The debate on the elimination of live patients in clinical licensure examinations.

Introduction

Clinical licensure exams utilizing live patients have evolved as a part of the evaluation process to access the unique skill sets that make up clinical competency for entry into dental or dental hygiene practice. Recently, traditional licensure exams have been placed under increased scrutiny.

Since the American Dental Association (ADA) (1) 2000 House of Delegates adopted resolution 64H, calling for the elimination of live patients in clinical licensure exams, practitioners, students and the examining community alike have continued a debate that's plagued the licensure process since the mid-nineties. In addition to the ADA, the American Dental Education Association (ADEA), (2) the American Association of Dental Examiners (AADE), (3) and the American Dental Hygienist's Association (ADHA) (4) have put forth opposing policies addressing the use of live patients in clinical licensure examinations (Table I). Opinions and passions on both sides of the issue are diverse and complex.

Currently, it is the role of the state boards to protect the public and assure competence in the practitioners they license. It is also necessary to provide a valid and reliable method of evaluation in doing so. Through the formation of regional testing agencies, clinical licensure examinations have historically changed to include standardization among examiners, more controlled patient variables, appeals procedures and statistical analysis, (5) yet some would argue that dental testing agencies have not gone far enough. While live patients have traditionally been used because they are reflective of true clinical practice, the use of these patients provides ethical considerations unique to a onetime examination. Lack of comprehensive patient care, quality of care, and patient follow-up are just a few of these considerations.

Few would argue that the current licensure system is not flawed. Alternatives suggested to the use of live patients include simulations, manikins, residency and elimination of the clinical exam all together. While a number of alternatives have been proposed, the literature is consistent in the lack of one clear solution.

As dentists and hygienists, we have a responsibility to understand the evolving licensure process that is the backbone of our profession. Licensure is the strongest form of professional regulation used today. In accordance with state law, licensed individuals are the only persons who meet the minimum qualifications necessary to practice their profession. Licensure is a means of protecting the public from unqualified individuals and unsafe practice. (4) We have a responsibility as a profession to insure that the licensure process continues to protect the public by licensing only competent practitioners in a manner consistent with the ethical standards of our profession.

While the elimination of live patients in clinical licensure exams has been a high-profile debate among educators, examiners and associations, the purpose of this paper is to expose the practicing dental hygiene clinician to all sides of the issue by reviewing the arguments both for and against the longstanding use of live patients in the clinical licensure exams required of dentists and dental hygienists, and to explore the proposed alternatives.

History

Dental education originally began with many independent dental schools teaching to different standards and using different curricula. The accreditation of dental education, initiated in the early 1900s, is conducted today by the Commission on Dental Accreditation (CODA) which developed standards to assure accredited dental and allied dental programs provide uniformity in the educational process. After graduation from an accredited program, the final steps required for licensure in the practice of dentistry and dental hygiene involve successful completion of an external evaluation of knowledge and clinical skills. The Joint Commission on National Dental Examination, housed and supported by the American Dental Association and governed by its own bylaws, is the agency responsible for the development and administration of the written national board exam that evaluates knowledge. The regional testing agencies and state boards assess clinical skills through the administration of a regional or state board examination. It is the responsibility of these authorities to protect the public's health and safety by insuring the competent practice of dentistry and dental hygiene through licensure.

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Clinical examinations were originally administered by member dentists of a state's licensing board who typically had little or no experience in examination, no training in methodology and few procedures for standardization among examiners. (6) Clinical licensure exams have, in fact, changed dramatically in the last 25 years. (5) The formation of regional boards (Figure 1), such as the Southern Regional Testing Agency (SRTA), has resulted in training and calibration (standardization) of the examiners, providing more stability and consistency of the examination process. (5) Now inherent to these exams is administrative protocol founded on accepted and sound principles of clinical evaluation, including comprehensive candidate manuals, predetermined performance criteria and candidate anonymity, as well as appeals procedures and comprehensive statistical analysis. Efforts continue to be made to equalize or control variables among live patients. The examining community would argue that these changes have created a valid and reliable assessment of clinical competence.

