I have spent the majority of my professional career in teaching institutions—where I supervise medical students and residents in their clinical care.
Those of us in these roles take it seriously. If there is a trainee about whom I have a concern—and it usually is about their clinical reasoning ability—I will let the clerkship or residency program leadership know. And I know that my colleagues do this, and we try to provide additional support and possibly remediation for that trainee so they can progress and grow.
Offering remediation and support is the appropriate thing to do to help our trainees improve in their clinical skills and other competencies (approximately 5% of pediatric residents receive remediation).
Pediatric program directors and clinical competency committees have the challenge of determining if a resident is “ready” for the next step. And sometimes there are external forces that influence that determination.
Daniel Schumacher, MD, PhD, and colleagues at the University of Cincinnati, Brown University, and Harvard Medical School discuss this challenge in an article and accompanying video abstract being early released in Pediatrics this week, entitled “Advancing, Graduating, and Attesting Readiness of Pediatrics Residents with Concerns” (10.1542/peds.2025-070594).
The authors surveyed pediatric program directors and asked them if they had graduated or advanced residents despite concerns about the resident’s abilities.
The results are striking:
- 79% reported graduating at least one resident from their program even if they had concerns.
- 43% reported graduating at least one resident whom they would not trust as a general pediatrician to care for a loved one.
- 26% reported attesting to at least one resident’s readiness so they could take the initial American Board of Pediatrics certifying exam.
- 79% reported advancing at least one resident despite concerns about the resident’s ability to do the work required at the next level.
Why is this happening? Often, program directors did not have enough data about performance concerns, or the program’s clinical competency committee thought that the resident was ready. With regard to graduating residents, program directors also felt that they could do this if the resident was entering a fellowship program (where they would still have close supervision) or was entering a practice setting where the program director thought the resident would be successful. With regard to advancing residents to the next level, program directors often did this if they had ensured additional support for the resident. Some cited pressure from the institution to assure that the resident graduated on time.
The authors of this article and Dr. Susan Guralnick at the University of California, Davis, who was invited to write a commentary on this article (10.1542/peds.2025-070862), all suggest that we need to look at multiple strategies to solve this problem. We need a way to reliably assess residents, such as Entrustable Professional Activities (assuring that residents can independently be entrusted to perform certain activities deemed critical to success). Additionally, it is crucial that all programs have faculty who are trained in remediation so that, when residents need a little extra support, there is a system in place to provide that support.
The authors note that this is both an education problem and a patient care problem. We need to be sure that we send our graduating residents out with the skills and abilities to become great pediatricians.
