Why it is so difficult to expel unsuitable medical students

It is September 2022, and general practitioner Marijn Elings feels as though he’s being deceived. After 37 medical interns, it was the first time he immediately thought: how is it possible that you have passed all your medical internships so far? He still loses sleep over it occasionally. “Letting her work in at my general practice did not feel safe. But sending her home was not very educational for her.” Elings was at his wit’s end. He wanted to help the student but felt like he was hitting a wall. “How is it that someone who knows nothing medically, is not communicative, lacks self-reflection, and scores zero on all core factors, ended up here? I really felt like I was being made a fool of.”

Before a medical intern arrives at a general practitioner, they have completed at least a year and a half of placements in various departments at different hospitals. Elings is used to interns having experience and quickly taking over his seat. Then, he shifts to the stool next to the office chair. “I kept trying for three weeks. I am also a GP for people from a care farm, who often have disabilities. A man with a mental disability eventually said to her: ‘You give little confidence that you know what you are talking about.'” It is the only time Elings has prematurely terminated a medical internship.

Expelling medical students who exhibit unprofessional behaviour from the programme is incredibly difficult. Programme directors and chairs of examination boards have been drawing attention to this problem for years, as it ultimately concerns a social interest and the safety of patients. Research from the United States shows that doctors who appear before the disciplinary court often exhibited unprofessional behaviour as students.

In 2022, the chairs of the examination boards of the eight Dutch medical programmes made an appeal to politicians. They want more legal options to exclude students who display unprofessional behaviour from the programme. What weighs heavier, the chairs wonder: “The protection of society against a potentially faulty future physician or the student’s right to continue their education?” Additionally: “Should a certificate be issued to a dysfunctional student who has obtained their internships through deceitful means or lying behaviour?”

The vast majority of medical students are highly suitable, all the doctors EM spoke with confirm. Only a handful of students consistently display unprofessional behaviour and do not improve. This is also the conclusion of the PhD research by GP and UvA researcher Marianne Mak-van der Vossen. She investigates how unprofessional behaviour can be identified and classified, and how to respond to it. “Students can learn that unprofessional behaviour is not tolerated because it negatively affects future patient care”, she concludes. But a small portion does not learn this. “At every faculty, we see about two or three students whom you really wish would never receive a diploma”, she says when speaking to Medisch Contact. “But we cannot remove them from the programme.”

Medical programmes have been trying to gain more possibilities to expel unsuitable medical students since the start of this century. Since then, programme directors and chairs of the Examination Board at Erasmus MC have been the driving force behind this in the Netherlands.

The lobbying led to a legislative amendment, an ultimate means to expel students who are clearly unsuitable for the profession from the programme. This so-called iudicium abeundi came into effect in 2010.

Based on this iudicium abeundi, students deemed unsuitable for the profession due to their behaviour can be expelled. According to the protocol of the Dutch Federation of University Medical Centres, this concerns behaviour for which they would’ve received a disciplinary sanction if they were a licensed doctor at the time of the incident. For example, when students pose a danger to others during lectures, or especially during practical exercises such as internships. This includes behaviour such as intimidation, aggression, violence, or ‘general dysfunction due to a severe personality disorder’.

However, medical programmes found these measures insufficient. In 2022, all examination boards presented a plan for improvement. In the plan, they state that the iudicium abeundi is ‘practically an empty shell’, as it rarely occurs that patient safety is at risk. The number of applications of the iudicium abeundi is low. Since its introduction on 1 September 2010, at least four cases have occurred in the Netherlands. All four unsuccessfully appealed against it. A fifth appeal by a student from Rotterdam is currently underway. The verdict is expected in early June.

In 2015, a student from Leiden was expelled based on this regulation. During his internship in paediatrics, the student approached a 15-year-old patient and her mother via chats and phone outside of working hours and made sexual remarks. This was sufficient reason to expel him from the programme. His appeal to the College of Appeal for Higher Education was rejected. As far as is known, this was the first iudicium abeundi.

The most recent verdict dates from 2022. In April of that year, Erasmus MC expelled a student; her appeal was later rejected by the Council of State. Already during her first internship, internal medicine at the Elisabeth-Tweesteden Hospital in Tilburg, she was expelled after a month due to ‘misconduct and thereby endangering patient care’. There were subsequent discussions with a psychologist, a one-year suspension, treatment by a psychiatrist, a resit, two more failures, more resits. Concerns had been raised about her suitability as a doctor during various internships and by a mentor. The Examination Board explicitly asked if she would consider discontinuing her studies. A new psychological evaluation followed. Only then was the dossier sufficiently substantiated for the iudicium abeundi.

