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Shifting focus on patients: New licensure exam seeks to address ethical dilemmas

August 22, 2016

By Kimber Solana

Buffalo, N.Y. — Every year, hundreds of patients enter the halls of dental schools throughout the country volunteering to receive treatment as part of a clinical licensing exam for graduating dental students. Some of these patients have waited weeks and months to have dental care provided during the clinical exam process.

For the vast majority, the treatment is a success, with the candidate passing the exam for initial licensure and the patient leaving satisfied. However, if a treatment complication arises during the exam, the student is often asked to place a temporary filling in the tooth, and the patient's care may be further delayed.

Because of the special situations and requirements of the clinical exam process, some of these patients may not have been patients of record in the dental school except for the exam treatment itself. To identify the specific oral health condition, exam patients may also be found through social media or online-based patient-finding services, which takes the focus away from comprehensive oral health needs of patients.

"I often ask in my lectures, 'How many times has anyone ever asked how a patient did in the [licensure] exam?'" said Dr. Joseph Gambacorta, assistant dean for clinical affairs at the University at Buffalo School of Dental Medicine. "It's always about the candidate. We needed to find a way to switch the focus from the candidate to the patient. How do we put the patient first?"

Mr. Soliman

Dr. Gambacorta

Dr. Shampaine

Dr. Kaufman

Dr. Feldman
That question was at the heart of a collaborative effort to create the American Board of Dental Examiners (ADEX) Patient-Centered Curriculum Integrated Format examination, which is administered by the Commission on Dental Competency Assessments and based on the 2007 ADA policy on curriculum integrated format (CIF) clinical licensure exams.

The goal of the new examination model: to create and provide an exam that eliminates or addresses many of the ethical issues involved in using patients in clinical licensure examinations.

The ADEX Patient Centered CIF was piloted at the University at Buffalo in January 2015. This year, another six schools have adopted all aspects of the model, while some schools have adopted portions of it, such as the processes of patient approval and follow-up care, said Dr. Guy Shampaine, CEO of the American Board of Dental Examiners, Inc.

"There are still flaws and ethical dilemmas built into all clinic examinations with a live patient, let's not kid ourselves," said Dr. Herb Kaufman, associate dean of clinic operations at the Arizona School of Dentistry and Oral Health at A.T. Still University, which adopted the new examination model this year. "But this is a big improvement. This change is a movement in the right direction."

However, the new model has its critics, including the American Student Dental Association, which believes the ideal licensure exam should not involve patients in a live clinical testing scenario.

Nonetheless, schools that have adopted the Patient-Centered CIF exam say it's a vast improvement from the traditional model.

"My expectation is that in the next two to three years, this is going to be the predominant [clinical licensure examination] model," Dr. Shampaine said.

Based on ADA policy

In the early 2000s, in opposition to the use of patients in licensure exams, the New York State Dental Association led the development of the PGY1 model, which was adopted from the medical model and requires an additional year of training in a Commission on Dental Accreditation-approved postgraduate program.

However, PGY1 is only recognized in New York and a handful of other states.

For dental students seeking to practice in other states, "they were still taking the regular licensure examination that we and the ADA were opposed to," said Dr. Mark Feldman, executive director of the New York State Dental Association.

Around the time the PGY1 concept was developed, the ADA House of Delegates adopted a policy in support of eliminating the use of patients in board examinations, with the exception of the curriculum integrated format-type exam, as defined by the ADA.

The ADA policy statement recognizes that ethical considerations may arise from the use of patients in the clinical licensure examination process even though the clinical examination process is itself ethical. According to the CIF format, the exam should be performed by candidates on patients of record and within an appropriately sequenced treatment plan. All portions of the assessment should be available at multiple times within each institution during dental school to ensure that patient care is accomplished within an appropriate treatment plan. Opportunities for student remediation should also be available as needed. The Association encourages all states to adopt methodologies for licensure that are consistent with this policy.

In 2014, Dr. Feldman said a team, which included Drs. Shampaine, Gambacorta, Michael Glick, then-dean of the University at Buffalo dental school, and members of NYSDA, worked together to help develop a new examination model based on the ADA's CIF policy.

"The goal was to satisfy every component of the ADA definition of CIF," Dr. Shampaine said.

After this initial meeting, Dr. Feldman said, Dr. Glick offered to have the new model piloted at the University at Buffalo.

"My initial thought was that we were going to do the exam in 2015-16, but Dean Glick wanted to start it in January [2015]," said Dr. Gambacorta. "So we did."

How it works

The first problem the CIF model seeks to eliminate is the patient having to wait weeks or months for the one scheduled examination day to receive the care they need.

Now, the dental school schedules when examiners should visit the school in regular intervals — based on the school's determination of the timing and appropriateness of treatment.

