#KEYLIMEPODCAST 357: The Scarlet Letter R

Lara presents a study which looks to describe residents’ perspectives on peers who are struggling as well as their thoughts on the remediation processes within graduate medical education programs.

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KeyLIME Session 357

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Krzyaniak et. al., Unheard Voices: A Qualitative Study of Resident Perspectives on Remediation. J Grad Med Educ. 2021 Aug;13(4):507-514.


Lara Varpio (@LaraVarpio)


  • Remediation in Medical Education by Kalet & Chou define remediation as “the act of facilitating a correction for trainees who started out on the journey towards becoming a physician but have moved off course.”
  • We are in the business of education. We ask learners to hold a growth mindset. We ask them to always be pushing the edge of their competence. So they should be making mistakes.
  • So, when have they veered off course? How many mistakes are too many?
  • We better be clear on that because if we place someone “in remediation”, that means something socially. The remediated learner will, hopefully, go back into the learning context.
  • What social position did we just throw them into? What situation did we create by placing someone into remediation if they successfully remediate?


  • to elicit and describe resident perspectives on peers who are struggling and on GME remediation processes

Key Points on the Methods

  • Participants: residents from all specialties who were beyond PGY1
  • Exploratory study using focus groups for data collection to foster and capture discussion across many different perspectives on this topic – one that we really don’t understand from the residents’ perspectives
  • Participants were not asked about their own remediation experiences. Instead, they explored residents perspectives on peers who are struggling and on the remediation processes
  • The research team conducted 2 to 3 focus group discussions at each of 3 participating institutions.
  • Data analysis: framework analysis

Key Outcomes

4 major categories:

  1. Lack of transparency. Residents don’t know how they’re doing because they are not getting feedback: “no news is good news”. No transparency about the remediation process itself.
  2. Negative stigma. Remediation = BAD; a taboo topic; labeled a “dirty word” by participants. Residents don’t comment on peers’ performance because it would put a colleague in trouble / result in punishment. Those residents in remediation are socially isolated
  3. Overwhelming emotions. Residents feel guilt and anxiety if they recognize a peer is struggling. Residents are disincentivized from saying anything about struggling peers.
  4. Need for change. Residents want to understand the remediation process and they want to be involved in the process. Residents are often more aware of who is struggling than faculty.

Key Conclusions

Call for 4 areas of change:

  • Develop an educational culture where residents understand the educational process, their performance in that process, and the means of improving their performance if they are struggling.
  • Develop structured forums for peer feedback that empower residents—with training about how to engage in constructive feedback—to identify struggling learners
  • Create a more positive culture around remediation.
  • Normalize the struggle by reframing remediation using concepts like adaptive learning or learning zones.

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