The clinical board examination without patients would be more fair and predictable, and no one would flunk if a patient was a no-show.
Unbridled enthusiasm among its American Student Dental Association, or ASDA, sponsors was evident when the 2000 ADA House of Delegates passed Resolution 64H, which called for the elimination of the use of human subjects in the clinical licensure examination. ASDA viewed the action as a "great" move by the ADA to rid itself of a process "that has been embarrassing, unethical and does not serve the purpose [for which] it was intended." Not so pleased were the resolution’s detractors, who now are being "encouraged" to work within their jurisdiction to rescind 64H.
Following passage of the live-patient resolution, a JADA Question of the Month asked if 64H was a positive move for dentistry. It elicited an unprecedented number of responses from students and dental practitioners.
Students universally acclaimed its passage, which indicated that many of the problems associated with clinical licensure examinations—such as cost of providing dental assistants, insurance, transportation and lodging—would be eliminated. The clinical board examination without patients would be more fair and predictable, and no one would flunk if a patient was a no-show. The ethical aspects of using live patients for detecting incompetence also would cease to be an issue.
The hundreds of letters received from students can be summed up best by this statement from a student from California: "This is a position which will move to establish greater equity in the clinical licensure exam. Dental schools provide the training and evaluation to ensure students develop appropriate skills in working with the variables associated with live patient interaction. In the ideal world, shouldn’t we be like our medical counterparts—placing the responsibility and accountability on the dental school to ensure clinical competency? We need to provide means for all dentists to have full freedom of movement unencumbered by the current restrictions by many states in not accepting all clinical board exams. This is one step in that direction."
The concept that dental schools should confirm and be held accountable for the clinical skills of their students in lieu of clinical licensure examinations was noted by many of the students and dentists who had responded in the affirmative to the JADA question. Many practitioners indicated this action was long overdue; one of these wrote that using "live patients is barbaric, unnerving, and unethical treatment of people—patients and students alike."
Not every respondent agreed that eliminating live patients would be good for dentistry. Comments such as "If students can’t handle the pressure of board exams with human subjects, how will they handle the real world of dentistry?" or "Real dentists should prove they can work on real people" and "Treating the live patient in an exam setting gives a more complete look at the applicant’s clinical and management skills" are just a few of the antiresolution comments. Concerns that dental schools also might become de facto licensing institutions also were voiced.
An editorial in the spring issue of Bulletin of the American Association of Dental Examiners1 captured the essence of the dentists’ negative comments in an editorial entitled "Ignorance." Implying that 64H was a stupid effort, it questions whether "this was an egalitarian effort on the part of the House of Delegates to spare the dental school consumer from the carnage produced by these future ‘competent by graduation’ candidates."
The idea that clinical board examinations and dental school accreditation should be considered "redundancies" if dental schools are "teaching what is required of them" is pooh-poohed by the writer, who expresses his contempt by stating, "Duh! My, my, my, it would certainly ease the transition of the freshly washed little cherubs into the ADA fold if we were to have no standards for licensure whatsoever."
The editorial implies that the 64H action was just the ADA’s pandering to the students to get them to join the ADA—that it had no relationship to human subjects or measuring competency. Furthermore, it states that the 64H vote was taken late in the day, when delegates apparently were "demonstrating more of a late cocktail desire than an interest in serious debate of issue."
Let’s examine the editorial’s comments. Was this just a ploy of the ADA to gain eventual members? No. The live patient issue is a troublesome one that continues to plague the students. Just look at what happened at the Central Regional Dental Testing Service’s August examination in Kansas City, Mo.: a broken water main leading to clinical facilities resulted in cancellation of the examination. Any clinical procedures not finished at that time had to be completed at a future examination. The examination in Chicago, three weeks later, would be the earliest opportunity. While candidates needn’t pay additional testing charges, costs for transporting and housing the candidate, a patient and perhaps even a dental assistant would have to be added to the already existing test expenditures.
This obviously was a very difficult situation for newly graduated students already burdened with a debt of more than $100,000 and no ready supply of cash to pay for the additional expenditure.
And it would be a nonissue if live patients were not involved.
But, yes, it also is a membership issue. Young dentists certainly warrant the ADA’s attention. Please consider that by 2010, 40,000 new dentists will have joined the dental work force. For organized dentistry to continue to speak with one voice, it is crucial that these potential members see value in an ADA membership. If they have a valid issue, why shouldn’t it be addressed?
The ideal solution to the entry licensure issue would be to have examiners and educators work together to ensure that graduates were competent to practice dentistry. Presently, I get the feeling that "live-patient" licensure advocates do not believe that dental schools are graduating dentists who are clinically capable.
They point to the failure rate on the present licensure examinations as evidence that simply licensing graduates from an accredited dental school does not protect the public from incompetence. I would question whether clinical examinations weed out the incompetent and ask this: where did the dentists who initially failed and then passed the licensure examination gain their newfound skills, since they had no opportunity for remediation?
Personally, I like the Canadian licensure model, which links the accreditation process with the licensing authority. With both entities participating in the schools’ onsite evaluations, no clinical examination is required for licensure. We can do that. In fact, we are doing it.
Initiated a few years ago, a member of the dental examining community (selected by the American Association of Dental Examiners) is included as a full participant in all U.S. dental school accreditations. If these examiners detect clinical problems, they are in an excellent position to bring them to the attention of the accreditation team and the dental school.
This could be the solution. But until both education and licensure communities gain sufficient trust in the system and each other, I suggest that if we must give a clinical examination, let’s do it in the presence of both faculty and dental board members while the dental student still is enrolled in school. This handles the ethical and remediation issues.
Meanwhile, the world of U.S. dentistry is not waiting for the dental education and licensure community to find some accommodation. The Texas Dental Association has become the latest to support the elimination of use of human subjects in the clinical licensure examination.
Recent action by the board of governors of the New York State Dental Association authorized its organization to seek legislation to eliminate live testing on clinical tests for dental licensure. They are also investigating requiring a fifth year in an accredited general practice residency program as the future criterion for licensure in New York.
Obviously, more than a few dentists think our "freshly washed little cherubs" are real dentists with real concerns.
