Improving Fellowship Training in Microsurgery: A Threshold Concepts Perspective on the Curricula of Fellowship Programs

Abstract

Background The theory of “threshold concepts” argues that within every discipline there is knowledge that transforms understanding and leads to a previously inaccessible way of thinking, without which the learner cannot progress. This study investigates the factors influencing the development of the characteristic ways of thinking and practicing as a microsurgeon during a microsurgical fellowship. We analyze the challenges in the development of these characteristics during focused fellowship training in microsurgery, of which some could potentially represent “threshold concepts.”

Methods A qualitative research methodology was followed. Semistructured interviews with trainers and trainees from microsurgical units in the United Kingdom (UK) and the United States (US) were conducted. Data were analyzed using the Dedoose (Manhattan Beach, CA) qualitative data analysis software and interpreted using the theory of “threshold concepts.”

Results Five trainees and four trainers from the UK and the US participated in this research project. Although initially some trainees had particular difficulty in developing their practical microsurgical skills, this improved rapidly with adequate practice. Cognitive skills and especially the ability to expect the unexpected and the ability recognize complications presented as a significant challenge for trainees and transformed their understandings regarding the qualities of a microsurgeon.

Conclusions Microsurgical fellowship curricula can be redesigned using the theory of threshold concepts, creating a dynamic framework that addresses individual trainee needs to develop the practical and cognitive skills necessary for independent practice of microsurgery.

