Royal Dutch Medical Association Research Articles

Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal

BackgroundRecognition of poor performance in General Practice trainees is important because underperformance compromises patients’ health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal.MethodsWe performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance.ResultsBetween 2011 and 2020, 24 residents who were dismissed from training challenged their programme director’s decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation.ConclusionsDeficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director’s decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others.

Dismissed Psychiatry Residents Who Appeal: Exploring Unprofessional Behavior

ObjectiveDutch psychiatry residents who are dismissed from their training program have the opportunity to appeal the decision. Those appeals are publicly available. This report explores the appeals of residents dismissed for unprofessional behavior.MethodsThe authors analyzed caselaw of dismissed psychiatry residents brought before the conciliation board of The Royal Dutch Medical Association and compared them to a control group of caselaw of dismissed family medicine residents.ResultsFrom 2011 to 2020, 19 psychiatry residents were dismissed for failing to meet the competencies of the CanMEDS professional domain and matched with 19 family medicine residents. Most psychiatry residents deficient in professionalism were considered deficient in their attitude, in reliability of keeping agreements, or in their ability to profit from supervisors’ feedback. Insufficient professional behavior overlapped with insufficient communication, collaboration, and management. Half of the psychiatry residents with deficits in professionalism went on sick leave at some time. Between residents in psychiatry and family medicine, or between psychiatry residents with and without a favorable conciliation board decision, no statistical differences were found regarding gender, year of residency, and number of insufficient competencies.ConclusionsThe deficiencies in the professionalism of residents who challenged their program director’s decision to be dismissed mostly consisted of inadequate attitude or the inability to profit from feedback, suggesting that these residents lack empathy, introspection, or both.

Efficacy and safety of drugs used for 'assisted dying'.

Background‘Assisted dying’ is practiced in some European countries and US states. Legislation suggests that there exists an easily prescribed drug which consistently brings about death quickly and painlessly. Evidence from jurisdictions where ‘assisted dying’ is practiced, however, reveals that hastening patient death is not so simple.Sources of dataThis report is a collation of assisted suicide and euthanasia drug protocols published by the Canadian Association of MAiD Assessors and Providers and the Royal Dutch Medical Association, annual data reports from the USA and Canada and relevant academic publications pertaining to methods of ‘assisted dying’ in the USA, Belgium, Canada and Switzerland.Areas of agreementA wide variety of lethal drug combinations are used for people who want their life ended, and the prevalence of complications and failures in intentionally ending life suggest that ‘assisted dying’ applicants are at risk of distressing deaths.Areas of controversyThe efficacy and safety of ‘assisted dying’ drugs are currently difficult to assess, as clinician reporting is often very low.Growing pointsThe findings from this report reveal that little attention has been given to the problem of unmonitored prescribing and administering of lethal drug combinations, whose mode of action is unclear.Areas timely for developing researchIn order to properly assess the efficacy and safety of ‘assisted dying’, a more thorough means of data collection regarding the drugs used must be implemented and research is urgently needed into their mode of action.

Physicians' norms and attitudes towards substance use in colleague physicians: A cross-sectional survey in the Netherlands.

IntroductionSubstance use disorders (SUD) in physicians often remain concealed for a long time. Peer monitoring and open discussions with colleagues are essential for identifying SUD. However, physicians often feel uncomfortable discussing substance use with a colleague. We explored physicians’ attitudes and norms about substance use (disorders) and their (intended) approach upon a presumption of substance use in a colleague.Materials and methodsAn online cross-sectional survey concerning “Addiction in physicians” was administered by the Royal Dutch Medical Association physician panel. Overall, 1685 physicians (47%) responded. Data were analyzed by logistic regression to explore factors associated with taking action upon a substance use presumption.ResultsMost physicians agreed that SUD can happen to anyone (67%), is not a sign of weakness (78%) and that it is a disease that can be treated (83%). Substance use in a working context was perceived as unacceptable (alcohol at work: 99%, alcohol during a standby duty: 91%, alcohol in the eight hours before work: 77%, and illicit drugs in the eight hours before work: 97%). Almost all respondents (97%) intend to act upon a substance use presumption in a colleague. Of the 29% who ever had this presumption, 65% took actual action. Actual action was associated with male gender and older age (OR = 1.81; 95% CI = 1.20–2.74 and OR = 1.03; 95% CI = 1.01–1.05, respectively).ConclusionsAbout one-third of physicians reported experience with a presumption of substance use in a colleague. Whilst most physicians intend to take action upon such a presumption, two-thirds actually do act upon a presumption. To bridge this intention-behavior gap continued medical education on signs and symptoms of SUD and instructions on how to enter a supportive dialogue with a colleague about personal issues, may enhance physicians’ knowledge, confidence, and ethical responsibility to act upon a presumption of substance use or other concerns in a colleague.

