Dentistry forum
Clinical exams |
keane
13-08-2007 01:13
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Rite of Passage
A landmark event of sorts took place on January 1, 2007: New York became the first state to abolish clinical licensure exams (and thus the deeply problematic use of human subjects in those exams) in the process of licensing new dentists.
Instead, dentists who want to practice in New York State must satisfactorily complete a clinically based, CODA approved postdoctoral general practice or specialty dental residency program of at least one year's duration, the so-called PGY-1. Minnesota and Connecticut do not mandate PGY-1, but they do offer it as an alternative route to licensure, with California also passing similar legislation last year. And Washington State has a PGY-1 pilot program.
Is PGY-1 the cure for what ails licensure? Alternative, yes; cure, no. Although it makes sense that a challenging year of supervised postgraduate training will produce a better dentist, there is no hard evidence to prove it. And, as a practical matter, there are simply not enough PGY-1 slots around the country to produce a generation of dentists licensed through a postgraduate year.
The issues related to testing for licensure have been a priority for me since I successfully completed the NERB examination just before graduation from dental school. Like so many dental students, I used—and I mean used—family and friends as human subjects for the procedures. Regrettably for them and me, I probably delayed some treatment for them as I anticipated the dreaded days of the NERB. As a Dean for Clinical Affairs at two dental schools in my career before joining ADEA, it was my responsibility to help dental and dental hygiene students prepare for licensure exams, sometimes during a period of more than a year. This was an incredible distraction to the basic clinical curriculum designed to graduate competent practitioners. A dentist/attorney faculty colleague of mine and I published an article in the American Journal of Law & Medicine in 1991 entitled "The Regulation of Dental Licensing: The Dark Ages?" Here we are 16 years later, and testing remains, in general, in the Dark Ages. In that article, we proposed that replacing the current regulatory system with a national clinical examination and a national licensure program would best serve the interests of the public and the dental profession.
Nevertheless, because it eliminates human subjects, what's happening in New York State is notable. It accomplishes one of the licensure goals set by the ADEA House of Delegates for dentists and dental hygienists who are students or graduates of accredited programs and have successfully completed the National Board Dental Examinations or the National Board Dental Hygiene Examinations. Those goals are freedom in geographic mobility, elimination of licensure and regulatory barriers that restrict access to care, high reliability of any licensure examination process and content as well as predictive validity of information used by licensing authorities to make licensing decisions, and elimination of the use of patients in clinical examinations.
Using human subjects to determine eligibility for licensure is a losing proposition from both the ethical and the testing viewpoints. On one hand, high stakes exams using human subjects do not adequately protect patients. Treatment sequences are disrupted, and licensure candidates may deliberately delay treatment until testing day arrives. On the other hand, human subjects introduce a level of variability that runs counter to effective testing practices. Instead of respecting one of the basic tenets of testing—frequent sampling of knowledge and skills over a period of time—these single-event tests have no evidence of reliability in differentiating between those who are not yet competent for independent clinical practice and those who are. It truly becomes a crapshoot, as any of us who have had to endure this process can attest.
The fact is that alternative testing methods exist, and we should and will explore them. Through the ADEA Commission on Change and Innovation (ADEA CCI), we are appointing a task force to look into traditional and innovative assessment methods. Greater use of simulations enhanced by modern technologies seems particularly promising. In this context, it's illuminating to step outside our own field and read about the ways in which another professional discipline is handling the challenge of documenting proficiency. The discipline is general surgery, and the article appeared just last month in The New England Journal of Medicine. It is "Medical Education: Teaching Surgical Skills—Changes in the Wind." The authors say that interest in laboratories designed to teach surgical skills has increased dramatically. "In this new model of surgical education," they continue, "basic surgical skills are learned and practiced on models and simulators, with the aim of better preparing trainees for the operating room experience."
Our own wind of change has brought a trend toward regionalism. Only a state board of dental examiners can license practitioners, but most state boards now authorize regional testing agencies to actually give the clinical licensure exam. As of September 2006, according to the American Dental Association (ADA), only Delaware, Florida, Nevada, and the Virgin Islands were still administering their own exams.
The other states and jurisdictions were contracting with the Central Regional Testing Agency (CRDTS), the Council of Interstate Testing Agencies (CITA), the Southern Regional Testing Agency (SRTA), the Western Regional Examining Board (WRE , and the North East Regional Board of Dental Examiners (NER. NERB administers the ADLEX exams, approved by the American Board of Dental Examiners, Inc. (ADEX), an independent agency responsible for developing a clinical licensure exam that can be given by existing agencies. CRDTS has adopted the ADLEX exam as the CRDTS exam.
Since we're unlikely to agree in the short term as to what to do about licensure, it's important for all state boards to accept results from all testing agencies. We're not there yet, although most states now recognize more than one exam, increasing freedom in geographic mobility.
What adds special confusion to the licensure picture right now is that state boards keep changing their minds about which testing agencies to recognize. In the long run, the current major competition among testing agencies should facilitate change and lead to more user-friendly testing. In the short run, it has spawned such unlovely practices as direct calls to students from examining agencies, trying to persuade them to advocate for or take their exam.
For more information, check out the ADA licensure link and the American Association of Dental Examiners. A handbook called Dental Boards and Licensure: Information for the New Graduate, a joint project of the ADA and the American Student Dental Association (ASDA), is filled with practical advice for the licensure candidate and draws a vivid picture of the clinical exam scene as it exists today. It includes candid essays by dentists who failed ("Apparently my periodontal patient didn't have the right amount of calculus"), tried again, and passed. I recommend this publication for a candidate's-eye view of a complicated issue that doesn't have an easy answer and requires our continued vigilance and collaboration. I also recommend the American Dental Hygienists' Association (ADHA) website, which has valuable information for hygienists seeking licensure in the United States.
The issues related to licensure testing, and particularly the use of human subjects in a high stakes, single event assessment of competency for a lifetime of practice, will continue to be a priority for the American Dental Education Association. ADEA supports third-party evaluation of dental and dental hygiene students before they are allowed to be licensed for practice, but let's do it using modern methods of assessment that neither involve human subjects nor disrupt the already compacted curricula.
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Re: Clinical exams |
ava
13-08-2007 01:14
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Yes, I know about the new ideas about state board exams, but what I was really referring to is competencies to test individual skills as they are taught to 1st year dental hygiene students. We do the traditional method of standing over the student watching them extra/intraoral exam or periodontal charting, etc. and grade them. This method is very stressful for most students and they are so nervous that it affects their performance. Does anyone have any innovative way to test 1st year students on clinical skills which would alleviate the stress?
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Re: Clinical exams |
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