Guidelines: The dos, don'ts and don't knows of remediation in

Guidelines

Perspect Med Educ (2019) 8:322–338https://doi.org/10.1007/s40037-019-00544-5

Guidelines: The dos, don’ts and don’t knows of remediationinmedical education

Calvin L. Chou · Adina Kalet · Manuel Joao Costa · Jennifer Cleland · Kalman Winston

Published online: 6 November 2019© The Author(s) 2019

AbstractIntroduction Two developing forces have achievedprominence in medical education: the advent ofcompetency-based assessments and a growing com-mitment to expand access to medicine for a broaderrange of learners with a wider array of preparation.Remediation is intended to support all learners toachieve sufficient competence. Therefore, it is timelyto provide practical guidelines for remediation inmedical education that clarify best practices, prac-tices to avoid, and areas requiring further research,in order to guide work with both individual strug-gling learners and development of training programpolicies.Methods Collectively, we generated an initial list ofDo’s, Don’ts, and Don’t Knows for remediation inmedical education, which was then iteratively refinedthrough discussions and additional evidence-gather-ing. The final guidelines were then graded for thestrength of the evidence by consensus.

C. L. Chou (�)Department of Medicine, University of California andVeterans Affairs Healthcare System, San Francisco, CA, [email protected]

A. KaletDepartment of Medicine, New York University School ofMedicine, New York, NY, USA

M. J. CostaLife and Health Sciences Research Institute, School ofMedicine, University of Minho, Minho, Portugal

J. ClelandCentre for Healthcare Education Research and Innovation(CHERI), University of Aberdeen, Aberdeen, UK

K. WinstonDepartment of Public Health and Primary Care, CambridgeUniversity, Cambridge, UK

Results We present 26 guidelines: two groupings ofDo’s (systems-level interventions and recommenda-tions for individual learners), along with short lists ofDon’ts and Don’t Knows, and our interpretation of thestrength of current evidence for each guideline.Conclusions Remediation is a high-stakes, highlycomplex process involving learners, faculty, systems,and societal factors. Our synthesis resulted in a listof guidelines that summarize the current state ofeducational theory and empirical evidence that canimprove remediation processes at individual and in-stitutional levels. Important unanswered questionsremain; ongoing research can further improve reme-diation practices to ensure the appropriate supportfor learners, institutions, and society.

Keywords Remediation · Feedback · Strugglinglearner · At-risk students

Definitions of dos, don’ts, and don’t knows

Do’s Educational activity for which there is evidenceof effectiveness

Don’ts Educational activity for which there is evi-dence of no effectiveness or of harms (negative ef-fects)

Don’t knows Educational activity for which there isno evidence of effectiveness

Introduction

Remediation in medical education is ‘the act of facil-itating a correction for trainees who started out on thejourney toward becoming a physician but have movedoff course’ [1]. In the past, when encountering strug-gling learners, medical educators had little guidance

322 Do’s, don’ts, and don’t knows of remediation

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Guidelines

on how to support or intervene effectively to ensurecompetence or make promotion judgments. In recentyears, in response to frustration with the piecemealapproach to remediation and its potentially unaccept-able consequence of graduating physicians not readyto practise safely, there has been a dramatic growth inthe literature on remediation in medical education.

Reports of the cumulative prevalence of trainees inneed of remediation have ranged from 2.0% in sur-gical residencies [2] to 3.3% in medical school [3].The reported success of remediation has ranged from77% [2] to 100% [3–5]. However, there is no stan-dard definition of ‘success’, and most programs reportonly short-term outcomes. For example, one reportshowed that while 91% of students passed the firstsemester after remediation, only 61% had completedthe entire program 2 years later [6]. Additionally, thecriteria programs use to identify learners needing re-mediation vary widely, even within the same institu-tion.

Not surprisingly, as demands on trainees shift overthe course of medical training, the types of remedia-tion challenges change. Early medical students tendto struggle with knowledge and skills gaps, ways ofthinking, self-regulation, and approaches to learning[7]. In addition to insufficient knowledge, studentsin clerkships can struggle with patient presentationskills, foundational communication skills (e.g. intro-ducing oneself), physical examination skills, and theapplication and synthesis of knowledge to create in-dividualized patient plans [8, 9]. For residents andfoundation years (the 2 years immediately after med-ical school in the UK), knowledge can continue to bea major area of struggle [5, 10, 11]. In addition, learn-ers at these stages of medical training can manifestdifficulty with clinical judgment [2, 5, 10, 11], com-munication [5], professionalism [2, 4, 5, 11, 12], timemanagement, and organization skills [5, 10, 13].

Medical students and physicians are not accus-tomed to struggling. Selection into medical schoolrequires high academic ability, and medical studentsare used to achieving. Consequently, when facedwith academic failure, many may experience dispro-portionate emotional reactions that can exacerbatethe problem and limit their ability to adapt quicklyand focus on remedial work. In some settings, theremay be a significant economic burden of failure (e.g.retaking exams or courses) which is mostly borne bythe student [14] or the program [15]. We also knowthat some learners minimize, externalize, and blamefaculty and the institution for their struggles [16, 17],making it even more challenging for supervisors andinstitutions to provide effective remediation.

Medical education and training programs mustnavigate competing interests surrounding identifica-tion and remediation of struggling learners. Generally,educators may feel tremendous responsibility for, andoften identify with, learners, particularly when sucha great deal of time, resources, ego, and energy has

been invested into medical training. Further, thepresence of a struggling learner requires increasedmonitoring, counselling, and other costly remedia-tion strategies, which may tax program and facultyresources. It may also damage the integrity of the pro-gram or negatively influence the experience of peers[18–20]. In addition, the well-documented ‘failureto fail’ in medical education is troubling because itchallenges the social contract medicine has with so-ciety by erring toward keeping marginally competentpractitioners in the profession [21–23]. It is commonto give struggling learners repeated marginal passesthat avoid addressing the underlying problems [16,24, 25]. Programs sometimes inadequately reassesslearners in remediation, failing to ensure remediationwas successful [26]. Ultimately, however, the medicalprofession has a responsibility to ensure that it willgraduate learners that fulfil its social responsibility forhigh quality, safe, professional care [27].

In sum, faculty members must possess the con-fidence, knowledge of systems and standards, moti-vation, and self-efficacy to recommend a strugglinglearner for remediation, in part because this decisionmust be defended to all stakeholders, including thelearners themselves, peers, program leadership, andsociety [22, 28]. Medical curricula must create learn-ing environments that support all students to thrive[29, 30]. This is especially important as the profes-sion works to increase access to medical careers fortraditionally underrepresented populations. Havingsuffered structural educational discrimination, thesegroups may need extra support when entering a med-ical culture slow to change norms and values aroundlearning [31]. Moreover, institutions, concerned aboutlegal consequences from trainees and future patients[21], may intentionally avoid having official policieson remediation and probation [32]. These phenom-ena, which together contribute to overall institutionalculture, create barriers to effective identification of,and intervention with, struggling learners, most ofwhom will soon be (or are already) practising physi-cians.

We thus present these guidelines with the aim ofaiding the development of remediation practice. Theguidelines are divided into two highly interrelatedgroupings: system and individual level guidelines [18,20, 33].

Methods

These guidelines are based on consensus of expertopinion across medical educators based in four coun-tries who have published scholarship in this area,supplemented with a targeted review of the literatureon remediation in medical education. We addressthe continuum of medical education from beginningmedical school to certification as an independent clin-ician at the end of specialty training. Sensitive to thefact that training differs somewhat across countries,

Do’s, don’ts, and don’t knows of remediation 323

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Table 1 Criteria for strength of recommendation

Strong A large and consistent body of evidence

Moderate Solid empirical evidence from one or more papers plus con-sensus of the authors

Tentative Limited empirical evidence, but clear consensus of the au-thors

we aim to provide guidelines that are relevant acrosscontexts. We also believe these guidelines may be ap-plicable across healthcare professions, even thoughour main experience is with training physicians.

We utilized an iterative process similar to that out-lined in previously published papers for this Guide-lines series [34]. Following agreement upon the defi-nition provided above, AK shared an initial list of Do’s,Don’ts, and Don’t Knows. Each author, drawing upontheir own scholarship, personal experience and un-derstanding of the relevant literature, added to thislist. The combined list was then consolidated andcategorized, initially by CC and MC, with further in-put from the other authors. Next, through a series ofdiscussions via email and Skype®, the lists were re-viewed, discussed and refined until reaching consen-sus on the Do’s, Don’ts, and Don’t Knows. We soughtto harmonize terminology so that it would be under-stood across countries. Many ‘Don’ts’ on the origi-nal lists were acknowledged to be simply negationsof some ‘Do’s’—these were removed to avoid unnec-essary repetition. When evidence was conflicting orthere was no clear consensus among us for Do’s orDon’ts, the item was categorized in the Don’t Knowsection—we consider these to be important areas forfurther research.

CC then conducted a targeted literature review ofthe literature on remediation in medical education,producing a final organized list of Do’s, Don’ts, andDon’t Knows in a first draft of this paper. All au-thors then contributed further comments, evidence,and edits. Subsequently, all offered their independentopinions on the strength of evidence for each guide-line and reached consensus on the rating for eachguideline (Tab. 1). We further refined the list aftersuggestions from journal editors.

Results (Tab. 2)

Part I. System level/Contextual issues

We agree with Steinert’s statement: ‘Many potentiallydifficult situations can be prevented by setting expec-tations, giving feedback, and providing thoughtful,ongoing evaluation’ [18]. We note that it is commonfor learners to struggle partly because the educationalsystem has failed them. We assert that, in manycases, the underlying cause of learner struggles issituated in a series of misalignments between themand the learning context, akin to how patient careerrors may arise from the interface between human

and systems failures [35]. For example, when a stu-dent fails a knowledge exam or a clerkship, it is rarelyhelpful to treat it as an isolated event addressed bya quick fix, such as teaching to a specific exam [7,17, 36]. Remediation is most successful when basedon an analysis to detect patterns of maladaptive de-velopment or alignment. Though remediation worktypically focuses on the individual learner, it shouldalso ideally feed back to the program and lead toadjustments that ultimately benefit a larger group oflearners.