Requests for futile treatments: what mechanisms play a role? Results of a qualitative study among Dutch physicians

ObjectivesOvertreatment is increasingly seen as a challenge in clinical practice and can lead to unnecessary interventions, poor healthcare outcomes and increasing costs. However, little is known as to what exactly...

Development of a national medical leadership competency framework: the Dutch approach

BackgroundThe concept of medical leadership (ML) can enhance physicians’ inclusion in efforts for higher quality healthcare. Despite ML’s spiking popularity, only a few countries have built a national taxonomy to facilitate ML competency education and training. In this paper we discuss the development of the Dutch ML competency framework with two objectives: to account for the framework’s making and to complement to known approaches of developing such frameworks.MethodsWe designed a research approach and analyzed data from multiple sources based on Grounded Theory. Facilitated by the Royal Dutch Medical Association, a group of 14 volunteer researchers met over a period of 2.5 years to perform: 1) literature review; 2) individual interviews; 3) focus groups; 4) online surveys; 5) international framework comparison; and 6) comprehensive data synthesis.ResultsThe developmental processes that led to the framework provided a taxonomic depiction of ML in Dutch perspective. It can be seen as a canonical ‘knowledge artefact’ created by a community of practice and comprises of a contemporary definition of ML and 12 domains, each entailing four distinct ML competencies.ConclusionsThis paper demonstrates how a new language for ML can be created in a healthcare system. The success of our approach to capture insights, expectations and demands relating leadership by Dutch physicians depended on close involvement of the Dutch national medical associations and a nationally active community of practice; voluntary work of diverse researchers and medical practitioners and an appropriate research design that used multiple methods and strategies to circumvent reverberation of established opinions and conventionalisms.ImplicationsThe experiences reported here may provide inspiration and guidance for those anticipating similar work in other countries to develop a tailored approach to create a ML framework.

Non-Therapeutic Circumcision: The Ethical Position of the Royal Dutch Medical Association

Non-Therapeutic Circumcision: The Ethical Position of the Royal Dutch Medical Association

Dutch Protocols for Deliberately Ending the Life of Newborns: A Defence.

The Groningen Protocol, introduced in the Netherlands in 2005 and accompanied by revised guidelines published in a report commissioned by the Royal Dutch Medical Association in 2014, specifies conditions under which the lives of severely ill newborns may be deliberately ended. Its publication came four years after the Netherlands became the first nation to legalize the voluntary active euthanasia of adults, and the Netherlands remains the only country to offer a pathway to protecting physicians who might engage in deliberately ending the life of a newborn (DELN). In this paper, I offer two lines of argument. The first is a positive argument for the Protocol, grounded in the good of the newborn as unanimously determined by those in a position to determine it. The second addresses the widely shared belief that the killing of newborns is morally prohibited, where I offer two arguments-one grounded in the fact that the kinds of cases the Protocol is meant to govern are very rare and highly unusual, and the other focused more broadly on the role of pre-theoretical beliefs in moral reasoning-meant to undermine the strong role that the critic of the Protocol affords this belief. I argue that, given this second line of argument, the beliefs underlying my positive argument for the Protocol are in fact more secure than the widely shared belief underlying the critic's position.

Circumcision: Is it worth it for 21st-century Australian boys?

Circumcision: Is it worth it for 21st-century Australian boys?

Palliative Sedation: An Analysis of International Guidelines and Position Statements.

