describe the aftermath—not the experience—of student’s successful acquisition of troublesome material.” Therefore, to identify threshold concepts in current trainees, we needed to identify areas of learning where learners report experiencing “troublesomeness.” Research Question Therefore, the research question for this study was as follows, “what knowledge and skills do pediatric surgical trainees find most troublesome to acquire?”
METHOD To seek examples of troublesome knowledge in pediatric surgical trainees, individual semistructured depth interviews were conducted by the lead author (S.B.). Depth interviews were selected to ensure confidentiality because of the potential sensitivity of the topic. Interviews were conducted off hospital premises in a quiet location. An interview guide was developed based on the ISCP,1 the theoretical framework of threshold concepts, and participants were encouraged to identify areas of pediatric surgical training they considered troublesome (Fig.). Participants were initially asked to consider the domains of technical skills, clinical judgment, and knowledge. These domains were also selected from the pediatric surgical curriculum of the ISCP,1 which provides the framework for postgraduate surgical training in the UK. Further areas of discussion, such as professionalism and communication skills, were discussed during the interviews as they were brought up. Interviews were recorded using a digital Dictaphone and the interviews were transcribed. Transcription was performed by a third-party company (HiTech Outsourcing services, Gujarat, India) and checked for accuracy by the lead author (S.B.). All participants were sent their transcribed interviews and given the opportunity to 2
validate them or to delete any sections that they did not want analyzed. However, this respondent validation was not taken up by any interviewees. Participants were drawn from the population of trainees in the higher surgical training program in pediatric surgery in London. Purposive sampling was used to ensure all levels within the 6-year training program were identified and that both genders were represented. A convenience element to the sampling was also used to ensure participants were accessible to the interviewer. As a consequence, participants were drawn from 3 hospitals within the training consortium. Brief field notes were kept after each interview and used to guide subsequent interviews. Formal data analysis was performed in 2 rounds, with analysis taking place after the first 5 interviews. The preliminary analysis was used to guide the following interviews. Data excerpts were initially grouped into broad categories and this was followed by a process of constant comparison, which was used to refine understanding of the themes. The study was approved by the medical education ethics committee of Imperial College, London.
RESULTS Overall, 8 of 10 interviewees accepted the invitation to participate in the study. Participants were from all 6 years of higher training in pediatric surgery; 2 of them were women. Detailed participant characteristics have been omitted to preserve anonymity. All participants in the study engaged well with the interview process and seemed to give their views freely. Thematic Extraction Thematic analysis of the transcripts revealed troublesomeness within the areas of: knowledge, clinical judgment, technical skills, transitions between different roles (including validation as a pediatric surgeon), relationships with trainers, and the effect of negative experiences. Knowledge Overall, 6 of 8 participants identified the breadth of pediatric surgery as a specialty as a source of difficulty in gaining the knowledge required. This was compounded by the rarity of some conditions encountered, particularly when neonatal surgery was considered. Specific topic areas were most notable by their absence from the discussion, although some areas of basic science were identified as difficult. Applied knowledge, the knowhow of pediatric surgery, was perceived as being much more troublesome by participants: Well, there’s what’s written in the textbook and people know that there’s an inner textbook. [Participant 3] Journal of Surgical Education Volume ]/Number ] ] 2014
Interview Outline Briefing The interviewer will explain: That the content of the interview will remain confidential A broad outline of the project That the interview will be recorded What will happen to audiotape and transcript That brief notes might be taken to guide further questions That the participant/interviewee can withdraw at any time That the participant/interviewee can ask questions/seek clarification at any time A definition of “learning” for the purposes of the interview will be offered "Activity that leads to towards the development of the skills, knowledge and attributes that might be expected of a consultant paediatric surgeon" Background of interviewee Age Stage of training Experience professional/academic before entering higher surgical training Questions related to a theoretical trainee "I'd like to talk about a new trainee starting as an ST3 in paediatric surgery. What do you think they might find most difficult to learn at this stage?” Follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subject’s response.
“Now let’s think about someone in the middle of their training, what difficulties might they be having with learning at this stage"?” Again, follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subjects response.
