Impact of a structured remediation program on academic performance of family medicine residents in difficulty: A training centre experience

Abstract

Background

Residents in difficulty represent a significant challenge in postgraduate medical education. Early, structured remediation may improve academic and clinical performance, yet regional evidence from family medicine training programs remains limited.

Objectives

To evaluate the impact of a structured remediation program on examination performance and clinical assessments of family medicine residents in difficulty, and to explore resident-perceived mechanisms contributing to improvement.

Methods

A mixed-methods study was conducted at a single accredited family medicine training center over three academic years (2022–2025). Quantitative analysis included a retrospective review of promotion examination scores and clinical assessment outcomes before and after participation in a standardized remediation program. Qualitative data were obtained through semi-structured interviews with participating residents and analyzed thematically. Wilcoxon signed-rank test, Stuart–Maxwell test, and multivariable linear regression were used to assess performance changes and predictors of post-course outcomes.

Results

Thirty-one first-year family medicine residents were included. Mean promotion examination scores improved significantly from 55.1 ± 2.4 pre-course to 79.0 ± 5.1 post-course (p < 0.0001). Clinical assessment outcomes improved from universal borderline or failing status to 100% pass rates (p = 0.0009). Perceived exam difficulty decreased significantly following remediation (p < 0.0001). Multivariable analysis showed that age, gender, and training sector were independently associated with post-course scores. Qualitative analysis identified five key themes underlying improvement: transformation of learning strategies, enhanced clinical exposure, mentorship support, feedback-driven reflection, and professional accountability.

Conclusion

A structured remediation program was associated with significant improvements in academic performance, clinical competence, and learner confidence among family medicine residents in difficulty. Early, supportive, and mentorship-driven remediation may represent an important component of postgraduate family medicine training.

Keywords

family medicine training program remediation program resident in difficulty

Introduction

Ensuring the development of competent and safe physicians is a central goal of postgraduate medical education. Residents in difficulty represent a significant challenge to training programs. Clinical educators must balance supporting struggling learners with maintaining clinical responsibilities, often within complex training environments.^1–3

Difficulties faced by medical residents on a daily basis may arise from challenges in understanding and applying medical knowledge in real-time patient care. These difficulties hinder performance and academic progression.^4,5 Internationally, approximately 10% of residents experience significant academic challenges, often requiring extended training.⁶ In Saudi Arabia, nearly 13% of family medicine residents do not achieve a passing score on board examinations, necessitating additional training time.⁷ Early identification of residents in difficulty is therefore critical to support their progression and ensure safe patient care.

Structured remediation programs—defined as formal, multi-component interventions with clear objectives, timelines, and reassessment strategies—are widely used to support underperforming trainees.⁸ Evidence suggests that such programs can lead to improvements in knowledge, clinical skills, and workplace performance, particularly when they incorporate individualized learning plans, mentorship, and repeated assessment.^9–11

The objective of this study was to evaluate the impact of a structured remediation program on academic performance and clinical outcomes among family medicine residents in difficulty. In addition, the study aimed to explore resident-perceived mechanisms contributing to improvement and to identify factors associated with post-remediation performance.

Material and methods

Study design and setting

This mixed-methods study was conducted at a single accredited family medicine training center over three academic years (2022–2025). This study followed a convergent mixed-methods design, where qualitative findings were used to complement and help interpret the quantitative results. It was conducted over a three-year period from September 2022 to February 2025 in accordance with the yearly remediation program. The study combined a retrospective quantitative analysis of academic performance with a qualitative exploration of residents’ experiences following participation in a structured remediation program.

Participants

The study included all first-year family medicine residents who were enrolled in the remediation program between the academic years 2022–2023, 2023–2024 and 2024–2025. Residents were identified and referred to the program based on predefined academic criteria, including suboptimal performance in promotion examinations, formative assessments, or faculty-identified concerns regarding academic progression.

All residents who were enrolled in the remediation program during the study period completed the program and had complete academic data; therefore, no participants were excluded from the analysis indicating complete program retention. A total of 31 residents were included. No formal sample size calculation was performed, as this study included all eligible residents enrolled in the remediation program during the study period.