To describe the suggested clinical practice of palliative sedation as it is presented in the literature and discuss available guidelines for its use. CINAHL, PubMed, and Web of Science were searched for publications since 1997 for recommended guidelines and position statements on palliative sedation as well as data on its provision. Keywords included palliative sedation, terminal sedation, guidelines, United States, and end of life. Inclusion criteria were palliative sedation policies, frameworks, guidelines, or discussion of its practice, general or oncology patient population, performance of the intervention in an inpatient unit, for humans, and in English. Exclusion criteria were palliative sedation in children, acute illness, procedural, or burns, and predominantly ethical discussions. Guidelines were published by American College of Physicians-American Society of Internal Medicine (2000), Hospice and Palliative Nurses Association (2003), American Academy of Hospice and Palliative Medicine (2006), American Medical Association (2008), Royal Dutch Medical Association (2009), European Association for Palliative Care (2009), National Hospice and Palliative Care Organization (2010), and National Comprehensive Cancer Network (2012). Variances throughout guidelines include definitions of the practice, indications for its use, continuation of life-prolonging therapies, medications used, and timing/prognosis. The development and implementation of institutional-based guidelines with clear stance on the discussed variances is necessary for consistency in practice. Data on provision of palliative sedation after implementation of guidelines needs to be collected and disseminated for a better understanding of the current practice in the United States.

Consultation with specialist palliative care services in palliative sedation: considerations of Dutch physicians

Palliative sedation is considered a normal medical practice by the Royal Dutch Medical Association. Therefore, consultation of an expert is not considered mandatory. The European Association of Palliative Care (EAPC) framework for palliative sedation, however, is more stringent: it considers the use of palliative sedation without consulting an expert as injudicious and insists on input from a multi-professional palliative care team. This study investigates the considerations of Dutch physicians concerning consultation about palliative sedation with specialist palliative care services. Fifty-four physicians were interviewed on their most recent case of palliative sedation. Reasons to consult were a lack of expertise and the view that consultation was generally supportive. Reasons not to consult were sufficient expertise, the view that palliative sedation is a normal medical procedure, time pressure, fear of disagreement with the service and regarding consultation as having little added value. Arguments in favour of mandatory consultation were that many physicians lack expertise and that palliative sedation is an exceptional intervention. Arguments against mandatory consultation were practical obstacles that may preclude fulfilling such an obligation (i.e. lack of time), palliative sedation being a standard medical procedure, corroding a physician's responsibility and deterring physicians from applying palliative sedation. Consultation about palliative sedation with specialist palliative care services is regarded as supportive and helpful when physicians lack expertise. However, Dutch physicians have both practical and theoretical objections against mandatory consultation. Based on the findings in this study, there seems to be little support among Dutch physicians for the EAPC recommendations on obligatory consultation.

Euthanasia in psychiatry can never be justified. A reply to Wijsbek

In a recent article, Henri Wijsbek discusses the 1991 Chabot "psychiatric euthanasia" case in the Netherlands, and argues that Chabot was justified in helping his patient to die. Dutch legislation at the time permitted physician assisted suicide when the patient's condition is severe, hopeless, and unbearable. The Dutch Supreme Court agreed with Chabot that the patient met these criteria because of her justified depression, even though she was somatically healthy. Wijsbek argues that in this case, the patient's integrity had been undermined by recent events, and that this is the basis for taking her request seriously; it was unreasonable to expect that she could start again. In this paper, I do not challenge the Dutch euthanasia criteria in the case of somatic illness, but I argue that both Chabot and Wijsbek are wrong because we can never be sufficiently confident in cases of severe exogenous depression to assist the patient in her irreversible act. This is partly because of the essential difference between somatic and mental illness, and because of the possibility of therapy and other help. In addition, I argue that Wijsbek's concept of integrity cannot do the work that he expects of it. Finally, I consider a 2011 position paper from the Royal Dutch Medical Association on euthanasia, and the implications it might have for Chabot-style cases in the future.

Male circumcision: risk versus benefit

Ancient wall paintings and mummies record the practice of male circumcision 6000 years ago.1 Its origins remain obscure but are variously derived from religion, ritual and culture. Today, surgical indications...

