Metacognitive Deficits in Residents: Unveiling Faculty Perceptions, Strategies, and Challenges

Purpose: Academic remediation and attrition rates in surgical residency are high. Remediation efforts typically focus on medical knowledge acquisition. While cognitive skill is important, metacognitive skill may be lacking in some residents requiring remediation. This study examined how teaching faculty perceive, characterize, and approach poor resident academic performance despite adequate cognitive knowledge or skill. Method: Utilizing a semi-structured interview methodology, teaching faculty were asked to consider a scenario involving an academically struggling senior resident without a cognitive skill deficit such as poor medical knowledge. Subsequently, they were queried about their personal experience in this educational context. The interviews, lasting 45 minutes each, were conducted between July 2022 and May 2023. Recordings of the interviews were transcribed and coded, and the authors identified themes and sub-themes through concurrent data analysis using the Framework Method. Results: Participants comprised 12 teaching faculty from two procedural specialties across four institutions. Faculty depicted a non-cognitive behavior archetype, encompassing poor clinical reasoning, a lack of awareness of their performance gap, and a maladaptive response to feedback. Faculty were unaware of any specific remedial program to address this pattern and described a composite of cognitive-forcing strategy, prompting self-awareness, promoting heuristics, and mentoring as piecemeal case-by-case solutions. They expressed a lack of an educational model for metacognitive remediation, experienced frustration in teaching to it, and harbored concerns about poor educational outcomes in residents exhibiting such behaviors. Conclusions: Teaching faculty can effectively describe metacognitive skill deficits in residents but encounter challenges in recognizing them for what they truly are, identifying their underlying causes, and presenting a systematic approach for remediation. This study provides language that enables faculty and programs to identify residents who are metacognitively-at-risk. Additionally, it underscores the need for faculty development in educational models tailored for clinical settings that integrate evidence-based educational methods aimed at remediating metacognitive deficits.