Using the Theory of Threshold Concepts as a Framework to Elucidate Development State in Professionalism Among Pediatric Residents

Unprofessional behavior among physicians significantly increases health care costs and negatively impacts patient care. 1 Residency training serves as a formative period of clinical and professional development for physicians. Notably, the Accreditation Council for Graduate Medical Education has listed professionalism as 1 of 6 core competencies and is a required assessment competency. 2 Despite advances in defining, teaching, and, providing formative and summative assessments for resident trainees within the professionalism domain, numerous studies have extensively demonstrated the high frequency of incidences of unprofessional behavior that compromise patient safety and increase health care costs. 3 Furthermore, trainee observations of lapses in professionalism during residency report little overlap between the values stated by accreditation standards in the United States and observed behavior during training. 4 The theory of threshold concepts can serve as a paradigm-shifting framework in understanding learner difficulties or otherwise termed troublesome knowledge in continuous modeling of professional behaviors. Recently, only a few studies have elucidated threshold concepts in medical students and residents. The purpose of our qualitative research study was to identify a framework for understanding threshold concepts in professionalism amongst residents in pediatric residency training through identifying a key component of threshold concepts, areas of troublesome knowledge. Our overarching goal is to better align national requirements in professionalism and observed behavior during residency training. To determine what threshold concepts pediatric residents experience during training in the domain of professionalism, we sought to identify difficult areas of knowledge, or troublesome knowledge, which is an essential component in identifying threshold concepts. We conducted a qualitative research study using constructivist approach to grounded theory to identify troublesome knowledge in professionalism. Eleven focus groups were conducted with residents from postgraduate years 1–3 at a large university-based pediatric hospital in the United States. To gain reflection from pediatricians who had “crossed” the threshold of learning professionalism skills during residency, we also conducted focus groups with BCM pediatric fellows across subspecialties and resident clinician–educators from across the United States. All interviews were conducted virtually, and video recordings were transcribed and coded. The methodology was the conceptual synthesis of the codes using threshold concepts as a sensitizing lens and themes were generated. To unpack domains of troublesome knowledge, we first sought to understand where they learned and how they defined professionalism. Five themes emanated from residents’ definition of professionalism, including (1) “interaction with others with subthemes of ‘role modeling’, ‘having integrity’, and ‘being respectful’; (2) competency including subthemes of ‘understanding limits’ and ‘confidence in decision making’; (3) self-awareness” including subthemes of “asset to continually develop” and “emotional intelligence”; (4) Delivery of Health Care including subthemes of “high standard,” “nonjudgmental,” and “solidarity in care for all patients”; and (5) role including subthemes of “leadership in action” and “responsibility.” Additionally, when elucidating if the residents observed professional behavior in the clinical environment, residents noted a high degree of lapses in professional behavior in the clinical environment with 3 themes of (1) “manifestations (of unprofessional behavior), (2) compromising patient health and safety, and (3) interpersonal behavior.” In identifying what were the difficult areas of professionalism to learn and or incorporate, residents noted 5 themes of racism, classism in both the arenas of patients and the interprofessional team, gender bias, the hidden curriculum, and microaggressions. Similar to published literature, pediatric resident trainees have an in-depth understanding of expectations and understanding of professionalism that stemmed from foundational training during medical school and continued to be explicitly taught during residency; however, similar to published reports, a predominant theme was that there was a strong discrepancy between professionalism expectations and witnessed behavior primarily from supervisory staff within the clinical learning environment. Residents identified complex challenges of difficult or troublesome knowledge in professionalism through highlighting individual, programmatic, and system-level stressors that are contextual. Despite these challenges, residents highlighted that continual reflection on exemplar models and lapses in professional behavior allows for refinement of forming their professional identity. Pediatric fellows and clinician–educator senior leaders highlighted the critical importance of role modeling and situational, real-time learning to overcome the domains of troublesome knowledge. The authors wish to thank Dr. Elaine Fielder and Dr. Linessa Zuniga for their support of the research study

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