Fighting medical windmills: No one would listen to Jaap Pesman

He’s disillusioned, says Jaap Pesman. When he started the internship portion of his medical studies, he was having the time of his life. He took part in committees and was making friends. He dreamed of a job as a physician, starting a family, settling down. 

Two years later, he hasn’t progressed at all. He lost valuable time after a conflict with the affiliate coordinator and examiner at the hospital in Deventer where he did his internship. This is the person who will make the final decision as to whether an intern will pass or fail.

He says he’s not the only one who’s been affected. He knows about other interns who got into trouble. Unfortunately, they’re all afraid of the consequences of complaining, since doctors are all powerful and everyone protects each other. 

Vulnerable position

The first annual report published by the UG’s ombudsperson proves that this isn’t just a single incident. In the report, she writes that eight medical students have come to her in the past year. ‘Medical interns are in an especially vulnerable position. They are largely dependent on their programme directors and affiliate coordinators or examiners and are afraid to speak up.’

This view is supported by the results of a survey held by interest group De Geneeskundestudent, which were published at the end of March. 10 percent of medical students experience inappropriate behaviour from supervisors and specialists, but 78 percent of those instances remain unreported, because people are afraid of the consequences.

They all protect one another

But Jaap Pesman did speak up. First, he decided to address what happened during his first internship in his second year, and then he spoke up about the examiner, who he felt refused to listen to what had gone wrong even as she developed her own bias against him. 

But no matter who he turned to – the exam committee, the Board of Appeal for Examinations, the Central Portal for the Legal Protection of Student Rights, and even the board of directors – he kept coming away empty-handed, often after waiting months for an answer. ‘Everyone knows everyone’, he says, ‘and they all protect one another.’

He wasn’t properly heard until he turned to the Council of State this summer. The Council ruled that the decision that he should do two extra internships to compensate for a single failing grade wasn’t properly motivated. Next week, the Groningen Board of Appeal for Examinations will re-evaluate his case. 

Failing grade

It all started when Pesman started his second year of medical internships. The thirty-seven-year-old student, who decided to switch to a medical career after working as an editor at Autoblog, had had no issues whatsoever during his first year. 

He says the atmosphere in the nursing home where he worked felt unsafe. ‘Two specialists kept making rude jokes about the interns.’ It didn’t seem like a problem, though. ‘You’re doing a great job, Jaap!’, his mentor emailed him on the eleventh day. 

However, twenty-four hours later, that same mentor told him he might get an NYOT (not yet on track) judgement for his internship. In other words, a failing grade. In fact, his fellow intern, who’d left a week ago, would also be failing. Retroactively, even, since they’d already received a passing grade for their internship. His mentor had contacted his examiner – the person in charge of internships at the hospital and who make the final judgement.

Pesman asked the department for feedback and was told he wasn’t ‘enthusiastic’ enough and that he didn’t show sufficient initiative. One specialist gave an example: when he’d invited the student to attend an assisted death, the latter had demurred.

Nonsense, said Pesman. ‘I had a mandatory class to attend and had to ask for dispensation. But I told them I did want to come.’

Note

The discussion that followed led to a note in his file. While he did ultimately pass, his mentor wrote that Pesman ‘has trouble accepting feedback’. After that, she called in sick, claiming she was burned out.

Pesman was worried. ‘In the medical world, that’s a serious accusation’, he says. ‘I was worried it would haunt me.’  Plus, he says, his fellow intern recognised the unsafe feeling he had at the nursing home. 

She told me that I made her very uncomfortable

When he was asked to meet with his examiner, he wanted to explain why the note on his file was wrong. ‘I sat down and she didn’t say anything. I just kind of started talking and eventually she said I was a grown man and that I should stop complaining. She told me I had to ask myself what I could have done differently. She also told me that I made her very uncomfortable.’

The examiner has a different recollection of the meeting. ‘During the first meeting, JP went off on a long tangent about everything that was wrong with the department – twenty minutes of the meeting were spent the department instead of how JP functioned at the department. […] This was cause for concern,’ states a report that retired professor Jos Snoek wrote after investigating the situation.

Unfair

After this, Pesman had two internships go smoothly. But when he ended up in his previous examiner’s department after these, things started going decidedly pear-shaped. She told her colleagues exactly what she thought of him, says Pesman. Email communication has shown that the examiner did in fact talk to colleagues about Pesman’s supervision.

According to him, however, that meant her colleagues were no longer able to judge him fairly. This meant that this time, he did receive the dreaded NYOT. 

