Threshold concepts: A portal into new ways of thinking and practising in psychiatry

Old dog, new tricks? Exploring the potential functionalities of ChatGPT in supporting educational methods in social psychiatry

BACKGROUND

Artificial Intelligence is ever-expanding and large-language models are increasingly shaping teaching and learning experiences. ChatGPT is a prominent recent example of this technology and has generated much debate around the benefits and disadvantages of chatbots in educational domains.

AIM

This study seeks to demonstrate the possible use-cases of ChatGPT in supporting educational methods specific to social psychiatry.

METHODS

Through interactions with ChatGPT 3.5, we asked this technology to list six ways in which it could aid social psychiatry teaching. Subsequently, we requested that ChatGPT perform one of the tasks it identified in its responses.

FINDINGS

ChatGPT highlighted several roles it could fulfil in educational settings, including as an information provider, a tool for debates and discussions, a facilitator of self-directed learning and a content-creator for course materials. For the latter scenario, based on another prompt, ChatGPT generated a hypothetical case vignette for a topic relevant to social psychiatry.

CONCLUSIONS

Based on our experiences, ChatGPT can be an effective teaching tool, offering opportunities for active and case-based learning for students and instructors in social psychiatry. However, in their current form, chatbots have several limitations that must be considered, including misinformation and inherent biases, although these may only be temporary in nature as these technologies continue to advance. Accordingly, we argue that large-language models can support social psychiatry education with appropriate caution and encourage educators to become attuned to their potential through further detailed research in this area.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Threshold concepts in health professions education research: a scoping review

Threshold concepts (TCs) are increasingly used in health professions education (HPE) research. TCs are claimed to be conceptual gateways which are often traversed with substantial difficulty. In this paper, we report on a scoping review investigating the following research question: What is the scope and nature of the currently available research on threshold concepts in health professions education literature? We employed Arksey and O'Malley's model for scoping reviews. A search for literature on TCs in HPE research between 2003 and 2020 yielded 999 records of which 59 were included in the review. The data set was subject to quantitative descriptive analysis of article characteristics as well as qualitative thematic analysis of the scope of research on TCs. Among the 59 articles selected for review, there were 30 empirical, 26 conceptual and three reviews. A majority were published in 2015 or later. Almost half of the included articles attempted to identify possible TCs within HPE. Others investigated how TCs can be traversed or suggested how TCs could influence curriculum design. Some critically appraised the framework of TC. Although TCs are increasingly utilised in HPE, the present review identified how researchers came across methodological challenges related to identifying possible TCs and definitional challenges around identifying the essential characteristics of TCs. Before embracing TCs as the next go-to theory for learning in HPE, we acknowledge the need for methodological stringeny and rigour as well as more data to support TCs. Until then, any implementation of TCs in HPE curricula should be done cautiously.

Threshold concepts in medical education: A scoping review

INTRODUCTION

The threshold concept framework (TCF) was first described nearly 20 years ago, but its application in the field of medical education has recently seen a significant growth of interest with a diverse range of literature published on the subject. The transformative nature of threshold concepts (TCs) offers potential for the design of learning experiences and curricula across the medical education continuum. A scoping review was conducted to map the extent of the current literature regarding TCs in medical education-to describe the types of available evidence and its focus-and identify research gaps.

METHODS

The review followed the JBI Manual for Evidence Synthesis approach for scoping reviews. Four databases and two additional websites were searched for articles exploring TCs in medical education. Data were analysed using quantitative and qualitative thematic approaches. A framework of conceptual change was used to synthesise the TCs identified.

RESULTS

Thirty-six papers, spanning undergraduate, postgraduate and continuing medical education, were included in the final analysis. The most frequent application of the TCF was in the identification of TCs, which related to basic scientific knowledge, ways of thinking and ways of practising in medicine. Uncertainty, patient care, clinical reasoning and professional identify formation were themes that emerged at multiple stages of training. Several papers evaluated the use of the TCF in teaching.