“Now let’s think about someone in the final part of their training, what difficulties might they be having with learning?” Again, follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subjects response.
Questions about interviewee “So we've talked about theoretical trainees in paediatric surgery, do you have any examples from your own experience that might mirror the problems you've described" "When you've found things difficult to learn, what strategies have you used to deal with this?"
Summarising "So you've given some examples of things that might be difficult to learn as a paediatric surgical trainee. In your own experience what's been the effect of getting past these difficulties, has it changed you as a surgeon in any way?" “Could you go back to the position you were in before you got past them?” Debriefing “The main things you've identified that have been difficult to learn are... would that be a fair reflection of what you've said” Participants/interviewees will be invited to offer any other information they think is useful.
FIGURE. Interview guide used to structure interviews.
Journal of Surgical Education Volume ]/Number ] ] 2014
3
Clinical Judgement Developing clinical judgment and recognizing and reflecting on incorrect clinical judgment (refer to section The Effects of Negative Experiences), was a commonly occurring theme, described by 6 of 8 participants. Participants often reflected on developing an ability to tolerate diagnostic doubt, and the fact that their judgment had developed from experience. Clinical judgment was also an area in which the expectations of more junior trainees (of themselves) differed from those of more senior trainees. Junior trainees had an expectation that their own judgments should be independent, a different view from that expressed by more senior participants: I think, as a ST3 it’s very difficult to make an independent decision about anything because everything is so overwhelming… [Participant 5] Technical Skills Within the domain of technical operative skills, there were few examples of specific areas of troublesomeness. Although there was a sense that certain operative procedures did “click” for some trainees, the individual difficulty of some surgical procedures was overwhelmed by the difficulty in accessing opportunities to operate, which was the most commonly occurring source of troublesomeness reported by participants, discussed in 7 of 8 interviews. This was thought to be related to the large number of rarely occurring operations encountered by individual trainees but mediated by an increase in trainee numbers. Transitions Between Roles Troublesomeness surrounding transitions in role was a dominant theme raised by participants in all 8 interviews. The transition from previously held roles to that of a higher surgical trainee was marked by an increased level of challenge, this was expressed in a perception of increased responsibility, increased expectations of technical skill, and the demands placed by the fact that those being looked after are children. Associated with this increase in technical demands and responsibility, several participants described difficulty with the sudden remoteness of support, with the consultant on call often at home and away from the hospital. Interestingly, this fear of seeking help seemed not to be recognized or recalled by the more senior participants. Validation as a Pediatric Surgeon Alongside this transition in role, 5 of 8 participants described a desire to prove themselves, reflecting a lack of validation as a pediatric surgeon, one responded to a discussion about technical skills by saying, 4
Yes, if you’re a bit clumsy you’d be shown a better technique then that happens, but that’s the default of the training pathway as opposed what is actually difficult for you as a trainee in those stages, the fact that you don’t have any self-belief. [Participant 1] Some participants reflected on the importance of external support, particularly from their consultants, to their feelings of self-belief. Other points of transition reported as troublesome were the progression toward teaching more junior staff how to perform operations. When troublesomeness in the context of more senior trainees was discussed, the transition from being a trainee to a consultant was again raised as a potential source of difficulty. Participants identified issues related to management, away from the direct clinical care of patients, as a possible source of difficulty. Relationships With Trainers All 8 participants made reference to the importance of their relationship with their consultant trainer. The effect of this relationship was described across the domains of practice discussed and was seen to have an effect at all levels of training. Particular areas identified included the way in which a relationship with an individual consultant determined access to opportunities to perform operative surgery. Within this setting, participants commonly remarked on the problems presented by frequently changing training consultants, who might have rather different views on the best way to perform a procedure. Participants also felt that their trainers support for clinical decision making was also important, with this relationship providing a source of support and stimulation to learn and study academically as well as helping to develop skills related directly to clinical judgment. The Effect of Negative Experiences All 8 participants described the effect on learning associated with “negative experiences”: situations where trainees had experienced an adverse outcome or had made a misjudgment. It was our view that the emotional language associated with negative experiences was more marked in the interviews with more junior trainees. Most participants were able to describe a specific instance in which a mistake or misjudgment on their part had led to a significant emotional response and also a process of reflection leading to a change in behavior. One participant summarized his understanding of this process in this way: I’d say it almost feels like the cerebral, cognitive part comes first……then the emotional part helps to impress it on you. [Participant 2] Journal of Surgical Education Volume ]/Number ] ] 2014
The emotional response to negative situations was quite marked, with participants describing a profound effect on their sense of self as a consequence of negative experiences. The use of emotional language at this point in the interviews was striking, with the term “cognitive scar” used by all participants to describe their memory of such experiences. Despite the profound emotional effect of these experiences, an interesting feature of the participants’ descriptions was that their eventual effect on learning was thought to be positive. The emotional “hit” of a negative experience followed by a process of reflection was thought to inform future practice in a way regarded as leading to improvement.