At the same time, his examiner had the assessment for the block, for his first three internships. She repeated the issue about ‘trouble with feedback’ and added another remark: ‘When it came to professional development, the plastic surgery department also noted that you need a more active attitude. You’re not using enough opportunities to learn.’

Pesman felt this was unfair. She ignored all the compliments his mentors gave him in favour of this one, slightly critical, remark.

He wrote another long email to his examiner, explaining how her actions were affecting his educational journey. ‘That email was a cry for help, but they saw it as “proof” that I couldn’t handle feedback.’

Shared concerns

Once again, the examiner has a different view: ‘The concerns about JP’s functioning at the department were shared by all supervisors. It wasn’t just her and she can say in good conscience that she shared no negative information with supervisors beforehand, and that all her actions are rooted in concern for JP’, the later report says.

All her actions were rooted in concern

After talking to the programme directors, she also referred Pesman to the SRC – the Signalling and Remediation Committee – where students back then were sent if they ‘showed insufficient progress in their professional development’. He also had to report the previous problems to his mentors. 

Pesman was sure they had it out for him and wanted to leave Deventer. ‘But then the examiner announced that she would be willing to the handover to a new hospital’, he says. ‘The whole situation made me feel so threatened.’

Eight internships

Was it really that bad, though?

Due to the Covid pandemic, Pesman did eight internships instead of the standard ten. The study programme says it agreed that a student with a failing grade would have to do ten internships after all, Snoek’s report states. But the TER never mentions this. It only says that a student could be forced to do one or two extra internships. But it was also fine to not make them do any extra work. 

The Council of State noted the same thing in its decision last month. It was also clear as day that there was an issue between the examiner and Pesman. And there was no one around to give a second opinion, since affiliate coordinators/examiners are the only ones who decide whether students pass or fail. 

This has led to previous problems. In May 2022, there was a similar case before the Board of Appeal for Exams at the UG. A student demanded a second opinion because she felt the examiners assessment hadn’t been fair. Her request was denied, because there is no regulation that gives medical interns the right to a second opinion. 

Snoek is critical of this in his research report. The affiliate coordinator is the sole person responsible for the final assessment. ‘That has given the affiliate coordinator a lot of power. At the same time, it’s become more difficult for that same affiliate coordinator to supervise interns at their own department and test them in a formative manner […]. That can be a problem for medical interns who stand out for whatever reason.’

Do-over

Pesman protested again. If push came to shove, he was willing to redo the entire second year, as long as he didn’t have to work with his examiner. His request was denied. Programme director Friso Muntinghe offered him a spot at a hospital in Friesland, Pesman says. ‘It was the one hospital I absolutely didn’t want to go. Later, I heard there was room for me at other hospitals. He also decided my examiner could do the handover, because he had faith that she would do great.’

Pesman had had enough. He unenrolled from the programme and went looking for help. But in spite of the many offices and authorities set up to help students, he was sent from pillar to post. 

The affiliate coordinator has a lot of power

He started with the confidential adviser at the hospital. They were willing to sit in on meetings, but they emphatically said they wouldn’t get substantially involved. 

He also went to the study adviser, but he said there wasn’t much he could do. He did say that he felt that the examiners had all the ‘power’ and that Pesman wasn’t the only one facing the problems he was.

He submitted a complaint to the Board of Appeal for Exams, but to no avail: his was only a partial grade, and the Board didn’t deal with those.

Step four was the UG’s new ombudsperson. She actually listened to him and advised Pesman to document everything thoroughly. 

Step five was seeing a lawyer for advice. ‘They told me to go to the exam committee and submit a formal complaint.’

Hen house

He wrote up an extensive report and submitted his complaint to the Central Portal for the Legal Protection of Student Rights in February 2022. They referred Pesman to the complaints mechanism at the Faculty of Medical Sciences, which turned out to be headed up by the programme director.  ‘However, I explicitly named the programme directors in my complaint. It’s like a fox guarding the hen house.’ 

He also started a complaints process with the exam committee at medical sciences. They refused to look into his complaint of 130 pages until he’d reduced it to a single page. Three months later, they just referred him back to the programme directors.

Step eight: the complaints department at the hospital in Deventer. ‘That was in March or April. They didn’t process my complaint until November.’ They ended up rejecting his complaint.

The ombudsperson issued an unsolicited recommendation, but that didn’t do anything, either, even though she had made it clear that a complaint could never be handled by the person the complaint is about.

At the end of his rope, he emailed university president Jouke de Vries – step nine. The president responded the very same day, promising to look into his complaint and get back to him. But what followed was only silence. ‘At first I thought I’d hear back from him after the summer’, says Pesman. ‘But when I contacted him again to ask him about it, I got no response.’