CONCLUSION

The understanding and embodiment of TCs increases in complexity across the medical education continuum, with TCs recurring with changes in clinical environment and responsibilities. This lends support to a holistic approach to curriculum design spanning all stages of training. Further research is needed to develop a consistent approach for describing and applying the TCF in medical education and to address how the TCF can be used in teaching and how threshold crossing can be measured.

Identifying threshold concepts in postgraduate general practice training: a focus group, qualitative study

OBJECTIVE

To identify threshold concepts (TCs) for physicians undergoing postgraduate medical education (PGME) in general practice.

DESIGN

An explorative, qualitative study with 65 min focus group interviews and thematic analysis was used. Participants were asked to describe their most transformative learning experiences. Heuristical TCs were identified from the thematic analysis.

SETTING

Aotearoa/New Zealand (A/NZ).

PARTICIPANTS

Fifty participants, mostly comprising current trainees and educators from urban centres, and of NZ/European ethnicity.

RESULTS

Twenty TCs covering many aspects of postgraduate general practice experience were derived from themes identified in the data. Presented in medical proverbial form for ease of recollection, these included: Money makes the practice go round; Be a legal eagle; Manage time or it will manage you; Guidelines, GPs' little helpers; Right tool, right word, right place; The whole of the practice is greater than the sum of the parts; The personal enhances the professional; Beat biases by reflection; Chew the Complexity, Unpredictability, Diversity; Embrace the uncertainty; Not knowing is knowing; Seek and you shall find; Waiting and seeing, waiting and being; Look, listen, think between the lines; Treat the patient beyond the disease; No patient is an island; Words work wonders; Hearing is healing; Being you and being there; and; The relationship is worth a thousand consults. These TCs mapped onto core competencies in A/NZ's PGME in general practice curriculum.

CONCLUSIONS

Participants readily identified transformative and troublesome moments in their PGME in general practice. These findings confirmed evidence for a wide range of TCs with many newly identified in this study. All TCs were fundamentally based on the doctor-patient relationship, although often involving the context and culture of general practice. Actively incorporating and teaching these identified TCs in PGME in general practice may enable trainees to grasp these important learning thresholds earlier and more easily and aid in identity and role formation.

Do We Need to Close the Door on Threshold Concepts?

ISSUE

Threshold Concepts are increasingly used and researched within health professions education. First proposed by Meyer and Land in 2003, they can be defined as ways of knowing central to the mastery of a subject. They are framed as profoundly transformative, impacting the identity of those who encounter them through irreversible shifts in an individual's outlook. Although Threshold Concepts have been identified in a multitude of educational settings across the continuum of health professions education, there has been little critique of Threshold Concepts as a theory of health professions education. Within adjacent fields critical discourse is also underdeveloped, perhaps given the educational resonance of the theory, or the way in which the theory encourages subject specialists to discuss their area of interest in depth. This commentary critically examines how Threshold Concepts have been used and researched within health professions education, applying critiques from other educational fields, to assist scholars in thinking critically regarding their application.

EVIDENCE

Three significant critiques are outlined: 1) 'The floating signifier problem'; 2) 'The body of knowledge problem'; and 3) 'The professional identity problem.' Critique 1, the floating signifier problem, outlines how Threshold Concept theory lacks articulation and has been inconsistently operationalized. Critique 2, the body of knowledge problem, outlines the issues associated with attempting to identify a singular body of knowledge, particularly in regard to the reinforcement of entrenched power dynamics. Critique 3, the professional identity problem, argues that the way in which Threshold Concepts conceptualize identity formation is problematic, inadequately grounded in wider academic debate, and at odds with increasingly constructionist conceptualizations of identity within health professions education.