DISCUSSION This study’s importance is in illuminating broader elements of trainees’ development. Several facts were thought by participants to be important components of successful learning, and consequently their absence led to difficulties. The most prominent example of this was the relationship with their training consultant, which was thought to govern access to opportunities to develop operative skills. The decision about whether an operation is performed by a trainee or their trainer is complex and multifactorial, and this is poorly characterized in this study. The trainer’s own level of experience and competence is likely to have an influence, as well as their perception of the trainee’s ability. However, this study does demonstrate the importance of this relationship to trainees. Outside the operating theater, participants felt less troubled when help and support were felt to be easily available and described moments of high anxiety and tension when it was not. The effect of negative experiences on all participants was clear, and the descriptions obtained of this were very rich. There seemed to be a clear pattern of the response to these experiences having both emotional and cognitive components. The emotional aftermath and subsequent cognitive rationalization seemed to be key points at which change occurred, with several participants describing changes in their behavior as a consequence of these experiences. This response could be viewed as a key event in development, analogous to a threshold. The early stages of training in this study were characterized by a lack of self-belief and a feeling of a lack of validity as a pediatric surgeon, with some participants describing an abject fear of making mistakes. Some participants viewed the transition from their previous role into that of a higher surgical trainee as the greatest source of troublesomeness they had encountered. This stage of transformation of role and identify can be viewed in terms of what Meyer and Land describe as a state of liminality, the idea of passing through a transitional phase from one state of being to another.3 Liminality, therefore, is transformative and involves space between the loss of a previous status and the acquisition of a new one. This Journal of Surgical Education Volume ]/Number ] ] 2014
moves the model of a threshold, certainly for the purposes of this study, from an epistemological obstacle, where cognitive understanding is a key component, to a more complex process involving an ontological component, in which a change in identity is important. Emerging from this state of liminality, it might be argued that trainees acquire what Rees-Lee describes as a “mature specialist identity.”5 Strengths and Limitations of the Study In adopting this method, we have been able to employ a grounded theory approach, which has allowed the conclusion of the study to evolve from the data. As a consequence, rich descriptions of phenomena, which had not previously been considered, have been possible. However, this study is limited by being confined to trainees’ perceptions and lacks the triangulation that might be offered by talking to trainers about trainees’ difficulties with learning. The sample used distributes the participants slightly centrally, with more participants in the middle of the 6-year program than at its senior and junior ends. Although qualitative methods might not require a truly representative sample, the ideal purposive sample for this study might have been rather the reverse. When compared with pediatric surgical training as a whole, women are underrepresented in the sample, and there are no trainees in less than full-time training included. One of the authors (S.B.) is currently a UK pediatric surgical trainee, which introduces the potential for bias. The potential for individual views to be superimposed on the study is therefore clear. In conducting the study, dual analysis of the transcripts was used to try to obviate this. In addition, because of the small number of pediatric surgical trainees in the UK, this author had pre-existing relationships with most participants. Despite this, participants engaged with the interviews candidly. Implications for Practice and Future Research This study demonstrates the danger of approaching educational development piecemeal by using specific curricular targets. Though a curriculum is clearly needed to define the learning that should occur, the potential exists for the sense and importance of the whole to be lost. The study shows the importance of troublesomeness in the process of becoming a pediatric surgeon, particularly in the context of negative experiences that trainees have encountered. The emotional effect of such experiences on trainees should be recognized by those training them, and trainers might be able to maximize their positive benefits that reflection on these negative experiences may have. The educational effect of negative experiences should also be maximized. This might be achieved by incorporating opportunities for trainees to discuss mistakes in sessions with their peers, perhaps away from the potentially confrontational context of mortality and morbidity meetings. 5
In practical terms, the ongoing development of a trainee needs to be given consideration alongside the acquisition of knowledge and practical skills. This could be achieved by a constant process of mentoring, where an individual trainee develops a relationship with a single senior colleague who supervises their training outside a role comprising clinical teaching or assessment. These relationships, of course, already exist informally, but their incorporation into the formal structure of a training program may be of value. Trainees occupy a state of transition, or liminality, early in their training, which should be recognized by their trainers. The potential for consultants to have lost the awareness of the troublesomeness associated with taking on the mantle of a specialty trainee and feeling the increased responsibility at this point is of great importance.
