‘Iudicium abeundi must protect both patients and students’, says advocacy group

“Although the iudicium abeundi is mostly known as a last resort to remove unsuitable students, it also serves as a safety net for the students themselves”, says Berk Uzunalioglu, of De Geneeskundestudent (translated:The Medicine Student). “The measure only follows after hearing both sides, clear explanations of what constitutes unacceptable behaviour, and support.” The advocacy group argues for protection of all parties involved: students against arbitrariness and injustice, and patients against future healthcare professionals who display unprofessional behaviour.

The iudicium abeundi is a protocol introduced nearly fifteen years ago. It allows students to be expelled from their programme if their behaviour or statements are deemed incompatible with the profession. This concerns behaviour that would have resulted in disciplinary action had they already been licensed doctors – such as intimidation, aggression or violence.

In practice, this regulation is an ’empty shell’, all examination boards said in 2022. To this day, they continue to call for its expansion. Investigation by EM shows that removing an unsuitable student is often difficult in practice.

“What happened on 28 September 2023 must never happen again”, says Uzunalioglu, referring to the attack at Erasmus MC by then-medical student Fouad L. Lecturer Jurgen Damen was killed in the attack. Just prior to that, L. had murdered his neighbour and her daughter. “A student who consistently displays dangerous behaviour should never be allowed to become a doctor. Such students must be expelled from the programme.”

In 2022, the chairs of the examination boards wrote: “Good supervision usually prevents actual breaches of patient safety during the programme.” They suggested that the decision not to allow a medical intern to see patients on their own should be treated with the same seriousness as an incident in which patient safety is actually compromised.

The chair of the advocacy group is cautious about expanding the iudicium abeundi. Any expansion must be carefully designed, Uzunalioglu argues, to avoid disproportionate consequences based on a snapshot in time. “The principle should be that such a drastic measure is only considered if a student repeatedly exhibits unprofessional behaviour and fails to complete a remediation process.”

A report on a student must be taken seriously, but De Geneeskundestudent is not in favour of harsher penalties for unprofessional conduct. “We support stronger remediation, initiated immediately after the report.” Uzunalioglu refers to the PhD research of GP and University of Amsterdam researcher Marianne Mak-van der Vossen. Her research explores how unprofessional behaviour can be identified and categorised, and how to respond. Students can learn that unprofessional behaviour will not be tolerated, as it negatively affects future patient care, she concludes.

Mak-van der Vossen also found that a small proportion of students who display unprofessional behaviour fail to improve. “After several failed remediation attempts, a student must be expelled”, says Uzunalioglu. “This process must be careful, consistent, independent and transparent – and often is.”

Another concern for medical schools is that expelled students can simply enrol in another programme. At present, a student could successfully apply to a different medical school. Students expelled under the iudicium abeundi must be reported to the education minister, but no central database exists. Neither the Ministry of Education, Culture and Science, nor the umbrella organisation Universities of the Netherlands tracks how many students this concerns.

Uzunalioglu supports the idea of such a database. “If a student is expelled under this protocol, they shouldn’t be able to start another medical degree. That seems obvious to me. I don’t think such a student would suddenly behave differently in another programme.”

The education minister has already indicated that they do not wish to amend the law to expand the iudicium abeundi. The right to education carries too much weight, is the official stance.

But patient safety and the right to education don’t have to be at odds, says Uzunalioglu. “If problematic behaviour is identified early, the student has a chance to grow through remediation and guidance. If that process is transparent, and if it is made clear that professional behaviour is crucial for patient safety, future patients will benefit. If that growth fails to materialise, there must be room to end the student’s programme.”