A realist review of the remediation of professionalism lapses in undergraduate medical students (RESTORE 3).

INTRODUCTION: Professionalism is a core element of medical curricula worldwide and remains a cross-cutting theme across all aspects of a medical programme. When a medical student fails to demonstrate the expected attributes and behaviours, medical schools have a duty to step in, and where appropriate, offer remediation that aims to facilitate behavioural change. There is sparse explanatory theory on this complex topic, resulting in little evidence-based guidance for medical schools to utilise. This review aims to explain how, why, to what extent and in what circumstances professionalism remediation works for undergraduate medical students. METHOD: We conducted a realist review that aligns with the RAMESES standards and Pawson's 5 step process. We searched databases (MEDLINE, EMBASE, ERIC and BEI) and carried out forward/backward citation and grey literature searches. Any studies, of any design, from any country that included data related to professionalism remediation of undergraduate medical students was included. Data was extracted and mapped to an existing theory to confirm, revise or refute its context-mechanism-outcome configurations (CMOc's) and devise new CMOcs using a realist logic of analysis. RESULTS: A total of 76 records were included. Publications ranged from 1994 to 2024 and originated mainly from North America and the UK. A realist programme theory was developed, comprising of 27 CMOcs, that explain the remedial cycle from insight to motivation, to sustained engagement and behavioural change, further interacting with three further domains; remediation processes, communication and the integral role of trust/safety. DISCUSSION: This review provides the first theory-driven model of medical undergraduate professionalism remediation. It has highlighted the interconnectedness of the systems surrounding the remediation interventions, their impact on behaviour, including the phenomenon of students 'gaming the system'. We have developed practical and implementable recommendations aimed at supporting those staff involved in facilitating student behaviour change to align with professional standards.