Reaching Beyond the Milestones: The Thresholds to Mastery in Obstetrics and Gynecology Training

BACKGROUND: Competency-based medical education aims to ensure that physicians develop the skills and knowledge necessary for independent clinical practice through graduated autonomy. Existing competencies in obstetrics and gynecology (OBGYN) residency often fail to capture higher-order transformations in clinical reasoning, professional identity, and emotional maturity. A more nuanced, applicable, and valid articulation of these developmental transitions is needed to better support resident growth and assessment. OBJECTIVE: To identify OBGYN-specific threshold concepts that represent transformative developmental milestones in training, as perceived by leaders in residency education. DESIGN: This qualitative study used a constructivist, inductive thematic analysis approach. Interviews explored moments of significant developmental transition, areas of learner struggle, and examples of transformative learning during residency. Audio-recorded interviews were transcribed, deidentified, and independently coded by 2 reviewers using line-by-line analysis. Codes were iteratively organized into themes through consensus, with thematic saturation reached after 9 interviews. Credibility was supported through expert review, member checking, and iterative refinement. SETTING: Semistructured, one-on-one interviews were conducted with 11 attending physicians holding formal educational leadership roles within OBGYN residency programs at 4 academic institutions in the New York City metropolitan area. RESULTS: Six threshold concepts were identified that characterize developmental transitions into OBGYN practice: recognition of clinical severity, anticipation and adjustment of surgical technique, ownership of patient care in dynamic settings, empathic collaboration and team management, confidence in independent decision-making, and advanced emotional regulation. These concepts reflected observable shifts in judgment, responsibility, teamwork, and emotional processing that educators consistently associated with readiness for independent practice. In a subsequent survey of n = 78 medical education leaders at a national conference, 90% of respondents endorsed incorporating these threshold concepts into resident assessment frameworks. CONCLUSIONS: This study identifies 6 threshold concepts that capture essential, yet under-recognized, developmental milestones in OBGYN residency training. These concepts offer a complementary framework to existing assessment systems by emphasizing transformative growth in clinical judgment, professional identity, and emotional resilience. Integrating threshold concepts into curriculum design and evaluation may enhance the ability of educators to support learners, identify developmental challenges, and promote readiness for independent practice.