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review practical steps in recognizing and assessing underperforming residents,
making an educational formulation and developing a learner-centered remediation
plan. We will also discuss common concerns and practices regarding due process
and academic legal issues. Although the work of helping an underperforming resi-
dent succeed or exit the program falls to all educators, the information in this chap-
ter is specifically geared toward program directors.
Predicting Performance Problems
A program director, even with the benefit of hindsight, may well review a struggling
resident’s file only to find no warning signs of the difficulties to come. However,
some pre-matriculation predictors have been identified in the literature. The pres-
ence of even one negative comment in the Dean’s letter, failing one or more courses
during medical school, low USMLE scores, transferring in from another program,
and time lapse between medical school and residency have all been associated with
being placed on warning status or probation [ 7 , 8 , 14 – 16 ]. Guerrasio et al. [ 14 ] ret-
rospectively compared 102 trainees on probation across multiple specialties at one
institution. Those on probation were more likely than matched controls to have
transferred from another training program, to have taken time off between medical
school and residency, and to have scored lower on all three USMLE examinations.
They also found that being male, married, older, not Caucasian, or an international
medical graduate were all independently associated with being on probation, but not
associated with poorer graduation or board certification outcomes. Other studies
have found no association with underperformance and gender, age, marital status, or
being an international medical graduate [ 4 , 7 – 9 ]. Yaghoubian et al. [ 7 ] retrospec-
tively analyzed remediation and attrition across six general surgery programs over
11 years. They found a positive association between remediation and lower USMLE
Step 1 and 2 scores, as well as (ironically) having received honors in the third-year
surgery clerkship.
Post-matriculation, even in the absence of identified deficits on rotation evalua-
tions, low in-training examination performance has been associated with both reme-
diation and low board passage rates [ 14 , 17 , 18 ]. The presence of any complaint or
critical incident should also be taken seriously. Resnick et al. [ 8 ] retrospectively
reviewed all founded complaints against general surgery residents in one institution
over a 10-year span. The vast majority (83%) of complaints were for unprofessional
conduct toward perceived subordinates, and 80% of the complaints were filed
against 15% of the residents. A high number of complaints were associated with the
resident leaving the program prior to graduation. Twenty-six percent of all residents
received at least one complaint. A resident who received one complaint had a 55%
chance of receiving an additional complaint. In other words, a resident with one
complaint was twice as likely to receive another as a resident with no complaints.
K. Broquet and J.S. Padmore