11th August 2017, Volume 130 Number 1460

Brian Grainger, Jill Yielder, Papaarangi Reid, Warwick Bagg

Selection to medical programmes is based largely on academic merit. Nevertheless, some medical students require academic remediation, which is described in our context as formal, planned opportunities for a student to either repeat an identified aspect of the curriculum or be offered formal assistance to demonstrate clear achievement of the required standard. The outcome of successful remediation for a student is progression towards graduation and ultimately the ability to work as a doctor. In our experience, academic staff are delighted when remediation is successful, but the process of remediation is a significant resource commitment.1

Between seven and 28% of doctors will require remedial assistance at some point in their career.1 Previous experience at the University of Auckland demonstrated that from 2009 to 2013, between two and 13% of students required remediation in their initial year of the medical programme and by the final year between 11 and 36% were still requiring some form of remedial attention or monitoring.

Academic performance early in medical school has been shown to correlate both with performance later in the programme2 and postgraduate ratings of clinical competence.3 Moreover, the decision to provide students with remediation within the medical programme both affirms the multi-faceted admission process developed through consultation with a number of stakeholders, and recognises the investment made by student, families and the New Zealand Government. This includes the Māori and Pacific Admission Scheme (MAPAS)—an equity-targeted admissions process established in 1971,4 which aims to develop a health workforce more reflective of the New Zealand society it aims to serve in accordance with the Treaty of Waitangi and the Australian Medical Council (AMC) standards on prioritising student diversity.5

Performance during medical school is strongly predicted by admission grade point average (GPA) on admission.6,7 However, explicit predictors of risk have not previously been examined, nor whether this effect is sustained at all levels. Little is known about the effectiveness of remediation, with a recent systematic review identifying that many interventional studies have been uncontrolled with small sample sizes and few long-term outcome measures.8

The attitudes and perspectives of educators and supervisors are crucial to the successful conduct of remediation. Previous qualitative research in this area has identified uncertainty about the efficacy of remediation, with educators citing concerns about a lack of standardisation, a paucity of robust post-remediation outcome data and even scepticism about whether remediation actually occurred.9 This uncertainty is important, as other work has demonstrated that clinical supervisors may be reluctant to fail underperforming students because of a concern over lack of remediation options10 or a lack of available time to sufficiently deliver it.8

This study aims to investigate what factors increase the likelihood of requiring remediation during the University of Auckland medical programme, as well as examining the perspectives of academic staff about the quality and effectiveness of the remediation work they are involved with.


Study context

The University of Auckland medical programme is a six-year undergraduate degree in which students are selected into Year 2 either from an initial overlapping health sciences general university year, or after completing another undergraduate degree, usually in a health sciences field. There are specific admission pathways targeted at widening participation for applicants with verifiable Māori or Pacific Island ancestry (MAPAS) (25% of admissions) and those who have completed their primary or secondary education in a non-urban area (Regional and Rural Admission Scheme; RRAS) (17% of admissions). These admission pathways seek to ensure the health workforce reflects the community in which they will practice. The medical programme also admits approximately 20 international students annually, equating to just over 7% of total student intake. Years 2 and 3 (Phase 1) are based on the University campus and consist of learning applied basic sciences, while Years 4 and 5 (Phase 2) and Year 6 (Phase 3) involve clinical placements at hospitals and general practice settings throughout the greater Auckland region and in regional centres in the upper North Island.

Phase directors and seven teaching hospital site coordinators work in conjunction with academic departments to oversee the progress of students. Other key staff involved when students require remediation are: Directors of Medical Student Affairs, academic staff who provide support regarding pastoral issues impacting on progress, MAPAS academic and professional staff, Clinical Medical Education Fellows (CMEFs), who are early postgraduate doctors employed by the faculty to provide tuition to students.

