Obstacles for international medical graduates in the Netherlands after the introduction of the assessment procedure in 2005
- Open Access
- 03-03-2026
- Forum
Abstract
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Introduction
The Dutch Journal of Medicine (Nederlands Tijdschrift Voor Geneeskunde) recently published an article by Groothoff et al. on foreign doctors in the Netherlands [1]. The authors concluded that international medical graduates (IMGs) are increasingly better qualified for medical practice in the Netherlands. At first glance, this is a positive development. However, there are still significant structural obstacles in the assessment procedure, which has been in effect since 2005.
One of the most recent bottlenecks is the increasing waiting time between part A (language exams) and part B (professional knowledge and skills exams). This waiting time now averages 22 months. Groothoff et al. attribute this to limited testing capacity and inadequate funding from the Dutch Ministry of Health, Welfare, and Sport. At the same time, they note a significant increase in the pass rate on the Clinical Knowledge Examination, which rose from 27.6% (2018–2021) to 74.2% (2022–2024). The authors attribute this improvement to better preparation of the candidates.
In this contribution, I will analyze that improvement in relation to developments in information provision, exam preparation, and language support. In addition, I will identify a structural selectivity in the literature on which Groothoff et al. base their conclusions. Research that presents a less rosy picture of the policies often remains unmentioned. In what follows, I will identify these overlooked sources and analyze their implications for admissions policies.
Improved test results and the role of information provision
Part B of the assessment procedure consists of the Interuniversity Progress Test Medicine, Clinical Knowledge Examination, and Clinical Skills Examination. As Groothoff et al. indicated, the results on the Clinical Knowledge Examination have significantly improved in recent years. However, less attention has been paid to the context of this improvement. In 2018, Teunissen and I noted that assessment candidates were told by the Commission for Foreign Healthcare Graduates that substantive preparation for the Professional Competency Examination was not necessary [2]. In hindsight, this advice proved incorrect and misleading, as IMGs were compared with regular medical students in the final phase of their training.
On the initiative of the Association of Foreign Medical Graduates in the Netherlands, structural efforts have ever since been made towards subject-specific preparation, including workshops, dedicated informational materials, and the use of the Compendium Medicine [3]. These efforts may largely explain the recent increase in test results.
Use of sources in literature on assessment policies
Several studies cited by Groothoff et al. originate from authors who are or have been involved with the Commission for Foreign Healthcare Graduates, an agency of the Ministry of Health, Welfare, and Sport responsible for the execution of the assessment procedure. For example, in a 2008 article by Ten Cate and Kooij (chair of the Commission for Foreign Healthcare Graduates), the procedure is described as being successful, although this judgement is based on impressions rather than empirical research [4]. A 2009 publication by Sonderen et al. in Medical Teacher, in which an 80% dropout rate is considered “good practice,” was later deemed incorrect by a Commission for Foreign Healthcare Graduates official [5]. Yet, the article has not been retracted. A 2017 study by Kooij et al. contained data on successful IMGs that did not correspond with the Commission for Foreign Healthcare Graduates annual reports [6]. Nonetheless, these publications continue to be cited as references.
At the same time, critical publications by independent researchers remain unmentioned. For instance, in my 2009 dissertation, I demonstrated that the assessment procedure had negative consequences for IMGs, particularly due to the lack of language courses and guidance [7]. Similarly, evaluations from the Foundation for Refugee Students UAF are missing, which warned of an almost stagnant influx of refugee doctors. They noted that 90% of the refugee doctors who took the first exam failed. A large number of doctors drop out disappointedly and pursue training at a lower level or stay home unemployed [8].
In 2013, I wrote an evaluation report on the assessment procedure [9]. The study showed that before the introduction of the assessment procedure, 100 or more IMGs entered the (higher years of) medical programs annually. A survey among the medical faculties revealed that since the introduction of the assessment procedure, 41 IMGs had enrolled over a period of five years. This report, extensively discussed at the office of the Commission for Foreign Healthcare Graduates, drew the attention of Het Financieele Dagblad (April 27, 2013) and Trouw (May 1, 2013); both are quality papers in the Netherlands. Radio 1 of the Dutch Broadcasting Company also interviewed the author about his findings. On the day that Trouw published its article, then Minister of Health, Welfare, and Sport Edith Schippers announced during the 8 o’clock evening news that an investigation would be conducted into the obstacles faced by IMGs.
