TO THE EDITOR: Tamura et al1 have gracefully emphasised the issues with regards to the lack of self-recognition of chronic constipation in an Asian setting. As a medical educationalist and gastroenterologist I wanted to impart discussion as to how we can potentially move this forward. A lack of self-recognition suggests simply one thing; a lack of understanding. Understanding is ultimately based on knowledge and experience. If we as doctors are tasked with educating our patients we can always aim to better enhance their appreciation of disease based pathology. For one thing it is well recognised that there is often a mismatch between how clinicians may or may not adequately explain disease occurrence. Furthermore, our educational practices may be overtly concrete as opposed to ensuring adaptation to the individual in question. In order to enhance patient understanding in this domain the well-recognised domain of threshold concepts comes to mind.2 In brief, a threshold concept enables a more accessible way of understanding which comprises of transformation and integration. Therefore, in determining how best to enhance the educational appreciation of constipation, we should aim to utilize the various theoretical educational elements on offer.