Validity: Reflective of Clinical Practice

In an effort to reflect clinical practice, the clinical licensure exams have required the treatment of live patients. Traditionally, the content and format of clinical exams have been focused on a narrow range of clinical skills. Formicola et al. argue that live patient examinations do not reflect the complex responsibilities of the dentist in contemporary practice. (7) Instead, these exams consider dentistry primarily as a set of narrow clinical restorative techniques; the few procedures tested do not reflect the complexity of today's practice. (7) The same could be said of a dental hygiene clinical exam. Successful clinical treatment of only one specific patient case type does not measure the clinical skill set necessary for a competent hygienist. While the use of manikins has been suggested as a possible alternative to live patients, a narrow range of examination procedures performed on manikins would present the same dilemma. According to a survey of dental school graduates after they have been in practice, the licensure examination is not a valid evaluation of their abilities. (8)

The American Association of Dental Examiners contends that the licensure examinations are intended to assess only basic critical clinical competencies required to enter unsupervised practice, rather than the complexities of contemporary practice. A candidate should be able to demonstrate these proficiencies on demand, in order to assure a minimum acceptable level of care. The written board, in combination with the clinical assessment, is intended to provide a measurement of the minimum requirements for entry into clinical practice. The two to eight percent of candidates who never pass the exam regardless of the number of attempts are the very candidates these exams target. (9)

Mackler, (10) an educator and examiner, is among those who favor the use of live patients as assurance of the validity--that is, the meaningfulness and usefulness--of the exam. Manikins or other forms of technology as an alternative to human patients would reduce the validity of the exam, since dentists/hygienists do not treat manikins in daily practice.

Reliability; Patient Standardization

In addition to validity, one of the hallmarks of a good evaluation tool is that it be reliable or reproducible: every student is measured in the same way with the same results. The use of live patients in licensing exams presents a formidable challenge to reliability, since it is impossible to totally standardize the level of treatment difficulty for all test takers when each uses a different live patient.

While considerable progress has been made in the effort to improve standardization of live patients since the advent of regional testing agencies, research conducted by Chambers and Loos (11) concluded that a single clinical exam involving live patients is inherently unreliable. This is due to the variability in live patients as well as the differences in examiners. Testing authorities have assured that extensive calibration of examiners have improved exam reliability, yet Chambers and Loos conclude that any combination of improved examiner calibration or increases in the number of evaluators cannot correct an exam that is not reliable. It is Chambers' recommendation, however, that live patients be retained as part of the licensure decision, believing valid determination of competency to begin unsupervised dental practice can be achieved only through testing that involves live patients, because that is what dentists (and hygienists) do. He instead suggests that the flaw in the current system is not the use of live patients, but the one-shot nature of the data collection. The solution for correcting the shortcomings of the "one-shot" live patient exam would be repeated testing on live patients.

Ethical Considerations

Of all the concerns related to the use of live patients, none raises more questions than the ethical considerations. As health care providers, our first priority is the ethical treatment of our patients. These principles, as outlined in the ADA Code of Ethics and ADHA Professional Code of Conduct, include the concept of beneficence: that is, the practitioner has a duty to promote the patient's welfare; to act for the benefit of others.

It has often been argued that those seeking licensure have so much at stake that a conflict is created between the best interests of the patient and the best interests of the candidate. In a written survey on issues in clinical testing for licensure sent to deans of dental schools in the United States, (12) the issue of greatest concern as potentially problematic for respondents was "ethical concerns in the use of live patients." Cited among the deans' concerns were financial transactions between patient and candidate, unnecessary treatment, delays in treatment and uncertainty of follow-up care. A randomized national study surveyed 1,000 general dentists regarding ethical lapses related to the use of live patients for clinical licensure examinations. (13) Over half the respondents knew with certainty of at least one instance of an ethical lapse. Approximately 24 percent reported that no follow-up care was sought for a patient when needed; 32.5 percent reported that unnecessary radiographs were taken; 14 percent reported knowledge that a classmate coerced a patient into an inappropriate treatment choice; and 19.3 percent reported knowledge that a patient had been treated overaggressively or prematurely. While follow-up care is strongly encouraged, not all exams have protocol currently in place to guarantee that a patient has follow-up care or recourse should treatment go wrong during an exam.

Conversely, AADE argues that, in reality, all treatment provided during the licensure exam is meticulously reviewed by trained examiners who assure that the treatments proposed are necessary and address definitive patient needs. (3) Patients are also advised as part of the patient consent process that the treatments to be rendered during the exam are specific to the needs of the candidate and that they, as a patient, may have other treatment needs. The fact that these treatments are provided outside of a defined treatment plan does not diminish the necessity of appropriateness of the treatment.

