Vignette 1: Sally’s story
Towards a systems theory of remediation
A cultural dimension of failure arises from assumptions and beliefs regarding whether, when, and why individuals fail. This includes the thresholds between failure and normal variance in performance, what dimensions of suboptimal performance are more or less important, whether failure can and should be remediated, whether incidents of failure should be permanently recorded, and whether information about a struggling learner should be ‘fed forward’ or kept strictly confidential [ 33]. For a school to allow for any remediation at all reifies a collective belief that failure can be recovered from, and that there is a zone between passing and dismissal [ 33]. Mak-van der Vossen et al. have increased the willingness of medical school faculty to fail struggling students by enhancing their optimism about professionalism remediation with a systems-level intervention [ 34].
A cultural dimension of responsibility is shaped by assumptions and beliefs regarding the mission of the school, its function, its goals, its accountabilities, and the way remediation aligns with these domains. For example, how much do a program’s responsibilities to society, its profession, its faculty, their patients, and other stakeholders balance with its responsibilities to their learners (as reflected in remediation practice)? How does this prioritization affect the design and practice of remediation? Is it more important to exclude ‘bad apples’ or to help those who misstep to recover and complete the program? What are learners’ responsibilities in remediation? To what extent should schools target their resources on the redemption of a few or on the successes of the many?
Vignette 2: Vin’s story
Remediation principles and practices should align with the medical education systems where they are situated. Currently, remediation tends to be an ‘outside’ activity, undertaken under duress and often unwillingly by all participants. This can encourage ‘rogue’ behaviour that undermines the process and can further separate the individual process from societal or professional needs. For instance, naming explicit requirements for initiation of remediation can facilitate a quality improvement process that all stakeholders, including learners, can embrace. This principle of ‘constructive alignment’ [ 41] lowers rather than raises barriers to remediation and ensures that the focus is on improvement.
We must enable and support a continuum of remediation, ranging from individual improvements in day-to-day medical education, to highly structured episodes that may end with dismissal. As we have previously argued, the remediation continuum should encompass proportional management of different degrees and forms of remediation, including structure, equity, documentation, and closure [ 3].
Remediation should be reframed from a matter of punishment and stigma to a form of training that many, if not most, will need and benefit from at some point. If failed remediation processes necessitate dismissal from training, compassionate systems would have already considered providing viable alternative career pathways or debt forgiveness.
Optimally, institutions should develop a community of remediation practice, which contains the needed expertise. This should include all tutors, clinical preceptors, and supervisors who are able to recognize and refer learners who fall below a standard competence curve; a team of remediators, who use appreciative coaching techniques and the development of learning plans to support struggling learners and manage the remediation process; and an ultimate arbiter, represented by a program or course director, dean, etc., who consults with the other two groups to inform their final judgment about the outcomes of the remediation process.