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Minnesota OKs Canadian exam

First state to recognize non-patient based exams for licensure

Minneapolis—Minnesota has become the first state in the country to offer candidates for dental licensure the opportunity to take a non-patient based clinical licensure examination.

The Minnesota Board of Dentistry voted unanimously June 26 to accept the results of the National Dental Examining Board of Canada's two-part exam for graduates of the University of Minnesota School of Dentistry in 2010. The NDEB exam includes a written component and non-patient based objective structured clinical examination (OSCE), a station-type exam in which candidates answer extended match questions based on models, X-rays, casts and case histories.

"Giving up the live patient portion of the licensure exam was not an easy decision for board members to make," said Dr. Candace Mensing, president of the Minnesota Board of Dentistry. "Once we realized there are other ways of evaluating clinical competencies at the School of Dentistry, this became a possibility. The students at the University of Minnesota now have to prove to us, and the rest of the U.S., that they are skilled professionals not because of the licensure exam but because of the quality of their education."

The board's decision was in the "best interest of the public," said Dr. Patrick M. Lloyd, dean of the University of Minnesota School of Dentistry.

Said Dr. Lloyd: "The non-patient based OSCE examination is a proven test of decision-making ability that avoids some of the ethical problems associated with a traditional patient-based examination, which include the potential for premature treatment; diagnosed treatment needs that are deferred until the date of examination; treatments rendered out of sequence; patients' care by a provider who is not the provider of record; and follow-up care that will not be offered by the provider of record."

The Canadian exam tests the decision-making ability of dental school graduates in a manner consistent with the ethical principles of the ADA, the Minnesota Dental Association and the American Dental Education Association, he added.

Nine years ago, the ADA House of Delegates passed Resolution 64H-2000 which supported the elimination of human subjects from the clinical licensure examination process by 2005, a goal that was reaffirmed in Res. 20H-2005.

For the last several years, the Minnesota dental board and U of M School of Dentistry have maintained frequent communication and information sharing that have provided the board with further insight into the school's educational processes.

"The board has had access to the school, the way that we admit students, education systems, our competencies to promote and graduate students, and we invited them to attend the committee meetings associated with these programs," said Dr. Lloyd.

He credits Dr. Judith Buchanan, associate dean for academic affairs at U of M, with encouraging this interaction.

"It used to be that students would do procedures a number of times and they would be judged competent," said Dr. Buchanan. "But we know that some people can do something five times and be competent, and with other people it takes a lot longer.

"The evaluation of students has changed so much, the accreditation process has been strengthened and schools are much more aware of the fact that they need to make sure their students are clinically competent through regular competency evaluations. We wanted the board to see that we've tested students' clinical skills in a way that they would find reassuring," said Dr. Buchanan, adding the school also demonstrated its student acceptance criteria and evaluation protocols to the dental board.

"Without a live patient as a part of the licensure examination, the board has to have a way of knowing that clinical competencies are met as a dental school experience," said Dr. Mensing. "In order to know that, we have to participate in the process, at least as observers."

Dr. Richard W. Valachovic, executive director of the American Dental Education Association, called the Minnesota board's decision a "tipping point" in the relationship between dental educators and members of state dental boards.

"An evidence-based alternative for licensure that does not involve patients has been recognized, and at the same time, relationships between professionals in the academic and the licensing dental communities have been significantly enhanced," said Dr. Valachovic. "We are very pleased."

When the Central Regional Dental Testing Service announced its intention to terminate its contract with the American Board of Dental Examiners Inc. (ADEX) as of June 30, 2009, Dr. Lloyd said "this gave us an opportunity to talk to the board about continuing to have a third-party assessment of our students but in a more non-patient based approach to licensing exams."

Earlier this year, the board of dentistry appointed a task force to study the feasibility of non-patient based examinations, and the School of Dentistry invited representatives from the National Dental Examining Board of Canada to present their exam and research validating its relationship to student performance.