The examples illustrate how much is needed to expel a student, says cardiologist René Tio from Catharina Hospital in Eindhoven. As a former chair of the Groningen Examination Board, he has often seen dossiers full of concerns about students. Without misconduct, an iudicium abeundi is virtually impossible, he explains, even when there are already multiple concerns about professional behaviour in a dossier. Hard evidence is needed that patient safety, or that of colleagues or fellow students, is at risk.

Expulsion is extremely difficult. “As a programme, you are obliged to offer resit after resit. You hope to make students increasingly aware that they’re not suitable for the profession. But with students displaying problematic behaviour, that lack of insight is precisely the problem. Then it’s a matter of frustrating them, to encourage them to do something else.” Exam results that eventually expire or need to be retaken are the means of the programme to get a student to quit, Tio explains. That’s basically all the programmes can do, until a student actually poses a danger to themselves or others. That’s why the iudicium abeundi was introduced.

In practice, a situation where patient safety is at stake rarely happens, it appears from discussions with doctors supervising interns. A doctor who doubts a intern’s suitability won’t leave them alone with a patient. “Through good supervision, the actual breach of patient safety during training is usually prevented”, the chairs of the examination boards wrote in 2022. They proposed that the decision to not leave a intern alone with patients should weigh as heavily as an incident in which patient safety has actually been compromised. Following parliamentary questions about this plan, then Minister of Education Robbert Dijkgraaf stated that he did not agree. The right to education was, in his opinion, too important, and it’s up to doctors to ensure patient safety when interns are at work.

Establishing a dossier is necessary to initiate a procedure, but not all doubts are sufficient to expel someone. ‘Insufficient functioning (…) in collegial interaction or professional behaviour’ is not enough, as stated in the protocol of the Dutch Federation of University Medical Centres.

Moreover, it is incredibly difficult to signal unprofessional behaviour, says someone involved in the Rotterdam programme. Anonymously, because this person faced serious threats in relation to this topic. “We rightly place demands on doctors as a society. Yet I often thought: I didn’t want you to become a doctor. But there was nothing we could do to prevent it. The iudicium abeundi is often only possible if multiple people have expressed their concerns, and even then it’s challenging. Students know what assessors look for and can often behave as expected when it matters. They are, by definition, smart, which can also lead to behaviour that is essentially a form of ‘faking good’. But medical students must behave towards patients and other stakeholders as a good doctor should, even when there is no assessor around. There was a student who once said to me: ‘If you want me to hold the door open for someone else, I will. But if no one is looking, I will just close it.'”

The most famous example in the Netherlands of a student you would prefer not to become a doctor is probably Fouad L., a student about whom there were concerns for years, about whom there was a dossier – both inside and outside Erasmus MC. It all wasn’t sufficient to expel him from the programme.

L. had already received all his credits and was about to receive his diploma. Following a report from the Public Prosecution Service, the Examination Board imposed an additional requirement: he would need to undergo a psychological evaluation. The medical student had previously been convicted of animal abuse and exhibited more erratic behaviour. Not receiving his diploma made him furious. In revenge, he murdered his neighbour, her 14-year-old daughter, and Erasmus MC lecturer and GP Jurgen Damen. Just before his arrest, he threw Molotov cocktails into the Education Centre and set fire.

How could this man progress through the entire programme without being expelled? During the trial against L., one of the judges posed this question. After all, he had, albeit with some delay, passed all exams and ultimately completed his internships. The expert from Pieter Baan Centre summarised the issue during the trial: “Interns come and go. Before you realise where the problem lies, they are gone again.” Especially when someone works hard and quickly picks up the theory, as L. did, it can take a while before problematic behaviour becomes apparent, the expert noted.

It seems so obvious: give an unsuitable intern a fail mark when they display problematic behaviour. However, fail marks are often not given, tell doctors and those involved in the programme. A fail has serious consequences for the student (delays), the assessing doctor (a lot of extra work), and the programme (growing waiting lists). Each year, Rotterdam students have five intake opportunities for their internships. Every ten weeks, 78 students can start, so 390 per year. If someone fails? That person or someone else has to wait longer, or an extra spot must be created.