Programmatic assessment includes written examinations, observed structured clinical examinations (OSCEs) and clinical supervisor reports at the conclusion of each attachment. Each year must be passed overall to allow the student to progress to the next, and remediation may be offered in a number of forms to those who fail to achieve this, as recommended by a board of examiners. This may take the form of a ‘special’ written examination, which is a supplementary repeat assessment offered when a student receives a failing grade in a single subject area and is offered additional academic support by departments and CMEFs. At a clinical level, a ‘tag’ for assistance during future attachments may be assigned by the board. This earmarks these students to their clinical preceptors as potentially requiring more academic support than their classmates, but the extent of support varies depending on the individual circumstances. More intensive remediation options include a directed selective in a particular area of medicine, or a specific period of intensive remediation at the end of their penultimate year (Year 5) before progressing onto Year 6. Alternatively, the board may recommend the student fail that year of study and repeat the following year. Subsequent failure of that repeated year results in exclusion from the medical programme.

The curriculum was reorganised recently to place more emphasis on longitudinal learning and programmatic assessment. This ‘new’ curriculum was introduced in a staged fashion to Years 2 and 4 in 2013, Years 3 and 5 in 2014 and finally Year 6 in 2015. Curriculum content is structured around five domains (Applied Science for Medicine, Clinical and Communication Skills, Personal and Professional Skills, Population Health and Hauora Māori) and this is delivered in a more longitudinal fashion across the programme than previously. Another key feature is thrice yearly summative progress testing, an assessment strategy developed independently in the 1970's at the University of Maastricht in the Netherlands11 and the University of Missouri-Kansas City in the US.12 It involves students at all levels sitting an identical comprehensive written examination requiring integrated knowledge of basic science and clinical practice across the entire curriculum. The test is set at the level of knowledge expected of a first-year postgraduate medical practitioner, and student progress relative to their own prior performance and that of their peers is tracked as they progress through the programme. A key philosophy of progress testing is early identification of academic issues and rapid remediation. Students in Phase 1 also have knowledge assessed by end-of-module examinations as well as written assignments and practical assessments at other stages throughout the programme. Clinical skills, communication and professional skills are assessed by a variety of methodologies, including workplace-based assessment, clinical examinations and a portfolio. As the introduction of this new curriculum represents a change in assessment structure, the quantitative analysis has been restricted to the time that has elapsed since its introduction.

Quantitative analysis

Anonymised data were obtained on all students who were offered formal remediation since the introduction of the new curriculum in 2013 and at each year level through until December 2014. Demographic data were obtained on student gender, year level, entry pathway (including possession of a prior degree), study location and type of remediation offered (special examination, tag, directed selective or repeating the year). Access to individual student files was not sought. To measure the effectiveness of this remediation, outcome data was also sought from each cohort in the following year—specifically whether the student successfully progressed in the programme, had to repeat a year level or was excluded. Results were analysed using Microsoft Excel and R statistical package (R Core Team, Vienna, Austria). Multivariate analysis was performed to determine which demographic factors best correlated with the need for remediation, with p≤0.05 deemed statistically significant.

Qualitative analysis

The lead faculty staff involved in medical student remediation were e-mailed an invitation to participate in a semi-structured interview. Twenty-two potential participants were identified. These included all three phase directors, all seven site coordinators, the two Directors of Medical Student Affairs, three academic staff responsible for the MAPAS programme and seven current and former CMEFs. Prospective participants were informed that involvement was voluntary and written consent was obtained prior to participation.

Between December 2015 and May 2016, the primary investigator (BG) conducted individual semi-structured interviews with each participant. These interviews were based on an interview guide comprised of open-ended questions relating to the role of each participant in providing remediation; problems faced by students and their underlying causes; the effectiveness of remediation; the amount of time spent providing remediation; knowledge of additional support services provided by the faculty and their effectiveness; and suggestions for improving the current remediation system. Additional questions were also asked on an ad-lib basis in keeping with a semi-structured design, allowing the interviewer to follow up on areas of interest that emerged. Interviews were recorded on a digital recorder and transcribed verbatim. Participants were given the opportunity to make amendments to their interview transcripts prior to them being analysed.

Data from the transcripts were coded and sorted into categories (BG), then arranged into themes using cross-sectional thematic analysis by the primary researcher as previously described by Mason.13 The process of categorising the data and formation of themes was cross-checked by another member of the research team (JY), with the themes agreed on by both researchers.

Ethical approval

Approval was granted by the University of Auckland Human Participants Ethics Committee (UAHPEC) on December 11, 2015 (Ref: 016486).


