Implementation of Critical Threshold Concept in Clinical Transplantation: A New Horizon in Distance Learning
Authors: Sharma Ajay , Halawa Ahmed , M Bridson Julie , Prescott Denise , Guha Arpan , Strivens Janet , Taylor David 
Published: April 2017

<p><strong><em>Background: </em></strong><em>While variations in medical practice are a norm and each patient poses a multitude of challenges, many clinicians are not comfortable in dealing with unexpected complex issues even though they may have enough knowledge as demonstrated by passing a number of tricky certifying (or exit) examinations.</em><em> </em><em>One reason for the lack of self-efficacy, even if being endowed with good knowledge, is that we are not good in learning from errors. A regular reflective practice offers superb learning opportunities when a clinician is </em><em>“</em><em>stuck in a mire</em><em>”</em><em>. Difficult clinical situations warrant a flexible and,</em><em> </em><em>at the same time,</em><em> </em><em>an evidence-based approach</em><em> </em><em>to ensure that</em><em> </em><em>crucial decision-making process is correct and efficient. Each clinical case offers a great opportunity to reinforce these </em><em>“</em><em>threshold concepts</em><em>”</em><em>, however</em><em>, not everyone of us is “blessed” with these crucial not-so-difficult-to-acquire skills so necessary to be a life-long learner. </em></p><p><em>The faculty of this course (a totally on-line MSc in Transplant Sciences) aims for unceasing engagement with students in order to facilitate them to negotiate through </em><em>“</em><em>stuck places</em><em>”</em><em> and </em><em>“</em><em>tricky bends</em><em>”</em><em> in their own work place. This course, not just meant for knowledge transfer, provides a platform</em><em> </em><em>that allows participants (the students and faculty) to learn from each other’s experience</em><em> </em><em>by using </em><em>“</em><em>e-blackboard</em><em>”</em><em>.</em><em> </em><em>The mainstay of this course are twofold: (a) Emphasis on achieving critical decision-making skills</em><em>,</em><em> (b) Regular feedback to allow reflective practice</em><em> </em><em>and, thereby, constantly learning from errors and reinforcing good practices. The aim of this article is to assess the performance of educators and how well the </em><em>“</em><em>ethos of critical threshold</em><em>”</em><em> has been accepted from the perspective of students. </em></p><p><strong><em>Methods:</em></strong><strong><em> </em></strong><em>The critical thresholds</em><em> </em><em>of each</em><em> </em><em>chapter in 4 modules</em><em> </em><em>of this totally on-line course were defined to a razor-sharp precision.</em><em> </em><em>Learning objectives of learning activity were</em><em> </em><em>defined to achieve constructive alignment with critical threshold. We employed level 1,</em><em> </em><em>2, 4 and 5 of Kirkpatrick pyramid</em><em>, </em><em>(a) for the</em><em> </em><em>evaluation of performance of educators of program, and (b) to evaluate the acceptance of this non-traditional format in clinical medicine education by postgraduate 80 students in 22 countries.</em><strong><em></em></strong></p><p><strong><em>Results:</em></strong><em> Students’ survey (Kirkpatrick level 1) was done only for module 1 of cohort 1 reported students’ satisfaction rate of 93%. Excluding a total of 12 drop-outs in 2 modules (n=10 in first cohort’s module 1, and n=2 in module 2), as many as 93% of</em><em> </em><em>students of first cohort</em><em> </em><em>passed module. Nine out of 60 registrants of module 1 in 2nd cohort took recess for one year requesting to join back as a part of 3rd cohort commencing one year later, all 51 who continued passed though 3 of them had to resit. All those who passed module 1 (both cohorts) and 2 (1st cohort) registered for their respective next module (return on investment Kirkpatrick level 5). </em></p><strong><em>Conclusion: </em></strong><em>For a successful model in distance learning in clinical transplantation it is imperative for the students to accomplish well defined “critical-decision making” skills. In order to learn critical thresholds, a regular feedback is integral to learning from reflective practice. This course equips the students to develop skills of negotiating “sticky mire”, as obvious from perceived high return of investment.</em>