ACKNOWLEDGMENTS The authors would like to gratefully acknowledge Dr Eleanor Bond’s helpful comments on the manuscript.
6
REFERENCES 1. ISCP. The Syllabus. 2011. Available at: Available at: https://
www.iscp.ac.uk/home/syllabus.aspx Accessed 23.06.11. 2. Kneebone R. Perspective: simulation and transforma-
tional change: the paradox of expertise. Acad Med. 2009;84(7):954-957. 3. Meyer JHF, Land R. Threshold concepts and trouble-
some knowledge: linkages to ways of thinking and practising within the disciplines. In: Rust C, ed. Improving Student Learning—Ten Years On. Oxford: OCSLD; 2003:1-16. 4. Schwartzman L. Transcending disciplinary boundaries: a
proposed theoretical foundation for threshold concepts. In: Meyer JH, Land R, Baillie C, eds. Threshold Concepts and Transformational Learning. Rotterdam: Sense Publishers; 2010:20-44. 5. Rees-Lee JE, O’ Donoghue JM. Inspirational surgical
education: the way to a mature specialist identity. J Plast Reconstr Aesthet Surg. 2009;62(5):564-567.
Journal of Surgical Education Volume ]/Number ] ] 2014
Troublesome Knowledge in Pediatric Surgical Trainees: A Qualitative Study Simon C. Blackburn, BSc, MBBS, MEd, FRCS(Eng),* and Debra Nestel, PhD, CHSE-A FAcadMEd† Imperial College, London, UK; and †School of Rural Health, Health PEER, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia *
BACKGROUND: Meyer and Land (2003) describe thresh-
old concepts as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. The successful completion of pediatric surgical training in the United Kingdom is a lengthy and complex professional journey in which trainees emerge as consultants with a professional identity. We sought to explore how “threshold concepts” applied to pediatric surgical training with a view to identifying elements that were “troublesome.”