Quantitative analysis

As of December 2014, 165 students from Years 2–5 of the medical programme were identified as requiring some form of remediation since the staged introduction of the new curriculum. This represented 17.7% of all students who had been introduced to the curriculum by this time. The breakdown of students by phase is shown in Table 1.

Table 1: Number of students requiring remediation during each phase.

Programme phase

Number of students

Progressed to subsequent year

Phase 1

64 (5 remediated twice)


Special written examination


47 (87%)

Repeat year


15 (100%)

Phase 2

101 (14 remediated twice)


End of year clinical examination


32 (100%)



62 (93%)

Repeat year


16 (100%) 

Sixty-four students encountered their difficulties during Phase 1 of the programme (representing 12.9% of all students in this phase). For the majority of these (54 students) remediation was in the form of a special examination at the end of the year. These exams had an 87% pass rate. Fifteen students were required to repeat a year and all of these eventually passed, although for two this was not without a special examination at the end of the repeated year. Five students required remediation in both Year 2 and Year 3 during the observation period (these students were not counted twice)—for four this meant sitting consecutive special examinations in Years 2 and 3 and one sat a special in Year 2 and then went on to fail and repeat Year 3.

One hundred and one students encountered difficulties in Phase 2 (23.2% of students in this phase). Thirty-two of these students only required a brief period of intensive remediation before progressing on to the subsequent year without further intervention. Sixty-seven students were ‘tagged’ as requiring remedial assistance for their subsequent year—27 of these were also required to complete an additional clinical skills examination and 17 were assigned to a directed selective (10 of these were in general medicine, five in general surgery, one in orthopaedics and one in geriatrics). Ninety-three percent of tagged students successfully passed their tagged year (excluding those who deferred or chose to withdraw from the programme themselves). Sixteen students were required to repeat a year and all of these eventually passed, although four still required further intervention at the end of their repeated year. Fourteen students required remediation twice and for two of these this meant failing a year despite being offered remediation.

Table 2 demonstrates the effect of student demographics on the need for remediation. International students were the entry group most likely to require remediation at any stage during the programme. Of the 31 international students requiring remediation across the programme, 25 (81%) reported first learning a language other than English and 30 (97%) came from countries where English is not the predominant language. MAPAS students were the next most likely group to require remediation and this reflected a significant over-representation at Phase 1 level, with the effect being less pronounced in Phase 2. Male students were also slightly more likely to require remediation than their female classmates during Phase 2 but not Phase 1. No significant difference was observed for RRAS students, those with a prior degree or those cohorted outside of the Auckland urban teaching hospitals in either Years 4 or 5.

Table 2: Effect of student demographic variables on the need for remediation.


Programme overall

Phase 1

Phase 2

P value


95% CI

P value


95% CI

P value


95% CI

Male gender










Entry pathway







































Prior degree










MAPAS—Māori and Pacific Admission Scheme.
RRAS—Regional and Rural Admission Scheme. 

Qualitative analysis

Fourteen of the 22 potential participants consented to the study and were interviewed. These interviews had a median duration of 35 minutes (range 11 to 56 minutes). Categories identified during analysis were grouped into two major themes: those that describe potential underlying causes for needing remediation; and those that identify the strengths of the current system for remediation or suggest areas for improvement.

Reasons for remediation

An under-developed ability to synthesise and apply theoretical knowledge was the most commonly cited reason for students to need remediation. It was mentioned explicitly by nine of the 14 participants in regard to students in all phases of the programme, and many of the other reasons mentioned can be subsumed within this category.

They’re trying to learn absolutely everything to the nth degree and reading Harrison’s [Textbook of Internal Medicine] or whatever and trying to learn that information, which is not what you require for medical [school] finals. I think they’re getting completely buried and struggling with the volume of information rather than actually reading about the basics and covering large areas in a shallow amount of detail. So getting overwhelmed in reading one chapter of Harrison’s on one particular subject and not covering basic things like ophthalmology or ENT or something. [P12]

A range of underlying causes for this problem were suggested by participants, ranging from poor study strategies and self-management skills on the part of the student, lack of opportunities for clinical practice, poor English language skills and even in some cases, learning disability.

