May 2022, Volume 72, Issue 5

Research Article

Threshold concepts encountered by second year medical students in a Basic Health Science module; a qualitative study

Memoona Mansoor  ( Department of Medical Education, , Islamabad Medical and Dental College, Islamabad, Pakistan. )
Ali Tayyab  ( Department of Ophthalmology, Islamabad Medical and Dental College, Islamabad, Pakistan. )
Syed Shoaib Shah  ( Department of Forensic Medicine, Islamabad Medical and Dental College, Islamabad, Pakistan. )
Rehmah Sarfraz  ( Department of Medical Education, , Islamabad Medical and Dental College, Islamabad, Pakistan. )


Objective: To explore threshold concepts in a Basic Health Sciences module.


Method: The qualitative study was conducted at the Islamabad Medical and Dental College, Islamabad, Pakistan, in March 2019, and comprised students and faculty members in the gastrointestinal tract module of spiral I of the integrated modular curriculum in Basic Health Sciences. Data on student experiences was collected using semi-structured interviews with open-ended questions. The data was coded and themes were identified by the researchers independently. A thematic matrix was produced, cross-referencing data relating to troublesome areas identified by the students against the threshold concept criteria. The identified themes were discussed among the researchers to reach consensus. Only the identified themes were taken as the expected threshold concepts in the gastrointestinal tract module.


Results: Of the 18 subjects, 14(77.8%) were students and 4(22.2%) were facilitators. There were 8 areas identified by the students as troublesome in the module; development of gastrointestinal tract, anatomical relations, electron transport chain, histology of gastrointestinal tract mucosa, peritoneal disposition, anal canal and ischioanal fossae, peristalsis, and absorption across gastrointestinal tract mucosa. Only development of gastrointestinal tract appeared to cross-match with all the criteria outlined for threshold concepts. The troublesome areas identified by the teachers were development of gastrointestinal tract, peritoneal disposition, anatomical relations, absorption across gastrointestinal tract and peristalsis.


Conclusion: Development of gastrointestinal tract was found to be the threshold concept in the system-based integrated module of gastrointestinal tract. Most of the students found their previous knowledge inadequate in learning concepts of the module.


Keywords: Threshold concepts, Gastrointestinal tract, Integrated curriculum, Basic health sciences.(JPMA 72: 901; 2022)





Since the introduction of the threshold concepts framework by Meyer and Land in 2002, extensive research has been done in this area in diverse professions, including economics, engineering, literature, accounting, arts and mathematics.1 A number of studies in health sciences have been reported, but the field has remained underexplored.

Threshold concepts are distinct ideas inevitable for meaningful learning of a discipline or content area. They are difficult to comprehend and assimilate, but once understood they alter the perspective of the learners toward that specific field.2 Threshold concepts are 'transformative' because, once learned, they change the viewpoint of students, 'integrative' as they reveal inter-relationship of previously known information resulting in a more refined understanding, 'irreversible' because these cannot be unlearned once acquired, 'troublesome' due to their overwhelming difficulty for the learners, 'liminal' for the reason they cause ambiguity, bounded by being discipline-specific, 're-constitutive' because repeated de-construction and re-construction of knowledge occur in the process of overcoming them, and 'discursive' because these enable the learners to communicate in the language of the subject.1

Researchers agree that identifying threshold concepts can inform medical curricula because it helps us discover limitations of curricular design and structure. Such shortcomings can be weakness of instruction, wasting of curricular time, communication gap between students and faculty and lack of meaningful formative feedback to the learner.3-5 Threshold concept framework is also valuable in recognising when and how students need assistance, direction or challenge for learning.6 Students' background knowledge of a content area may affect assimilation of threshold concepts in that field.1 Studies recommend revisiting of spiral curricula in the light of identified threshold concepts.5

Most of the studies targeting threshold concepts in medical education have been done in Europe, the United States and Australia, focussing on identifying threshold concepts in either clinical subjects or soft disciplines, including ethics, professionalism and professional identity formation.3,7,8 Several studies are carried out without direct student involvement in identifying the threshold concepts.9

Robust curricular reforms are under way in Pakistan with an obvious drive to adopt and implement an integrated curriculum in Basic Health Sciences. Identifying threshold concepts in medical education thus demands particular attention because such initiatives can guide the curricular goals and decision-making. The current study was planned to determine threshold concepts in gastrointestinal tract (GIT) module of second year undergraduate medical programme in Pakistan.


Subjects and Methods


The qualitative study was conducted at the Islamabad Medical and Dental College (IMDC), Islamabad, Pakistan, in March 2019. After approval was obtained from the institutional ethics review board, the sample was raised using purposive sampling technique. Those included were students of second year of the medical undergraduate programme and faculty members of Basic Health Sciences regardless of age and gender. The faculty members were instructors with at least two-year experience of facilitating academic sessions in small group discussions (SGDs) and laboratory classes, and were also involved in the planning of academic activities and assessments.

