A Review of the Ethics of Patient-Based Licensure Examinations.

Purpose Concerns regarding the ethical justification for the use of single-encounter, procedure-based examinations on live patients for the licensure of dental hygienists and dentists in the United States persists despite decades of debate and publication on the subject. The purpose of this literature review was to summarize the specific ethical concerns and quantify recommendations in favor or against this examination methodology.Methods A population, intervention, control or comparison, outcome (PICO) question was developed to review the topic as follows: "For individuals receiving dental care as part of determination of candidates for competency and readiness for licensure, do patient-based licensure examinations, as compared to other assessment methods, violate or infringe upon ethical principles or ethical standards for health care or society?" An electronic search was performed in three databases: PubMed/Medline, Scopus, and Embase. Key search terms and Medical Subject Headings (MeSH) included the following: ethics, clinical, competence, dental, dental hygiene, dentistry, education, licensure, live patient, and practice.Results Ethical concerns about the use of patient examinations have been published in the professional literature for over 35 years. Of the 29 selected or endpoint articles identified, 27 articles cited one or more ethical concerns relating to single-encounter patient-based examinations while 20 articles recommended the elimination of this type of examination with an additional 6 articles citing elimination as an option in resolving the ethical issues regarding this type of licensure examination.Conclusion The literature holds a predominant, prevailing professional opinion that single-encounter, procedure-based examinations on live patients presents significant ethical concerns and should be eliminated as a method in initial dental hygiene and dental licensure. The literature also suggests that state dental boards should initiate corrective regulatory or legislative actions to expeditiously end recognition of live patient examinations in their licensure processes.

Should Live Patient Licensing Examinations in Dentistry Be Discontinued? Two Viewpoints: Viewpoint 1: Alternative Assessment Models Are Not Yet Viable Replacements for Live Patients in Clinical Licensure Exams and Viewpoint 2: Ethical and Patient Care Concerns About Live Patient Exams Require Full Acceptance of Justifiable Alternatives.

This Point/Counterpoint article addresses a long-standing but still-unresolved debate on the advantages and disadvantages of using live patients in dental licensure exams. Two contrasting viewpoints are presented. Viewpoint 1 supports the traditional use of live patients, arguing that other assessment models have not yet been demonstrated to be viable alternatives to the actual treatment of patients in the clinical licensure process. This viewpoint also contends that the use of live patients and inherent variances in live patient treatment represent the realities of daily private practice. Viewpoint 2 argues that the use of live patients in licensure exams needs to be discontinued considering those exams' ethical dilemmas of exposing patients to potential harm, as well as their lack of reliability and validity and limited scope. According to this viewpoint, the current presence of viable alternatives means that the risk of harm inherent in live patient exams can finally be eliminated and those exams replaced with other means to confirm that candidates are qualified for licensure to practice.

The Buffalo Model: Shifting the Focus of Clinical Licensure Exams in Dentistry to Address Ethical Concerns Regarding Patient Care.

Most jurisdictions grant dental licensure to graduating students following successful completion of a clinical exam. Testing agencies, which are independent of dental schools, nevertheless conduct their exams at school facilities. Patient participation in these exams raises ethical concerns regarding such issues as unlicensed providers' performing irreversible procedures with minimal supervision and graduates' limited accessibility to provide follow-up treatment. To address these concerns, a collaborative effort between University at Buffalo School of Dental Medicine faculty and testing agency personnel was launched. The aims of this article are to describe the development and implementation of the resulting Buffalo Model, to highlight ethical advantages in its application, and to identify areas of improvement to be addressed in future iterations. With the Buffalo Model, modifications were made to the traditional exam format in order to integrate the exam into the school curriculum, enabling candidates to take it at various points during their fourth year. In addition, after calibration of school faculty members, 98.5% of cases verified by faculty were accepted by the Commission on Dental Competency Assessments for use in the exam. In two cases, restorative treatment completed during the exam did not meet the school's competency standard. This new approach ameliorates ethical concerns associated with clinical licensure exams because treatment is provided only to patients of record within a sequenced treatment plan and timely and appropriate treatment is provided to all patients. The results of this first year of implementation also suggest that calibrated faculty members will not show bias in the selection of lesions or competency evaluations of candidates.

What Contract? With Whom? For What Purpose?

The central point in the U.S. Supreme Court upholding the Federal Trade Commission's action against the North Carolina State Board of Dental Examiners was that they acted without proper supervision from the State of North Carolina in curbing commercial activity: issuing cease and desist orders to teeth-whitening businesses, for example. It appears unlikely that the law of the land will allow professions to enforce and may substantially limit a profession's voice in defining nearby commercial activity. The line between professional services and commercial ones is not clear. Vending whitening agents, as drug stores do, is commercial but may not be professional. Providing such services in the dental office certainly should be professional, but is also certainly commercial. As dentistry becomes more overtly commercial in nature, it is likely that the profession will have less say over defining and enforcing oral healthcare practices.

Dental students choosing licensure path give more consideration to career flexibility rather than ethical dilemmas.

Although a patient-based clinical licensure examination (CLE) has been used in the United States for many decades to evaluate an individual's competency to practice dentistry, there continue to be validity, reliability, and ethical issues of concern to the profession. As a result of a 2009 decision by the Minnesota Board of Dentistry, dental students from the University of Minnesota School of Dentistry, beginning with the Class of 2010, are eligible for initial licensure in Minnesota by passing the nonpatient-based National Dental Examining Board of Canada Examination. Surveys were distributed to 101 senior dental students to assess what factors students used to decide whether or not to register for a patient-based CLE. The response rate to the survey was 84.2% (85/101). The opportunity to apply for a license in multiple states after passing a patient-based CLE was the primary factor in influencing the students to register for a patient-based CLE. Regarding the use of live patients in a CLE, students were most concerned with having to operatively restore teeth that could be treated more conservatively and for other reasons outside of their control, such as the patient failing to show up, patient not being accepted by the examiners, and procedural issues during the examination.

The hidden curriculum and my three wishes.

Personal ideals often clash with the reward structure of dental education. The hidden curriculum sometimes teaches corner-cutting and worse while publically espousing high standards. Changing the professionals without changing the profession in which they work multiplies frustration and offers little hope of progress. Three wishes for changes to the system are identified: (a) fixed dates for National Board testing, (b) comprehensive admissions standards, and (c) no live-patient, one-shot initial licensure examinations.

Clinical licensure exams: the unruly gatekeepers.

A dental student approaching graduation reflects on concerns over initial licensure examinations. Among the issues that have been recognized but remain unaddressed are ethical treatment of live patients, unfair treatment of candidates, excellent reliability among examiners on any single case but poor consistency across testing, lack of validity, and no evidence of protecting the public. The licensure system would be improved by paying attention to issues of mobility and continued competence.