There was one instance when another physician suggested “Well that’s an interesting thing, this guy’s really smart when we’re together but when it comes to written exams, it’s just a total disaster!” Then he suggested “does he have dyslexia?” and then different interventions were targeted towards this student. [P11]

The progress test was mentioned explicitly by seven participants as being particularly sensitive at identifying students with a range of these problems, for example:

We’re talking about a timed, written multiple choice exam that’s very heavy on reading of content that’s very dense and requires concentration over a three-hour period. So you can appreciate there are a number of subgroups who may have a problem with that. If your English language isn’t great, if your reading speed isn’t great, if your reading comprehension isn’t great, if you have a learning disability that is as of now undiagnosed, you will have problems…This particular assessment…requires people to be very adept at all of those things as well as content matter expert. [P1]

Wider pastoral issues were also identified, and included unrealistic parental or self-expectation, financial problems, family issues and anxiety, particularly regarding performance in examinations.

Every once in a while I do find someone who simply doesn’t have the intellectual or academic capacity to be a doctor. They’re usually in this position because of someone’s unrealistic expectations of them and whether that’s their own or family…or societal expectation…people who realise…that this was their father’s dream and not their dream [and] that actually “I love kids and I don’t want to be a paediatrician and stick needles in and deal with them when they’re puking—I’d much rather be a children’s librarian!”. [P1]

We select people…because they have perfectionistic traits that are very useful for other things, we put them under high pressure. They’re not necessarily used to failing things or not being the best at things. They’re away from home, often learning new skills. Sometimes it’s a matter of helping someone adjust their self-expectations or expectations from elsewhere that they’re always going to get an A+, and if you get them to let go of that sort of pressure they start realising that they’re human and they’re fallible and they’re not always going to get everything right. [P7]

Some participants also identified that MAPAS students as a group faced unique challenges, including an average GPA at entry two points lower than applicants to other admission pathways, prejudice from some peers regarding widening participation interventions and external pressures such as being the first in their family to attend university. However, there was also anecdotal belief that their performance in the later phases of the programme was not significantly different from their peers.

Generally speaking, most people would say that MAPAS students tend to shine as they go through the programme because they get into the real life situations the people skills…you know, it becomes more real for them rather than those fundamental science subjects. [P5]

Strengths of remediation

The majority of participants (10 of the 14) indicated they felt remediation was effective. Reasons cited included the sharing of information between stakeholders, express awareness by faculty of a wide range of possible underlying causes for poor academic performance and the use of an aggregate score derived through the thrice-yearly progress test rather than a single high-stakes examination.

I remember we had a student who was having problems only when it comes to OSCEs. When it came to written exams, he was good but when it came to OSCEs he had problems. So we identified that this was not a knowledge issue—there’s something else happening here, probably a performance issue or a degree of anxiety. [P11]

Weaknesses of remediation

Among those who expressed reservations, the main areas of concern were the level of support provided to remediators and the expectation that remedial students simply undertake “more of the same” rather than have a specific, targeted approach.

Frankly the [clinical] teams are the ones tasked with patient care and patient safety. They don’t have time…I would recommend additional staffing resources so that we can assign struggling students to someone who can provide additional teaching and support, rather than just one or two meetings with a CMEF and then work on this in your own time. [P1]

We currently consider ‘remediation’ as repeating the year—I don’t see that as remediation, I see it as doing the same damn thing all over again! The real remediation is the little bits around the side where we say you have to meet with the CMEFs etcetera. [P1]

Suggestions for improvement to the remediation system included more flexibility in the programme structure, improved diagnostics and improved access to dedicated teaching staff, particularly in remote areas.

