“Can you hear me? Can anybody pretty please validate [me]?”: The Long Shadow of Separation and Liminality in Remediation

Introduction : Throughout medical education, learners participate in numerous rites of passage where they ‘transition’ from one state to another in their journey to becoming a physician. However, the literature on rites of passage has typically been conceptualized as a positive transition into a better social position, one of higher stature. As a result, remediation has yet to be conceptualized in this way even though learners undergo an important transition in their careers. This study captures the narratives of practicing physicians who remediated in the last 5-15 years using the framework of rites of passage. Methods: We identified 14 physicians who had remediated within the last 5-15 years at our institution and interviewed them about their experiences as medical students. Data were transcribed and analyzed using narrative analysis, which included attending to the overall plot, main and supporting characters, order of events, and outcomes at each point in their story. In the analysis, we noticed an emerging pattern that showed participants went through stages. After consulting the ‘transitions theory’ literature we found numerous references to rites of passage. We then analyzed the data through the framework of van Geenep’s three phases within rites of passage. Results : Participants’ experience of remediation remained a salient experience in their career. Each one could easily recall vivid memories and feelings of uncertainty and disorientation as they transitioned through the process. Participants described separation as strained interactions with the community and heightened awareness of symbols communicating a parting. The liminal phase was marked with isolation and ambiguity while their fate was decided by the institution’s Committee. Aggregation, described as reintegration back into the community was experienced by only a few, such that more than half of the participants still do not feel fully integrated post remediation. Discussion: Remediation is harrowing for learners and filled with long-lasting consequences. While everyone experienced separation and liminality , only a few achieved aggregation pointing to the long shadow remediation casts over their careers. We suggest medical education provide individuals who are in constant contact with those being remediated and extra support around the final phase of reintegrating. “Life itself means to separate and to be reunited, to change form and condition, to die and to be reborn. It is to act and to cease, to wait and to rest, and then to begin acting again, but in a different way.” – Arnold Van Gennep, in The Rites of Passage, 1909