Guideline 1. Do advertise to the entire medical edu-cation community that learners commonly need reme-diation, which is resourced and available to all learners(tentative)

Whether or not an institution openly acknowl-edges the predictable need for remediation and worksto destigmatize and adequately resource remediationin medical education is a reflection of the cultureof that institution [37]. Medical education programshave traditionally used deficit-based approaches toeducation, which can encourage learners to focuson surface performance rather than deeper under-standing to avoid negative labels [38]. More recently,programs have increased adoption of competency-based approaches, which de-emphasize time spent intraining and emphasize the developmental, possiblytime-variable, nature of the acquisition of capacities[39]. In this model, many, if not most, students mightneed support at one time or another [27]. Indeed,we advocate explicitly reframing, and thereby destig-matizing, remediation as a special zone of learning,self-improvement, personal development, resiliencebuilding, and an opportunity to practise with feed-back, all to develop the adaptive capacity needed byall medical professionals in the current era [27, 40,41]. This goal requires that program leadership andfaculty embody this approach in substantial ways.Adopting a culture in which ‘educational alliances’are formed with learners, where there is uncondi-tional positive regard for the person rather than tak-ing a deficit-based approach, can support a growthmindset [42–44].

An institutionally-based programmatic approachnormalizes remediation. For example, one schoolincreased the percentage of students attending vol-untary remediation sessions from 40% to nearly 70%when it instituted a transparent academic policy thatrequired satisfactory completion of tasks and facil-itated early identification and support of strugglingstudents [45]. Accordingly, we strongly encourageprograms to explicitly advertise an expectation thatlearners may require remediation services and todirect learners on how to access these services.


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Table 2 Summary of guidelines for remediation in medical education

Guideline Systems level, Do’s Recommendation

1 Do advertise to the entire medical education community that learners commonly need remediation, which is resourced andavailable to all learners

Tentative

2 Do develop a robust feedback culture that impels learner improvement Moderate

3 Do align selection and assessment systems with desired outcomes and graduate qualities Strong

4 Do construct strategies aimed at averting the need for remediation Strong

5 Do deliver remediation as highly individualized processes while recognizing common patterns across struggling learners Moderate

6 Do ‘feed forward’ remediation information, with an abundance of caution Moderate

7 Do provide faculty development and tangible support for frontline educators in early identification of, effective interventionsfor, and appropriate referral of struggling learners

Tentative

8 Do separate the individuals conducting the remediation process from those who determine the outcome of remediation Tentative

9 Do ensure due process, balancing empathy for individual students’ struggles with the medical profession’s responsibility tosociety

Moderate

10 Do create compassionate alternative pathways for those who do not choose to or cannot complete medical training Tentative

Remediation process, Do’s

11 Do aim to detect a need for remediation early Moderate

12 Do collect relevant data from multiple sources across case content Strong

13 Do explore multiple causes of learner struggle beyond educational or workplace issues Strong

14 Do intervene proactively with struggling learners—do not rely on their initiative Strong

15 Do have trainees in remediation undergo intensive, longitudinal tutoring with emphasis on study skills, collaborativelydesigned plans, frequent high-quality feedback, and individualized assessment

Strong

16 Do assess for and improve skills in learning self-regulation Strong

17 Do remediate knowledge and skills in small groups with expert facilitators Moderate

18 Do follow up with learners, even after the presumed end of the remediation period Moderate

Don’ts

19 Don’t rely solely on traditional academic markers of performance Moderate

20 Don’t merely give more time, repeat the learner experience, give general or vague advice, or just ‘teach to the test’ withoutadditional support

Strong

Don’t knows

21 What are the long-term outcomes of remediation?

22 What is the optimal blend and duration of remediation?

23 How does remediation fit with CBME and its approach of learner-centredness and de-emphasis of time?

24 What is the optimal balance between the benefits of educational handovers and the need to protect learners from negativebias that may arise from such handovers?

25 What specific measures predict the need for remediation?

26 Apart from establishing a longitudinal remediation program (Guideline 15), what are the most effective remediation prac-tices?

Guideline 2. Do develop a robust feedback culturethat impels learner improvement (moderate)

The importance of a robust feedback culture is oneof the best-documented aspects of effective educa-tion [34, 46–48]. All learners benefit from close obser-vation, effective feedback, and ongoing formative as-sessment [34]. Immersing learners fully and activelyin ongoing feedback processes increases their moti-vation and engagement in the lifelong learning thatcharacterizes ideal medical practice [31, 49]. Identify-ing how best to support clinical teachers in deliveringfeedback to students has been a focus of research ac-tivity for many years [50, 51]. Unfortunately, studentsconsistently report dissatisfaction with the feedbackthey receive [52–54].

Multisource feedback enhances the impact of rec-ommendations for improvement. In a randomizedcontrolled study of multisource feedback on commu-

nication skills and professionalism, paediatrics resi-dents performed self-assessments, received reports ofparent and nurse evaluations of their skills, and un-derwent tailored coaching. Nurse ratings of residents’communication skills, timeliness, and demonstrationof responsibility and accountability increased for res-idents receiving multisource feedback and decreasedfor the control group [55].

Establishing a trustworthy, dialogic, learner-fo-cused and transparent programmatic feedback cul-ture [56, 57], where all members of the medical ed-ucation program are trained to give, receive, expectand respect feedback from all other members of theprogram, is especially important in helping strugglinglearners attain and maintain performance improve-ments.


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Guideline 3. Do align selection and assessment sys-tems with desired outcomes and graduate qualities(strong)

As mentioned earlier, remediation involves morethan intervening at an individual level. Globally, thereis increasing interest in incorporating groups whohave not traditionally participated in medical edu-cation and therefore may need help transitioning toprofessional education. Increasing the diversity ofstudents has highlighted the need to align selection,assessment, and support systems, to ensure a cultureof support in medical education rather than one of‘sink or swim.’

Selection is the first, and perhaps most important,assessment in medical education [58]. Developinga fair and accurate selection process capable of iden-tifying applicants based on the necessary academicand interpersonal, ‘noncognitive’ criteria is challeng-ing [59, 60]. This is likely best achieved by definingthe competencies of a ‘good doctor’ and using themas the basis of an outcome-based selection procedure[61–63].

All subsequent assessments, curricula and teachingmust incorporate high degrees of fairness, reliability,and validity, and should ideally align with the desiredknowledge, attitudes, and behaviours expected fromgraduates, and ultimately practising clinicians [64, 65].

Guideline 4. Do construct strategies aimed at avertingthe need for remediation (strong)

In addition to our arguments in the above sectionfor robust explicit educational systems, there is strongevidence for two specific strategies that can poten-tially prevent the need for remediation: retrieval re-hearsal and support groups.

Frequent quizzing, or retrieval rehearsal, improvesperformance on knowledge exams [66, 67]. In ad-dition to strong evidence in support of retrieval re-hearsal on the retention of knowledge from a widerange of settings [68–70], one study showed that resi-dents who were tested with multiple choice questionsbefore and after didactic lectures improved their per-formance on an otolaryngology in-training examina-tion. [71].

Many stressors, particularly those fostered by theimplicit curriculum, can influence the need for fu-ture remediation. Students report feeling that they areconstantly being evaluated, particularly in the settingof clerkships where the criteria and expectations forgrades are subjective and appear arbitrary and whim-sical [38, 72, 73]. A strategy shown to have potential toalleviate some of that stress is the facilitated supportgroup with sessions aimed at increasing self-aware-ness, self-care, and/or mindfulness training [74–76].

Guideline 5. Do deliver remediation as highly indi-vidualized processes while recognizing common pat-terns across struggling learners (moderate)

Because learner difficulties have a multitude ofcauses and manifestations, a single course/programdirector or remediator, while essential to guide andcoordinate remediation, cannot adequately synthe-size all the skills necessary to conduct impactful re-mediation. Therefore, the responsibility for effectiveremediation lies with teams that include complemen-tary expertise and institutional roles. Remediationteams, assembled ad hoc for a particular learner, maycomprise faculty with deep expertise in particularareas (e.g., communication skills, clinical reasoning),learning specialists, standardized patient trainers,mental health professionals, public speaking coaches,among many others [77, 78]. The team-based ap-proach can allow for the highly customized, multi-pronged remediation that struggling learners need tosucceed.

However, there are some common patterns to thestruggles of medical learners (see Guideline 13) thatcan be addressed efficiently in groups. Both individ-ualized and group remediation experience should in-form curricular and systems improvements for all stu-dents.

Guideline 6. Do ‘feed-forward’ remediation informa-tion, with an abundance of caution (moderate)

Learner handover, sometimes termed ‘feeding for-ward’, is a controversial area of remediation practicewhere subsequent course directors or clinical super-visors receive information about struggling learners.The main detractors of this practice, which includesome learners, prioritize their concerns that learnersmay suffer from stigmatization and bias, explicit orimplicit, that result in unfair treatment [79]. On theother hand, others argue that lack of continuity of in-formation hinders the early identification of strugglingstudents and the remediators’ ability to intervene ef-fectively [25, 29, 80–83]. The approach to learner han-dover appears to be highly variable. For example, ap-proximately half of US schools claim that they do (ordon’t) engage in the practice, and many schools lacka formal policy on this issue [84]. Though privacy con-cerns about learner handovers may arise, in some set-tings, university officials with legitimate educationalinterests may legally engage in such activities withoutexplicit student consent [85–87].

There is evidence for both potential harms and ben-efits of educational handovers about struggling learn-ers, making the judgment about doing so complex.A recent scoping review evaluating learner handoversin a wide variety of mostly nonmedical settings, sug-gests that prior information about performance biasessubsequent ratings, with some evidence that negativeprior information may exert a larger effect than pos-itive prior information [88]. However, using specificperformance standards to share information may mit-


Guidelines

igate bias in subsequent judgments [89]. As far as wehave been able to ascertain, there has been no le-gal case raised in the US against sharing informationabout a struggling learner for educational purposes.Indeed, this is common practice in other countries,including the UK. Moreover, when program leaders ofa pre-clerkship curriculum feed-forward informationabout students to the subsequent module leader, ithelps identify struggling students, reduces ‘failure tofail’ by distributing responsibility for failing a student,reduces concerns about some students, and increasesthe detection of professionalism problems [24]. Fi-nally, simply sharing information about students atrisk (e.g. from low-income backgrounds) resulted inmore resources for struggling learners and improvedgrades [90].

We believe that the learner handover is a prac-tice which is in most cases justified by our profes-sion’s social contract. We therefore recommend thatprograms formally institutionalize this practice withstrong caveats: that it occurs with the student’s knowl-edge and sensitivity to the student’s privacy, consistsof low-inference information based in specific perfor-mance standards that are likely to lead to an effectiveremediation strategy, and is shared only with othermembers of the faculty who can support the remedi-ation goals (see Guideline 24).