The problem I have is that you come to those students who have passed everything clinically, everything in terms of knowledge base etcetera and then they fall over on the progress test. Should there be a back-up system? If you fail a [clinical] attachment…we have the ability either through the remediation period or the directed selective… I’d like to see us say that before you fail the year [based on the progress test], you have to sit an oral exam…Tell me about cardiac ischaemia. What is the pathophysiology? Where does each drug affect in that pathway? If you can demonstrate that in a completely different setting to a multiple choice exam that you know what you’re talking about then you should get some kind of diversion programme. [P1]

I think the resource that we miss is Clinical Medical Education Fellows [CMEFs] and students often comment on that—that they don’t have the access which people do in Auckland. So I think that’s one resource we could potentially use more of. We’ve thought about [setting up a similar role in our site]. It would be a reasonably minor role I think it would be good to have there. So it’s that extra bit of expertise which would be useful. [P2]

However, some participants expressed concern that the level of remediation already offered by the faculty was in some cases inappropriate and that there should be clear restrictions on exactly how much support is provided, for example:

We actually do an enormous amount for the medical programme, far more than we do for any other programme that I teach in, and one of the issues that we have talked about…is whether we’re actually over-doing it to the extent that students expect that that’s what life’s going to be like and they don’t develop the adequate resilience they need in order to become effective clinicians. So are we wrapping them in cotton wool and spoon feeding them too much? There’s a certain point to which remediation may be effective if it leads to long-term improvement, but if it leads to the need to continually do it then we’re going to end up with students who get through Year 6 and end up as poor clinicians. [P3]


Medical students often require remediation (17.7%), with most students achieving a successful outcome. This proportion was higher in Phase 2 of our programme (23.2%) than during Phase 1.

Ninety-three percent of students who were offered remedial assistance managed to successfully complete the year of study in which it was offered, including all of those who were repeating a year. However, there was an 11.5% rate of needing additional assistance the following year. Previous studies indicate that remediation targeted at a specific assessment is unlikely to be associated with sustained long-term success,14 however, broader remediation programmes encompassing a more generalised approach to skills and knowledge acquisition accompanied by personal support, are more likely to lead to sustained progression.8

Our qualitative analysis revealed a common belief among lead academic staff involved with remediation that knowledge application and information synthesis is frequently an underlying area of difficulty among this group of students. This is consistent with previous studies identifying that at-risk students commonly struggle with knowledge organisation and integration.15 Participants identified several possible underlying causes for this, encompassing both student and institutional factors. Student factors such as self-regulated learning, motivation and interpersonal skills have been identified elsewhere as contributory to remedial difficulties.16,17 However, our study also raised the possible role of institutional factors in providing students with the opportunities they need to attain competency, an issue which has been highlighted elsewhere regarding the experience in procedural skills of newly-qualified postgraduate doctors.18 Improved clarity and specificity regarding competence-based outcomes, as well as standardising available opportunities to achieve these across different clinical sites, are potential methods by which these factors may be addressed.

International students were the most likely entry cohort to require remedial assistance across the programme as a whole. The majority of the remedial international students in this study reported English as their second language and prior research from North America indicates such students have a significantly reduced pass rate for written multiple-choice medical licensing examinations.19 However, recent Australian research has highlighted that international medical students also experience a range of other challenges, including social isolation, financial pressures and poor engagement with group learning activities.20

This study found that MAPAS students were 3.4 times more likely to require remedial assistance during the programme, but 6.8 times more likely during Phase 1, where they were the single largest at-risk group. This corresponds with lower tertiary level enrolment and retention rates observed among Māori in other tertiary degree programmes in New Zealand.21 MAPAS students entering the medical programme under widening participation initiatives have a lower average GPA on admission and unsurprisingly are more likely to require remediation. Interestingly, the magnitude of this effect was smaller for students in Phase 2. A 20-year retrospective cohort study in the US demonstrated a similar trend with applicants admitted via widening participation interventions having lower admission scores comparable to regular admissions.22 The impact of racism and colonisation are recognised to have given rise to a range of disparities between Māori and non-Māori.23 Specifically, the secondary education system has been observed to result in inequitable outcomes for both Māori and Pacific students compared to other New Zealanders, with only 31.0% of Year 13 Māori and 29.5% of Pacific students attaining university entrance in 2015, compared to 57.4% of New Zealand European students.24 This may explain the increased need for remediation of these students at a tertiary level as observed here. The faculty is committed to increased student diversity in the medical programme to reduce these ethnic disparities in the medical workforce. It is also committed to providing support programmes to ensure that MAPAS students succeed and historical disadvantage is mitigated, working towards graduating doctors who both reflect and can serve the New Zealand population.