The ombudsperson did tell him that the university president didn’t get involved in individual cases, Pesman says.

Independent investigation

The tenth step was emailing the dean of the medical faculty. Only then did something finally start happening. A month after he emailed the dean, he was invited for a meeting with pro-dean Gerda Croiset. The ombudsperson accompanied him. 

It was decided that an independent investigation into what happened was needed. ‘They also decided that I should get a say in where they sent me for internships’, says Pesman. ‘They also made sure my record was purged and that my examiner would no longer be involved in the handover.’ 

Examiners don’t make this decision by themselves

Not that this was a speedy process. The investigative report took two months to put together. The final verdict was that the incident happened so long ago there wasn’t much left to say about the complaint. About this, Snoek writes that while he ‘can fully understand why JP felt like he didn’t get a fair chance at the department of nursing home medicine or at the department of internal medicine and that he feels like people didn’t listen to him or even actively worked against him’, but that he doesn’t ‘doubt the genuinely professional motives of the supervisors’. 

But even Snoek realised there were issues. First of all, there was the fact that the examiner was solely responsible for the students’ assessments. And then there was the fact that this very same examiner has access to all information in the students’ digital files, including the things they might have discussed during confidential coaching meetings. ‘That’s not okay’, said Snoek. 

Meeting

He suggests limiting the examiner’s access. It might also be a good idea to have examiners confer with a small committee before handing out failing grades. ‘I would advise this even more strongly if an affiliate coordinator plans to fail a student who interned at the department where that affiliate coordinator works’, writes Snoek. ‘Because of the relationships they forged over the years with their fellow specialists, it becomes difficult if not impossible for examiners to be impartial, which is necessary for a summative assessment.’

Finally, Snoek writes that the complaints mechanics must ‘be improved’. ‘I feel, for instance, that a report to the Central Portal for the Legal Protection of Student Rights shouldn’t exclusively be handled by mail by the programme directors of the medical master.’ 

While the report led to access to students’ digital records being limited at the start of this year, programme director Friso Muntinghe says the examiners aren’t as omnipotent as some people might think. 

Assessing practical elements such as internships, there are various people giving feedback, he explains. All that feedback ends up with the examiner. ‘Those subjective assessments together lead to an objective picture.’

But the examiner doesn’t make any decisions on their own, he emphasises. He won’t comment on the Pesman case itself, but if anyone has concerns about an intern, they discuss that with other examiners in a monthly meeting. The students’ information is always anonymised. And yes, sometimes someone with an NYOT can still pass their final assessment. ‘But examiners don’t make this decision by themselves, although they are personally responsible for the decision.’

Hard look

The complaints process couldn’t have been improved or fast-tracked. ‘My time was limited and I followed all the applicable regulations’, he says. ‘But feedback on the current procedure will obviously mean we’ll take a critical look at it, no matter what we do.’ 

The way I’ve been treated is a sign to other interns

Even Muntinghe is aware of the fact that many students fail to report problems because they don’t feel safe enough to do so. ‘I read De Geneeskundestudent, too’, he says. ‘We have to do something about that. We want students to feel safe enough to address things.’

Pesman isn’t impressed. ‘If you want people to speak freely, maybe don’t punish the ones that do. I’m convinced that the way I’ve been treated is meant as a sign to other interns: “This is what happens when you criticise us”.’  

Right before the summer, he finally got a response from the board of directors, a full year after he’d emailed the university president. His complaint had been investigated. There wasn’t anything substantive they could say about it. He wasn’t surprised.

Farce

The UG’s legal department judged that nothing untoward had happened and that none of the many covenants and rules had been broken. Pesman was heard and there had been an independent investigation. As such, ‘everything has been done in accordance with regulations’, the letter states. ‘The report also states that the parties involved in the complaint have been given the opportunity to be heard […]. We’ve complied with all the formal demands of the complaints procedure.’

Pesman says it’s a farce. ‘The ombudsperson, who has a legal background, said the same thing.’

Pesman decided it was time for the next step: the Council of State. In August, this body decided that the rules had not been followed in handling this case. While they can’t act as examiner, the Council did determine that the Board of Appeal for Exams provided insufficient arguments for why Pesman had to do so many additional internships.

In the meantime, the examiner has provided new arguments. On September 16, the Board of Appeals for Exams will reconvene to reassess Pesman’s complaint. 

Pesman has gone back to school in the meantime. After two more internships, he’ll finally be done.

Dutch