METHODS: Semistructured interviews were conducted. Transcripts were generated from audio recordings and thematically analyzed by the authors. Constant comparison was used to refine themes. Participants were purposively recruited across all years of training. A total of 8 pediatric surgical trainees participated in the study. Approval from obtained from the Human Research Ethics committee. RESULTS: Although there is overlap between themes, analysis revealed “troublesome” areas of training related to knowledge (breadth and rarity of some conditions), clinical judgment (shifting expectation of independence), technical skills (accessing opportunities), transitions between roles (increasing responsibility and remoteness of support), relationships with trainers, and the effect of negative experiences. CONCLUSIONS: Viewing trainees’ experiences of surgical
training through the lens of “threshold concepts” provides insight to the importance of viewing the curriculum in a holistic way. Negative experiences in training were an important catalyst for development, inducing a fundamental change in perception, which might be characterized as a rupture of a “meaning frame.” Trainees in pediatric surgery can be viewed as moving to a mature specialist identity via a transitional state—liminality, from entry into specialist C 2014 Association of Program training. ( J Surg ]:]]]-]]]. J Correspondence: Inquiries to Simon Blackburn, BSc, MBBS, MEd, FRCS(Eng), Department of Paediatric Surgery, St George’s Hospital, Blackshaw Road, London, SW13 0QT; fax: (207) 813-8260; e-mail: [email protected]
Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: troublesome knowledge, paediatric surgery,
threshold concepts, specialist identity, qualitative study COMPETENCIES: Patient Care, Practice Based Learning
and Improvement, Interpersonal Skills and Communications, Professionalism
INTRODUCTION Pediatric surgery in the United Kingdom (UK) involves the delivery of specialist surgical care to patients under the age of 16 years. As a consequence of this, the specialty encompasses specialist gastrointestinal surgery, thoracic surgery, urology, surgical oncology, and neonatal surgery. Pediatric surgeons, therefore, encounter a wide range of pathology and a wide range of sizes of patient. Pediatric surgical training consists of a 6-year higher surgical training program, which follows a period of core surgical training. Higher training is governed by the curriculum laid down in the Intercollegiate Surgical Curriculum Project (ISCP).1 Within the 5-year training program, trainees have to gain experience and expertise across the wide range of subspecialties already described. The training system requires regular workplace-based assessments (approximately 40 per year), including an annual 3601 appraisal. Trainees’ progress is reviewed at a formal meeting at least annually. Knowledge is assessed summatively at the end of training by the intercollegiate Fellowship of the Royal College of Surgeons examination. Within the training period, therefore, trainees must make the transition from a core surgical trainee to consultant, competent and confident in dealing with a wide range of types of patient and clinical problems. Knowledge of the specific difficulties faced by trainees during the process may enhance the training system. To identify these difficulties, we decided to approach this study from the perspective of the trainee. This has the advantage of avoiding approaching difficulty from the
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.03.004
1
perspective of the trainer, whose perception might be significantly different; it has been argued that “an expert’s perception may be radically different from a novice’s, and a novice may struggle with difficulties that the expert can no longer see.”2 Threshold Concepts To approach the issue of difficulty, we chose the framework of threshold concepts described by Meyer and Land3 as being “akin to a portal, opening up a new and previously inaccessible way of thinking about something.” As a consequence, threshold concepts have a transformational potential and may lead to an associated change in identity. Meyer and Land further characterized the crossing of a threshold as being irreversible, integrative, and troublesome. As Schwartzman4 points out, “all defining characteristics, except for troublesome, describe the aftermath—not the experience—of student’s successful acquisition of troublesome material.” Therefore, to identify threshold concepts in current trainees, we needed to identify areas of learning where learners report experiencing “troublesomeness.” Research Question Therefore, the research question for this study was as follows, “what knowledge and skills do pediatric surgical trainees find most troublesome to acquire?”
METHOD To seek examples of troublesome knowledge in pediatric surgical trainees, individual semistructured depth interviews were conducted by the lead author (S.B.). Depth interviews were selected to ensure confidentiality because of the potential sensitivity of the topic. Interviews were conducted off hospital premises in a quiet location. An interview guide was developed based on the ISCP,1 the theoretical framework of threshold concepts, and participants were encouraged to identify areas of pediatric surgical training they considered troublesome (Fig.). Participants were initially asked to consider the domains of technical skills, clinical judgment, and knowledge. These domains were also selected from the pediatric surgical curriculum of the ISCP,1 which provides the framework for postgraduate surgical training in the UK. Further areas of discussion, such as professionalism and communication skills, were discussed during the interviews as they were brought up. Interviews were recorded using a digital Dictaphone and the interviews were transcribed. Transcription was performed by a third-party company (HiTech Outsourcing services, Gujarat, India) and checked for accuracy by the lead author (S.B.). All participants were sent their transcribed interviews and given the opportunity to 2
validate them or to delete any sections that they did not want analyzed. However, this respondent validation was not taken up by any interviewees. Participants were drawn from the population of trainees in the higher surgical training program in pediatric surgery in London. Purposive sampling was used to ensure all levels within the 6-year training program were identified and that both genders were represented. A convenience element to the sampling was also used to ensure participants were accessible to the interviewer. As a consequence, participants were drawn from 3 hospitals within the training consortium. Brief field notes were kept after each interview and used to guide subsequent interviews. Formal data analysis was performed in 2 rounds, with analysis taking place after the first 5 interviews. The preliminary analysis was used to guide the following interviews. Data excerpts were initially grouped into broad categories and this was followed by a process of constant comparison, which was used to refine understanding of the themes. The study was approved by the medical education ethics committee of Imperial College, London.