Baseline demographic and training characteristics included age, gender, training sector, prior clinical experience, and year of enrollment.

Measures

Quantitative measures

The primary outcome was change in promotion examination scores before and after participation in the remediation program. Secondary outcomes included: Clinical assessment outcomes (pass, borderline, fail) and perceived examination difficulty (categorized into three levels: easy, moderate, difficult) Independent variables included: Age, Gender, Training sector, Previous clinical experience, Mentor characteristics and pre-course examination scores. Promotion examination scores were obtained from institutional academic records by the training program administration for the quantitative component. Clinical assessments were based on standardized faculty evaluations conducted during clinical rotations. Qualitative interviews were conducted by a member of the training program that was not directly involved in the assessment process following completion of the remediation program. Academic data were collected at two time points: prior to enrolment in the remediation program and immediately after program completion.

Qualitative interviews

Qualitative data were collected using semi-structured interviews conducted after completion of the remediation program. The interviews explored residents’ perceptions of the program and mechanisms contributing to improvement.

Participants were asked the following open-ended questions:

• “What were your expectations from the course?”

• “In your opinion, did the course meet those expectations?”

• “Do you think this course improved your performance? Why?”

Interviews lasted approximately 15–20 minutes and were audio-recorded with participant consent. Verbal informed consent was obtained from all participants prior to the interviews. Interviews were documented through written minutes, and no identifying information was recorded. Qualitative data were analyzed using thematic analysis. Coding was conducted by a single researcher, with themes iteratively developed from the data. To enhance analytical rigor, codes and themes were reviewed and refined through repeated examination of the data. Data collection continued until thematic saturation was achieved, which occurred toward the later stages of data collection, when no new themes or insights emerged from successive interviews.

Procedures

Residents meeting inclusion criteria were enrolled in a structured remediation program designed to address gaps in knowledge, clinical performance, and examination readiness.

The program consisted of:

• Weekly academic sessions focusing on high-yield topics aligned with the family medicine curriculum

• Assigned readings (including selected American Academy of Family Physicians materials)

• Monthly formative assessments using multiple-choice questions (MCQs)

• Regular one-on-one mentorship meetings with family medicine consultants

• Supervised clinical exposure and targeted feedback

The program duration ranged from 10 to 12 weeks and was conducted annually between September and January/February. Residents were required to maintain at least 80% attendance rates and achieve a minimum score of 70% on the final assessment. Qualitative interviews were conducted after completion of the program. Participation in interviews was voluntary, and residents were informed that their responses would be anonymized and used for research purposes.

Statistical analysis

Data were analyzed using R statistical software (RStudio, version 4.4.0). Descriptive statistics were presented as means ± standard deviations (SD) for normally distributed variables, medians and interquartile ranges (IQR) for non-normally distributed variables and frequencies and percentages for categorical variables. Normality of distribution was assessed using the Shapiro–Wilk test. Comparative analyses included paired t-test for normally distributed continuous variables, Wilcoxon signed-rank test for non-parametric paired data and Stuart–Maxwell test for paired categorical variables with more than two categories. Univariable and multivariable linear regression analyses were performed to identify predictors of post-course examination scores. Regression coefficients (β), 95% confidence intervals (CI), and p-values were reported. A p-value of <0.05 was considered statistically significant. Statistical tests were selected based on the type and distribution of the data. Parametric tests were used for normally distributed continuous variables, while non-parametric tests were applied when normality assumptions were not met. Categorical paired data were analyzed using appropriate tests for dependent samples.

Results

Thirty-one (31) participants were enrolled in the remedial course. Their age ranged from 28 to 35 years, with a mean ± SD of 30.77 ± 2.01 years and a median of 30 years. The majority were male (77.42%). Participants were from the Ministry of Health (38.71%), military sector (35.48%), and self-employed sector (25.81%). Most participants reported previous clinical experience (64.52%), with a duration ranging from 1 to 4 years (mean ± SD: 2.15 ± 1.04 years). All participants were at the R1 level of training. Enrolment in the remedial course occurred in 2022 (35.48%), 2023 (32.26%), and 2024 (32.26%). Additional course-related characteristics are presented in Table 1.

