Students’ Academic Performance Remediation Techniques for Student Performance Problems After a Comprehensive Clinical Skills Assessment Varun Saxena, MD, Patricia S. O’Sullivan, EdD, Arianne Teherani, PhD, David M. Irby, PhD, and Karen E. Hauer, MD Abstract Purpose Poor performance on a medical school comprehensive clinical skills assessment after core clerkships requires remediation. Little is known about techniques used to remedy students’ skills deficits and their effectiveness. The authors identified remediation strategies used at U.S. medical schools and determined instructors’ confidence in remediation. Method In the fall of 2007, the authors surveyed persons responsible for remediation at U.S. medical schools that conduct comprehensive clinical assessments and remediation. Respondents reported their use of four types of remediation strategies: (1) clinical activities, (2) independent study, (3) precepted video review of exam recording, and (4) organized group activities for deficits in history-taking, physical examination, knowledge, clinical reasoning, professionalism, and communication. The authors assessed confidence in remediation for the six skill areas and analyzed these measures using repeated- measures analysis of variance. Results Fifty-three of 71 (74.6%) participants responded. Educators most commonly employ the precepted video review remediation activity across the six skill areas, and they use the clinical activities least commonly. Confidence in remediating the six skill areas was below the “agree” level. Confidence was highest for remediating history-taking and physical examination problems and lowest for professionalism. Conclusion Educators express modest confidence in remediating fourth-year students’ clinical skills deficiencies. The finding that schools employ primarily video review for remediation suggests a potential need to augment opportunities for mentored skills practice to address deficits more effectively. The remediation literature similarly stresses the importance of multiple approaches tailored to particular deficits. Acad Med. 2009; 84:669–676. Medical schools strive to ensure that students achieve clinical skills competence. Unfortunately, faculty members rarely observe students’ clinical skills during clerkships or employ evaluation methods that specifically assess students’ achievement of clinical skills. 1–3 In addition, evaluating clinicians lack confidence in their ability to identify incompetent students or feel reluctant to fail poorly performing students. 4,5 To help assess clinical competence, most U.S. medical schools now administer a comprehensive clinical skills assessment using standardized patients (SPs). 6 Multiple studies have confirmed the validity of comprehensive assessment scores in assessing students’ clinical competence and have even shown that these scores correlate with subsequent performance during internship and further training. 7–11 Students failing any part of the comprehensive assessment should receive remediation to improve their failing performance. Failing students manifest problems in either cognitive skills (history-taking, physical examination, clinical knowledge, and clinical reasoning), noncognitive skills (professionalism and communication), or both. 12 Although small, single- institution studies have reported strategies designed to remediate deficits in the cognitive and noncognitive domains, 13–17 approaches to remediation vary widely. 13–18 To our knowledge, no studies identify optimal remediation strategies, nor are there guidelines regarding how to remediate a particular skill deficit. Educators are thus left to select remediation strategies on an ad hoc basis. However, certain skill areas may be particularly challenging to remediate. A growing body of evidence suggests that remediating noncognitive problems is more challenging and less effective than remediation of cognitive problems. 19 –21 This study explores the strategies educators use to remediate medical students after a comprehensive clinical skills assessment. We sought to describe how educators verify comprehensive assessment scores, who identifies failing students’ needed area (or areas) of remediation, which remediation activities they employ, and the relationship between strategies selected and deficits identified. We also examined educators’ Dr. Saxena is a first-year medical resident, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. O’Sullivan is professor and director for educational research and faculty development, Office of Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. Teherani is assistant professor of medicine and director of program assessment, Office of Medical Education, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. Irby is vice dean for education and professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. Hauer is professor of medicine, director of internal medicine clerkships, and Gold Headed Cane Endowed Chair in Medical Education, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Correspondence should be addressed to Dr. Hauer, University of California, San Francisco, 533 Parnassus Ave, U137, Box 0131, San Francisco, CA 94143-0131; telephone: (415) 476-1964; fax: (415) 502-7544; e-mail: (khauer@medicine.ucsf.edu). Academic Medicine, Vol. 84, No. 5 / May 2009 669