OBJECTIVES A mandatory remedial programme for students who repeat their first semester at medical school has resulted in large gains in academic performance and greatly reduced attrition. Here, we explore the students' views of this in order to clarify understanding of optimal remediation practice. METHODS Using a mixed-methods approach, quantitative and qualitative data were gathered from student surveys (n = 333) and three in-depth focus groups. Results were analysed for emergent themes. RESULTS Remedial programmes for at-risk medical students should be mandatory, but should respect students' identity as repeaters. Attitude and motivation are key, and working in stable groups provides essential emotional and cognitive support. The learning environment needs to foster changes in students' ways of thinking and their development as flexible, reflective learners. These endeavours require support from honest teachers with rigorous expectations and good facilitation skills. CONCLUSIONS Successful remediation needs to challenge students' conceptions of learning, works best in groups with skilled facilitators, and must take into account a blend of cognitive and affective factors and the complex interplay between learner and environment. Given a carefully designed programme, at-risk medical students can learn to make effective and lasting changes to their approach to study, and their views of learning can come to converge with influential ideas in the education literature.