Gender differences in medical students’ motives and career choice

BackgroundThe main subject is the influence of gender and the stage of life on the choice of specialty in medical education. In particular we looked at the influence of intrinsic and external motives on this relationship. The choice of specialty was divided into two moments: the choice between medical specialties and general practice; and the preference within medical specialties. In earlier studies the topic of motivation was explored, mostly related to gender. In this study stage of life in terms of living with a partner -or not- and stage of education was added.MethodsA questionnaire concerning career preferences was used. The online questionnaire was sent to all student members of the KNMG (Royal Dutch Medical Association). 58% of these students responded (N = 2397). Only 1478 responses could be used for analyses (36%). For stipulating the motives that played a role, principal components factor analysis has been carried out. For testing the mediation effect a set of regression analyses was performed: logistic regressions and multiple regressions.ResultsAlthough basic findings about gender differences in motivations for preferred careers are consistent with earlier research, we found that whether or not living with a partner is determinant for differences in profession-related motives and external motives (lifestyle and social situation). Furthermore living with a partner is not a specific female argument anymore, since no interactions are found between gender and living with a partner. Another issue is that motives are mediating the relationship between, living with a partner, and the choice of GP or medical specialty. For more clarity in the mediating effect of motives a longitudinal study is needed to find out about motives and changing circumstances.ConclusionsThe present study provides a contribution to the knowledge of career aspirations of medical students, especially the impact of motivation. Gender and living with a partner influence both choices, but they are not interacting, so living with a partner is similarly important for male and female students in choosing their preferences. Moreover, external and intrinsic motives mediate this relationship to a greater of lesser degree. First stage students are influenced by life-style and intrinsic motives in their choice of general practice. For second stage students, the results show influences of life-style motives next to profession-related motives on both moments of choice.

Palliative Sedation: Reliability and Validity of Sedation Scales

ContextObserver-based sedation scales have been used to provide a measurable estimate of the comfort of nonalert patients in palliative sedation. However, their usefulness and appropriateness in this setting has not been demonstrated. ObjectivesTo study the reliability and validity of observer-based sedation scales in palliative sedation. MethodsA prospective evaluation of 54 patients under intermittent or continuous sedation with four sedation scales was performed by 52 nurses. Included scales were the Minnesota Sedation Assessment Tool (MSAT), Richmond Agitation-Sedation Scale (RASS), Vancouver Interaction and Calmness Scale (VICS), and a sedation score proposed in the Guideline for Palliative Sedation of the Royal Dutch Medical Association (KNMG). Inter-rater reliability was tested with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient. Correlations between the scales using Spearman's rho tested concurrent validity. We also examined construct, discriminative, and evaluative validity. In addition, nurses completed a user-friendliness survey. ResultsOverall moderate to high inter-rater reliability was found for the VICS interaction subscale (ICC=0.85), RASS (ICC=0.73), and KNMG (ICC=0.71). The largest correlation between scales was found for the RASS and KNMG (rho=0.836). All scales showed discriminative and evaluative validity, except for the MSAT motor subscale and VICS calmness subscale. Finally, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. ConclusionThe RASS and KNMG scales stand as the most reliable and valid among the evaluated scales. In addition, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. Further research is needed to evaluate the impact of the scales on better symptom control and patient comfort.

Palliative sedation: not just normal medical practice. Ethical reflections on the Royal Dutch Medical Association's guideline on palliative sedation

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny...

Versterven bij een psychiatrische patiënt: hindernissen voor patiënt, familie en behandelteam

In this case-report we present a patient with a psychiatric history of a chronic depressive disorder. After a period of several years of ambivalence, he decided to refuse nutrition and hydration because he--in the words of the Royal Dutch Medical Association--was "suffering from life". There was no request for euthanasia or physician assisted suicide. His first attempt, that lasted six weeks, did not result in his death. A second attempt, four months later, ended successfully. We describe the pitfalls that the patient, his family and the professional caregivers faced in both trajectories. The premorbid psychiatric disorder with polypharmacy and several psychotropic drugs as a result, the enormous complaints of thirst, the role of his wife and the dilemmas faced by the professionals made this case very complex. These issues make such cases very challenging for professional teams that have to provide good palliative care.