Guideline 7. Do provide faculty development andtangible support for frontline educators in early identi-fication of, effective interventions for, and appropriatereferral of struggling learners (tentative)

Faculty remediators generally have low confidencein their ability to conduct remediation [91], particu-larly in professionalism [92]. Many faculty are unsureabout identifying what is permissible and what doesnot meet the standard [22], while more experiencedfaculty likely remediate more effectively [93, 94].

Remediation requires much more time, expertiseand resources than most faculty allocate or expect [95,96]. One study placed the number of faculty hoursneeded to address efficiency and organizational skillsat 25–75hours per struggling resident [13]. We believethat remediation cannot be done solely on a volun-tary basis and should be done by highly experiencedpeople who are remunerated adequately.

Faculty development for remediation requires bothindividually and institutionally focused capacity-building processes. A set of specific competencies,attributes of teachers, theories of learning, and teach-ing strategies specific to remediation work have beenproposed [97]. In particular, effective faculty reme-diators must be able to judge the performance ofmedical learners across a full range of competencies,develop facilitation skills, and cultivate emotionalintelligence, courage, and attitudes consistent witheffective remediation work. We recommend programsto build faculty development processes that nurturea community of practice of select, highly motivated

educators that develop specialized domains of ex-pertise. This community should integrate with otherimportant communities of practice (e.g., educationand workplace), where all medical educators developa focused set of skills (e.g., identifying and referringthe struggling learner to remediation, cultivating thefeedback culture and expertise).

Guideline 8. Do separate the individuals conductingthe remediation process from those who determine theoutcome of remediation (tentative)

Medical education promotion or dismissal judg-ments are complex and highly consequential. Ideally,experienced faculty make these decisions dispassion-ately, after careful contextual review of the learner’sperformance against stated expectations. Invariably,significant uncertainty exists in the available data.

Remediators must personally engage with thestruggling learner in order to establish trust, con-fidentiality, and boundary limits [37, 41]. Therefore,to avoid inherent conflicts of interest and make de-fensible judgments, those conducting the intimateremediation with the trainee must not be the samepeople who make the final adjudication decisions [37,98]. This can be a challenge in small programs withfew faculty members with the necessary experience.In such cases, program directors can establish ad hoccommittees of faculty from other similar programsto remediate or make final promotion decisions. Ac-creditation requirements in some parts of the worldmay offer policy and procedural guidance.

Guideline 9. Do ensure due process, balancing empa-thy for individual students’ struggles with the medicalprofession’s responsibility to society (moderate)

Learners, particularly some who most need help,commonly do not like to expose themselves and mayfear they have been labelled, perhaps unfairly, as‘struggling’. It can be helpful for the embarrassedlearner to know that any individual’s privacy will beprotected [6, 83, 99]. The process must be fair andconfidential and include informed consent, in thatthe learner should know as much about the pro-cesses and potential outcomes, including dismissal,as possible. Institutional policies must support care-ful documentation and communication among teammembers delineating the decision and the reasonsfor remediation, a written individualized remedia-tion plan (with goals, instructional strategies, andassessments) as well as the sequence of events, andwho is responsible for each remediation area, report-ing structure, time frame, and decision making [22].Supporting data are key, including the interventionplan and learning contract, observed outcomes, andongoing summaries of discussions with learners andcolleagues [37]. While there is a responsibility to en-sure fair process for the individual trainee, it is equallyimportant that medical education fulfils its contract


Guidelines

with society to produce competent physicians [37,98].

Guideline 10. Do create compassionate alternativepathways for those who do not choose to or cannotcomplete medical training (tentative)

While most would agree that not every learner whois admitted can, or should, graduate from the healthprofession program they start, there is great regionalvariation in how this manifests and impacts remedia-tion policy and practice. For example, the remediationgoals of a medical school in a system where not every-one who starts is expected to graduate (e.g., Switzer-land) differ from schools in the UK, where the num-ber of medical school enrolments is controlled by thegovernment on the basis of national workforce plan-ning forecasts. However, whilst taking context into ac-count, an important role of remediation is to enablea realistic assessment of the likelihood of long-termsuccess, encourage honest learner self-reflection, andoffer other viable options. Some experienced educa-tors believe that some struggling students, particularlythose who felt pressure from family to enter the pro-fession, may ‘self-sabotage’ as a face-saving way tochange career path. Especially important in the US,but relevant in many regions, restructuring or forgiv-ing financial debt may enable students who cannotor do not choose to continue to train as physiciansto leave medical training without crushing financialand/or personal consequences. Counselling on viableoptions for alternative career paths must be developedand made available to all medical trainees. Studiesof alternate pathways taken in countries where manywho enter medical school do not finish would informthe development of such policies elsewhere [100, 101].

Part II. The remediation process

While the systems-level guidelines above are criti-cally important, ultimately the remediation processis highly individualized to the needs of the particularstruggling learner. For remediation to be effective,the learner must be identified; the areas of struggleclarified; underlying causes or explanations exploredand understood [18]; a flexible remediation inter-vention crafted [3, 90, 102, 103] and implemented;and progress assessed. Responsibility for remedia-tion starts with course or program directors. Thework of the clarification and intervention is mostlyconducted within the remediator-struggling learnerdyad. Finally, the responsibility returns to course orprogram directors for assessment of outcome. Ulti-mately a disposition judgment needs to be made (seeGuideline 8).

The centrepiece of excellent remediation responsesis establishment of an appropriate, achievable inter-vention or learning plan that directly addresses thedeficiencies via skilled feedback [34], often based ondirect observation in clinical settings [104]. However,

remediation plans for individual struggling learnersnever exist in isolation. As previously mentioned, re-mediation exerts emotional impacts on and resourcecosts to other individuals in the program. For exam-ple, remediation interventions for one learner may beperceived by peers as unfair special treatment, espe-cially if it requires those peers to assume extra dutiesto cover the time needed for the struggling learner’sremediation activities. We recommend that programleadership provides clear, supportive, empathic antic-ipatory guidance to peers of struggling learners, whilemaintaining respect for the remediating learner’s pri-vacy. In our experience, this approach helps peersrise to challenges and gain a sense of positive, in-spired, and supportive camaraderie. Finally, since re-sources to undertake remediation efforts are almostalways limited, institutions and course/program di-rectors must remain strategic in deployment, inter-vention, and evaluation (Guidelines 1 and 9).

Guideline 11. Do aim to detect a need for remediationearly (moderate)

Early identification of learners who struggle inmany competency areas can maximize the successof remediation interventions. For knowledge deficits,early struggle on any assessment in the pre-clerk-ship phase of medical school predicts later under-performance [22, 105–107]. Analysis of strugglingstudents at one UK medical school suggested thata combination of predictors, including performanceon examinations, unprofessional behaviour, healthproblems, social problems, and missed required vac-cinations, may augur the need for remediation in thepre-clerkship phase [108]. At another UK medicalschool, when early identification of struggling pre-clerkship students occurred at 4, 7, and 12 months af-ter starting, more students participated in supportiveservices, compared with historical controls, and thoseengaging in one-on-one remediation services weremore likely to successfully complete pre-clerkshipstudies [45].

There is some literature that defines parametersthat influence early identification of struggling stu-dents in clerkships. Pre-clerkship knowledge and earlyclinical performance predict workplace-based clinicalperformance in medical schools in the UK [97], theNetherlands [105], and United Arab Emirates [109].Low clerkship ratings and lack of student progresson communication skills or professionalism concernspredict failure on the patient-provider interaction por-tion of a high-stakes clinical skills examination givenat the end of foundational clerkships [110]. Studentsreferred for remediation after their internal medicineclerkship were more likely to receive poor ratings ininternship and fail USMLE Step 3 [111]. Guerrasio re-ported that three medical students with previously-identified interpersonal skills deficits did not matchinto any residency program and therefore could notcontinue their medical training [3].


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Professionalism lapses predict future struggles inmedical school and probably much more. Papadakis[112] showed that while low MCAT scores (pre-medi-cal school) and low grades during the first 2 years ofmedical school carry a 7% risk of subsequent disci-plinary action as practising physicians, identificationof unprofessional behaviour in that same period in-creases this risk to 26%. In a pre-clerkship curriculum,three or more unexcused absences from attendance-required sessions and negative peer assessment corre-late with unprofessional conduct during clinical years[113]. While personality measures seem to have lit-tle power to predict academic struggles [114, 115],there may be an association between behaviour andpersonality. Physicians who demonstrated unprofes-sional behaviour during medical school scored loweron four out of six scales of the California PsychologicalInventory [116]. Finally, poor professionalism was theonly statistically significant predictor for placementof clinically-based learners or practitioners on officialprobationary status at one US institution [3].

This literature supports early identification of stu-dents who struggle with learning medical knowledge,patient care, and professionalism behaviours. How-ever, more work must identify the best approachesto intervene early with underperforming learners inthese domains and to mitigate the potential negativeconsequences of early labelling of a learner as ‘strug-gling’. (Guideline 25).

Guideline 12. Do collect relevant data from multiplesources across case content (strong)

Ideally, multisource feedback facilitates accurateidentification and effective remediation more thana single-rater tool or informal workplace-based ob-servation [117]. However, waiting to accumulate mul-tiple pieces of evidence must be balanced against therisk of delayed identification of the struggling learner.Once a struggling learner is identified, usually as a re-sult of an objective measure (for example, a failedexam) or a clinical teacher’s concern that a learneris not demonstrating the expected competency, it isimperative to review additional performance data.This review must be done with awareness of potentialof implicit bias [118] and the fact that clinical com-petence is greatly impacted by case specificity andshould therefore not be determined based on a singlecase [119]. Accordingly, when possible, we recom-mend multiple direct observations in more than onecontext (e.g. hospital, ambulatory clinic) across morethan one clinical domain. It can also help if reme-diators have access to the academic records of thelearner in order to assess for performance patterns.

Guideline 13. Do explore multiple causes of learnerstruggle beyond educational or workplace issues(strong)

It is common that non-academic factors contributeto or are a consequence of academic struggles. These

include physical (new-onset medical conditions) andmental health issues (including psychiatric illness,personality disorders, substance abuse) and previ-ously undiagnosed learning disabilities [78, 108].Obviously, young adults are at risk of experiencingother stressors including juggling family and financialchallenges, navigating cultural and community expec-tations, dealing with hierarchy, all the while learningto deal with the significant strains and constraintsof medical training. In particular, junior medicallearners must learn to manage their distress aboutand frustration with a chaotic and poorly organizedhealthcare delivery system and adjust to poorly per-ceived or understood learning environments [120],cognitive dissonance with ethical dilemmas [121, 122]and poor role modelling [94]. Assessment across mul-tiple domains can also determine the overlap betweenskill deficits and attitudinal problems [123]. Becauseresponses to stress can be adaptive or maladaptive[124, 125], only some learners facing these stressorsmay present with academic struggles.