The internships are described as ‘a moving train’, says Jasper Klasen, PhD candidate and former member of the Joint Assembly, the faculty council at Erasmus MC. Every period is a train that must stay on schedule for efficiency. If a student fails, they must wait on the platform until the next train arrives. The problem is, every train is completely full. “The system is not built for resits or fails. So when that happens, the programme has to start calling around to hospitals: ‘Do you have any extra spots?'” Therefore, there have been instances of mercy passes being given, multiple supervisors confirm.

Klasen has been involved in the new assessment system for the internships, alongside former chair of the Medical Student Amir Abdelmoumen. One of the goals was to prevent unsuitable students from progressing through the internships. “The question was: we all want fewer jerks at the bedside, but how do you achieve that?”

The new Rotterdam assessment system started nearly two years ago. Students no longer receive a final grade per internship; instead, supervising doctors must now fill out multiple assessment forms and approve assignments, more focused on skills and professional behaviour. All of this is reviewed by a committee that decides on the student’s progress. Klasen believes the new assessment system will help, but not sufficiently: “Politics should take this issue seriously. It concerns a societal interest.”

The new assessments are less focused on the specific internship and more on the skills that a registered doctor must possess. Where students previously received one assessment at the end of the period, they now receive multiple and smaller assessments. This effectively forces students to master a variety of different skills. As a result, it can no longer happen that an intern graduates without ever having performed a catheterisation, for example.

The new system also prevents mercy passes, which used to occur to avoid study delays or administrative hassle. There are no grades anymore, and successfully completing an internship no longer depends on one final grade. All written feedback is collected per student and reviewed by an appointed committee. This committee determines a student’s progress based on the feedback collected.

According to cardiologist Tio, the grading system was due for an update anyway: “The grades for the internship have undergone significant inflation in the last ten to fifteen years. An eight had become quite normal, whereas previously it was a seven. If you now received a six, it simply wasn’t very good”, Tio observed. Other doctor assessors confirm this.

The initial results of the new assessment system are promising, says Jelle Meerstra from Erasmus MC. As a policy advisor, he was involved in the new system and is now researching the results. The idea is that doctors can be constructively critical without immediately giving a fail. “At least three times during the internships, the decision committee reviews the portfolios. In pairs, always a clinical specialist and a medical psychologist. Students can then receive three types of decisions”, Meerstra explains. A ‘one’ stands for: keep it up. With a ‘two’, you are allowed to continue but under conditions. You are informed about what to focus on and who can help you. With a ‘three’, the internships are paused. The examination board is notified, you receive extra support and may not proceed until you meet the conditions set.

The first time the decision committee met, most assessments were ones, but some twos and threes were given as well, Meerstra reports. “Not many, but significantly more than there were fail marks in the previous system. So there may be more people dropping out in this system, but there can also be more tailored attention to what is needed. This way, we can – hopefully – provide early support and not let someone feel like they are ‘drowning’, and if someone is unsuitable, engage in a conversation about what an alternative might be. Yes, giving good substantial feedback takes time, but one thing is paramount: delivering reliable, good doctors.”

Delivering reliable, good doctors that society can trust is the priority of the programmes. In 2022, the Minister of Education did not wish to amend the iudicium abeundi precisely due to the protection of the student and their right to education. “It concerns the accessibility of higher education and the student’s interest in being able to complete a programme or not”, then Minister Robbert Dijkgraaf wrote in 2022. Programmes must raise their own barriers to filter out unsuitable students. For example, by adjusting the Educational and Examination Regulations, said the minister. Other options include limiting the number of assessment opportunities and the validity period of assessments.

This position remains unchanged, a spokesperson for the Ministry of Education, Culture and Science informs. “It is about the Executive Board sufficiently substantiating that the student in question has shown unsuitability for the profession for which the programme trains.”

When asked whether the triple murder by former medical student Fouad L. has prompted a change in that stance, the spokesperson from the ministry writes: “Ending the enrolment of students who pose a threat to others by their statements or actions was and is still possible under the law.” The spokesperson further states: “During the programme, medical students work under the responsibility of BIG-registered doctors who are subject to disciplinary law. This way, patient safety is ensured as much as possible.”

The call for a broader iudicium abeundi options remains, confirms the Rotterdam Examination Board in a written response. The Erasmus MC states it will not respond to additional questions from EM. “The concern of not influencing the appeal of Fouad L. weighs heavily on the management of Erasmus MC”, a spokesperson for the hospital writes. “Therefore, careful consideration is given to what is said. Additionally, other ongoing matters further contribute to the decision not to make further statements.”