The opponents of the use of live patients in the licensure process have also argued that this practice is barbaric and inhumane, since these patients are subjected to inadequate care. Yet, whether patients receive treatment from students as part of their dental/dental hygiene training or as part of the licensure process, their care is supervised by licensed dental professionals. By the time candidates reach the licensure examination, they have performed these procedures daily for several years on live patients; to classify these individuals as barbarians is unjust and does a tremendous disservice to the educational process, (5) It is inconsistent to suggest that the clinical licensure examination performed on live patients is experimental or abusive.

Alternatives to Live Patients

While the calls to eliminate live patients in the clinical licensure exam have been many, the viable alternatives proposed have been few. With the advent of changes in dental education that include advancing technology, dental/dental hygiene instruction now includes remote education, distance education, simulation clinics and computer-based simulations in addition to the use of live patients to insure student competence. Opponents to the use of live patients have suggested a number of possible alternatives for the licensure process involving technology as well.

Computer-based interactive examinations have evolved as an adjunct assessment of treatment skills in medical and dental education. For example, these technologies currently have the capability to assess restorative tooth preparation. However, simulations were never intended to replace patient-based treatments, and they lack the capability to assess caries recognition and caries removal, as well as the final restoration of a preparation. As to testing the broad scope of services rendered by dentists and hygienists, a simulation modality does not exist to assess periodontal clinical skills. (3) Additionally, the potential for a breech in security is also of grave concern in the use of computer-based testing in the licensure process. While technology is a valuable adjunct to traditional education, its effectiveness at replacing existing licensure methodology currently falls short.

Another suggested alternative to the use of live patients is the third-party evaluation of a portfolio developed during the educational process. In a portfolio, students provide examples of evidence (patient experiences) to support and document their claims of clinical competency, based on their institutional program's competencies. In a dental licensure scenario, the portfolio could include two endodontic test cases and two crown placements, three comprehensive periodontal management cases, a removable prosthesis and a surgery case, three randomly selected chart reviews and defense of three completed cases with predetermined parameters. (14) Candidates would be able to choose their best cases for submission, perhaps in the last six months of their dental school education. While little data is available to support reliable and valid portfolio assessments in clinical dental evaluations, high inter-rater reliability has been documented in a dental hygiene program. (13) Portfolios are emerging as effective and appropriate for the evaluation of a candidate's performance in an educational setting. However, a portfolio assessment does not address a graduate's current competence as an unsupervised practitioner. The question should be about not what a student accomplished in school with consultation and educational guidance, but the quality of work a candidate can demonstrate independently at a time near when he or she wishes to enter practice. (15) Clearly, an investment in research is needed to determine if portfolios can be a valid alternative to the current clinical licensure exam.

New York state has taken a bold step in the licensure debate by becoming the first state to substitute the traditional clinical exam by allowing the successful completion of a residency approved by CODA as a requirement for licensure of dentists. Similar to the medical model, the state of New York has determined the best way to insure competency is one year of experience (also known as Post Graduate Year-1 or PGY-1) in a supervised setting. The fundamental principle of New York's new system is that a clinical examination is unnecessary to verify that a dentist is competent to enter practice following postdoctoral clinical training consisting of ongoing patient care, continuous oversight, mentoring, and evaluation. (16) There is little doubt that this additional educational opportunity would allow less practiced learners to gain competence. Concerns arise not over what the fifth-year programs will provide, but how that mission of further education relates to fair, unbiased assessment of critical competencies required for licensure. (17) As of this date, Minnesota is offering PGY-1 as a choice for licensure, as well as the traditional clinical exam. Data is not yet available to substantiate the outcomes of the PGY-1 programs.

Finally, there are those who call for the elimination of the clinical licensure examinations all together, with no need for an alternative. (2) The argument is that graduation from a CODA-accredited dental/dental hygiene school should, in and of itself, insure competency. (18) It is important to note that the accreditation system evaluates the process of education, not the practitioner (the product). The examining community argues that delegating licensing authority to educators eliminates an important set of checks and balances and is a conflict of interest. While it is logical to assume that faculty who have been with students throughout their dental/dental hygiene education are most capable of assessing the candidates' capabilities, those faculty members have engaged themselves in the treatments rendered by students. Educators also experience political and economic pressure to graduate students. In spite of their concerns with the clinical licensure process, 88 percent of dental school deans who responded to a survey on clinical licensure issues thought it was appropriate for dental school graduates to be evaluated for licensure by an independent third party. (12)

Conclusion

Few would argue the current clinical licensure system isn't flawed in its use of live patients. Issues of validity and reliability, patient standardization and examiner calibration are central to the problem. While many improvements have occurred in the last 20 years as a result of the formation of regional testing authorities, ethical issues still plague the system. There is a division between educators and examiners as to the elimination of live patients as well as viable alternatives, yet the licensure process will continue to evolve. As dentists and hygienists, we have a responsibility to understand this evolving process that is the backbone of our profession. As a profession, we are unlikely to agree to a solution in the short-term; we need to continue to dialogue and work together to develop a satisfactory solution that satisfies all communities of interest, most importantly the public we serve.