International medical graduates, underrepresentedminority trainees, older trainees, and trainees withprior failures are more likely to be identified asneeding remediation [126]. Students from under-represented minority groups in medicine are po-tentially at risk of stress from the consequences ofdiscrimination. Underrepresented minority studentsin medicine report regular experiences of microag-gressions as well as overt discrimination leading tounpleasant or harmful psychological impact [127].Non-white candidates underperformed with respectto white candidates in the UK [128]. In the US, medi-cal students who are older, have a child, or self-iden-tify as Native American or Pacific Islander have morefrequent ‘serious thoughts’ of dropping out. Thesegroups are also at greater risk of academic problemswith significant psychosocial stressors [129]. Similarpatterns are seen in other contexts [130].

Independent of actual ability, underrepresentedminority learners are at additional risk of under-performing in academic settings when they becomeanxious about confirming commonly held negativestereotypes about them. It has been our experiencethat this phenomenon, called stereotype threat [131],is operative in medical education. In a prior re-view of strategies for addressing struggling learners,Steinert speaks to this dynamic by explicitly asking,‘whose problem is it?’ [18]. A range of systems-leveland interpersonal interventions reduce the impactof stereotype threat, including raising awareness ofthis dynamic and restructuring assessments to avoidinadvertently reinforcing stereotypes. Until societal,institutional, and interpersonal interventions reducediscrimination, remediators must remain aware ofthese dynamics and design remediation strategieswhich address the critical underlying causes of under-performance [132], including advocacy for a student.


Guidelines

Guideline 14. Do intervene proactively with strug-gling learners—do not rely on their initiative (strong)

Even when the struggling learner is identified, earlyintervention may not follow [118]. Weaker learnersinaccurately self-assess, tending to overrate them-selves [99, 133]. In remediation programs specifi-cally, only about 7% of struggling learners accuratelyself-referred to one guidance program; the majorityof people in the program were high achievers withchronic anxiety about performance [3]. Academicallyweaker students and those suffering burnout tendto avoid seeking assistance [129, 134], so the systemmust do its best to identify and support these learn-ers and the program must have the capacity, support,and willingness to compel struggling learners intoremediation [6]. Students who accept remediationdemonstrate longer-term improvement in test-takingthan those who decline [135].

Guideline 15. Do have trainees in remediation un-dergo intensive, longitudinal tutoring with emphasison study skills, collaboratively designed plans, frequenthigh-quality feedback, and individualized assessment(strong)

Most remediating students have multiple chal-lenges and therefore generally do not respond to lim-ited interventions, such as ‘teaching to the test’ [3, 7].Successful interventions rely on a holistic approachthat combines content development and improvingself-regulated learning strategies. Specifically, suchstrategies target both cognitive and affective domainsof learning, and focus on study skills using relevantacademic content as exemplars [6, 7, 105, 136–138].One common hallmark of these successful programsincorporates regular pre-arranged meetings to assessprogress and achievement of goals, with high-qual-ity feedback and assessments determining the needfor mid-course corrections and/or consequences inthe absence of acceptable improvement [6, 139, 140].For medical knowledge remediation, ongoing regularfacilitated small group work can enhance learners’study skills using evidence-based strategies, such asretrieval rehearsal (Guideline 4), mixing content andtypes of problems in a given study session ratherthan focusing only on one subject or type of problem(‘interleaved practice’;[68]), generating explanations,and having students write their own multiple-choicequestions [6, 7, 105, 137].

Data support the benefits of longitudinal interven-tion and follow-up. In non-medical settings, effectiveprograms encompassed at least 12 sessions [139]. Inpre-clerkship remediation interventions, Winston [6]found a strong enough dose effect to mandate atten-dance for a full semester in order to ensure success forup to 2 years: 15 or more sessions doubled the long-term pass rates over 10 or fewer sessions, a statisticallysignificant finding consistent with other relevant stud-ies [30, 104, 107, 137]. In addition to longer durationof remediation, longer-term follow-up leads to opti-

mal outcomes [141, 142] (see also Guideline 18). Fi-nally, increased faculty face time with struggling learn-ers decreased the probability of probation (referral toadministrative leadership due to unsuccessful remedi-ation) by 3.1% per hour spent, and of all negative out-comes, by 2.6% per hour [3]. Of course, for pragmaticreasons, remediators must specify a time frame forexpected improvement [94]. We emphasize that timeis not the only component of worth—quality of theremediation interventions matters (see Guideline 26).

Guideline 16. Do assess for and improve skills inlearning self-regulation (strong)

High-achieving students exhibit increased motiva-tion [143] and have more awareness about how to ef-fectively learn and cope with difficulty [144]. In con-trast, the literature describes struggling students astypically not engaging in self-regulated learning, mak-ing inappropriate choices of learning strategies forwritten and clinical formats of assessment, and usingmaladaptive strategies for coping with failure. Thesemaladaptive strategies include relying on rote memo-rization, adhering rigidly to prior strategies that pre-viously worked in other contexts, emphasizing timeand effort spent studying rather than actual knowl-edge acquisition and improvement of understanding,and externalizing reasons for failure [16, 99].

In struggling students, once the emotional reactionto failure passes, it is important to reframe failure asa normal, even expected or desirable outcome, in or-der to allow for readjustment of study approaches, re-examination of interaction challenges, and incorpora-tion of improved techniques toward success. However,some learners externalize blame, which may manifestas an inability to process feedback, criticism of cur-riculum and assessmentmethods, dissatisfaction withprograms that did not intervene earlier (and thereforeare accountable for not upholding their implicit con-tract to teach effectively), and failure to seek formalsupport because it is viewed as policing. It is com-mon for struggling learners to cycle through a rangeof these often contradictory negative attitudes as theycome to terms with their predicament. Remediatorswho are able to establish a trusting relationship withthe struggling learner can provide reality checks whileproviding empathic emotional guidance.

Remediation is most successful when remediatorsadopt a self-regulated learning perspective as a lensthrough which to view variations in learners’ beliefsand behaviours about remediation [145]. It is im-portant to address a struggling learner’s self-efficacywith respect to remediating and pessimism aboutremediation, even if the learner expresses negative oropenly defiant attitudes at first. Collaborative designof the remediation plan (for example, introducingevidence-based study strategies and encouraging stu-dents to select the course material to apply them to)supports learner autonomy [6]. Learners can developtheir own formal remediation plans with personal


Guidelines

reflections and specific strategies to gather evidenceof improved performance [146]. We reiterate that be-cause it takes many struggling learners time to accepttheir situation, as mentioned above, programs mustnot rely solely on learners’ motivations to initiateremediation. However, one study showed that evenwith mandatory remediation, participating learnerscan still report high self-motivation [7], suggestingthat with patience, a supportive relationship, andtime, these learners can strengthen their self-regula-tion skills and make progress.

Some residents and house officers may need extrasupport to develop the sophisticated level of self-regulation required to attain workplace efficiencyand organization while also developing their clini-cal competence. DeKosky et al. [13] report in detailon a process and tools to help residents organizearound common time-consuming tasks, includingadmitting a patient efficiently, performing effectivepre-rounding, and composing daily progress notesand presentations.

Mild to moderate lapses in professionalism arecommon. In our experience, strategies that supportself-regulation are the mainstay of the most effectiveremediation in these cases. Engaging learners in sup-portive, non-judgmental conversations about theirbehaviour with experienced individuals or a profes-sionalism committee can impel deep and behaviour-altering self-reflection [147, 148]. Other well-publi-cized professionalism remediation practices includemandated mental health evaluation and critical re-flection writing assignments [86]. Importantly, it isgenerally acknowledged that lapses in professionalismoccur on a continuum and that markedly egregiousunprofessional behaviour is much less likely to beremediable, especially if there is a pattern of unpro-fessional behaviour and evidence of serious charac-terological disorder. It is critical to consider each caseindividually [149].

Guideline 17. Do remediate knowledge and skills insmall groups with expert facilitators (moderate)

Social cognitive theory posits that the effectivenessof group learning is based in discourse and devel-opment of critical thinking [150, 151]. Numerousexamples of instructional designs in medical educa-tion are based on this theory, such as problem-basedand team-based learning. Particularly in remediation,struggling students are often ‘unskilled and unaware’[133] and may not recognize their own weaknesses.Seeing others with alternative solutions to similarchallenges can help develop a sense of group identityand social regulation, which may in turn support self-regulation [152–154]. This group approach can helpreduce stigma by emphasizing the pride of belonging,supporting each other, and feeling understood ratherthan isolated [102, 103]. Additional benefit ariseswhen the group practises giving and receiving feed-back. This develops lifelong skills of self-assessment,

feedback, and possibly self-regulated learning. Wenote that while there is experience doing remediationfor cognitive skills in small groups, there is no such ev-idence to support professionalism remediation usingthis strategy.

Expert faculty facilitation is crucial if remedia-tion is to be done in groups. Skilful facilitation ofsmall group learning, allowing for emotional support,explicit description and recognition of high qualitywork, and encouraging collaboration leads to suc-cess in both classroom-based as well as clinical skillsremediation [6, 76, 103, 143, 153]. Trained facultycan prevent groupthink and premature closure of dis-cussion, which is especially important for strugglingstudents [93, 153]. In addition, faculty must highlightcognitive conflict and inconsistency, ask disruptivequestions, and model intellectual curiosity [155, 156].In general, learners prefer supervisors to be presentto enhance their learning [156]; without guidance,they can develop bad habits and form ‘illusions ofcompetence’ [157, 158].

Guideline 18. Do follow-up with learners, even afterthe presumed end of the remediation period (moder-ate)

The evidence is that for many (but not all) learners,underperformance is a pattern over time rather thanan isolated easily resolvable problem [159]. This islikely multifactorial. An individual may initially havedifficulty adjusting to the demands of medical educa-tion and training but ultimately acclimatize, or alter-natively, never gain independent ability to accommo-date to these demands. Only observation over timewill tell. Additionally, even the most hardy learnershave complex lives, and academic performance mayfluctuate with non-academic demands on their timeand energy. A supportive institutional culture encour-ages learners to self-monitor and seek help in adjust-ing to new challenges and invites private discussionsabout underachievement. These discussions can helpboth learners and faculty decide when and what typeof support is necessary. For professionalism remedia-tion, long-term engagement is needed to ensure thatstudents have internalized new attitudes and skills.