Throughout this process, the Minnesota Dental Association was informed of the School of Dentistry's efforts to develop a non-patient based clinical exam, said Richard Diercks, MDA executive director. MDA participated in the program at the U of M School of Dentistry where the Canadian testing process was presented.

"The MDA is well aware of the outcomes basis of education at the School of Dentistry that is based on performance and mastery of skills rather than just a number of procedures performed by a student in various clinical areas," said Mr. Diercks. "We believe that the new model for a non-patient based clinical exam, similar to the Canadian model, will provide a superior examination of dental school students and without the ethical compromises of patient-based examinations."

Dr. Jack D. Gerrow, executive director and registrar of the National Dental Examining Board of Canada, was one of the NDEB representatives who presented the exam to the U of M this year.

"We are honored and pleased to help Minnesota," said Dr. Gerrow. "However, we hope and expect that a U.S. board will eventually develop a non-patient based exam that reliably protects the public."

The NDEB administered a patient-based clinical exam for international graduates until 1999. (Information on the exam can be found online at www.ndeb.ca.)

Many in the dental profession have questioned the validity and reliability of patient-based clinical licensure exams. In his research published in The Journal of the American Dental Association ("An Analysis of the Contribution of a Patient-Based Component to a Clinical Licensure Examination," October 2006), Dr. Gerrow showed that candidates who had previously passed the non-patient portions of the examination eventually passed the live patient portion.

"The live patient portion did not contribute to decision-making and the ethical problems were still there," said Dr. Gerrow. "We conducted patient-based exams as best we could and as ethically as we could and it felt like they worked. It wasn't until we analyzed the data that we found that the patient-based component didn't work."

The Canadian OSCE, on the other hand, has concurrent validity, said Dr. Gerrow, "meaning that we compared results of the NDEB/OSCE with something that has validity—that is, standing in dental school," he said. In the study, "Concurrent Validity of Written and OSCE Components of the Canadian Dental Certification Examinations" (Journal of Dental Education, August 2003), Dr. Gerrow and associates evaluated graduates of Canadian dental schools for five years and compared their marks on the OSCE exam with their standing in dental school.

"Those who got good marks on the OSCE were in the top third of their graduating classes, the middle third was mixed, and the lower third was where the failures were," said Dr. Gerrow. "In five years, there was no one in the top third of their graduating class that failed the OSCE, and the vast majority of failures were in the bottom third."

Practicing dentists play an important role in selecting the questions for Canadian examinations, and that will be the case with Minnesota dentists, too. Questions are initially developed by dental school faculty members but those questions that appear on the exam are selected by general dentists appointed by licensing boards.

"We will be pleased to invite U of M faculty to participate in question development workshops," said Dr. Gerrow. "The NDEB will also invite the Minnesota Board of Dentistry to send general dentist representatives to question selection workshops."

The complexity of the scenarios presented on the OSCE also requires students to "really think it out and make the right decisions," said Dr. Buchanan of the University of Minnesota, and "that's what you want graduates to have—good clinical decision-making."

Besides the successful completion of an approved licensure exam, Minnesota also requires that candidates for licensure graduate from a dental school accredited by the Commission on Dental Accreditation, successfully complete Part I and Part II of the National Board Dental Examination, and pass the Minnesota jurisprudence exam. Because the NDEB of Canada is a two-part exam—written and OSCE—U of M graduates who take the Canadian exam will have to take an additional written test.

Dr. Lloyd said that about two-thirds of the school's students are from Minnesota. The Canadian licensure exam is not an option for those planning to practice outside of Minnesota. "They will have to take the exam that those state boards recognize," he said.

Since 2007, New York has required candidates for dental licensure in that state to complete an accredited dental residency program called PGY1 (postgraduate residency of one year's duration) instead of taking a clinical licensure exam. Several states, including Minnesota, also permit graduates the option of passing a clinical exam or completing a postdoctoral CODA-accredited residency of at least one year's duration. But Minnesota is now the first state to accept the results of a non-patient based clinical examination for initial licensure.