The most significant feature of the new curriculum was the introduction of the progress testing, which half of all participants mentioned as a sensitive measure of a range of remedial difficulties, although some also had concerns about the lack of specific expertise available for assisting students for whom it was an area of difficulty. More experienced institutions argue the detailed performance breakdown provided by progress testing is valuable in analysing problem areas and targeting remediation.25 However, a recent qualitative study reported that students often did not find this useful.26 More investigation is therefore needed in how to best use progress test results to accurately guide remediation.

Some participants identified learning disabilities as a specific underlying cause of difficulty with the progress test, particularly where performance in other forms of assessment was satisfactory. Prior research from the UK has indicated that up to 2% of medical students may suffer dyslexia and that this may manifest as poor performance with both literacy and non-literacy associated skills such as poor time management on clinical attachments.27 While this study did not set out to identify students with learning disabilities, the University has formal processes for identifying and supporting students who have such disabilities. These assessment processes for learning disabilities are considered for MAPAS students requiring repeated remediation.

One limitation of this study was that the quantitative analysis was limited to the initial cohort who participated in the new curriculum, none of whom at the time of data collection had completed both Phase 1 and 2 under this new curriculum structure. As progress testing is designed to improve longitudinal learning, further review of student outcomes in subsequent cohorts may yield different results. A further limitation is that students were not interviewed.

In conclusion, this cross sectional study has identified that a significant proportion of students require remediation, which is completed successfully. Long-term follow up of the students will assist in determining the impact of the new curriculum on the number of students requiring remediation in the final year of the medical programme. Targeted support for at-risk students continues to be a high priority for the faculty as we attempt to meet equity goals and successfully graduate doctors to serve all New Zealand populations.


Most medical students who need remediation are successful in passing the year. We have identified those students who are in greatest need of additional assistance. Interventions to help students are generally seen as helpful, but more could be done to assist students who have academic difficulty. As the cause of academic difficulty is multifactorial, a system-wide approach to addressing inequity, eg, in pre-university education outcomes, may reduce the need for remediation during university.



The purpose of this study was to identify predictors of remediation in a medical programme and assess the underlying causes and the quality of remediation provided within the context of a recent curriculum change.


A mixed methods study incorporating a retrospective cohort analysis of demographic predictors of remediation during 2013 and 2014, combined with thematic qualitative analysis of educator perspectives derived by interview on factors underlying remediation and the quality of that currently provided by the faculty.


17.7% of all students required some form of remedial assistance and 93% of all students offered remediation passed their year of study. Multivariate analysis showed international students (OR 4.59 95% CI 2.62–7.98) and students admitted via the Māori and Pacific Admission Scheme (OR 3.43 2.29–5.15) were significantly more likely to require remediation. Male students were also slightly more likely than their female classmates to require assistance. No effect was observed for rural origin students, completion of a prior degree or completion of clinical placement in a peripheral hospital. Knowledge application and information synthesis were the most frequently identified underlying problems. Most faculty believed remediation was successful, however, flexibility in the programme structure, improved diagnostics and improved access to dedicated teaching staff were cited as areas for improvement.


Remediation is required by nearly a fifth of University of Auckland medical students, with MAPAS and international students being particularly vulnerable groups. Remediation is largely successful, however, interventions addressing reasoning and knowledge application may improve its effectiveness.

Author Information

Brian Grainger, Clinical Medical Education Fellow in Medical Programme Directorate, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Jill Yielder, Senior Lecturer, Medical Programme Directorate, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Papaarangi Reid, Head of Department, Te Kupenga Hauora Māori and Tumuaki, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Warwick Bagg, Head of the Medical Programme and Professor of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland. 


The authors wish to thank Nicholas Fitzherbert, Ian Wood and Kate Snow for their assistance with data extraction and Vernon Mogol for his assistance with statistical methods.


Warwick Bagg, Head of the Medical Programme and Professor of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Park Road, Auckland 1142.

Correspondence Email


Competing Interests

P Reid is is Deputy Dean (Māori) for the Faculty of Medical and Health Sciences and oversees programmes related to Māori and Pacific students within the Medical Programme. W Bagg is Head of the Medical Programme at the University of Auckland.


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