Don’ts

Guideline 19. Don’t rely solely on quantitative aca-demic markers of performance (moderate)

The best predictor of academic performance inmedical school is academic performance prior tomedical school [160]; however, experiences and per-formance in medical school still matter. Though pre-admission aptitude tests and grade-point averageaccount for approximately one-quarter of the vari-ance in knowledge testing in medical school [128,160–162], much room for growth and developmentremains within medical school. Given that there arescant long-term follow-up data showing that medical


Guidelines

school applicants with higher grades become betterphysicians, providing remedial support on the basisof pre-application data alone is not justified, and maystigmatize some students. One study found that whileperformance on standardized academic metrics didnot predict the need for remediation in the future,atypical characteristics of workplace assessments likeambiguous or negative comments or excessive lengthof text comments, did [163]. We believe emergingresearch will support these findings. Holistic pro-grammatic portfolio-based assessment approacheshold some promise, although they are challengingto implement [164]. Multisource assessment dataand competency or outcomes-based frameworks formedical education will likely provide much richer andmore comprehensive data upon which to base aca-demic coaching, promotion, and remediation judg-ments and a more reliable basis for the prediction ofsuccess in medical school and beyond.

Guideline 20. Don’t merely give more time, repeat thelearner experience, give general or vague advice, or just‘teach to the test’ without additional support (strong)

This guideline is essentially the opposite of guide-lines 15–16. Merely decelerating a trainee without ad-ditional support does not significantly affect dismissalrates [165].

Don’t knows

Guideline 21. What are the long-term outcomes of re-mediation?

We know very little about long-term outcomes ofremediation programs. We do know that there was nolongitudinal improvement in one 5-year study, for stu-dents who initially failed OSCEs and then engaged ina standard remediation plan with short-term success[30]. Another case-control study of residents showedthat remediating learners eventually reached compe-tence levels similar to the mean but needed more ex-ams and a longer time for completion [95]. Amongstudents who failed a clinical performance exam, Kla-men and Williams noted an improvement in post-re-mediation scores [96]. More of this longitudinal track-ing of program outcomes is necessary to evaluate theefficacy of our interventions [166], and we stronglyrecommend long-term monitoring of students whohave undergone remediation. This kind of prospec-tive, longitudinal follow-up may highlight, for exam-ple, that remediation in medical school or residencypredicts practice difficulties in the future. Addition-ally, given that trainees commonly move along thetraining path from one institutional context to an-other, tracking learner progress across such contextsmay further illuminate the extent to which remedia-tion practices and systems are institution-specific andlongitudinally durable.

Guideline 22. What is the optimal blend and dura-tion of remediation?

Especially for specific situations and difficulties, wedo not know when to determine the completion ofa learner’s remediation. Reasons for remediation varyfor any given student, and there is rarely a singledeficit. Given the complexity of remediation work,it is likely best conducted and assessed on a case-by-case basis.

That said, the educational evidence base supportsthat teaching struggling learners with a toolbox of ap-proaches makes good sense. The key is to maximizethe evidence-based approach for every component ofa struggling learner’s remediation plan. These tendto be complex, highly individualized interventions.Therefore, it is difficult to tease out the impact of anyspecific element of the intervention, making generalremediation rules elusive [138].

Though the weight of the data supports a dose ef-fect (Guideline 15), it is unknown exactly how manyinterventions are necessary for optimal performance.Furthermore, a dose effect for clinical skills remedia-tion is unclear, although the approach is quite similarto that of pre-clerkship remediation. In addition, itis possible that too many interventions may lead toa decrease in self-efficacy or independence. This is anarea for future study.

Guideline 23. How does remediation fit with CBMEand its approach of learner-centredness and de-empha-sis of time?

Ideally, time-variable competency-based medicaleducation (CBME) wouldmake remediation as a sepa-rate educational activity irrelevant. However, traineesstruggle for many reasons including, for example, am-bivalence about career fit. Therefore, even in a fullyrealized CBME framework, there is likely to be a needfor a ‘zone of remediation’ between the normal cur-riculum and exclusion [27]. This zone frameworkdemonstrates how educational practice in differentzones is based on different rules, roles and responsi-bilities. Thresholds for moving between zones wouldrequire explicit and transparent policies and specificexpertise in remediation. While currently there arevery few examples of truly time-variable CBME, it willbe important to monitor challenges experienced bystudents in such a system to understand how policyand practise in the zone of remediation will need toevolve.

The move towards CBME brings with it the oppor-tunity for an alternative paradigm to the current iden-tify-and-intervene approach to remediation. How-ever, to do so will require a shift in culture, fromregarding those who take a little longer than othersto achieve the required competencies as struggling tothinking about learning pace as an individual factorin ultimate success in practice. This is difficult toconceive of in systems which inherently remain time-based and competitive. CBME may provide an op-


Guidelines

portunity to consider ‘struggling’ learners with morepositive regard and take a broader view of the manychallenges that our learners encounter, while main-taining our obligation of high standards to society.

Guideline 24. What is the optimal balance betweenthe benefits of educational handovers and the need toprotect learners from negative bias that may arise fromsuch handovers? (See Guideline 6 for further discus-sion.)

Guideline 25. What specificmeasures predict the needfor remediation?

Several studies show that many quantifiable mea-sures of performance carry neither reliable nor spe-cific information to identify struggling learners earlyin medical training. Personality and study skills in-ventories add little to prediction of performance [114,167] and are susceptible to faking [115]. Learning styleassessments correlate weakly with academic perfor-mance [128], if at all [168, 169]. However, some in-dicators may be fruitful for future research. For ex-ample, one recent study found that systematic fac-ulty ratings of in-class participation predicted failureof year 1 medical students before students began tounderperform [170].

For clinical performance, USMLE Step 1 scores,part of the licensing exam taken early in medicalschool in the US, weakly predicted low clinical per-formance in medical school [171] and low knowledge;they did not predict professionalism issues in res-idency [172]. We believe that any further work todelineate some of these predictors must be balancedby the significant potential to stigmatize a studentthrough early identification who would otherwise dowell later in training. This paradox again emphasizesthe utility of prospective, longitudinal studies.

Guideline 26. Apart from establishing a longitudinalremediation program (Guideline 15), what are the mosteffective remediation practices?

Few studies have explicitly attempted to delineatewhat components are necessary and sufficient for aneffective remediation program. The wider remedia-tion literature suggests that different things work fordifferent people and that there is a complex relation-ship between individual and systems/organizationalfactors. Ultimately resources are limited, and the listof possible remediation strategies is long, highlightingthe need for research that informs remediation policyand practices [17].

Conclusion

Remediation is a highly complex process involvinglearners and faculty, individuals, systems and societalfactors. The good news is that as medical educators,we have increasing awareness of and expertise inpractices that can maximize educational outcomes

for struggling learners. This paper summarizes whatwe currently know from the published literature andour own extensive experiences about remediationprocesses. We believe that whilst there is great needfor ongoing improvement in this field, and whilstrigorous hypothesis testing in remediation studiesremains challenging because of the ethical peril ofa non-intervention condition, there is reason to beoptimistic.

More than half of the ‘Do’s’ guidelines reach be-yond individual interventions. These guidelines re-flect the core values of education, highlighting the im-portance of expectation-setting and transparent edu-cational policies and structures; balance of commit-ment to and compassion for our learners with oursocietal responsibility; the importance of a cultureof feedback, due process, and non-judgmental pos-itive regard for learners; proactivity when learners donot recognize their level of struggle; and a holistic ap-proach to understanding the full range of causes whenlearners experience academic struggle. We aim to en-sure that our guidelines underscore the importanceof context, prevention, and early detection in this do-main of medical education practice.

Most commonly, research in this domain has fo-cused on testing the relationship between learners’performance on a particular assessment and perfor-mances on later assessments and how a particular re-mediation program assists in helping a learner passa specific examination. This type of work tends toobscure our understanding of the ways in which thecontext, learning environment, or an individual reme-diation intervention may lead to unintended conse-quences for certain individuals or groups. This limitsour ability to make choices and understand trade-offsin remediation practice.

Remediation in medical education highlights theperennial tensions that pervade the field in general,and institutions and program leadership must nav-igate these tensions to ultimately make many com-plex and difficult decisions. What is the appropriatebalance between providing resources to remediationand other important educational activities? How doesa program determine when a learner in remediationis unlikely to succeed? What is the defensible balancebetween responsibility to society and ongoing supportto a struggling learner who has already made high per-sonal and financial sacrifice? What is any institution/program’s responsibility to address academic struggleswhose causes lie wholly outside the purview of theinstitution (e.g., personal, family, illness)? Althoughresearch is desperately needed to guide this decision-making, educators working within the pragmatic limi-tations of institutions and programs must continue toanswer these questions in the absence of clear data.Ultimately, decisions about remediation reflect insti-tutional values, and therefore, clarifying those valuesis critical. Our hope is that this summary of the cur-rent state of remediation will enable individuals, in-


Guidelines

stitutions, and the medical profession to make moreinformed choices about how to support our strugglinglearners most effectively.

Conflict of interest C.L. Chou, A. Kalet, M.J. Costa, J. Clelandand K. Winston declare that they have no competing inter-ests.

Open Access This article is distributed under the terms ofthe Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which per-mits unrestricted use, distribution, and reproduction in anymedium, provided you give appropriate credit to the origi-nal author(s) and the source, provide a link to the CreativeCommons license, and indicate if changes were made.

References

1. Kalet A, Chou CL, editors. Remediation in medical edu-cation: a mid-course correction. Heidelberg, Berlin, NewYork: Springer;2014.

2. Bhatti NI, Ahmed A, Stewart MG, Miller RH, Choi SS.Remediation of problematic residents—a national survey.Laryngoscope. 2016;126:834–8.

3. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits andacademic outcomes of medical students, residents, fel-lows, and attending physicians referred to a remediationprogram,2006–2012. AcadMed. 2014;89:352–8.

4. Turner JA, FitzsimonsMG,PardoMC, et al. Effect of perfor-mance deficiencies on graduation and board certificationrates: a10-yrmulticenterstudyofanesthesiologyresidents.Anesthesiology. 2016;125:221–9.

5. Warburton KM, Goren E, Dine CJ. Comprehensive assess-ment of struggling learners referred to a graduate medi-cal education remediation program. J Grad Med Educ.2017;9:763–7.