The contract from the Ministry of Health, Welfare, and Sport was awarded to the research agency Panteia Research for Policy [10]. The researchers wanted to determine whether unnecessary obstacles were being erected for IMGs. Based on inflow and outflow data obtained from the Commission for Foreign Healthcare Graduates, they attempted to gain insight into dropouts. The researchers found that the figures for the period 2005–2012 were incomplete. Therefore, the Minister’s primary research question regarding unnecessary obstacles for IMGs remained unanswered. In the 2017 publication by Kooij and colleagues, the research carried out on behalf of the Minister of Health, Welfare, and Sport Schippers went unmentioned [6].
In 2018, Teunissen and I wrote an article in the journal Asylum & Migration Law titled “About time to improve procedure and organization” [2]. The article contained a large number of concrete proposals for improving the assessment procedure. These proposals stemmed from a survey that was conducted among IMGs. It did not lead to any response and/or action from the Commission for Foreign Healthcare Graduates.
During the COVID-19 pandemic, following a call from the Association of Foreign Medical Graduates, 175 IMGs signed up for the Ministry of Health, Welfare, and Sport initiative “Extra Hands at the Bedside,” of whom only one foreign doctor was actually deployed in the end [11, 12]. This underutilization led to questions in the Dutch Parliament, after which limited policy adjustments were made several years later.
In 2025, Chernova and I demonstrated that the average waiting time of 22 months between the Language Proficiency and Professional Competency Examinations has significant consequences for knowledge retention and the mental well-being of IMGs [13].
Language proficiency and preparation
IMGs who want to work as doctors in Dutch healthcare must have command of the Dutch language at a minimum B2+ level of the Common European Framework of Reference for Languages. IMGs are aware of this, as evidenced by the recent publication by De Muijnck et al. [12]. For a long time, there were no suitable teaching materials and/or courses to reach this level. The medical language teaching method “Hoe zit het met staan?” (in English: “What’s the situation?”) and the book Succesrecept voor de AKV-toets (in English: A Recipe for Success on the Language Proficiency Examination) were both developed through private initiatives [14, 15]. In the Tijdschrift LES, a journal for teachers of Dutch as a second language, it is noted that this dependence on private initiatives exposes a fundamental deficiency in government policy regarding IMGs [16]. Structural language support is still lacking, leaving IMGs vulnerable to inadequate and prolonged preparation, setbacks, and financial loss.
Structural obstacles in twenty years of international medical graduate policies
The main obstacles are as follows:
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When the assessment procedure was introduced in 2005, it appeared that the Dutch exam tested a higher level (approximately C1 level) than usual. This was unknown to the participants, and, as a result, the results were very poor.
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In the period 2005–2010, there was hardly any insight into the results of the Language Proficiency Examination. The Commission for Foreign Healthcare Graduates kept that information “under wraps.” Later, I learned from the Commission for Foreign Healthcare Graduates that this was done deliberately to avoid giving politicians sensitive data. Member of Parliament F. Koser Kaya (D66 party) forced the then Minister of Health, Welfare, and Sport Ab Klink to open the Commission for Foreign Healthcare Graduates black box by presenting the results in annual reports.
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In the information provided about the Language Proficiency Examination, the Commission for Foreign Healthcare Graduates stated that passing the State Exam NT2 Program 2 (B2 level) was not required. This misled many foreign doctors. IMGs assumed that if they had passed the State Exam NT2, they possessed sufficient knowledge of the Dutch language to pass the Language Proficiency Examination at C1 level.