IMPLICATIONS

These critiques have implications for both educators and researchers. Educators using Threshold Concepts theory must think carefully about the tacit messages their use communicates, consider how the use of Threshold Concepts could reinforce entrenched power dynamics, and reflect on how their use may make material less accessible to some learners. Further, given that Threshold Concept theory lacks articulation, using the theory to structure curricula or educational sessions is problematic. Threshold Concepts are not synonymous with course learning outcomes and so, While considering Threshold Concepts may enable pedagogical discussion, the theory cannot help educators decide which concepts it applies to; this requires careful planning which extends beyond the bounds of this theory. For researchers, there are issues too with power and inconsistent theoretical operationalization, but also with the way in which Threshold Concepts theory conceptualizes identity formation, which cast doubt on its use as a theory of identity development. On balance, we believe Threshold Concept theory suffers a number of fundamental flaws that necessitate a shift from the positioning of Threshold Concepts as a theory, toward the use of Threshold Concepts as a less prescriptive reflective prompt to stimulate pedagogical discussion.

Introducing a Psychiatry Clerkship Curriculum Based on Entrustable Professional Activities: an Explorative Pilot Study

OBJECTIVE

The authors evaluated a reformed psychiatry clerkship curriculum based on entrustable professional activities (EPAs).

METHODS

The authors conducted an exploratory pilot study of a reformed clerkship curriculum based on EPAs. A novel workplace-based assessment format including an entrustment-supervision scale and curricular adaptations were introduced. The Kirkpatrick model was used to evaluate outcomes of the reformed clerkship curriculum on three levels (1 = acceptance, 2 = learning, 3 = change of behavior).

RESULTS

The pilot student cohort (n = 10) completed a questionnaire, 180 self-assessments (18 per student) on need for supervision, and 63 workplace-based assessments (6.3 per student, in 4 weeks). Level 1: high overall satisfaction with the clerkship (five-point Likert item: average, 4.9; range: 4.0-5.0). Level 2: the overall significant decrease in self-assessed need for supervision before and after the clerkship was two supervision levels (direct to indirect supervision; p < 0.05). The most frequently documented admissions included schizophrenic disorders (n = 11; 28%), affective disorders (n = 10; 25%), substance abuse disorders (n = 5; 13%), and anxiety and stress-related disorders (n = 5; 13%). Level 3: clinical supervisors used history taking, assessing the mental status, and documentation and presentation for workplace-based assessments. According to supervisors' ratings, there was a decreasing need for supervision from the first to last week of the clerkship.

CONCLUSIONS

Students reacted positively to the reformed clerkship curriculum. The workplace-based assessments with entrustment ratings appeared to support achievement of competency-based learning objectives. Better understanding of how to cover assessment of all core EPAs in the psychiatry clerkship is needed.

Curriculum Development with the Implementation of an Open-Source Learning Management System for Training Early Clinical Students: An Educational Design Research Study

BACKGROUND

Learning management systems (LMSs) have not been explored from an educational design research (EDR) perspective for developing clinical curricula and supporting novice clinical students with self-regulated learning during their early clinical rotations.

METHODS

An EDR approach was used to inform a de novo implementation of an LMS during an early clinical rotation of medical students. The EDR consisted of three phases: analysis and exploration; design and construction; and evaluation and reflection. Process and evaluation data (including academic years 2018 and 2019) from two student cohorts (total n = 190, 107 without and 83 with LMS exposure) at one academic teaching hospital were analyzed.

RESULTS

Learning theories and concepts of self-regulated learning were used to develop and implement an LMS clerkship prototype. For design and construction, the maturing prototype design included flipped-classroom elements, in-class activation, voluntary digital self-assessments, and clinical teaching videos. For evaluation and reflection, global satisfaction improvement was significant (from 3.9 to 4.4 on a 5-point Likert scale, p < 0.05). There was a positive evaluation trend for all evaluation items related to learning climate, self-regulated learning, and perceived usefulness of the LMS prototype; however, these changes were not statistically significant. The teaching hospital also improved its ranking after the introduction of the LMS prototype. Nearly all students (94%) used the LMS material. The average number of times the LMS course was accessed per student was 70 (range: 7-172), and the average duration students spent online was 58 minutes (range: 9-165).

CONCLUSION

Our data indicate that using an EDR approach was helpful for systematically introducing an LMS in a clerkship curriculum informed by learning theory. Our evidence-oriented curriculum reform was associated with higher student satisfaction and appeared to support self-regulated learning in the workplace. Further research should explore which elements of an LMS most effectively help to achieve educational outcomes.