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Using patients in board exams under debate in Iowa

February 15, 2016

By Kimber Solana

Editor's note: This is the first in a series of articles on licensure reform, a debate occurring in various states as students, educators and dental leaders seek alternatives and/or changes to the licensure process.

Iowa City, Iowa — Advertising on Craigslist. Delaying treatment. Paying for patients.

When it comes to finding an appropriate patient for the dental board exam, students resort to creative, but sometimes inappropriate, methods.

"You're not supposed to compensate patients, but it's pretty well-known that it happens," said Dr. Jarod Johnson, a 2013 graduate from the University of Iowa.

Dr. Johnson said he found his patient less than a month before his exam. But when the patient didn't show up, near panic ensued. Luckily, he said, a classmate was gracious enough to let him treat a backup patient.

Although most dental students won't experience problems, according to the University of Iowa College of Dentistry, the difficulty dental students face in finding reliable patients who meet examination criteria is just one reason, along with ethical and validity concerns, underscoring an issue with the use of patients for clinical board exams with the Central Regional Dental Testing Service in Iowa and other dental licensing exam agencies. With alternatives available, the use of patients may no longer be necessary, said Dr. Michael Kanellis, University of Iowa associate dean for patient care.

However, the Iowa Dental Board disagrees, contending that the use of patients remains essential to ensure recent dental school graduates are ready to practice.

"It's an important part of the process. It's another way to provide checks and balances," said Dr. Kaaren Vargas, a member of the Iowa Dental Board and a diplomate at the American Board of Pediatric Dentistry. "We are here to protect the public from incompetent professionals."

It's a debate ongoing in several states as students, educators and dental associations seek alternatives or changes to the licensure process.

Primary objections

In Iowa, the debate over the use of patients in the clinical board exam for dental students has been under discussion for about a decade, Dr. Kanellis said.

"The strongest push to end it began in 2010," he said. "But here we are five, six years later and it's still a concern we haven't been able to change."

Last summer, Dr. Kanellis wrote to the Iowa Dental Board outlining "troubling aspects" of the patient portion of the exam.

Dr. Kanellis

Dr. Vargas

Dr. Johnson
There are, Dr. Kanellis said, serious ethical concerns with the use of patients for board exams. To pass the restorative section of clinical examinations, some students end up treating lesions that were simply being monitored for remineralization. Meanwhile, some patients who need restorative treatment are asked to wait weeks or months — irritating or destroying more support structure — so they are available for the student's exam.

"Our primary objection is that it is no longer ethical to be using live patients," he said.

In addition, Dr. Kanellis said the use of patients to test graduating students does nothing to protect the public — in contrast to the dental board's argument — arguing that a one-time, high-stakes exam does not accurately reflect a student's competency.

"The medical board in Iowa would never dream of going into a medical school or any medical/surgical residency to see if an individual person on a one-time procedure was competent to become licensed in the state," he said. "This is why colleges of dentistry and medicine are accredited, and why the education is intense."

Dr. Vargas, however, points out that there is a difference between medical and dental students.

"In the state of Iowa, once a medical student has completed his/her four years of medical school, the state will issue a restricted resident license that can only be used during a residency program under direct supervision," she said. "Once a resident has completed one year of his/her residency and has successfully taken the United States Medical Licensing Examination, which is a three-step examination process, then he/she can apply for an unrestricted medical license. The dental licensing examination is therefore akin to the USMLE process for medical licensure with the added clinical component since dental students are not required to go through a residency program before practicing."

Then there are the issues Dr. Johnson faced.

"We spend a great deal of time and effort identifying patients for the clinical licensure examinations, including advertising on Craigslist, posting tear-sheets at area stores and hosting multiple free evening screenings," Dr. Kanellis wrote. "Using patients who often have no appreciation for these high-stakes examinations has increasingly put our students in a position where they have very little control."

Providing oversight

For Dr. Vargas, a clinical examination exam provides an unbiased, third-party oversight to safeguard the public from incompetent dentists.

There are five regional boards, or regional testing services, in the country; each have state dental board members.

"Every dental school is different. Every dental school teaches differently with different faculty," she said, adding that although schools are accredited and there are Commission on Dental Accreditation standards to follow, it doesn't necessarily mean the students are taught the same thing.

The exam, she said, tries to standardize and make sure dental students from different dental schools meet the same criteria.

