Study: 31% of general surgery residents need remediation. Why?

A recent paper in Annals of Surgery depicts the rate of resident remediation over a decade or so at six general surgery programs in California. The authors reviewed the records of 348 categorical general surgery residents and found that 107 (31%) required mediation with knowledge deficits the primary reason in 74%. Other issues, such as interpersonal and communication skills, patient care and professionalism, were cited far less often.

Need for remediation did not correlate with attrition. Remediated residents left programs at a rate of 20% compared to 15% of non-remediated residents, p = 0.40.

On multivariate analysis, only two factors were associated with the need for remediation. One was USMLE Step 1 scores which were lower in the remediated group. But the median difference in scores between remediated and non-remediated residents was only 7 points with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.

The other factor was quite remarkable. Remediated residents were significantly more likely to have received a grade of "honors" for their medical school clerkship and surgery. How can this be?

The authors speculated, "One thought is that medical students start residency under-prepared for the rigors of surgical residency." Now where I heard that before? I have previously blogged (here) about the unrealistic third-year experiences of medical students on surgical rotations. While I agree that they likely are not ready for the workload, I'm not sure what it has to do with the primary reason for their poor performance—a perceived knowledge deficit. Does hard work cause them to forget everything they’ve learned or are they taught the wrong stuff in med school?

I think not. The real reason may be found in the way medical students are graded. A group from Harvard looked at medical school grading systems and found that honors grades in third-year surgery clerkships are given to an average of about 30% of students ranging from a low of 7% to an mind-boggling high of 67%. I understand that those accepted to med school are smart, but how is it that two-thirds of the class can achieve honors in surgery? Could it be that some of the honors grades given to residents who eventually needed remediation were not warranted?

If you would like to read more about this, you may read the full text of the paper on medical school grades here or a summary on my blog.