Expelling unsuitable medical students is very difficult, and the faculty considers this a serious problem

Research from EM shows that Erasmus MC has been trying to gain more power to expel unsuitable students since the beginning of this century, but the existing regulations are inadequate. The programme is working hard on changes within the education system, and a national regulation was introduced in 2010. Nevertheless, the call for more options still stands. 

Students who pose a danger to others, for example by displaying inappropriate behaviour in classes or during their medical internships, can be expelled from the programme based on the so-called iudicium abeundi since 2010. If a student shows behaviour or statements for which they would receive a disciplinary sanction had they been qualified doctors, this could be ground for removing the student from the programme. 

However, it is rare for a student to be expelled under this regulation. Since the introduction of the iudicium abeundi, at least four students have been expelled from medical programmes in the Netherlands. All four unsuccessfully appealed that decision. In 2015, for example, a medical student from Leiden was expelled. During his internship in paediatrics, the student had contacted a 15-year-old patient and her mother via chats and phone calls outside working hours and made sexual comments. In 2022, Erasmus MC terminated a student’s enrolment based on the regulation. Another case involving a medical student from Rotterdam is currently ongoing at the Council of State. 

Expelling students is extremely difficult, asserts cardiologist René Tio from Eindhoven. He was the chairman of the Groningen Examination Board for many years. “As a programme, you are obliged to offer resit after resit. You hope to hold up a mirror so that students realise they’re not suitable for the medical profession. But with students who display problematic behaviour, that lack of insight is precisely the issue.” 

Without a serious error by a student, an iudicium abeundi is virtually impossible to implement, he believes. Hard evidence is required that patient safety, or the safety of colleagues or fellow students, is at risk. Several doctors whom EM spoke to confirm this. If a doctor has concerns about an intern, they are not left alone with a patient, and there is a lack of concrete evidence, even though those concerns exist.  

Therefore, the examination boards of all Dutch medical programmes have been requesting an expansion of the iudicium abeundi since 2022. They describe the regulation as ‘an empty shell in practice’ and want the choice to not leave a student alone with a patient for safety reasons to also be grounds for expulsion from the programme. 

After parliamentary questions regarding this request, then education minister Robbert Dijkgraaf stated that he did not agree with this. The right to education was, in his view, too important, and it is up to doctors to ensure patient safety when medical interns are working. The minister believed that programmes themselves are responsible for structuring education in such a way that unsuitable students cannot graduate.  

This position remains unchanged, responds a spokesperson from the Ministry of Education, Culture and Science, also after the incident in which former medical student Fouad L. killed a lecturer and set fire to the Education Centre because he did not receive his diploma. “During their training, medical students work under the supervision of BIG-registered doctors (the legal public register for healthcare professionals, eds.) who are subject to disciplinary law. This way, patient safety is safeguarded as much as possible.” The ministry thus places the responsibility back with the programmes and the supervising doctors in the hospitals. 

To prevent unsuitable medical students from graduating, Erasmus MC has adjusted its assessment system for medical internships. This is intended to solve multiple issues: ensuring that students cannot graduate without mastering a certain skill, allowing doctors to be critical without immediately having to award a failing grade, addressing problems such as unprofessional behaviour in a timely manner, and preventing mercy passing. There is also now greater attention to ethics and professional development in medical education. 

Nevertheless, broader possibilities for the iudicium abeundi are highly desirable for Erasmus MC, confirms a spokesperson on behalf of the Examination Board. Due to the ongoing appeal involving Fouad L., Erasmus MC does not wish to comment further on this subject.