Graduate Medical Education “Trainee in difficulty” current remediation practices and outcomes

  • Qi Yan
    Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, TX, USA

    South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, TX, USA
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  • Rebecca N. Treffalls
    University of the Incarnate World School of Medicine, San Antonio, TX, USA
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  • Taoran Li
    Department of Medicine, Icahn School of Medicine at Mount Sinai Morningside-West Hospital, New York, NY, USA
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  • Sanaa Prasla
    Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
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  • Mark G. Davies
    Corresponding author. Division of Vascular and Endovascular Surgery South Texas Center for Vascular Care, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC7741, San Antonio, TX, 78229, USA.
    Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, TX, USA

    South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, TX, USA
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Published:December 29, 2021DOI:


      • Significant heterogeneity existed for prevalence not explained by specialty.
      • Overall attrition in trainees in difficulty was 18%.
      • Trainees in difficulty had lower odds of board certification.
      • Attrition was not found to be different in trainees in difficulty.
      • Standardized criteria and better reporting of outcome is necessary.



      Trainees in difficulty require additional support to complete training program and become successful physicians. This study reviewed the current remediation practices and outcomes of trainees in difficulty.


      A PRISMA-based literature review was performed. Meta-analyses were performed using random effects model.


      30 studies met inclusion criteria. Sixteen studies surveyed program directors and 14 were observational. Prevalence and attrition of trainees in difficulty ranged widely from 2.0% to 30.7% and 0.0%–50.0%, respectively, with significant heterogeneity. Pooled odds of attrition was higher for trainees in difficulty, however, the confidence interval crossed one and there was statistically significant heterogeneity. Residents in difficulty were significantly less likely to become board certified (OR = 0.08, 95%-CI = 0.04–0.18; I2 = 0%, P = .70).


      Trainees in difficulty were less likely to be board certified but attrition rate did not differ. Future studies with standardized criteria for trainees in difficulty and better reporting of the outcomes can better guide our remediation practices.


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