Table 1.

Baseline demographic, professional, and training characteristics of participants (N = 31).

Variable	N (%)/Value
Age (years)
Min–Max	28.00 – 35.00
Mean ± SD	30.77 ± 2.01
Median (IQR)	30.00 (29.00, 33.00)
Gender
Female	7 (22.58%)
Male	24 (77.42%)
Sector
Ministry of Health	12 (38.71%)
Military	11 (35.48%)
Self-employed	8 (25.81%)
Previous experience
Yes	20 (64.52%)
No	11 (35.48%)
Years of experience (if yes)
Min–Max	1.00 – 4.00
Mean ± SD	2.15 ± 1.04
Median (IQR)	2.00 (1.00, 3.00)
Training level
R1	31 (100%)
Year of enrollment
2022	11 (35.48%)
2023	10 (32.26%)
2024	10 (32.26%)
Mentor gender
Female consultant	18 (58.06%)
Male consultant	13 (41.94%)
Class average score
Min–Max	74.20 – 76.90
Mean ± SD	75.55 ± 1.13
Median (IQR)	75.70 (74.20, 76.90)
Perceived benefit from course
Yes	16 (51.61%)
No	15 (48.39%)

Using the Wilcoxon signed-rank test, promotion examination scores showed a significant improvement following the remediation program. Pre-test scores ranged from 51 to 59, with a mean ± SD of 55.10 ± 2.39, while post-test scores ranged from 71 to 79, with a significantly higher mean ± SD of 78.97 ± 5.13. This improvement was statistically significant (p < 0.0001), as shown in Table 2 and Figure 1.

Table 2.

Comparison between promotion exam scores pre- and post-remedial course.

Promotion exam score	Pre-test	Post-test	p-value
Min–Max	51.00 – 59.00	71.00 – 79.00	<0.0001*
Mean ± SD	55.10 ± 2.39	78.97 ± 5.13
Median (IQR)	55.00 (53.00, 57.00)	79.00 (75.00, 81.50)

*Wilcoxon signed-rank test.

*p < 0.05.

Figure 1.

Comparison between promotion exam score before and after remedial course.

Using the Stuart–Maxwell test, clinical assessment outcomes demonstrated a significant improvement after course completion. At the pre-test, 54.84% of participants were classified as borderline and 45.16% had failed, with no participants achieving a passing score. Post-test results showed that all participants (100%) achieved a passing score. Similarly, perceived exam difficulty improved significantly following the intervention. At baseline, all participants rated exam difficulty at the highest level (level 3), whereas post-course ratings shifted to level 1 (41.94%) and level 2 (58.06%), with no participants remaining at level 3. Both improvements were statistically significant (p = 0.0009 and p < 0.0001, respectively), as shown in Table 3 and Figures 2 and 3.

Table 3.

Comparison of clinical assessment and perceived exam difficulty pre- and post-remedial course.

Outcome	Category	Pre-test n (%)	Post-test n (%)	p-value
Clinical assessment	Pass	0 (0.0%)	31 (100.0%)	0.0009*
	Borderline	17 (54.84%)	0 (0.0%)
	Fail	14 (45.16%)	0 (0.0%)
Perceived difficulty	Level 1(easy)	0 (0.0%)	13 (41.94%)	<0.0001*
	Level 2 (moderate)	0 (0.0%)	18 (58.06%)
	Level 3 (hard)	31 (100.0%)	0 (0.0%)

*Stuart–Maxwell test.

*p < 0.05.

Figure 2.

Comparison between clinical assessment before and after remedial course.

Figure 3.

Comparison between perceived difficulty before and after remedial course.

In univariable analysis, none of the examined predictors showed a statistically significant association with post-course promotion exam scores. In the multivariable linear regression model, increasing age was significantly associated with lower post-course scores (β = −1.40, 95% CI: −2.46 to −0.34; p = 0.012). Male gender was associated with significantly higher post-course scores compared with females (β = 4.75, 95% CI: 0.66 to 8.84; p = 0.025). Participants from the Ministry of Health and self-employed sectors had significantly lower post-course scores compared with military participants (β = −5.11, p = 0.014 and β = −8.45, p = 0.009, respectively). Previous experience, mentor gender, and pre-course exam scores were not significantly associated with post-course performance after adjustment (Table 4).

