Challenges, Strategies, and Explanatory Mechanisms in Clinical Skills Remediation Programs in Undergraduate and Postgraduate Medical Education in Low- and Middle-Income Countries: Realist Review Protocol.

Background: Clinical skills deficits are a patient-safety concern, yet remediation remains underexamined, particularly in low- and middle-income countries, where faculty shortages, uneven access to simulation and supervised practice, inconsistent assessment, and stigma can hinder timely and effective support. The effects of trainee underperformance extend beyond the individual, with implications for patient care, supervisory workload, and team functioning. Although interest in remediation is increasing, the evidence base remains fragmented, dominated by high-income settings, and largely descriptive. A theory-driven review is therefore needed to explain how remediation works, for whom, and under what conditions. Objective: This realist review protocol aims to identify the main challenges and strategies reported in clinical skills remediation in undergraduate and postgraduate medical training, explain for whom these strategies work, in what contexts, and through which mechanisms, and develop an evidence-informed initial program theory for low- and middle-income country settings. Methods: Following the RAMESES (Realist and Meta-narrative Evidence Syntheses: Evolving Standards) for realist synthesis, this review will draw on a broad range of sources, including MEDLINE or PubMed, CINAHL, PsycINFO, ERIC, and Scopus, alongside gray literature such as dissertations, World Health Organization resources, medical education policy documents, and institutional reports. Sources published from January 2000 onward will be considered eligible, spanning empirical studies, program evaluations, and theory-informing documents focused on the remediation of clinical or procedural underperformance among medical learners at any training stage. Screening, extraction, and appraisal will be performed in duplicate. Extracted data will include learner characteristics, remediation triggers, intervention features, contextual conditions, candidate mechanisms, and outcomes related to competence, progression, and patient safety. Synthesis will apply retroductive reasoning to develop and refine context-mechanism-outcome configurations and a middle-range program theory. Results: Funding was secured through Badan Riset dan Inovasi Nasional (National Research and Innovation Agency of Indonesia; 2023). The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews) (CRD42023447029). Protocol development, stakeholder-informed scoping, preliminary literature familiarization, and initial program theory construction were completed by April 2026. Formal database and gray-literature searching is planned for mid-2026, followed by duplicate screening, relevance and rigor appraisal, data extraction, and iterative realist synthesis through 2026-2027. The primary review manuscript is targeted for submission in 2027. Conclusions: This review aims to move remediation scholarship beyond description, toward a clearer understanding of what works, for whom, and why. By bridging evidence, theory, and real-world practice, it hopes to guide the design of remediation systems that are contextually grounded, educationally sound, and ultimately capable of restoring safe clinical performance across both undergraduate and postgraduate medical training.