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In the period 2005–2015, language courses for IMGs at (university) language institutes were virtually nonexistent. IMGs lived spread out across the country, and language institutes could hardly form groups large enough to organize a financially viable Medical Dutch course.
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There was little information available to IMGs about the quality of language institutes and the courses provided by these institutes. At the same time, there was a proliferation of language institutes in the Netherlands. As a result, many IMGs started at institutes that provided substandard quality. This led to significant delays in reaching B2 and C1 levels.
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For refugee students who were clients of the Foundation for Refugee Students UAF, adequate guidance was available. However, for IMGs who had joined their partners in the Netherlands, this guidance was lacking. Dutch partners of these doctors often had no idea about the “Dutch-as-a-second-language jungle” and the Ministry of Health, Welfare, and Sport regulations regarding IMGs.
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In the first ten years after the introduction of the assessment procedure, it was particularly costly for many IMGs. Those who accidentally ended up at the wrong language institute and made no progress could lose valuable time with no corresponding income.
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During periodically organized informational meetings, the Commission for Foreign Healthcare Graduates (Ministry of Health, Welfare, and Sport) did not provide information about language institutes offering courses of sufficient quality for IMGs. The rationale for withholding relevant information about language institutes and courses stemmed from the neutral stance of government institutions toward market parties.
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The IMGs who passed the Language Proficiency Examination could register for the Professional Competency Examination. I have explained earlier that IMGs were informed during informational meetings organized by the Commission for Foreign Healthcare Graduates that content preparation for the Interuniversity Progress Test Medicine and Clinical Knowledge Examination was not necessary. This advice was followed. The consequence was that for years, the test results were low. IMGs who spent 3–4 years on the Language Proficiency Examination lost their medical knowledge and scored poorly on the Interuniversity Progress Test Medicine and the Clinical Knowledge Examination due to lack of preparation. Due to their poor scores, they had to register as medical students for several clinical rotations. This also led to delays and high expenses with no corresponding income.
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In 2015, IMGs from all corners of the world founded the Dutch Association of Foreign Medical Graduates. They wanted to save IMGs who newly arrived in the Netherlands from the same traumatic experiences. They included information about the assessment procedure on their website, were available for advice, could provide information about high-quality language institutes, and so on. The Association of Foreign Medical Graduates also organized training sessions in preparation for the Clinical Skills Examination, using simulation patients. This helped to mitigate the worst shortcomings in the implementation practices of the governmental administrative organization.
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Recently, a new obstacle has arisen. Due to the increase in the number of IMGs registering with the Commission for Foreign Healthcare Graduates for the Professional Competency Examination, the capacity, especially for the Clinical Skills Examination, is inadequate. In the study by Chernova and me, we found that there is a waiting time of 22 months for candidates who have passed the Language Proficiency Examination and wish to proceed with the Professional Competency Examination [13]. This leads to a loss of medical knowledge, decline in Dutch language proficiency, difficulties in finding suitable work, problems with government benefits agencies, and/or psychological issues. Moreover, the test results of the Professional Competency Examination are so good that 80% of the IMGs only need to work under supervision for three more months before they are registered as medical doctors in the Dutch Professions in Individual Health Care registry (BIG-register). This makes the waiting time even more frustrating. Meanwhile, it appears that IMGs can no longer just register for the Professional Competency Examination. This means that the waiting time situation has further deteriorated.
Conclusion
Although the test results of IMGs have recently improved, structural obstacles in the admission procedure remain. These obstacles are partly the result of inadequate conditions, including a lack of transparent information, language support, and testing capacity. The current situation leads to a loss of potential for Dutch healthcare and increases inequality in access to the medical profession.
Solutions are possible through the expansion of testing capacity, structured preparatory programs, and systematic involvement of field organizations such as the Association of Foreign Medical Graduates and the Foundation for Refugee Students UAF. This could result in a fairer and more effective policy that recognizes the qualifications and commitment of IMGs with permanent residency in the Netherlands.
Funding
Publication of this article was made possible by the Professions in Individual Health Care (BIG) Coalition and the Goldschmeding Foundation.
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