References

(1.) American Dental Association. Online at www.ada.org/.

(2.) American Dental Education Association. Online at www.adea.org/.

(3.) American Association of Dental Examiners. Online at www.aadexam.org/.

(4.) American Dental Hygienists' Association. Online at www.adha.org/.

(5.) Pattalochi RE. Patients on clinical board examinations: an examiner's perspective. J Dent Educ 2002; 66: 600-4.

(6.) Kalkwarf KL. How the licensure process will evolve. J Am Dent Assoc 1999; Dec; 130: 1737-42.

(7.) Formicola, et al. Banning live patients as test subjects on licensing examinations. J Dent Educ 2002; 66: 605-9.

(8.) Meeske J. Clinical board examinations; feedback from graduates. J Dent Educ 1995; 59: 351.

(9.) Pattalochi RE. Of human patients. J Am Dent Assoc 2001; 1638-9.

(10.) Mackler FS. Licensing exams. J Am Dent Assoc 2001;132: 720.

(11.) Chambers DW, Loos L. Analyzing the sources of unreliability in fixed prosthodontics mock examinations for 1990 and 1991. J Dent Educ 1992; 56: 348-50.

(12.) Ranney et al. A survey of deans and ADEA activities on dental licensure issues J Dent Educ 2003; 67: 1149-60.

(13.) Gadbury-Amyot CC et al. Predictive validity of dental hygiene competency assessment measures on one-shot clinical licensure examinations. J Dent Educ 2005:69 (3): 363-70.

(14.) Hammond D, Beckendahl CW. No, portfolios assessments should not be used in in dental licensure. J Am Dent Assoc 2006;137: 30-42.

(15.) Ranney RR, Hambleton R. Yes, portfolio assessments can be used successfully in dental licensure. J Am Dent Assoc 2006; 137:31-41.

(16.) Lansky RE, Shub JL. Dental licensure reaches a crossroads: the rationale and method for reform. J Dent Educ 2003; 67: 295-300.

(17.) Maitland RI. The New York state postgraduate fifth-year dental residency as a new licensure path: concerns for public protection. J Dent Educ 2003; 67: 301-10.

(18.) American Student Dental Association. Online at www.asdanet.org/.

By Cathy Elliott, RDH 

Cathy Elliott, RDH, graduated from Southern Illinois University and is a degree completion student at the University of Missouri-Kansas City. A former clinician and educator, she is currently the manager of education for the American Dental Hygienists' Association in Chicago.

Table I.

Professional association Policy or position statement

American Dental Association   In 2005, the ADA reaffirmed its
                              support for the elimination of
                              human subjects in the  clinical
                              licensure examination process with
                              the exception of the curriculum-
                              integrated  format. The curriculum-
                              integrated format involves multiple
                              examination times during the school
                              year, allows for remediation and
                              quite often allows the students
                              to use their own patients.

American Association of       AADE supports the use of live patients
Dental Examiners              in the clinical licensure exam as a
                              realistic and reasonable approach in
                              assessing competency for licensure
                              until such time new methodologies
                              emerge as an alternative (2001).

American Dental Education     ADEA has always supported periodic third
Association                   party evaluations like the National
                              Board exam, but supports the elimination
                              of the use of patients in clinical
                              licensure exams. ADEA also supports the
                              ADA in the principle that Post Graduate
                              Year 1 (PGY-1) may meet the clinical
                              licensure requirement for dentists
                              (2004).

American Dental Hygienists'   ADHA supports the elimination of
Association                   patients in the dental hygiene clinical
                              board examinations for candidates who
                              are graduates of accredited dental
                              hygiene programs and who have
                              successfully completed the National
                              Board Dental Hygiene Examination when a
                              valid and reliable substitute
                              examination becomes available. ADHA
                              also supports research to identify a
                              valid and reliable alternative to the
                              use of human subjects in the clinical
                              licensure examination (2008).