During a typical board exam, three independent examiners, relying on a set of metrics and experience, oversee a student's examination. Multiple examiners need to reach a consensus to ensure a student doesn't pass or fail based on one examiner's opinion.

"If there is a dispute among the examiners, the chair of that section comes over and verifies," Dr. Vargas said.

In addressing the university's concerns against the use of patients for the exam — that it's burdensome to the students and raises ethical issues — Dr. Vargas said the rationalization rings false because dental schools utilize patients every day.

"If you start with that premise, dental schools should only use a simulation," she said. "Can that happen? No, because if students don't have the experience working with patients, they can't transfer that experience into the work setting."

The same goes when it comes to the board exam and finding out if a student is ready to practice, Dr. Vargas said, adding that there is no substitute to a real patient.

However, Dr. Kanellis said there is a difference because unlike a one-time exam, patients of record are seen by dental students throughout their study and receive continuing care.

"We have board-certified specialists in every specialty watching every step our students make in patient care during an intensive four-year education period," he said. "That's much more valid than a governor-appointed member seeing a one-time restoration."

Possible alternatives

In an effort to address the school's concern that the exam is burdensome, Dr. Vargas said the dental board discussed last summer implementing a testing format recommended by the ADA called curriculum integrated format piloted in the University of Buffalo where board examiners come several times during the year to assess students providing care for patients of record.  ADA policy supports the use of the curriculum integrated format examination, which involves having all parts of the exam available at multiple times during dental school to ensure that patient care is accomplished within an appropriate treatment plan, and to allow candidates to remediate and retake any portions of the assessment they have not successfully completed.

"That would have eliminated the scramble to find a patient or several patients. It eliminates the concern that a patient in the exam is not a patient of record, and it eliminates the concern that a patient may be unreliable," she said. "The university has gone to great lengths to reject the proposal."

Dr. Kanellis said the model still utilizes patients, which is the school's primary objection to the exam. Better alternatives, he said, are already in place in some states.

For example, Dr. Kanellis said, the use of the Objective Structured Clinical Examination (OSCE) is being offered in Minnesota. In this exam model, dental students rotate through various stations and answer extended match multiple choice questions using simulated clinical scenarios and patient situations. In California, a portfolio examination model is used to evaluate candidates on key clinical areas utilizing patients of record throughout dental school.

However, Dr. Vargas said there could be problems with the portfolio exam because it doesn't properly represent what a student can and cannot do. In a portfolio exam, students choose what cases they've worked on to

"It is that person's best work," she said. "It may show something a student can do, but it doesn't show you if they can do it every time."

As for the OSCE exam, Dr. Vargas said the use of an inanimate object can't determine the clinical competency on an actual patient.

"It's a glorified mannequin exam," she said.

According to the National Dental Examining Board of Canada, which administers the OSCE exam, the exam is developed based on the "Competencies for a Beginning Dental Practitioner in Canada," which list nearly 50 items a beginning dental practitioner must be competent to do.

On Jan. 21, legislation (House Study Bill 532) was proposed in Iowa that would require the dental board "to approve and offer at least one station-based licensing examination that does not involve the use of human subjects to applicants for dental license." A subcommittee meeting was scheduled for Feb. 10.

The Iowa Dental Association has taken a "neutral" position on the debate, according to IDA Executive Director Lawrence Carl, adding that "many questions" remain when it comes to offering alternatives to the licensing exam.

For Dr. Johnson, the completion of the course of study and clinical hours should be enough to prove "minimum competency."

Dr. Johnson voiced his opinion in a Des Moines newspaper editorial in 2013.

"If this exam is about protecting the public health, why are applicants who fail allowed to retake it within a month?" he wrote. "Why aren't practicing dentists required to take it when they renew their licenses to ensure they have maintained their skills? Why doesn't the state require such an exam for other health professionals to secure state permission to work."

According to the Des Moines Register, only two professions in Iowa are required to pass a state-mandated exam using live human subjects to secure a state license to work: dentists and barbers.

ADA policy on patient use in board examinations

The ADA supports eliminating 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, including those identified in the ADA Council on Ethics, Bylaws and Judicial Affairs statement entitled Ethical Considerations When Using Patients in the Examination Process (Annual Reports and Resolutions 2008:103), may arise from the use of patients in the clinical licensure examination process, even though the clinical examination process is itself ethical. 

The Association encourages all states to adopt methodologies for licensure that are consistent with this policy.

For more information on ADA online licensure resources, click here.  To read more on ADA's current policies, including licensure policy statements, click here.