Seventeen Building Blocks Could Finally Fix How Medicine Handles Struggling Trainees

When a surgeon-in-training begins to falter, the stakes could hardly be higher. The trainee’s career hangs in the balance, patients’ safety is on the line, and the institution responsible for both must navigate a process that, according to a new review, remains strikingly haphazard across the medical profession. A team of Australian researchers has now distilled decades of scattered literature into a single, structured blueprint for how postgraduate medical training programs should identify, support, and remediate underperforming trainees. The work, published in Global Surgical Education, the journal of the Association for Surgical Education, identifies seventeen core components organized into three overlapping phases, offering institutions something they have largely lacked: an evidence-informed scaffold for one of medicine’s most delicate tasks.

The scale of the problem the review addresses is considerable. Despite repeated calls for a programmatic approach to remediation, practices across training programs remain highly variable, and up to half of relevant institutions have no written remediation policy at all. The reasons for this institutional reluctance are revealing. Many training bodies avoid documenting remediation policies because they fear legal challenges from trainees, which helps explain why reforms have historically focused on due process rather than educational principles. The evidence base itself has been thin, with limited outcome data proving the benefits of specific interventions, and most proposed frameworks resting on commentary and literature reviews rather than empirical testing.

Led by Kathryn McLeod, a surgeon and researcher affiliated with University Hospital Geelong, Deakin University, and the University of Melbourne, the team chose a narrative review format precisely because the existing data were so diverse and methodologically inconsistent that meaningful statistical comparison was impossible. Working with a specialist research librarian, they searched Medline, Embase, PubMed, and Google Scholar in July 2025, using a combination of MeSH and natural language terms, supplemented by hand searching of reference lists. From 519 papers screened, 54 made the final analysis: 28 commentaries, 12 reviews, 7 survey studies, 3 qualitative studies, 2 case studies or series, and 2 retrospective cohort studies. The team analyzed the material using reflexive thematic analysis, iteratively building a codebook of components and re-reading earlier papers as new codes emerged, until consensus was reached on definitions and their consistent application.

The seventeen components the researchers identified fall into three overarching phases: assess and support, plan and implement, and evaluate and follow-up. Crucially, the authors stress that these phases are not discrete boxes on a checklist but an iterative, dynamic cycle. Elements of assessment and support often persist throughout the entire process, planning evolves in response to ongoing trainee development, and evaluation is not a terminal stage but a continuous loop that feeds back into earlier stages of assessment and intervention. This temporal framing reflects a growing recognition in medical education that remediation is not an event but a sustained relationship between a struggling learner and a responsive system.

The first phase begins with what the authors call ensuring an accurate diagnosis of underperformance, a step they describe as critical because it underpins the success of everything that follows. Without a clear understanding of why a trainee is struggling, remediation risks being misaligned with the actual cause. The recommended approach involves mapping performance against established competency frameworks such as CanMEDS or the standards of the General Medical Council, sampling assessment data from multiple sources including workplace-based assessments, logbooks, and supervisor reports, and convening round-table discussions with supervisors, trainers, and program directors. These multi-perspective discussions reduce the risk of bias and enable earlier identification, since many trainers are more willing to voice concerns verbally to a program director than to issue formal documentation at a lower threshold.

Equally important in the first phase is the human dimension. Many trainees are not fully aware they are underperforming, or they underestimate the severity and scope of their difficulties, so clear, honest, specific feedback illustrated with concrete examples is essential. The review emphasizes empathetic, two-way feedback conversations that focus on behaviors rather than personal traits, noting that constructive, actionable feedback can increase motivation, restore confidence, and foster a growth mindset. Trainees report feeling unheard when feedback is delivered at them rather than with them, and if a trainee disagrees with the description of their underperformance, the designated intervention will usually fail. The reviewers also urge programs to look beneath the surface: mental health conditions such as depression, anxiety, and burnout, disabilities including dyslexia and ADHD, and external stressors like addiction, financial problems, and bereavement can all impair performance, and professionalism is the competency most commonly affected among trainees with mental health conditions. Systemic causes, too, deserve scrutiny, since inadequate supervision, excessive workload, and poor organizational culture may drive difficulties that are too often framed as individual failings.