The curriculum at the study institution is at level 7 (correlation) of Harden's integration ladder.10 At this level, integrated instruction is done along with subject-based teaching to give a holistic picture to the students. The curriculum for the first three years is organised in two spirals with horizontal integration of pre-clinical subjects. Spiral I spans first two years of learning with horizontal integration of Anatomy, Physiology and Biochemistry, spiral II covers third year with the integration of Pathology, Pharmacology and Forensic Medicine. Each spiral is divided in blocks and each block has two or more system-based integrated modules. GIT module was selected for the identification of threshold concepts due to student feedback from previous year and also because of the fact that second year medical students are more familiar with the system of teaching and more confident with the use of terms etc. It was module VI in spiral I. It dealt with Anatomy, Applied Physiology and biochemistry. It was organised around five themes based on clinical conditions related to anterior abdominal wall and GIT. SGD was the most frequently relied upon method of instruction, followed by large-group sessions to cover patients with hernia, achlasia, peptic ulcer, intestinal obstruction, and chronic liver disease.

Qualitative approach of phenomenology was adopted because the idea was to explore the experiences of students while facing and overcoming challenging concepts in this particular module.11 These experiences were explored with the help of an interview guide with a standardised script. The questions were developed after literature search and all questions of the interview were open-ended.7 Seven questions were designed for the students, and nine for the faculty. Interviews were conducted after the conclusion of the GIT module. A written informed consent was obtained before the interview and a brief introduction of the threshold concepts was given to the participants. All interviews were face-to-face and lasted 12-15 minutes each, and were recorded with the permission of the participants. There were no repeat interviews. All interviews were conducted in the conference room of the Department of Medical Education (DME) by the principal investigator who had an active role in curriculum planning and faculty development activities, while her non-involvement in active teaching reduced the element of bias and pre-suppositions.

All the interviews were conducted bilingually in English and Urdu. The audio files were transcribed first by the interviewer. The conversation/ sentences in Urdu were translated into English while transcribing. The transcribed data was then reviewed by the other researchers one by one who suggested corrections/modifications which were done with consensus. Manual coding and thematic analysis was done for data analysis.

The team identified the troublesome areas from the answers to question number 1. Grouped them under similar themes; coded and themed each answer verbatim to identify the criteria of threshold concept it apparently expressed; and produced a matrix cross-referencing data related to troublesome areas with data meeting particular threshold concepts criteria.

The identified themes were discussed among the researchers to reach consensus. Troublesome concepts which appeared to have all the six criteria of being re-constitutive, liminal, integrative, discursive, transformative and irreversible were taken as threshold concepts in the GIT module.




Of the 100 eligible students approached 14(14%) agreed to participate, while, of the seven faculty members, 4(57%) participated. Among the students, there were 10(71.4%) females and 4(28.6%) males with overall age range 19-21years. Among the faculty members, there were 3(75%) females and 1(25%) male with overall age range 27-30 years.

Interviews with the students led to 20 broad troublesome areas. From among them, 8(40%) areas were declared troublesome by the researchers after grouping them together in multiple discussion sessions. The troublesome areas were development of GIT, anatomical relations, electron transport chain, histology of GIT mucosa, peritoneal disposition, anal canal and ischioanal fossae, peristalsis, and absorption across GIT mucosa. Only development of GIT appeared to cross-match with all the criteria outlined for threshold concepts (Table-1).



The observation was based on the relevant verbatim answers of the students (Table-2).



The troublesome areas identified by the faculty members were development of GIT, peritoneal disposition, anatomical relations, absorption across GIT and peristalsis (Table-3).



Faculty response was varied about the reason of troublesomeness of these concepts. The reasons they recognised included limited background knowledge, inability to do cadaveric dissection and content overload.

On the whole it seemed that the students found the threshold concepts related to the discipline of anatomy difficult to visualise and imagine, and there was much new knowledge to handle. However, one threshold concept related to Biochemical aspect was attributed to the external factor of limited preparation time, and one related to Physiology was attributed to information overload. The faculty members, too, identified that limited background knowledge and inability to visualise the development of gut on their own could be the reason of troublesomeness of these concepts.

Students described that mostly they handled the troublesome concepts by discussing with peers or some faculty member and by watching videos. The teachers explained that they facilitated the students through the phase of liminality by making them visualise things in a better way with the help of different techniques, videos, cadavers and specimens.

For most of the troublesome areas, the students found their previous knowledge inadequate in understanding, except for electron transport chain for which they believed their background knowledge helped them with the understanding. For development of GIT, only one out of three students thought that the previous knowledge was useful. Another interesting aspect was that students finding ischioanal fossae as a troublesome concept clearly said that they were unable to correlate the knowledge because it was related to something they had yet to study. This was because the module Reproduction is in succession of the GIT module. The faculty was of the view that although background knowledge of the students was not enough to understand the difficult concepts, but while preparing to teach, their own previous knowledge helped them a lot in identifying areas of emphasis and choosing instructional tools.

