Sorting out competence related conflicts of physicians in specialty training

It is the programme director’s task to teach and guide physicians in the postgraduate training programme towards standard sufficient for the specialty. Conflicts regarding competence levels contain intriguing and important information about standards for the functioning of the individual specialist. The contents and outcomes of such conflicts during specialty training are potentially relevant for the educational quality and safety of health care. Residents and clinical supervisors may benefit from making currently implicitly used criteria and considerations on dismissal more explicit. This would assist detecting inadmissible behaviour and fostering residents to avoid dismissal.

Personal persuasion to initiate PhD-research

As a Dutch psychiatrist with a background in ethics and law, I served as programme director and member of the Dutch conciliation board that provides Alternative Dispute Resolution (ADR) in postgraduate medical education (from 2020-2024). This job inspired me to study and share the learning points provided by disputes in postgraduate medical education. My supervisors (Walther van Mook and Rankie ten Hoopen), a medical and legal professional, joint in on a project combining law and health professions education conducting a study on conflict resolution routes.

The resident’s route starts with mediation at the centralised education committee of a teaching hospital, may continue at the national conciliation board, or the courthouse. Generally, education conflicts stern from diverging insights on assessment, guidance or training termination in case the programme director decides to fail or dismiss the resident from the training programme. A programme director may terminate the training of a resident who performs insufficiently or is unapt for the specialty. Outcomes of the education conflicts entering this route could be either resident’s dismissal, or another attempt at remediation, eventually leading to specialist registration.

Professional self-regulation on education standards and conflict resolution

According to the Dutch Individual Healthcare Professions Act, the medical profession is entitled to self-regulate to safeguard the norms governing the education of future professionals. These regulations are laid down in a General Directive and additional regulations including standards per specialty and internal procedures on alternative dispute regulation. From 2010 onwards, Canadian Medical Education Directives for Specialists (Standards on Competencies), the so called CanMEDS competencies for medical professions were implemented in training regulations. Evaluating the application and effectiveness of these rules through rulings on education conflicts were a novum.

A programme director may dismiss a doctor from residency training in the interest of society, solely when individually tailored remediation attempts have failed repeatedly. Dismissal decisions are seldomly shared with the public and hardly ever researched. Reasons for researchers’ reluctance may be privacy protection, marginal prevalence, or stigma on dysfunctional doctors. Continuing the silence on this topic prevents medical educators from collectively learning about struggling residents, compelling situations, and complicated procedures in legal contexts.

Approach and answers provided by the project

I questioned Dutch teaching hospitals on their approach and outcomes when applying mediation between the programme director and the resident who wishes to become a specialist. Unfortunately, residents did not perceive hospital’s mediating committees as independent, impartial, and neutral. Residents were, therefore, reluctant to approach the committees, and they exclusively did in severe disputes about training dismissal. Consequently, these highly escalated disputes were difficult to resolve, evidencing ineffective mediation attempts.

Most residents’ cases submitted for mediation at hospital committees passed through to the Dutch National Conciliation Board, where a total of 120 residents (approximately 1,2 % of all the residents in training) pleaded their case after a dismissal decision (between 2010 and 2021). The research elucidated programme directors’ reasons for residents’ dismissals via considerations and particularities preserved in caselaw:

• Over 70 % of the dismissed residents had deficiencies in three or more CanMEDS competencies, most frequently communication, medical expertise and professionalism.¹
• Patterns of unprofessional behaviour in residents were related to interaction/attitude and handling feedback (introspection), lack of involvement, such as unavailability when on call, and lack of integrity such as resumé fraud, and stealing medication.²
• Success-rates of residents’ conciliation requests and ultimate registration as an independent partitioner differed significantly between specialties, maybe due to differences in training regulations for assessment, remediation and dismissal (success-rates for requests and registration respectively were 17 % and 3 % for general practice, and 44 % and 18 % for hospital-based specialties.³

Several residents approached the courts to decide on their education conflicts with their programme directors or employees. Dutch courts generally respect the discretion of the Dutch conciliation board, and insist that programme directors dismissal decisions should be based on a reasonable explanation.

Potential professional and social impact

Research on programme directors’ views on minimum professional standards is relevant for continuous professional development and reflection on assessment bias. For example, residents with a physical or mental illness were overrepresented in Conciliation Board cases, and subcultural conceptions of the resident’s interaction, collaboration, and professionalism may contribute to bias. Comparing current practices of resident remediation methods with the literature sheds light on additional approaches for remediation.

The study on mediation, conciliation and law cases primarily focused on the period between 2011-2020, leading to several publications and oral presentations. From 2022, programme directors struggling with regulations on postgraduate education for potential dismissal disputes had access to our findings. Subsequently, the number of conciliation board cases ruled in favour of training continuation declined (from 56% in 2021 to 17% in 2024), reaching statistical significance.⁴ Hopefully, programme directors were enabled to provide better guidance and support to residents with good prospects, and effectively dealt with residents who should not graduate.

This research project reviewed ten years of law cases on residents’ dismissal from training programmes in medical specialties, and provided opportunities for improving the quality of residents’ assessment, remediation, and dismissal procedures. Case examples of dismissal procedures demonstrated the potential of 'learning from law cases', whether these cases were typical or exceptional. Unexpected and unfavourable outcomes after (re)mediation provided material for learning and contributed to the continuous professional education of clinicians.

Exploring the content of conflicts on training continuation explicates the often implicit expectations about the functioning of future medical specialists. Ultimately, the increased awareness on minimal quality in professionals and inclusivity in medical education may benefit society because residents as highly educated healthcare professionals are future role models within a hospital’s hierarchy.

1. Godschalx-Dekker JA, Gerritse FL, Mook WNKA van, Luykx JJ. Do deficiencies in CanMEDS competencies of dismissed residents differ according to specialty? Medical Teacher 2023;45(7):772-777.
2.  Godschalx-Dekker J, Pronk S, Olthuis G, Hoopen R ten, Mook W van. Ethical issues in unprofessional behavior of residents who dispute dismissal: ten year analysis of case law in hospital-based specialties. BMC Med Ethics 2025;26(11):25.
3. Godschalx-Dekker JA, Mook W van. Dutch dismissal practices: characteristics, consequences, and contrasts in residents’ case law in community-based practice versus hospital-based specialties. BMC Medical Education 2024;24(160).
4. Godschalx-Dekker JA, Mook WNKA van. Research on residents’ (re)mediation and dismissal in the interest of society. Societal Impacts 2025;(6):100130.