6. WinstonKA.Coreconcepts inremediation: lessons learnedfromasixyearcasestudy.MedSciEduc. 2015;25:307–15.

7. WinstonKA, VanDer VleutenCPM, Scherpbier AJJA. An in-vestigationintothedesignandeffectivenessofamandatorycognitive skills programme for at-risk medical students.MedTeach. 2010;32:236–43.

8. NixonLJ,GladdingSP,DuffyBL.Describing failure inaclin-ical clerkship: Implications for identification, assessmentand remediation for struggling learners. J Gen InternMed.2016;31:1172–9.

9. MavisBE,WagnerDP,HenryRC,etal. Documentingclinicalperformanceproblemsamongmedical students: feedbackfor learner remediation and curriculum enhancement.MedEducOnline. 2013;18:20598.

10. Yao DC, Wright SM. National survey of internal medicineresidency program directors regarding problem residents.JAMA.2000;284:1099–104.

11. SilverbergM,WeizbergM,MuranoT,SmithJL,BurkhardtJC,Santen SA.What is the prevalence and success of remedia-tion of emergencymedicine residents? West J EmergMed.2015;16:839–44.

12. Vermeulen MI, Kuyvenhoven MM, de Groot E, et al. Poorperformance among trainees in a Dutch postgraduate GPtrainingprogram. FamMed. 2016;48:430–8.

13. DeKosky AS, SedrakMS, Goren E, Dine CJ, Warburton KM.Simple frameworks for daily work: innovative strategies tocoach residents strugglingwith timemanagement, organi-zation,andefficiency. JGradMedEduc. 2018;10:325–30.

14. Foo J, RiversG, Ilic D, et al. The economic cost of failure inclinicaleducation: amulti-perspectiveanalysis.MedEduc.2017;51:740–54.

15. Davison I,McManusC,TaylorC. EvaluationofGP specialtyselection, Health Education England. 2016. https://www.ucl.ac.uk/medical-education/sites/medical-education/files/GPspecSelReport.pdf. Accessed22Apr2019.

16. Cleland JA, Arnold R, Chesser A. Failing finals is oftena surprise for the student but not the teacher. Med Teach.2005;27:504–8.

17. Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Mof-fatM.Theremediationchallenge: theoretical andmethod-ological insights from a systematic review. Med Educ.2013;47:242–51.

18. Steinert Y. The ‘problem’ learner: whose problem is it?AMEEGuideNo. 76.MedTeach. 2013;35:e1035–e45.

19. Brenner AM, Mathai S, Jain S, Mohl PC. Can we predict‘problemresidents’? AcadMed. 2010;85:1147–51.

20. Yao DC, Wright SM. The challenge of problem residents.JGenInternMed. 2001;16:486–92.

21. Guerrasio J, Furfari KA, Rosenthal LD, Nogar CL, Wray KW,Aagaard EM. Failure to fail: the institutional perspective.MedTeach. 2014;36:799–803.

22. Cleland JA, Knight L, Rees C, Tracey S, Bond CB. ‘Is it meor is it them?’ Factors influencing assessors’ failure toreport underperformance inmedical students. Med Educ.2008;42:800–9.

23. Luhanga FL, Larocque S, MacEwan L, Yovita N, Danyluk P.Exploringtheissueoffailuretofailinprofessionaleducationprograms: a multidisciplinary study. J Univ Teach LearnPrac. 2014;11:3.

24. Wilkinson TJ, Tweed MJ, Egan TG, et al. Joining the dots:conditional pass and programmatic assessment enhancesrecognition of problems with professionalism and factorshamperingstudentprogress. BMCMedEduc. 2011;11:29.

25. GoldWL,McArdle P, FedermanDD. Shouldmedical schoolfaculty see assessments of students made by previousteachers? AcadMed. 2002;77:1096–100.

26. Hawthorne MR, Chretien KC, Torre D, Chheda SG. Re-demonstration without remediation—a missed opportu-nity? A national survey of internal medicine clerkshipdirectors.MedEducOnline. 2014;19:25991.

27. Ellaway RH, Chou CL, Kalet AL. Situating remediation:accommodating success and failure in medical educationsystems. AcadMed. 2018;93:391–8.

28. HuntLA,McGeeP,GutteridgeR,HughesM.Failingsecurely:the processes and support which underpin English nursementors’ assessment decisions regarding under-perform-ingstudents. NurseEducToday. 2016;39:79–86.

29. FrellsenSL, Baker EA, PappKK,DurningSJ.Medical schoolpolicies regarding struggling medical students during theinternal medicine clerkships: results of a national survey.AcadMed. 2008;83:876–81.

30. PellG,FullerR,HomerM,RobertsT. Is short-termremedia-tionafterOSCEfailuresustained?Aretrospectiveanalysisofthe longitudinal attainment of underperforming studentsinOSCEassessments.MedTeach. 2012;34:146–50.

31. ClelandJA,CilliersF,vanSchalkwykS.Thelearningenviron-mentinremediation: areview. ClinTeach. 2018;15:13–8.

32. Weizberg M, Smith JL, Murano T, SilverbergM, Santen SA.What does remediation andprobation statusmean? A sur-vey of emergency medicine residency program directors.AcadEmergMed. 2015;22:113–6.

33. KrzyzaniakSM,Wolf SJ,ByynyR, etal. Aqualitativestudyofmedical educators’perspectivesonremediation: Adoptinga holistic approach to struggling residents. Med Teach.2017;39:967–74.

34. Lefroy J, Watling C, Teunissen PW, Brand P. Guidelines:the do’s, don’ts and don’t knows of feedback for clinicaleducation. PerspectMedEduc. 2015;4(284):99.


http://creativecommons.org/licenses/by/4.0/

https://www.ucl.ac.uk/medical-education/sites/medical-education/files/GPspecSelReport.pdf



Guidelines

35. Reason J. Human error: models and management. BMJ.2000;320:768–70.

36. Mattick K, Knight L. High-quality learning: harder toachievethanwethink?MedEduc. 2007;41:638–44.

37. KaletA,ChouCL,EllawayRH.Tofail ishuman: remediatingremediation in medical education. Perspect Med Educ.2017;6:418–24.

38. Bullock JL, Lai CJ, Lockspeiser T, et al. In pursuit ofHonors: amulti-institutionalstudyofstudents’perceptionsof clerkship evaluation and grading. Acad Med. 2019;https://doi.org/10.1097/ACM.0000000000002905. epubaheadofprint.

39. Lucey CR, Thibault GE, ten Cate O. Competency-based,time-variable education in the health professions: cross-roads. AcadMed. 2018;93:S1–S5.

40. Cutrer WB, Miller B, Pusic MV, et al. Fostering the devel-opment of master adaptive learners: a conceptual modelto guide skill acquisition inmedical education. AcadMed.2017;92:70–5.

41. Bennion LD, Durning SJ, LaRochelle J, et al. Untying theGordian knot: remediation problems in medical schoolsthatneedremediation. BMCMedEduc. 2018;18:120.

42. Rogers CR. On becoming a person: a therapist’s view ofpsychotherapy. 1961.

43. Telio S, Ajjawi R, Regehr G. The ‘educational alliance’ asa framework for reconceptualizing feedback in medicaleducation. AcadMed. 2015;90:609–14.

44. Dweck CS. Mindset: the new psychology of success. NewYork: BallantineBooks;2016.

45. Stegers-Jager KM, Cohen-Schotanus J, Splinter TA, Them-men AP. Academic dismissal policy for medical students:effect on study progress and help-seeking behaviour. MedEduc. 2011;45:987–94.

46. Hattie J,TimperleyH.Thepowerof feedback. RevEducRes.2007;77:81–112.

47. Watling CJ, Ginsburg S. Assessment, feedback and thealchemyof learning.MedEduc. 2019;53:76–85.

48. Rougas S, Clyne B, Cianciolo AT, Chan TM, Sherbino J,Yarris LM. An extended validity argument for assessingfeedbackculture. TeachLearnMed. 2015;27:355–8.

49. BoudD, Molloy E, editors. Feedback in higher and profes-sionaleducation. London: Routledge;2013.

50. Neville S, French S. Clinical education: students’ andclinical tutors’views. Physiotherapy. 1991;77:351–4.

51. Bearman M, Tai J, Kent F, Edouard V, Nestel D, Molloy E.Whatshouldweteachtheteachers? Identifyingthelearningpriorities of clinical supervisors. Adv in Health Sci Educ.2018;23:29–41.

52. HigginsR,HartleyP, Skelton A.Getting themessage across:the problem of communicating assessment feedback.TeachHighEduc. 2001;6:269–74.

53. Gibbs G. How assessment frames student learning. In:BryanC, Clegg K, editors. Innovativeassessment in highereducation. London: Routledge;2006.

54. Poulos A, Mahony MJ. Effectiveness of feedback: the stu-dents’perspective. AssessEvalHighEduc. 2008;33:143–54.

55. Brinkman WB, Geraghty SR, Lanphear BP, et al. Effectofmultisource feedback on resident communication skillsand professionalism: a randomized controlled trial. ArchPediatrAdolescMed. 2007;161:44–9.

56. Winstone NE, Nash RA, Parker M, Rowntree J. Supportinglearners’ agentic engagement with feedback: a systematicreview and a taxonomy of recipience processes. EducPsychol. 2017;52:17–37.

57. Carless D, Salter D, YangM, Lam J. Developing sustainablefeedbackpractices. StudHighEduc. 2011;36:395–407.

58. Cleland JA, Dowell J, McLachlan J, Nicholson S, Pat-terson F. Identifying best practice in the selection ofmedical students. General Medical Council (GMC).2013. https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/identifying-best-practice-in-the-selection-of-medical-students. Accessed22Apr2019.

59. MacKenzieRK,DowellJ,AyansinaD,ClelandJA.Doperson-ality traits assessed on medical school admission predictexit performance? A UK-wide longitudinal cohort study.AdvHealthSciEduc. 2017;22:365–85.

60. HeckerK,NormanG.Haveadmissionscommitteesconsid-eredall theevidence? AdvHealthSciEduc. 2017;22:573.

61. Wilkinson TJ, McKenzie JM, Ali AN, Rudland J, Carter FA,Bell CJ. Identifying medical students at risk of underper-formance from significant stressors. BMC Med Educ.2016;16:43.

62. Frank JR, Snell L, Englander R,HolmboeES. Implementingcompetency-based medical education: moving forward.MedTeach. 2017;39:568–73.

63. GruppenLD,BurkhardtJC,FitzgeraldJT,etal. Competency-based education: programme design and challenges toimplementation.MedEduc. 2016;50:532–9.

64. FrankJR,DanoffD.TheCanMEDSinitiative: implementinganoutcomes-basedframeworkofphysiciancompetencies.MedTeach. 2007;29:642–7.