"If a candidate has a patient who needs treatment that we also happen to test, the school schedules the patient for the session that the school has arranged for examiners to visit and evaluate the care," Dr. Shampaine said. "This way we don't have to worry about a candidate holding on to treatment, delaying treatment, or, probably more important, that the more urgent needs are not ignored to treat a lesser problem."

Second, all patients treated are patients of record with a comprehensive treatment plan. Because they are patients of record, the faculty will independently check the work after the examiners.

"This way, they can do their own assessment, approve the treatment and approve the follow-up," Dr. Shampaine said. "They're also evaluating the care and completeness of the dental record." In other words, the entire process is similar to the competency exams dental schools give their students but an outside examiner is also present to evaluate the procedure.

When a candidate is unsuccessful, it's the faculty who explain to them what mistakes were made and how to address it — making the exam a part of an educational process.

Dr. Kaufman said that in the past, a candidate would get a failing grade and wouldn't know exactly why he or she failed.

"It's the true definition of CIF because real remediation happens when the faculty sees the performance and can counsel the student in real time," Dr. Shampaine said. "If a student is unsuccessful, they can retake the sections, and the rescheduling is again up to the school."

Finally, because the patient is a patient of record at the school, the students and school provide follow-up care.

"The patient is not given a temporary restoration and sent out to fend for themselves," Dr. Kaufman said. They are taken care of right there, "and if follow-up care is needed, I don't have the impossible job of tracking these patients down since in this improved format, they are all patients of record."

ASDA adamant on alternatives

Despite some improvements to the traditional examination model, problems remain in the new model when addressing larger concerns involving ethics in using a patient in examinations and the exam's overall reliability and validity, according to the American Student Dental Association.

"ASDA does not support the curriculum integrated format," said Sohaib Soliman, ASDA president and University of Washington School of Dentistry student. "No current model meets all of ASDA's criteria."

ASDA's ideal examination model involves a combination of three components. The first is a manikin-based kinesthetic exam, which addresses candidates' hand skills. Second, it involves a nonpatient-based examination that addresses candidates' clinical decision-making skills and understanding of what's happening with the patient. And lastly, the submission of a portfolio on comprehensive patient care to showcase what a student has done for four years in dental school.

ASDA acknowledges that the CIF model is preferable to the current traditional licensure process because it is offered more than one time per year at each dental school; incorporates familiar faculty to assess the student's competency on care provided via a separate but simultaneous process; allows students to complete a comprehensive exam and form a phased treatment plan for the patient; and provides follow-up care for substandard procedures.

However, according to ASDA, the CIF model may not adequately address their questions of validity and reliability given that clinical exams with patients are difficult to standardize.

"No two humans are anatomically, physiologically, pathologically and psychologically identical, and therefore each clinical licensure examination is different," according to ASDA's position statement on the CIF exam.

In addition, while the CIF model requires exam patients to be patients of record at the dental school, students may still struggle with obtaining patients as required by the testing agency with the ideal carious lesion or periodontal condition for the examinations, Mr. Soliman said.

"In that case, it still requires students to advertise to the public and conduct outside screening," he said. "This model doesn't change the environment where the patient is treated as a commodity."

For many students, he said, they still have to resort to creative, but sometimes inappropriate, ways — such as paying patients to participate in the exam.

"ASDA strongly advocates the complete elimination of human subjects from initial licensure examinations," Mr. Soliman said. "Unfortunately, as long as there's a patient involved, it won't fit the model ASDA is looking for."

'A step forward'

Taking into account remaining flaws and ethical dilemmas built into patient-based clinical examinations, the CIF model remains a movement in the right direction and may be a bridge to the creation of a nonpatient-based exam, some educators say.

"As long as there are testing agencies and state boards of examiners to determine whether a candidate is granted a license, this model to me is by far ahead of what I've seen in the many years I've been involved in dentistry," Dr. Kaufman said.

After hearing about the new model, A.T. Still educators immediately contacted the Commission on Dental Competency Assessments to be considered as a beta test site and asked to participate.

A.T. Still dental school isn't considered a large school with class sizes of about 76, plus a residency and advanced education programs. Despite the size, lack of resources to implement the new model was not a problem, Dr. Kaufman said.

"There are flexibilities to the exam. We try to encourage our students to take the clinicals in one day," he said. "What we've implemented here may be different from what is done at other programs like Midwestern, Boston or [New York University]."

While they're still hoping for some improvements, Dr. Kaufman said, the school is favorably disposed on the new model. The students seem calmer, which then helps calm their patients.

"The patients leave here much less disappointed. There are many of my colleagues who believe that patient-based exams have no place in dental schools," Dr. Kaufman said. "I'm not generally political. I just want to take care of patients and educate students. And from what I've seen, this is a step forward."