Implementation of Critical Threshold Concept in Clinical Transplantation: A New Horizon in Distance Learning

Ajay Sharma, Ahmed Halawa, Julie M Bridson, Denise Prescott, Arpan Guha, Janet Strivens, David Taylor


Background: 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. 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 stuck in a mire. Difficult clinical situations warrant a flexible and, at the same time, an evidence-based approach to ensure that crucial decision-making process is correct and efficient. Each clinical case offers a great opportunity to reinforce these threshold concepts, however, not everyone of us is “blessed” with these crucial not-so-difficult-to-acquire skills so necessary to be a life-long learner.

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 stuck places and tricky bends in their own work place. This course, not just meant for knowledge transfer, provides a platform that allows participants (the students and faculty) to learn from each other’s experience by using e-blackboard. The mainstay of this course are twofold: (a) Emphasis on achieving critical decision-making skills, (b) Regular feedback to allow reflective practice 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 ethos of critical threshold has been accepted from the perspective of students.

Methods: The critical thresholds of each chapter in 4 modules of this totally on-line course were defined to a razor-sharp precision. Learning objectives of learning activity were defined to achieve constructive alignment with critical threshold. We employed level 1, 2, 4 and 5 of Kirkpatrick pyramid, (a) for the 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.

Results: 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 students of first cohort 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).

Conclusion: 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.

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