CAM-education in the medical curriculum: Attitude towards and knowledge of CAM among Dutch medical students

Aim of the study The purpose of the study was to investigate the attitudes and knowledge of medical students towards complementary and alternative medicine (CAM) at Dutch medical schools. The increased use of CAM and the changing perspectives of the Royal Dutch Medical Association (RDMA) on medical education and CAM raised the question what medical students think about CAM and its place in the medical curriculum. Materials and methods In total 10,532 RDMA student members from all Dutch medical schools were invited to complete a questionnaire by email. Participants were asked to state their attitude and knowledge about CAM, and the role of CAM in the medical curriculum. Results The response rate was 19% ( N = 2004). Students of all medical schools responded equally. Student's average age was 22.0 years (SD: 3.0) and 72.4% was female. Further, 74.2% indicated that their knowledge about CAM is limited and two-thirds (62%) emphasized the importance of CAM education in the medical curriculum. One-third (35.7%) of the students would like CAM to be part of the core medical curriculum. More than three-quarters of the students (76.9%) indicated that doctors should have knowledge about CAM. The majority of respondents (83.0%) answered that doctors should be able to give patients objective information about CAM. Seventy percent (69.9%) stated that more research should be performed on the effectiveness and safety of CAM. Conclusions The results show that medical students in the Netherlands have a positive attitude towards CAM as well as its place in the medical curriculum.

Disclosure of Medical Data to Relatives after the Patient’s Death: Recent Legal Developments with Respect to Relatives’ Entitlements in The Netherlands.

In the Netherlands the physician is still bound to professional confidentiality after the patient's death. However, in the legal doctrine and in case law some exceptions have been recognized, especially for circumstances where the relatives have a legitimate interest in the inspection of medical records of the deceased. Today developments as regards the Dutch proposal to new legislation on patients' rights, notably the proposed insertion of a provision stipulating the conditions under which the relatives have a right of access to medical records of the deceased, give cause for renewed consideration of this issue related to legal protection after death. This article explores whether the proposed provision corresponds to the prevailing principles regarding disclosure of medical data after death. It is concluded that there is a need to reconsider the provision's wording or to adhere to self-regulation of the Royal Dutch Medical Association in order to strike an appropriate balance between the various interests concerned.

CAM-education in the medical curriculum: Vision of medical students

Objective Purpose of our study was to investigate the attitudes and knowledge of medical students towards complementary and alternative medicine (CAM) at all eight medical universities in the Netherlands. Design Empirical quantitative research using a questionnaire survey. Methods In total 10,532 student members of the Royal Dutch Medical Association (KNMG), at all eight universities in the Netherlands, were invited to complete a short questionnaire by email. The questions were divided into three parts. The questions in the first part were about self-reported use of CAM, scientific research skills to appraise the CAM literature and attitude, opinion and interests in CAM. The second part consisted of six questions asked about each of the nine most used CAM-therapies in the Netherlands. The six questions were about knowledge, effectiveness, existing and desired education, referral to CAM services and integration into the Dutch health care service. The third part were 30 statements about evidence-based-medicine, the side effects and safety of CAM, the place of CAM in the Dutch Health Care Service, CAM in the medical education, the position and visibility of CAM in professional education, reasons for using CAM, and the role and influence of the Royal Dutch Medical Association on the availability of CAM services. Results A total of 2004 medical students responded to our questionnaire. The average age of respondents was 22.7 year (SD: 3.9) and 71.9% were female. The most students (83%) said that doctors should be able to give patients objective information about CAM. The opinion of 69.9% was that more research must be done to establish the effectiveness and safety of CAM. The majority (74.2%) responded that they do not have enough knowledge about CAM and more than three quarters (76.9%) responded that doctors should have such knowledge about CAM. Two-third felt it is important that knowledge about CAM therapies should be taught at medical school while one-third felt it should be in the core medical education. Conclusions The result of this study shows that medical students in the Netherlands have a positive attitude towards CAM and think it should be part of their medical education.