65. Holmboe ES, Edgar L, Hamstra S. The Milestones Guide-book. Chicago: ACGME;2016.

66. LarsenDP,ButlerAC,RoedigerHLIII.Test-enhancedlearn-inginmedicaleducation.MedEduc. 2008;42:959–66.

67. Larsen DP, Butler AC, Roediger HL III. Repeated testingimproves long-term retention relative to repeated study:arandomisedcontrolledtrial.MedEduc. 2009;43:1174–81.

68. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Will-ingham DT. Improving students’ learning with effectivelearning techniques: promising directions from cognitiveand educational psychology. Psychol Sci Public Interest.2013;14:4–58.

69. Bangert-Drowns RL, Kulik JA, Kulik CL. Effects of frequentclassroomtesting. JEducRes. 1991;85:89–99.

70. Roediger HL III, Karpicke JD. Test-enhanced learning: tak-ing memory tests improves long-term retention. PsycholSci. 2006;17:249–55.

71. Platt MP, Davis EM, Grundfast K, Grillone G. Early de-tection of factual knowledge deficiency and remediationin otolaryngology residency education. Laryngoscope.2014;124:E309–E11.

72. HaysRB,LawsonM,GrayC.Problemspresentedbymedicalstudents seeking support: a possible intervention frame-work.MedTeach. 2011;33:161–4.

73. Hauer KE, Lucey CR. Core clerkshipgrading: the illusionofobjectivity. AcadMed. 2019;94:469–72.

74. Krasner MS, Epstein RM, Beckman H, et al. Associationof an educational program in mindful communicationwith burnout, empathy, and attitudes among primary carephysicians. JAMA.2009;302:1284–93.

75. Dyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D,Wolanskyj AP. The impact of a required longitudinal stressmanagement and resilience training course for first-yearmedicalstudents. JGenInternMed. 2017;32:1309–14.

76. Chou CL, Johnston CB, Singh B, et al. A ‘safe space’ forlearning and reflection: one school’s design for continuitywith a peer group across clinical clerkships. Acad Med.2011;86:1560–5.

77. BearmanM,MolloyE,AjjawiR,KeatingJ. ‘Is thereaPlanB?’:clinicaleducatorssupportingunderperformingstudentsinpracticesettings. TeachHighEduc. 2013;18:531–44.


https://doi.org/10.1097/ACM.0000000000002905

https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/identifying-best-practice-in-the-selection-of-medical-students




Guidelines

78. Yellin PB. Learning differences and medical education.In: Kalet A, Chou CL, editors. Remediation in medicaleducation: a mid-course correction. Heidelberg, Berlin,NewYork: Springer;2014.

79. Cox SM. ‘Forward feeding’ about students’ progress: in-formation on struggling medical students should not beshared among clerkshipdirectors orwith students’ currentteachers. AcadMed. 2008;83:801.

80. Cleary L. ‘Forward feeding’ about students’ progress: thecase for longitudinal, progressive, and shared assessmentofmedicalstudents. AcadMed. 2008;83:800.

81. Cohen GS, Blumberg P. Investigating whether teachersshouldbe given assessments of studentsmade by previousteachers. AcadMed. 1991;66:288–9.

82. Pangaro L. ‘Forward feeding’ about students’ progress:more information will enable better policy. Acad Med.2008;83:802–3.

83. Warm EJ, Englander R, Pereira A, Barach P. Improvinglearner handovers in medical education. Acad Med.2017;92:927–31.

84. Ziring D, Danoff D, Grosseman S, et al. How do medicalschools identify and remediate professionalism lapses inmedical students? A study of US and Canadian medicalschools. AcadMed. 2015;90:913–20.

85. Rinehart-Thompson LA. Amendments to FERPA regula-tions. JAHIMA.2009;80:56.

86. Graham R, Hall R, Gilmer WG. Connecting the dots . . . :information sharing by post-secondary educational insti-tutions under the Family Education Rights and Privacy Act(FERPA).EducLaw. 2008;20:301–16.

87. Schulze LN Jr.. Balancing law student privacy interestsand progressivepedagogy: dispelling themyth that FERPAprohibits cutting-edge academic support methodologies.WidenerLawJ.2009;19:215.

88. Humphrey-Murto S, LeBlanc A, TouchieC, et al. The influ-enceofpriorperformanceinformationonratingsofcurrentperformance and implications for learner handover: ascoping review. Acad Med. 2019;94:1050–7. https://doi.org/10.1097/ACM.0000000000002731.

89. HuberVL.Comparisonof theeffectsof specificandgeneralperformance standards on performance appraisal deci-sions.DecisSci. 1989;20:545–57.

90. Price JA. Sharing student background information withfaculty: does it make a difference? Dissertation, HarvardUniversity;2012.

91. DudekNL,MarksMB,RegehrG.Failure to fail: theperspec-tivesofclinicalsupervisors. AcadMed. 2005;80:S84–S7.

92. SaxenaV,O’SullivanPS,TeheraniA, IrbyDM,HauerKE.Re-mediation techniques for student performance problemsafteracomprehensiveclinicalskillsassessment. AcadMed.2009;4:669–76.

93. Winston KA, Van Der Vleuten CPM, Scherpbier AJJA. Therole of the teacher in remediating at-riskmedical students.MedTeach. 2012;34:e732–e42.

94. Mak-van der Vossen MC, de la Croix A, Teherani A, vanMookWN,CroisetG,KusurkarRA.Aroadmapforattendingto medical students’ professionalism lapses. Acad Med.2019;94:570–8.

95. O’Neill LD, Norberg K, Thomsen M, et al. Residents indifficulty—just slower learners? Acase-control study. BMCMedEduc. 2014;14:1047.

96. Klamen DL, Williams RG. The efficacy of a targeted reme-diation process for students who fail standardized patientexaminations. TeachLearnMed. 2011;23:3–11.

97. Kalet A, Zabar S. Preparing to conduct remediation. In:Kalet A, Chou CL, editors. Remediation in medical edu-

cation: a mid-course correction. Heidelberg, Berlin, NewYork: Springer;2014.

98. KebaetseMB,WinstonK.Physicianremediation: acceptingandworkingwithcomplementaryconceptualisations.MedEduc. 2019;53:210–1.

99. Patel R, Tarrant C, Bonas S, Yates J, Sandars J. The strug-gling student: a thematic analysis from the self-regulatedlearningperspective.MedEduc. 2015;49:417–26.

100. Bellini LM, Kalet A, Englander R. Providing compassion-ate off-ramps for medical students is a moral imperative.Acad Med. 2019;94:656–8. https://doi.org/10.1097/ACM.0000000000002568.

101. Aagaard EM, Moscoso L. Practical implications of com-passionate off-ramps for medical students. Acad Med.2019;94:619–22.

102. Winston KA, Van Der Vleuten CPM, Scherpbier AJJA. At-risk medical students: implications of students’ voicefor the theory and practice of remediation. Med Educ.2010;44:1038–47.

103. Zbieranowski I, Takahashi SG, Verma S, Spadafora SM.Remediation of residents in difficulty: a retrospective 10-year review of the experience of a postgraduate board ofexaminers. AcadMed. 2013;88:111–6.

104. Kogan JR, Hatala R, Hauer KE, Holmboe E. Guidelines:the do’s, don’ts and don’t knows of direct observation ofclinical skills in medical education. Perspect Med Educ.2017;6:286–305.

105. Stegers-JagerK,Cohen-SchotanusJ,ThemmenA.Theeffectof a short integrated study skills programme for first-yearmedical studentsat riskof failure: a randomisedcontrolledtrial.MedTeach. 2013;35:120–6.

106. TanilonJ,VedderP,SegersM,TillemaH.Incrementalvalidityof a performance-based test over and above conventionalacademicpredictors. LearnIndividDiffer. 2011;21:223–6.

107. WinstonKA,VanDerVleutenCPM,ScherpbierAJJA.Predic-tionandpreventionof failure: anearly interventiontoassistat-riskmedicalstudents.MedTeach. 2014;36:25–31.

108. Yates J. Development of a ‘toolkit’ to identify medicalstudents at risk of failure to thrive on the course: anexploratory retrospective case study. BMC Med Educ.2011;11:95.

109. Shaban S, McLean M. Predicting performance at medicalschool: can we identify at-risk students? Adv Med EducPract. 2011;2:139.

110. Chang A, Boscardin C, Chou CL, Loeser H, Hauer KE.Predicting failing performance on a standardized patientclinicalperformanceexamination: the importanceofcom-munication and professionalism skills deficits. AcadMed.2009;84:S101–S4.

111. Hemann BA, Durning SJ, Kelly W, Dong T, Pangaro LN,Hemmer PA. Referral for competency committee reviewfor poor performanceon the internalmedicine clerkship isassociatedwith poor performance in internship. MilMed.2015;180:71–6.

112. Papadakis MA, Teherani A, BanachMA, et al. Disciplinaryaction by medical boards and prior behavior in medicalschool. NEngl JMed. 2005;353:2673–82.

113. BurnsCA, LambrosMA, AtkinsonHH, Russell G, FitchMT.Preclinical medical student observations associated withlaterprofessionalismconcerns.MedTeach. 2017;39:38–43.

114. Haight SJ, Chibnall JT, SchindlerDL, Slavin SJ. Associationsofmedicalstudentpersonalityandhealth/wellnesscharac-teristics with their medical school performance across thecurriculum. AcadMed. 2012;87:476–85.

115. Griffin B, Wilson IG. Faking good: self-enhancement inmedicalschoolapplicants.MedEduc. 2012;46:485–90.


https://doi.org/10.1097/ACM.0000000000002731

https://doi.org/10.1097/ACM.0000000000002731

https://doi.org/10.1097/ACM.0000000000002568

https://doi.org/10.1097/ACM.0000000000002568

Guidelines

116. Hodgson CS, Teherani A, Gough HG, Bradley P, Pa-padakis MA. The relationship between measures ofunprofessionalbehaviorduringmedicalschoolandindiceson the California Psychological Inventory. Acad Med.2007;82:S4–S7.

117. Barrett A, GalvinR, Steinert Y, et al. A BEME (Best EvidenceinMedicalEducation)reviewoftheuseofworkplace-basedassessment in identifying and remediating underperfor-manceamongpostgraduatemedical trainees: BEMEGuideNo. 43.MedTeach. 2016;38:1188–98.

118. BoileauE, St-OngeC,AudétatMC. Is thereaway for clinicalteachers to assist struggling learners? A synthetic reviewoftheliterature. AdvMedEducPract. 2017;8:89.