RESULTS Overall, 8 of 10 interviewees accepted the invitation to participate in the study. Participants were from all 6 years of higher training in pediatric surgery; 2 of them were women. Detailed participant characteristics have been omitted to preserve anonymity. All participants in the study engaged well with the interview process and seemed to give their views freely. Thematic Extraction Thematic analysis of the transcripts revealed troublesomeness within the areas of: knowledge, clinical judgment, technical skills, transitions between different roles (including validation as a pediatric surgeon), relationships with trainers, and the effect of negative experiences. Knowledge Overall, 6 of 8 participants identified the breadth of pediatric surgery as a specialty as a source of difficulty in gaining the knowledge required. This was compounded by the rarity of some conditions encountered, particularly when neonatal surgery was considered. Specific topic areas were most notable by their absence from the discussion, although some areas of basic science were identified as difficult. Applied knowledge, the knowhow of pediatric surgery, was perceived as being much more troublesome by participants: Well, there’s what’s written in the textbook and people know that there’s an inner textbook. [Participant 3] Journal of Surgical Education Volume ]/Number ] ] 2014
Interview Outline Briefing The interviewer will explain: That the content of the interview will remain confidential A broad outline of the project That the interview will be recorded What will happen to audiotape and transcript That brief notes might be taken to guide further questions That the participant/interviewee can withdraw at any time That the participant/interviewee can ask questions/seek clarification at any time A definition of “learning” for the purposes of the interview will be offered "Activity that leads to towards the development of the skills, knowledge and attributes that might be expected of a consultant paediatric surgeon" Background of interviewee Age Stage of training Experience professional/academic before entering higher surgical training Questions related to a theoretical trainee "I'd like to talk about a new trainee starting as an ST3 in paediatric surgery. What do you think they might find most difficult to learn at this stage?” Follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subject’s response.
“Now let’s think about someone in the middle of their training, what difficulties might they be having with learning at this stage"?” Again, follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subjects response.
“Now let’s think about someone in the final part of their training, what difficulties might they be having with learning?” Again, follow on questions will try to elicit examples related to technical skill, judgement and knowledge if these are not all covered in the subjects response.
Questions about interviewee “So we've talked about theoretical trainees in paediatric surgery, do you have any examples from your own experience that might mirror the problems you've described" "When you've found things difficult to learn, what strategies have you used to deal with this?"
Summarising "So you've given some examples of things that might be difficult to learn as a paediatric surgical trainee. In your own experience what's been the effect of getting past these difficulties, has it changed you as a surgeon in any way?" “Could you go back to the position you were in before you got past them?” Debriefing “The main things you've identified that have been difficult to learn are... would that be a fair reflection of what you've said” Participants/interviewees will be invited to offer any other information they think is useful.
FIGURE. Interview guide used to structure interviews.