The teachers could not identify any new approach they developed during teaching this module. Students assessed their learning of troublesome concepts by discussing it with peers, seniors and facilitators. Similarly, the faculty assessed assimilation of content by learners by asking questions and marking their tests.




A total of eight areas were identified by the students as troublesome in the system-based module of GIT in spiral I of the integrated curriculum at the study institution. Most of these concepts recognised by the students matched with the ones identified by their facilitators. Development of GIT was found to be the threshold concept for this module because of having all the characteristics of the threshold concept framework.

So far, most of the studies done in identifying threshold concepts have been discipline-specific done in traditional curricula and or clinical subjects. Despite extensive search of different databases, inlcluding PubMed, ERIC and CINAHL, we could not find any study done in a system-based modular curriculum to compare the findings of the current study with. A system-based curriculum is designed for correlating structure and function with the disease for better understanding and practice of medical knowledge and has the same aim as the idea of threshold concepts.

Kramer and Soley, while seeking perceptions of medical students about difficult concepts in a traditional course of Anatomy, observed that 30% of their students had difficulty in understanding omenta, mesenteries and peritoneal sac, and more than 49% faced problem with comprehension of body cavities, mesenteries and rotation of gut.12 Although the study targeted the subject of Anatomy only and the focus was not on threshold concepts, but only on the identification of troublesome areas, the findings are interestingly similar to the ones in the current study which was done in an integrated module of GIT. We used structured interviews compared to the survey approach by Kramer and Soley, yet the troublesome concepts identified in the specific areas were similar.12

Horrigan explored threshold concepts in Physiology across different modules in Biomedical Sciences and the role of laboratory class in learning these concepts. The investigator did one-on-one interviews with students and faculty to identify the threshold concepts. In GI Physiology, the threshold concept identified by the teachers was absorption across GI membrane.13 In the current study, absorption as well as peristalsis were identified as threshold concepts by one of the students and one member of the teaching staff. However, Horrigan had some interesting observations behind the troublesome nature of these threshold concepts. He observed that their foundations lay in premedical subjects, like Chemistry and Physics which were not relatable to individual experiences and were difficult to integrate. Interestingly, students and faculty members in the current study were unable to pinpoint the intellectual reason behind their threshold concepts and attributed the troublesomeness of their threshold concepts to external factors, like inadequate time for preparation, content overload and unavailability of physical aids.

Loertscher et al. identified threshold concepts in Biochemistry involving both students and experts, and came up with a list of five major threshold concepts in the subject. They observed that these concepts were interconnected with foundational biochemical ideas and constituted a conceptual network.14 The threshold concept of electron transport chain identified by students in the current study can easily fit in the categories 'steady state' and 'free energy' identified in the earlier study. They identified the threshold concept in the whole of Biochemistry in five phases and used focus group discussions (FGDs) and workshops for the purpose, while the current study did it in a limited duration module with a questionnaire already structured according to threshold concept framework. We share their belief that in planning instructional strategies for future, these threshold concepts will help focus on specific areas, like visual literacy skills, to facilitate student learning.14 They intended a reorganisation and realignment of undergraduate Biochemistry courses in the light of their findings which was exactly the aim while planning the current study. The current finding of electron transport chain as troublesome for students is verified by Forni et al. who tried different methods of instruction for teaching electron transport chain to medical students.15 They tried board games to teach this concept to first year medical students and got an encouraging response from the qualitative feedback of the students. We observed that the students struggled by consulting more books for clarification of the concept.

One of the two challenges detected by Barradell and Peseta in the identification of threshold concepts in their review was disagreement among the study participants about threshold concept in a particular discipline.4 Contrary to this finding, students and teacher in the current study broadly agreed to the three threshold concepts identified in the GI module, which surprisingly were related to the single discipline of Anatomy.

Moeller and Fawns explored threshold concepts in learning electroencephalography (EEG), and acknowledged that taking experts only as participants was a limitation to their study because experts may not be able to comprehend why a concept is troublesome for the students.7 Evgeniou and Loizou had similar suggestion that experts might differ in their opinion of troublesome concepts they faced as beginners.16 In contrast, most of our students were of the view that they had limited previous knowledge of the concepts they found troublesome. This idea was verified by the observation of their teachers as well. It was also observed that teachers found these concepts challenging for themselves during their own student life too.

Some students did identify their 'AHA!' moments for the troublesome concepts they had; some seemed still stuck in the liminal phase and had no transformative moments regarding their difficult concepts. This was a valuable insight and allowed us to examine those content areas of the GI module meticulously to come up with suggestions for future improvements.

The current study has its limitations, as it was done with a single cohort in one institution. As such, the findings cannot be generalised. The same module can be explored in other medical schools following the same curriculum or may be in the same school with different group of students to validate the current results. The average response to interviews both by faculty and students was very low.




Development of GIT was found to be the threshold concept in the system-based integrated module of GIT. Most of the students found their previous knowledge inadequate in learning concepts of the module.


Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.




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