Thursday, November 12, 2015

Reflecting on Dental Licensure

This past Monday, I took the Comprehensive Treatment Planning (CTP) portion of the WREB exam. For those of you unfamiliar with dental licensure, here's a brief rundown: in order to legally practice dentistry in the United States, you need (1) a degree from an accredited institution, (2) pass the written National Board Dental Examination part I & II, and (3) pass a live-patient clinical exam. Licensure is regulated by state dental boards and aims to protect the public. To learn more about licensure, visit ASDA's website here and here.

What I REALLY want to discuss is licensure from a dental student's perspective. There are many ethical issues surrounding these clinical exams. As someone who has been heavily involved in the American Student Dental Association for the past 3 years, I've been at the forefront of the licensure battle. I've seen our organization toil endlessly to make a change in the state of dental licensure and to spread awareness to members. It pains me to see the complacency that dental students have about live-patient exams. These exams are simply treated as the "status quo" at our school. Nobody is demanding change.

Here are some of the current issues with live-patient licensure exams:
  • There is no universal licensure exam: Is it bizarre that I can become a licensed dentist in one state but I'm not allowed to practice in another state? There are five regional testing agencies that run these board exams and there isn't a single exam that confers universal licensure to practice in all 50 states. Most dental students in California take the WREB exam, which allows you to practice in California as well as a number of other states. Yet even if I pass WREBs, I won't be allowed to practice in Hawaii, or New York, or Florida. In order to practice in Massachusetts (where I will be going for residency next year), I still have to take the NERB diagnostic skill examination. 
  • Because there is no universal licensure exam, sometimes students have to take live-patient exams that are not offered at their dental school. Live-patient clinical exams are hard enough at your home school. You get the benefit of familiarity and ease of recruiting patients. Can you imagine finding the right patient and adjusting to the clinic layout and intricacies at another dental school? Perhaps even in another state? I've heard stories about dental students having to fly their patient and assistant to another state just to take a different live-patient licensing exam. For all of my dental school classmates who want to practice in states that don't accept the WREB exam (i.e. Hawaii), this is a very real nightmare. 
  • If you don't see an ethical dilemma yet, here's one: paying patients to be patients for licensure examinations. It's no secret that most dental students pay patients a hefty sum to be present for the exams. When we're already shelling out thousands of dollars to take the licensure exam, what's another hundred to ensure patient compliance and attendance? Although I've never actually witnessed it, there are rumors that some candidates try to "steal" patients by offering them more money. When I assisted WREBs as a first year dental student, I was specifically instructed to walk the patient from the parking lot to the exam floor and not let anybody come near the patient (can't risk someone else offering the patient more cash on exam day). 
  • Aside from the monetary issues, patients are also seen as "lesions" and not as patients during live-patient exams. During dental school, we're trained in comprehensive care. We are taught to create the ideal treatment plan and to deliver a full range of treatment from cleanings to CAMBRA to crowns in a proper sequence. For the purpose of live-patient exams, all of this goes out the window. All of a sudden, patients become a "DO lesion past the DEJ" or "7 clicks of calculus". Patients are traded around like cards in a deck. "I'll give you this Class III if you find me a quad". 
  • Not to mention, a one day live-patient exam is not an accurate representation of your skill as a dentist. Everyone can have a bad day. Everyone can also have a no-show patient. Guess what? If your patient doesn't show up for the exam, you automatically fail. I had one faculty joke that the exam was more about luck than actual skill. Will your patient show up on time that day? Will your patient's case get accepted by the examiners? Will your equipment work properly that day? 
  • Lastly, no other medical profession utilizes live-patient exams to grant licensure. Can you imagine a neurosurgeon having to find patients to undergo a one-day live-patient licensure exam? 
What are your thoughts on live-patient examinations for dental licensure? 

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