Medical students that you don’t want at your bedside

Medical students that you don’t want at your bedside

Fouad L. was about to receive his diploma

02-10-2023 · Background

Should Fouad L., a student who shot three people dead in Rotterdam last week, become a primary care doctor? The Public Prosecution Service (Openbaar Ministerie) doubted this and warned Erasmus University. But it turns out to be almost impossible to send away unsuitable medical students. Observant already wrote an article about the difficult issue in February. UM professor Walther van Mook: "I would like to submit a case to the judge."

An intern who writes herself a prescription and who gives a child an unsupervised injection during a work placement. The student is suspended and given intensive supervision afterwards. To no avail. During her last internship – she is studying at Vrije Universiteit – things go horrible wrong: she harms a patient, takes on an authoritarian tone and sends a letter of referral without permission. The Board of Examiners has lost faith. According to the board, the student’s behaviour is characterised by ‘systematic shortcomings in the application of knowledge, skills, reflection, professional behaviour, dealing with patients and co-operation. 

Another student, from Leiden, is guilty of unacceptable behaviour towards an underage patient and her mother. The man used Facebook to seek contact with the daughter and the mother and did so in sexually tinted wording. The mother filed a complaint. The student admitted to the unacceptable use of language, but thought that it wouldn’t be a problem as he did so as a private person.

Yet another student, from Rotterdam, threatened to hang nude photographs of his ex-girlfriend in the hospital where she worked as a trainee nurse. There was already 'an accumulation of serious misconduct' prior to this instance of intimidation.

Danger

All three students were removed from their study programmes. In all Dutch medical faculties together, this has only happened a handful of times in the past thirteen years. In Maastricht, there wasn’t a single one. This may be considered as remarkable as a national measure was introduced in 2010 – the so-called iudicium abeundi – which enables institutes to expel their students.

However, the measure appears to be complex, time-consuming and sets the bar much too high. The student concerned must be found guilty of ‘morally reprehensible behaviour’, resulting in danger for a patient or colleagues. It hardly ever comes to that. Also, collecting evidence sometimes takes so much time that the student has been graduated for some time.

The right to higher education is considered a higher good than the right of the faculty to expel students, says intensivist Walther van Mook, also professor of Professional Development and chairman of the Maastricht Committee in that field. “And yes, the right to education is certainly important, until you yourself have a student or a doctor at your bedside who is completely unsuitable. Then you will feel differently about it.”

Dying

A few years ago, Van Mook carried out research into this and discovered that 8 per cent of the Maastricht medical students – a total of 350 – scored insufficiently for professional behaviour at some time during their studies. 

“That is quite a lot, but anyway, it can happen. It is not a reason for expelling a student. If you cause a traffic accident, your driving licence is not immediately revoked either. But it can be worse: 1 per cent of the students make mistake after mistake, don’t do anything with feedback and don’t learn from it. So, he or she is simply not suitable to become a doctor.”

These students don’t just have a problem with professional behaviour, but often also score insufficiently when it comes to knowledge and skills, says Van Mook. ”All of this appears to be a risk factor for later on, because as doctors they make comparatively more mistakes and have more complaints made against them. Not just because their behaviour is unpleasant for patients but complications occur more often and more people die.”

More than enough reasons to expel students: why hasn’t that happened in Maastricht? “Firstly, there is an improvement period during which the student receives intensive supervision and possible alternatives are considered, such as a free bachelor’s or a different study programme. Should this not provide a solution, it is up to the Board of Examiners or the dean to initiate an iudicium abeundi procedure. Usually, the right to education weighs heavier and the decision will be made in favour of the student.”

Minister

In the three years that Kitty Cleutjens has been chairperson of the Board of Examiners for the Faculty of Health, Medicine & Life Sciences, there were two UM students who made the alarm bells go off, she says. Before her time, there was a case in which a student left at the last moment when he heard that the Board of Examiners were planning to start an iudicium abeundi."

Besides sending someone packing – or actually, advising the Executive Board to expel someone – the Board of Examiners can also suspend someone. "We do that when students are found guilty of fraud, for example after having committed plagiarism. Suspension can be imposed for a single exam, for three months or for a whole year. I have not encountered the last two options yet. It doesn’t happen much, because students have intensive supervision in the Maastricht curriculum and we intervene at an early stage when things go wrong." 

If none of those measures work, Cleutjens agrees that it is game over. As far as she is concerned, the iudicium abeundi works below par. What’s more, that the Board of Examiners from all medical programmes have joined forces and presented a plan to the minister last year. The boards want the law to be adapted in order to lower the threshold for starting an iudicium abeundi. If supervisors dare not leave the student alone with a patient, that should be sufficient reason to initiate such a measure. 

Lobbying

Questions on the matter were submitted in Parliament in September, but minister Dijkgraaf bounced the ball back, says Cleutjens. "He feels that It is up to the medical faculties themselves to repair any shortcomings in the OER. However, this is easier for some programmes than for others. It can be done if you test each part separately, but in Maastricht we apply programmed testing. This means that you take the whole picture into account each time."

The Board of Examiners can also take a 'disciplinary measure', says Cleutjens. Should a student show serious shortcomings, the board can appoint an independent assessor to investigate the case. Based on this, the student can be expelled, but only if the misconduct took place in MUMC+, not in another hospital. "A case with another medical institute in the country fell through because of that fact.” 

What now? "We will continue to lobby to have the threshold for an iudicium abeundi lowered." 

Court

In the meantime, the Maastricht professional behaviour committee has added an extra procedural step. Each case of a student not functioning properly is put before the Dutch Association for Medical Education (Nederlandse Vereniging voor Medisch Onderwijs, NVMO), of which the chairpersons of professional behaviour committees of all UMCs are members. If they come to the conclusion that everything possible has been done to get the student back on the right track, the Board of Examiners could decide to start the iudicium abeundi procedure.  

However, all too often the committee makes a different assessment, says Van Mook, or cases are settled amicably. “My opinion is different to that of the Board of Examiners. I want them to speak out about cases in order to better define the limitations of what is permissible. The Board of Examiners and the lawyers however, end up with everything that has to do with this on their plates."

Van Mook would like to "push things to their limits," he says. "I would like to take a case in which absolutely everything has been tried and take it to court. With the argument: imagine your wife ends up in hospital and has a student at her bedside who we know has made mistake after mistake during his or her studies. If it turns out that the court or whoever is not happy with this, you shouldn’t give such a student the opportunity to become a doctor."

Cleutjens emphasises that the procedure should be impeccable. "You must prevent students from being damaged unjustly. The institute must be 100 per cent sure of their case before they expel someone."

Van Mook is prepared to accept that the wrong decision is taken every now and again. "If you unjustly expel one medical student out of a hundred, then let that be the case. Unfortunately, we will have to accept that uncertainty."

This article was previously published on 28 February 28 2023

Illustration: Bas van der Schot

Tags: fhml, medical students

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