287variance. Raters with the highest degree of trust provide the most accurate and least
lenient ratings [ 28 ]. Likewise, the resident’s level of trust that the assessment system
is fair and just strongly impacts a struggling resident’s willingness to accept feed-
back regarding their performance and progression in the program.
Despite active efforts to increase diversity in surgical training and a steady
increase in the number of women residents [ 44 ], representation in surgical programs
remains low for Asian-Americans (17%) and for African-Americans, Latin
Americans, and international medical graduates (about 5% each). The number of
minority surgical faculty, particularly in academic programs, remains even lower
[ 45 – 47 ]. An underperforming minority resident may experience some unique chal-
lenges in processing and navigating remediation. It’s not uncommon for minority
residents to enter training with a history of discriminatory experiences and may
perceive the overall assessment system as less fair as a result. Because of the relative
paucity of minority faculty, minority residents may have fewer opportunities for
role modeling or mentoring. And, even with the best of intentions, faculty and CCC
members may carry some level of stereotypical assumptions about minority train-
ees. Active steps to maintain and cultivate a positive learning environment that is
respectful and as free as possible of implicit bias can go a long way in mitigating
some of this. Most academic institutions have an official well versed in diversity
who can provide support and consultation to the minority resident, program direc-
tor, or both. Residents can be encouraged to bring an advocate or support person to
formal discussions of their remediation or progress in the program.
The Nonreflective Learner
Every resident wants to succeed, and the majority of residents who receive feedback
that their performance is not where it should be actively embrace recommendations
on how to improve it. However, learners come to us with varying levels of self-
reflection. Occasionally a program director will encounter a resident who lacks
insight into the presence, nature, or seriousness of the deficits. This is more common
when the deficits lie in domains with a higher level of assessment subjectivity, such
as clinical judgment or interpersonal skills, or when deficits are identified later in
training. A nonreflective resident will often selectively attend to positive feedback
or assessments in areas in which they are performing well and tune out information
about deficits. At the completion of training, the program director must certify that
the resident is an independent lifelong learner, and a resident who is very resistive
to feedback and unable to reflect upon performance does not meet this standard. In
an effort to be supportive, kindhearted supervisors may unwittingly reinforce this
pattern by giving frequent words of encouragement to the resident but less (or no)
ongoing feedback about the performance areas of concern. If supervisors are also
less than direct and honest on their written evaluations, it creates a greater disso-
nance between the resident’s and the program director’s assessment of performance.
This can be mitigated somewhat by following the assessment and feedback guide-
lines outlined earlier in the chapter. We cannot overemphasize the importance of
17 Optimizing Success for the Underperforming Resident