Journal of Surgical Education Volume ]/Number ] ] 2014
3
Clinical Judgement Developing clinical judgment and recognizing and reflecting on incorrect clinical judgment (refer to section The Effects of Negative Experiences), was a commonly occurring theme, described by 6 of 8 participants. Participants often reflected on developing an ability to tolerate diagnostic doubt, and the fact that their judgment had developed from experience. Clinical judgment was also an area in which the expectations of more junior trainees (of themselves) differed from those of more senior trainees. Junior trainees had an expectation that their own judgments should be independent, a different view from that expressed by more senior participants: I think, as a ST3 it’s very difficult to make an independent decision about anything because everything is so overwhelming… [Participant 5] Technical Skills Within the domain of technical operative skills, there were few examples of specific areas of troublesomeness. Although there was a sense that certain operative procedures did “click” for some trainees, the individual difficulty of some surgical procedures was overwhelmed by the difficulty in accessing opportunities to operate, which was the most commonly occurring source of troublesomeness reported by participants, discussed in 7 of 8 interviews. This was thought to be related to the large number of rarely occurring operations encountered by individual trainees but mediated by an increase in trainee numbers. Transitions Between Roles Troublesomeness surrounding transitions in role was a dominant theme raised by participants in all 8 interviews. The transition from previously held roles to that of a higher surgical trainee was marked by an increased level of challenge, this was expressed in a perception of increased responsibility, increased expectations of technical skill, and the demands placed by the fact that those being looked after are children. Associated with this increase in technical demands and responsibility, several participants described difficulty with the sudden remoteness of support, with the consultant on call often at home and away from the hospital. Interestingly, this fear of seeking help seemed not to be recognized or recalled by the more senior participants. Validation as a Pediatric Surgeon Alongside this transition in role, 5 of 8 participants described a desire to prove themselves, reflecting a lack of validation as a pediatric surgeon, one responded to a discussion about technical skills by saying, 4
Yes, if you’re a bit clumsy you’d be shown a better technique then that happens, but that’s the default of the training pathway as opposed what is actually difficult for you as a trainee in those stages, the fact that you don’t have any self-belief. [Participant 1] Some participants reflected on the importance of external support, particularly from their consultants, to their feelings of self-belief. Other points of transition reported as troublesome were the progression toward teaching more junior staff how to perform operations. When troublesomeness in the context of more senior trainees was discussed, the transition from being a trainee to a consultant was again raised as a potential source of difficulty. Participants identified issues related to management, away from the direct clinical care of patients, as a possible source of difficulty. Relationships With Trainers All 8 participants made reference to the importance of their relationship with their consultant trainer. The effect of this relationship was described across the domains of practice discussed and was seen to have an effect at all levels of training. Particular areas identified included the way in which a relationship with an individual consultant determined access to opportunities to perform operative surgery. Within this setting, participants commonly remarked on the problems presented by frequently changing training consultants, who might have rather different views on the best way to perform a procedure. Participants also felt that their trainers support for clinical decision making was also important, with this relationship providing a source of support and stimulation to learn and study academically as well as helping to develop skills related directly to clinical judgment. The Effect of Negative Experiences All 8 participants described the effect on learning associated with “negative experiences”: situations where trainees had experienced an adverse outcome or had made a misjudgment. It was our view that the emotional language associated with negative experiences was more marked in the interviews with more junior trainees. Most participants were able to describe a specific instance in which a mistake or misjudgment on their part had led to a significant emotional response and also a process of reflection leading to a change in behavior. One participant summarized his understanding of this process in this way: I’d say it almost feels like the cerebral, cognitive part comes first……then the emotional part helps to impress it on you. [Participant 2] Journal of Surgical Education Volume ]/Number ] ] 2014
The emotional response to negative situations was quite marked, with participants describing a profound effect on their sense of self as a consequence of negative experiences. The use of emotional language at this point in the interviews was striking, with the term “cognitive scar” used by all participants to describe their memory of such experiences. Despite the profound emotional effect of these experiences, an interesting feature of the participants’ descriptions was that their eventual effect on learning was thought to be positive. The emotional “hit” of a negative experience followed by a process of reflection was thought to inform future practice in a way regarded as leading to improvement.