The second phase, plan and implement, shifts from understanding to action. The review recommends involving remediation and educational experts, noting that supervisors may lack the time and skills to manage underperformance appropriately and that centralized remediation programs have demonstrated better outcomes than individual training programs. Team-based approaches and communities of surgical educators supporting supervisors have been successfully implemented at institutional, regional, and national levels. Individualized remediation plans, developed collaboratively between trainees and educators wherever possible, build trust, encourage self-reflection, and foster shared responsibility, although plans created solely by experts may be necessary when a trainee lacks insight or when the process must begin urgently. Clear documentation is vital: plans should state the reasons for remediation, the steps to be taken, desired outcomes, time frames, and the consequences of failing to remediate, and should be distributed to all relevant parties including the trainee. Teaching goal setting, self-monitoring, and self-regulation rounds out this phase, fostering learner autonomy and sustained improvement, potentially supported by a mastery approach in which trainees achieve defined proficiencies before progressing to more complex material.

The third phase tackles the awkward realities of follow-up. Regular monitoring and reassessment allow early identification of ongoing barriers and timely adjustments, while improving transparency through honest discussions about progress. The reviewers highlight the delicate task of feeding forward: performance issues can persist despite successful short-term remediation, so sharing pertinent information with new supervisors, with the trainee’s knowledge and only with those who have a legitimate need to know, reduces the risk of recurrence without breeding prejudgment. Perhaps the most structurally significant recommendation is to separate those conducting remediation from those judging it. An effective educational alliance depends on trust and emotional support, which becomes impossible if the supervisor also holds progression decisions. Remediation is best delivered by educational experts, while outcome decisions rest with independent panels evaluating evidence against standards. The review also notes that decisions to terminate training are often overturned not because the decision was wrong but because due process was not followed, underscoring the need for well-defined, transparent policies with thorough documentation.

Two further components carry particular emotional weight. The authors call for actively destigmatizing remediation, recommending that programs flag the possible need for additional support during orientation, before any problem is apparent, and that institutions abandon labels like problem resident or difficult resident in favor of constructive language such as performance improvement plan or individual learning program. And when remediation fails despite everyone’s best efforts, the review insists on compassionate exit pathways: trainees who cannot meet required standards often feel guilt, loss of confidence, and fear of further decision-making, and they should receive career counseling, networking support, recognition of prior learning, and emotional help to transition into alternative paths better aligned with their strengths.

The authors are candid about the limitations of their work. Narrative reviews lack the rigor of systematic reviews, and with 28 of the 54 included papers being opinion pieces lacking evidence-based outcomes, they could not comment definitively on the effectiveness of specific components. The framework should therefore be read as a literature-informed synthesis of current thinking rather than a validated protocol, and the team highlights the need for further empirical research on the efficacy and optimal design of each component. Still, the value of the synthesis lies in its comprehensiveness and its practical orientation. By naming seventeen interlocking components and showing how they connect across three dynamic phases, the review gives institutions a concrete starting point for building frameworks that are transparent, grounded in sound educational theory, and adaptable to local contexts. With growing calls for standardization and half of institutions still operating without written policies, the message to the medical education community is unambiguous: remediation should no longer be improvised, and the blueprint for doing it properly now exists.

Subject of Research: Components of remediation frameworks for underperforming postgraduate medical trainees

Article Title: Components of postgraduate remediation frameworks: a narrative review

Article References: McLeod, K., Woodward-Kron, R., Rashid, P., & Nestel, D. (2026). Components of postgraduate remediation frameworks: a narrative review. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 132. https://doi.org/10.1007/s44186-026-00536-0

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00536-0

Keywords: medical education, remediation, postgraduate training, surgical education, underperformance, feedback, trainee support, due process, individualized learning plans, narrative review, competency frameworks, mental health