Thank you for the opportunity to read the mind of the examining community on the subject of clinical examination versus portfolio as a means to assess entry-level competence (Hammond D, Buckendahl CW, Ranney RR, Hambleton R. Do Portfolio Assessments Have a Place in Dental Licensure?
JADA 2006;137:30–41[Medline]
).
A core belief remains that requiring a recruited human subject to be treated during one highly stressful examination in a few specific ways is both a guarantor of quality and protective of the public. The American Association of Dental Examiners, or AADE, has wedded itself to the notion that there are no alternatives, nor will it scientifically search for them.
It has arrogated to itself the authority to assess its means and outcomes, claiming reliability and validity of the clinical examination and an essential public need for its existence. That it has done so for more than a century, without having to prove its claims, is truly amazing.
The current AADE-backed system of a clinical examination, administered by politically appointed dentists, is disruptive of accredited educational processes, expensive, inefficient and ethically challenged. Examining dental students and dental hygiene students costs approximately $12 million per year, all of it out of young, and often empty, pockets. Hundreds of examiners are transported, housed in hotels and fed, at significant expense.
Perhaps most importantly, thousands of human subjects are recruited specifically for the purpose of examination. These patients often have been "stored" for months, their diseases untreated, that they might serve as test subjects. Dental students often have mentioned the existence of entrepreneurs among them who have charged $500 for a suitable board patient. Examiners ignore the importance of comprehensive care, as only required procedures are of concern. Follow-up care is paid lip service.
All of this is in the pursuit of the approximately 1.5 percent of graduates who ultimately fail such examinations. Is it believable that the clinical examination is sensitive enough to find the right 1.5 percent, and that finding those individuals is reliably protective of the public? Does the end justify the means?
Examiners themselves are one day indistinguishable from the body of dentistry, the next day among a select cadre privileged to sit in judgment without undergoing any examination themselves. In my opinion, all it takes is knowing a state governor, or someone who knows the governor, and a dental license.
Almost half a century ago, W. Edwards Deming began a movement that ultimately changed how the world looked at quality. He taught us that quality could be measured and continuously improved, that it can occur in many ways and that it must occur if producers of goods and services are to remain viable. Can the examining community honestly face America, and our profession, and claim that there are simply no alternatives? Perhaps even more troubling is that dental examiners, by focusing so much of their resources on examination of young dentists, have limited their capacities in areas where they are needed more.
Members of the profession acknowledge that there may be some problems with quality and ethical behaviors in American dentistry. Examiners should identify where the problems come from and focus on them, rather than focusing the bulk of their energy on examination of dental students. There may be little benefit from picking such low-hanging fruit.
American dentistry has undergone tremendous change since the creation of clinical examinations for the purpose of dental licensure. Contemporary dental practices and the American population are far more complex than the clinical performance narrowly focused on by examiners. The old saying, "If all you have is a hammer, everything starts looking like a nail," is well-suited for the attitude of the dental examining community.
How many ADA House of Delegates resolutions and policies have the AADE simply ignored over the years? Should the examining community be allowed to chart its own directions within a profession that has differing values? Can American dentistry afford to allow dental examiners to insulate themselves from change?