119. van der Vleuten CP, Schuwirth LW, Driessen EW, et al. Amodel for programmatic assessment fit for purpose. MedTeach. 2012;34:205–14.

120. Masters DE, O’Brien BC, Chou CL. The third-year medicalstudent ‘grapevine’: managing transitions between third-year clerkships using peer-to-peer handoffs. Acad Med.2013;88:1534–8.

121. Berger JT.Moraldistress inmedical educationandtraining.JGenInternMed. 2014;29:395–8.

122. Frost HD, Regehr G. ‘I am a doctor’: negotiating thediscourses of standardization anddiversity in professionalidentityconstruction. AcadMed. 2013;88:1570–7.

123. Steinert Y, Levitt C. Working with the “problem” resident:Guidelines for definition and intervention. Fam Med.1993;25:627–32.

124. DyrbyeLN,MassieFS,EackerA,etal. Relationshipbetweenburnoutandprofessional conductandattitudesamongUSmedicalstudents. JAMA.2010;304:1173–80.

125. Dyrbye L, Shanafelt T. A narrative review on burnout ex-perienced by medical students and residents. Med Educ.2016;50:132–49.

126. Grainger B, Yielder J, Reid P, BaggW. Predictors of medicalstudent remediation and their underlying causes: earlylessons from a curriculum change in the University ofAucklandMedicalProgramme.NZMedJ.2017;130:73–82.

127. Wheeler DJ, Zapata J, Davis D, Chou C. Twelve tips forresponding to microaggressions and overt discrimina-tion: when the patient offends the learner. Med Teach.2019;41:1112–7. https://doi.org/10.1080/0142159X.2018.1506097.

128. Woolf K, Potts HW, McManus IC. Ethnicity and academicperformance in UK trained doctors andmedical students:systematicreviewandmeta-analysis. BMJ.2011;342:d901.

129. Dyrbye LN, Thomas MR, Power DV, et al. Burnout andseriousthoughtsofdroppingoutofmedicalschool: amulti-institutionalstudy. AcadMed. 2010;85:94–102.

130. Curtis E, Wikaire E, Kool B, et al. What helps and hindersindigenous student success in higher education healthprogrammes: a qualitative study using the critical incidenttechnique.HighEducResDev. 2015;34:486–500.

131. SteeleCM,Aronson J. Stereotype threatandthe intellectualtest performanceof AfricanAmericans. J Pers Soc Psychol.1995;69:797.

132. BrondoloE, Jean-PierreKL. ‘YouSaid, IHeard’: speakingthesubtext in interracial conversations. In: Kalet A, Chou CL,editors. Remediation inmedical education: a mid-coursecorrection.Heidelberg,Berlin,NewYork: Springer;2014.

133. Kruger J, Dunning D. Unskilled and unaware of it: howdifficulties in recognizing one’s own incompetencelead to inflated self-assessments. J Pers Soc Psychol.1999;77:1121–34.

134. Devoe P, Niles C, Andrews N, et al. Lessons learned fromastudy-grouppilotprogramformedicalstudentsperceivedtobe‘atrisk’.MedTeach. 2007;29:e37–e40.

135. Coelho C, Zahra D, Ali K, Tredwin C. To accept or declineacademic remediation: whatdifferencedoes itmake? MedTeach. 2019;41:824–9. https://doi.org/10.1080/0142159X.2019.1585789.

136. Leggett H, Sandars J, Burns P. Helping students to improvetheir academic performance: A pilot study of a workbookwithself-monitoringexercises.MedTeach. 2012;34:751–3.

137. Alexander R, Badenhorst E, Gibbs T. Intervention pro-gramme: a supported learning programme for education-allydisadvantagedstudents.MedTeach. 2005;27:66–70.

138. Gray CP, Toms N. A holistic remediation intervention forstruggling undergraduate medical students affords sus-tainedprogress testperformancerecovery. MedEdPublish.2018;https://doi.org/10.15694/mep.2018.0000210.1.

139. Muraskin L. “Best Practices” in student support services:a study of five exemplary sites. 1997. US Department ofEducation.

140. Sayer M, Chaput de Saintonge M, Evans D, Wood D. Sup-port for students with academic difficulties. Med Educ.2002;36:643–50.

141. HaysRB.Remediationandre-assessmentinundergraduatemedicalschoolexaminations.MedTeach. 2012;34:91–2.

142. Whitehead D. Do we give them a fair chance? Attritionamong first year tertiary students. J Furth High Educ.2012;36:383–402.

143. Stegers-Jager KM, Cohen-Schotanus J, Themmen AP. Mo-tivation, learning strategies, participation and medicalschoolperformance.MedEduc. 2012;46:678–88.

144. Todres M, Tsimtsiou Z, Sidhu K, Stephenson A, Jones R.Medical students’ perceptions of the factors influencingtheir academic performance: an exploratory interviewstudywith high-achieving and re-sittingmedical students.MedTeach. 2012;34:e325–e31.

145. Durning SJ, Cleary TJ, Sandars J, Hemmer P, Kokotailo P,Artino AR. Viewing ‘strugglers’ through a different lens:howa self-regulated learningperspective canhelpmedicaleducators with assessment and remediation. Acad Med.2011;86:488:r95.

146. Bierer SB, Dannefer EF, Tetzlaff JE. Time to loosen theapron strings: cohort-based evaluation of a learner-drivenremediation model at one medical school. J Gen InternMed. 2015;30:1339–43.

147. HicksonGB,PichertJW,WebbLE,GabbeSG.Acomplemen-tary approach to promoting professionalism: identifying,measuring,andaddressingunprofessionalbehaviors. AcadMed. 2007;82:1040–8.

148. Gill AC, Nelson EA, Mian AI, Raphael JL, Rowley DR,Mcguire AL. Responding to moderate breaches in pro-fessionalism: an intervention for medical students. MedTeach. 2015;37:136–9.

149. Cullen MJ, Konia MR, Borman-Shoap EC, et al. Notall unprofessional behaviors are equal: the creation ofachecklistofbadbehaviors.MedTeach. 2017;39:85–91.

150. DeweyJ.Howwethink. Lexington:DCHeathandCo;1910.151. Mercer N. Words & minds: how we use language to think

together. London: Routledge;2000.152. Volet S, Vauras M, Salonen P. Self- and social regulation in

learningcontexts: anintegrativeperspective. EducPsychol.2009;44:215–26.

153. WinstonKA,VanDerVleutenCPM,ScherpbierAJJA.Reme-diation of at-riskmedical students: theory in action. BMCMedEduc. 2013;13:132.

154. Hmelo-Silver CE, Barrows HS. Facilitating collaborativeknowledgebuilding. CognInstr. 2008;26:48–94.

155. StoyanovaN,KennedyD.Betweenchaosandentropy: com-munity of inquiry froma systems perspective. Complicity.2010;7:1–15.


https://doi.org/10.1080/0142159X.2018.1506097

https://doi.org/10.1080/0142159X.2018.1506097

https://doi.org/10.1080/0142159X.2019.1585789

https://doi.org/10.1080/0142159X.2019.1585789

https://doi.org/10.15694/mep.2018.0000210.1

Guidelines

156. Tai JH, Canny BJ, Haines TP, Molloy EK. Identifying op-portunities for peer learning: an observational study ofmedical studentsonclinicalplacements. TeachLearnMed.2017;29:13–24.

157. Brydges R, Dubrowski A, Regehr G. A new concept ofunsupervised learning: directedself-guided learning in thehealthprofessions. AcadMed. 2010;85:S49–S55.

158. Topping K, Ehly S. Peer assisted learning. Mahwah: Erl-baum;1998.

159. Guerrasio J, Cumbler E, Trosterman A, Wald H, Bran-denburg S, Aagaard E. Determining need for remediationthrough post-rotation evaluations. J Grad Med Educ.2012;4:47–51.

160. Patterson F, Knight A, Dowell J, Nicholson S, Cousans F,Cleland J. How effective are selection methods in medicaleducation? Asystematicreview.MedEduc. 2016;50:36–60.

161. Donnon T, Paolucci EO, Violato C. The predictive validityof the MCAT for medical school performance and medi-cal board licensing examinations: a meta-analysis of thepublishedresearch. AcadMed. 2007;82:100–6.

162. CallahanCA,HojatM,VeloskiJ,ErdmannJB,GonellaJS.Thepredictive validity of three versionsof theMCAT in relationtoperformance inmedical school, residency, and licensingexaminations: a longitudinal studyof36classesof JeffersonMedicalCollege. AcadMed. 2010;85:980–7.

163. McGrath B, McQuail D. Decelerated medical education.MedTeach. 2004;26:510–3.

164. Bok HG, Teunissen PW, Favier RP, et al. Programmatic as-sessment of competency-based workplace learning: whentheorymeetspractice. BMCMedEduc. 2013;13:123.

165. Cleland JA, Milne A, Sinclair HK, Lee AJ. Predicting per-formance cohort study: is performance on early MBChBassessmentspredictiveof laterundergraduategrades? MedEduc. 2008;42:676–83.

166. Cohen DM, Clinchot DM, Werman HA. A framework foranalysis of sentinel events in medical student education.AcadMed. 2013;88:1680–4.

167. McLaughlin K. Navigating in the fog of medical schooladmissionsdata. AdvHealthSciEduc. 2012;17:627–9.

168. Kirschner PA, van Merriënboer JJ. Do learners really knowbest? Urban legends in education. Educ Psychol.2013;48:169–83.

169. Pashler H, McDaniel M, Rohrer D, Bjork R. Learningstyles: concepts and evidence. Psychol Sci Public Interest.2008;9:105–19.

170. Araujo AM, Leite C, Costa P, Costa MJ. Early identifica-tion of first-year students at risk of dropping out of high-school entry medical school: the usefulness of teachers’ratings of class participation. Adv Health Sci Educ TheoryPract. 2019;24:251–68. https://doi.org/10.1007/s10459-018-9863-9.

171. KlamenDL,BorgiaPT.Canstudents’scoresonpreclerkshipclinical performance examinations predict that they willfail a senior clinical performance examination? AcadMed.2011;86:516–20.

172. GreenburgDL,DurningSJ,CohenDL,CruessD, Jackson JL.Identifying medical students likely to exhibit poor profes-sionalism and knowledge during internship. J Gen InternMed. 2007;22:1711–7.


https://doi.org/10.1007/s10459-018-9863-9

https://doi.org/10.1007/s10459-018-9863-9

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Guidelines: The dos, don'ts and don't knows of remediation in