Table 4.

Univariable and multivariable linear regression analysis of predictors of post-course promotion exam score.

Dependent: Promotion exam score post course		Coefficient (univariable) (95% CI-p-value)	Coefficient (multivariable) (95% CI-p-value)
Promotion exams score pre-course		0.76 (-0.01 to 1.52, p=0.052)	0.59 (-0.13 to 1.31, p=0.101)
Age in years		-0.72 (-1.65 to 0.21, p=0.125)	-1.40 (-2.46 to -0.34, p=0.012*)
Gender	Female	-	-
	Male	2.36 (-2.14 to 6.85, p=0.292)	4.75 (0.66 to 8.84, p=0.025*)
Sector	Military	-	-
	MOH	-2.66 (-7.00 to 1.68, p=0.220)	-5.11 (-9.07 to -1.15, p=0.014*)
	Self	-3.53 (-8.36 to 1.30, p=0.145)	-8.45 (-14.60 to -2.31, p=0.009*)
Previous experience	No	-	-
	Yes	-1.32 (-5.29 to 2.65, p=0.503)	-0.06 (-6.76 to 6.65, p=0.986)
Mentor	Female consultant	-	-
	Male consultant	0.72 (-3.16 to 4.59, p=0.707)	1.83 (-1.52 to 5.19, p=0.270)

Bold values indicate statistical significance at p < 0.05

Qualitative results

The qualitative analysis identified five key themes explaining improvements in academic performance and clinical outcomes following participation in the remediation program. These themes reflect changes in learning behavior, clinical engagement, mentorship experience, feedback utilization, and professional accountability.

Theme 1: Transformation of learning strategies

Residents described a shift from passive memorization to deeper, concept-based learning. Many attributed prior difficulties to unstructured study approaches, whereas the remediation program promoted more organized and effective strategies. As one participant noted: “Improvement came from understanding the topic itself rather than just memorizing exam questions.” Others emphasized the role of structured practice: “Regular review of MCQs significantly increased my chances of passing exams.” And “Allocating daily, organized study time made my preparation clearer and more effective.”

Theme 2: Enhanced clinical exposure and experiential learning

Residents highlighted the importance of increased clinical exposure under direct supervision in improving both clinical competence and academic performance. Active participation in patient care strengthened clinical reasoning and application of knowledge. Participants stated: “Seeing as many patients as possible helped me understand conditions better.” And “Commitment to clinic attendance made a clear difference in my performance.”

Theme 3: Importance of mentorship and consultant support

Structured mentorship and regular interactions with consultants were consistently identified as key facilitators of improvement. Residents valued guidance, prioritization of learning objectives, and emotional support. As reflected by participants: “Mentor meetings are very important during the training period.” And “Discussions with consultants helped clarify difficult topics, especially during stressful times.” Post-assessment discussions were also perceived as highly beneficial: “Discussing exams with consultants helped me understand my mistakes and improve.”

Theme 4: Feedback, reflection, and insight development

Residents emphasized the role of constructive feedback in promoting reflection and continuous improvement. Feedback was increasingly perceived as an opportunity for growth rather than criticism. One participant noted: “Feedback has a major impact on development and should be taken seriously.” Another added: “After each exam, it becomes a chance to understand errors and improve performance.”

Theme 5: Professional accountability and ownership of learning

A strong sense of personal responsibility emerged as a key driver of improvement. Residents recognized that active engagement, attendance, and commitment were essential for achieving better outcomes. Participants expressed: “Commitment to attendance and interaction reflects seriousness and affects performance.” And “Proving yourself through effort and results is essential.”

Overall, these themes provide insight into the mechanisms underlying the observed quantitative improvements. Changes in learning strategies, structured mentorship, reflective feedback, and increased accountability collectively contributed to enhanced academic and clinical performance.