Keywords

microsurgery - plastic surgery - training

• References

• 1 Carrel A. La technique operatoire des anastomoses vasculaires et la transplantation des visceres. Lyon Med 1902; 98: 859-863
• 2 Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg 1973; 52 (2) 111-117
• 3 Tamai S. History of microsurgery. Plast Reconstr Surg 2009; 124 (6, Suppl): e282-e294
• 4 Pratt GF, Rozen WM, Chubb D , et al. Modern adjuncts and technologies in microsurgery: an historical and evidence-based review. Microsurgery 2010; 30 (8) 657-666
• 5 Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current principles of facial allotransplantation: the Brigham and Women's Hospital Experience. Plast Reconstr Surg 2013; 131 (5) 1069-1076
• 6 Wang WZ. Investigation of reperfusion injury and ischemic preconditioning in microsurgery. Microsurgery 2009; 29 (1) 72-79
• 7 Fitzgerald JE, Milburn JA, Khera G, Davies RS, Hornby ST, Giddings CE. Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey. World J Surg 2013; 37 (5) 945-952
• 8 Whitaker IS, Shokrollahi K. Subspecialization in plastic surgery: the importance of fellowship training. Ann Plast Surg 2009; 63 (4) 355
• 9 Nugent E, Joyce C, Perez-Abadia G , et al. Factors influencing microsurgical skill acquisition during a dedicated training course. Microsurgery 2012; 32 (8) 649-656
• 10 Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE. Training in microsurgical skills: Does course-based learning deliver?. Microsurgery 2005; 25 (6) 481-485
• 11 Gould SH. The role of the microsurgical laboratory in orthopedic training programs. Orthopedics 1986; 9 (6) 881-882
• 12 Hui KC, Zhang F, Shaw WW , et al. Learning curve of microvascular venous anastomosis: a never ending struggle?. Microsurgery 2000; 20 (1) 22-24
• 13 Brosious JP, Tsuda ST, Menezes JM , et al. Objective evaluation of skill acquisition in novice microsurgeons. J Reconstr Microsurg 2012; 28 (8) 539-542
• 14 Jeong HS, Moon MS, Kim HS, Lee HK, Yi SY. Microsurgical training with fresh chicken legs. Ann Plast Surg 2013; 70 (1) 57-61
• 15 Lausada NR, Escudero E, Lamonega R, Dreizzen E, Raimondi JC. Use of cryopreserved rat arteries for microsurgical training. Microsurgery 2005; 25 (6) 500-501
• 16 Nam SM, Shin HS, Kim YB, Park ES, Choi CY. Microsurgical training with porcine thigh infusion model. J Reconstr Microsurg 2013; 29 (5) 303-306
• 17 Bates BJ, Wimalawansa SM, Monson B, Rymer MC, Shapiro R, Johnson RM. A simple cost-effective method of microsurgical simulation training: the turkey wing model. J Reconstr Microsurg 2013; 29 (9) 615-618
• 18 Sakrak T, Köse AA, Karabağli Y, Koçman AE, Ozbayoğlu AC, Cetįn C. Rat tail revascularization model for advanced microsurgery training and research. J Reconstr Microsurg 2011; 27 (7) 391-396
• 19 Lannon DA, Atkins JA, Butler PE. Non-vital, prosthetic, and virtual reality models of microsurgical training. Microsurgery 2001; 21 (8) 389-393
• 20 Lorenzo AR, Alvarez A, Garcia-Barreiro J, Centeno A, Lopez E, Martelo F. Design and creation of an experimental program of advanced training in reconstructive microsurgery. Microsurgery 2006; 26 (6) 421-428
• 21 Balasundaram I, Aggarwal R, Darzi LA. Development of a training curriculum for microsurgery. Br J Oral Maxillofac Surg 2010; 48 (8) 598-606
• 22 Lascar I, Totir D, Cinca A , et al. Training program and learning curve in experimental microsurgery during the residency in plastic surgery. Microsurgery 2007; 27 (4) 263-267
• 23 Chan WY, Matteucci P, Southern SJ. Validation of microsurgical models in microsurgery training and competence: a review. Microsurgery 2007; 27 (5) 494-499
• 24 Selber JC, Chang EI, Liu J , et al. Tracking the learning curve in microsurgical skill acquisition. Plast Reconstr Surg 2012; 130 (4) 550e-557e
• 25 Chan W, Niranjan N, Ramakrishnan V. Structured assessment of microsurgery skills in the clinical setting. J Plast Reconstr Aesthet Surg 2010; 63 (8) 1329-1334
• 26 Studinger R, Bradford M, Jackson I. Microsurgical training: Is it adequate for the operating room?. Eur J Plast Surg 2005; 28 (2) 91-93
• 27 Meyer J, Land R. Threshold concepts and troublesome knowledge: linkages to ways of thinking and practicing within the disciplines. In: Rust C, , ed. Improving Student Learning: Theory and Practice–Ten Years On. Oxford, United Kingdom: OCSLD; 2003: 412-424
• 28 Land R, Cousin G, Meyer JH, Davies P. Threshold concepts and troublesome knowledge: implications for course design and evaluation. In: Improving Student Learning: Equality and Diversity; Oxford, United Kingdom: OCSLD; 2005
• 29 Davies P. Threshold concepts: How can we recognize them?. In: Meyer J, Land R, , eds. Overcoming Barriers to Student Understanding: Threshold Concepts and Troublesome Knowledge. ; London, United Kingdom: Routledge; 2006: 70-84
• 30 Entwistle N. Learning outcomes and ways of thinking across contrasting disciplines and settings in higher education. Curric J 2005; 16 (1) 67-82
• 31 Perkins D. The many faces of constructivism. Educ Leadersh 1999; 57 (3) 6-11
• 32 Perkins D. Constructivism and troublesome knowledge. In: Meyer J, Land R, , eds. Overcoming Barriers to Student Understanding: Threshold Concepts and Troublesome Knowledge. London, United Kingdom: Routledge; 2006: 33-47
• 33 Meyer J, Land R. Threshold concepts and troublesome knowledge: an introduction. In: Meyer J, Land R, , eds. Overcoming Barriers to Student Understanding: Threshold Concepts and Troublesome Knowledge. London, United Kingdom: Routledge; 2006: 3-18
• 34 Meyer J, Land R. Threshold concepts and troublesome knowledge: issues of liminality. In: Meyer J, Land R, , eds. Overcoming Barriers to Student Understanding: Threshold Concepts and Troublesome Knowledge. London, United Kingdom: Routledge; 2006: 19-32
• 35 Land R, Meyer J. The scalpel and the mask: Threshold concepts and surgical education. In: Fry H, Kneebone R, , eds. Surgical Education: Theorising an Emerging Domain. Netherlands: Springer; 2011: 91-106
• 36 Kinchin IM, Cabot LB, Kobus M, Woolford M. Threshold concepts in dental education. Eur J Dent Educ 2011; 15 (4) 210-215
• 37 Patton M. Qualitative research and evaluation methods. Thousand Oaks: SAGE Publications; 2002
• 38 Seidman I. Interviewing as qualitative research: A guide for researchers in education and the social sciences. New York, NY: Teachers college press; 2006