title: 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.
authors.affiliation: Department of Plastic Surgery, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Evgenios
authors.initials: E
authors.lastname: Evgeniou
authors.affiliation: Department of ENT, North Staffordshire NHS Trust, Stoke-on-Trent, United Kingdom.
authors.forename: Maria
authors.initials: M
authors.lastname: Tsironi
authors.affiliation: Educational Development Unit, Imperial College London, London, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Riley
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003479:Curriculum; D004503:Education, Medical, Graduate / Q000379:methods; D005257:Fellowships and Scholarships / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008866:Microsurgery / Q000193:education*; D015397:Program Evaluation; D036301:Qualitative Research; D058996:Quality Improvement; D006113:United Kingdom