Discussion

This study demonstrated that participation in a structured remediation program was associated with significant improvements in examination performance, clinical assessment outcomes, and perceived examination difficulty among family medicine residents in difficulty. All participants achieved passing clinical assessments following the intervention, and examination scores improved substantially. Qualitative findings provided insight into the mechanisms underlying these improvements, particularly the roles of mentorship, structured feedback, supervised clinical exposure, and increased learner accountability.^12–14

The magnitude and consistency of improvement across all cohorts, with an average increase exceeding 20 points in examination scores, suggests that structured and targeted remediation can produce meaningful educational gains. These findings are consistent with existing literature demonstrating that individualized, well-designed remediation strategies can improve academic performance among struggling trainees. In the context of family medicine, where workforce demands are high, timely remediation may also help reduce training delays and associated professional and psychological burden.^7,8

The observed reduction in perceived examination difficulty suggests that the benefits of remediation extend beyond objective performance to include improved learner confidence and reduced performance-related anxiety. Self-efficacy has been shown to play a central role in learning behavior, motivation, and resilience, and improvements in perceived competence may contribute to sustained academic progress beyond the immediate post-intervention period.^15,16

The alignment between improved clinical evaluation outcomes and qualitative findings suggests that supervised clinical exposure and active engagement in patient care may contribute to improvements in both clinical competence and academic performance. This is supported by literature indicating that experiential learning and deliberate practice are associated with improved performance across medical training contexts.^17,18

Mentorship and structured feedback emerged as central components of the remediation process. Residents consistently highlighted the value of post-assessment discussions and ongoing clinical supervision. The role of mentorship in supporting trainee development is well established in medical education, particularly in facilitating goal setting, performance improvement, and professional growth.^19–21

Resident accountability and active engagement emerged as important contributors to successful remediation. Participation, attendance, and preparation appeared to promote a sense of ownership over the learning process, supporting shared responsibility between residents, mentors, and program leadership. This may partly explain the observed improvements in both performance outcomes and learner perceptions.^21,22

All participants in this study were first-year residents, supporting the concept that early identification and timely remediation may be more effective than delayed intervention. Early support may help prevent the development of maladaptive learning behaviors and reduce the psychological burden associated with persistent underperformance.^23,24

Recommendations

1. Early identification of residents in difficulty is a priority to maximize on the benefits of remediation programs.

2. Structured, time-limited remediation programs with clear learning objectives, attendance requirements, and reassessment should be integrated into family medicine training programs

3. Mentorship and protected faculty time should be formally embedded into any training program and offered to all residents with special focus on underperformers

4. Building a culture of Feedback and normalizing it is crucial to the overall growth of residents, faculty and practice in general.

5. Individualized remediation pathways may be considered for residents with differing backgrounds or learning needs.

At a national level, these findings support investment in remediation as a quality assurance and patient safety strategy within postgraduate medical education.

Limitations

Several limitations should be considered when interpreting these findings. The study included a relatively small sample size without a priori sample size calculation, which may limit statistical power. The single-center design limits external validity and generalizability to other training settings. The absence of a control group restricts the ability to establish causal relationships between the intervention and observed outcomes. Additionally, qualitative findings may be influenced by social desirability bias. Outcomes were assessed in the short term, and long-term sustainability of improvement was not evaluated.

Conclusion

A structured remediation program was associated with significant improvements in academic performance, clinical competence, and learner confidence among family medicine residents in difficulty. Quantitative gains were reinforced by qualitative evidence of meaningful changes in learning behavior, mentorship engagement, feedback utilization, and professional accountability. Early, structured, and supportive remediation represents a powerful educational strategy to support struggling residents and should be considered an essential component of postgraduate family medicine training programs.

Footnotes

Acknowledgements

The author acknowledges the support of the family medicine training program and all individuals who contributed to the implementation of the remediation program.

ORCID iD

Malak A. Al Shammari

Ethical considerations

This study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IRB No. IRB-2025-01-0898) and conducted in accordance with the Declaration of Helsinki. For the retrospective component, the requirement for written informed consent was waived due to the use of de-identified data. For the qualitative component, verbal informed consent was obtained from all participants prior to the interviews. All procedures were conducted in accordance with institutional ethical guidelines.

Author contributions

The author contributed to data analysis, drafting and revising the article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon request.*

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