DISCUSSION This study’s importance is in illuminating broader elements of trainees’ development. Several facts were thought by participants to be important components of successful learning, and consequently their absence led to difficulties. The most prominent example of this was the relationship with their training consultant, which was thought to govern access to opportunities to develop operative skills. The decision about whether an operation is performed by a trainee or their trainer is complex and multifactorial, and this is poorly characterized in this study. The trainer’s own level of experience and competence is likely to have an influence, as well as their perception of the trainee’s ability. However, this study does demonstrate the importance of this relationship to trainees. Outside the operating theater, participants felt less troubled when help and support were felt to be easily available and described moments of high anxiety and tension when it was not. The effect of negative experiences on all participants was clear, and the descriptions obtained of this were very rich. There seemed to be a clear pattern of the response to these experiences having both emotional and cognitive components. The emotional aftermath and subsequent cognitive rationalization seemed to be key points at which change occurred, with several participants describing changes in their behavior as a consequence of these experiences. This response could be viewed as a key event in development, analogous to a threshold. The early stages of training in this study were characterized by a lack of self-belief and a feeling of a lack of validity as a pediatric surgeon, with some participants describing an abject fear of making mistakes. Some participants viewed the transition from their previous role into that of a higher surgical trainee as the greatest source of troublesomeness they had encountered. This stage of transformation of role and identify can be viewed in terms of what Meyer and Land describe as a state of liminality, the idea of passing through a transitional phase from one state of being to another.3 Liminality, therefore, is transformative and involves space between the loss of a previous status and the acquisition of a new one. This Journal of Surgical Education Volume ]/Number ] ] 2014
moves the model of a threshold, certainly for the purposes of this study, from an epistemological obstacle, where cognitive understanding is a key component, to a more complex process involving an ontological component, in which a change in identity is important. Emerging from this state of liminality, it might be argued that trainees acquire what Rees-Lee describes as a “mature specialist identity.”5 Strengths and Limitations of the Study In adopting this method, we have been able to employ a grounded theory approach, which has allowed the conclusion of the study to evolve from the data. As a consequence, rich descriptions of phenomena, which had not previously been considered, have been possible. However, this study is limited by being confined to trainees’ perceptions and lacks the triangulation that might be offered by talking to trainers about trainees’ difficulties with learning. The sample used distributes the participants slightly centrally, with more participants in the middle of the 6-year program than at its senior and junior ends. Although qualitative methods might not require a truly representative sample, the ideal purposive sample for this study might have been rather the reverse. When compared with pediatric surgical training as a whole, women are underrepresented in the sample, and there are no trainees in less than full-time training included. One of the authors (S.B.) is currently a UK pediatric surgical trainee, which introduces the potential for bias. The potential for individual views to be superimposed on the study is therefore clear. In conducting the study, dual analysis of the transcripts was used to try to obviate this. In addition, because of the small number of pediatric surgical trainees in the UK, this author had pre-existing relationships with most participants. Despite this, participants engaged with the interviews candidly. Implications for Practice and Future Research This study demonstrates the danger of approaching educational development piecemeal by using specific curricular targets. Though a curriculum is clearly needed to define the learning that should occur, the potential exists for the sense and importance of the whole to be lost. The study shows the importance of troublesomeness in the process of becoming a pediatric surgeon, particularly in the context of negative experiences that trainees have encountered. The emotional effect of such experiences on trainees should be recognized by those training them, and trainers might be able to maximize their positive benefits that reflection on these negative experiences may have. The educational effect of negative experiences should also be maximized. This might be achieved by incorporating opportunities for trainees to discuss mistakes in sessions with their peers, perhaps away from the potentially confrontational context of mortality and morbidity meetings. 5
In practical terms, the ongoing development of a trainee needs to be given consideration alongside the acquisition of knowledge and practical skills. This could be achieved by a constant process of mentoring, where an individual trainee develops a relationship with a single senior colleague who supervises their training outside a role comprising clinical teaching or assessment. These relationships, of course, already exist informally, but their incorporation into the formal structure of a training program may be of value. Trainees occupy a state of transition, or liminality, early in their training, which should be recognized by their trainers. The potential for consultants to have lost the awareness of the troublesomeness associated with taking on the mantle of a specialty trainee and feeling the increased responsibility at this point is of great importance.
ACKNOWLEDGMENTS The authors would like to gratefully acknowledge Dr Eleanor Bond’s helpful comments on the manuscript.
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some knowledge: linkages to ways of thinking and practising within the disciplines. In: Rust C, ed. Improving Student Learning—Ten Years On. Oxford: OCSLD; 2003:1-16. 4. Schwartzman L. Transcending disciplinary boundaries: a
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