Is it ethical to use human subjects for the purpose of discovering incompetence?
Although managed care continues to grab the headlines, licensure issues still account for the largest flow of unsolicited e-mail and letters to the editor. The profession’s entry examination has consistently drawn the wrath of young graduates, who perceive the examination as unfair. Licensed dentists cite barriers to mobility as their objection to present dental licensure requirements. Nothing new. This issue doesn’t even recycle. It just keeps on rolling.
Admittedly, some progress has been made. All licensing bodies accept Part I of the National Boards, and just maybe, with a big push, they soon may accept Part II. The problem that remains—the big barrier—is the clinical examination. Four independent regional boards and 12 separate licensing bodies all require their own examinations.
High expectations accompanied consolidation of two of the largest regional boards in 1994 when the Northeast Regional Board, or NERB, and the Central Regional Dental Testing Service, or CRDTS, came together in offering a common clinical examination. The two boards represent 23 states.
Unfortunately, the agreement between the two lasted only one year. Reasonableness has not prevailed, and the two agencies are showing little inclination to reconcile their differences.
While licensing is totally within the jurisdiction of the states, dentists continue to look to the ADA for some formal action. Not forthcoming, dentists lay the blame on the Association.
The lack of an acceptable solution to the licensure issue has generated side effects that go beyond inconvenience and cost. According to an article published in last year’s Journal of Dental Education,1 some dental board candidates are displaying behaviors unacceptable to the ethical standards of the profession.
A nationwide survey of general dentists who graduated between 1980 and 1994 pinpointed some unacceptable professional activities in connection with these dentists’ clinical board experiences. For example, 24 percent failed to arrange for indicated follow-up care for their board patients. One-third took unneeded radiographs, 20 percent pointed out colleagues who allegedly provided premature treatment before the examination, and 8 percent claimed definite knowledge of colleagues who intentionally created a lesion for the board examination.
These results raise obvious questions about the ethics of using live patients for clinical board examinations. Forget the unneeded X-ray exposure or the lack of follow-up treatment. Ignore the creation of "new" carious lesions. Consider answering this larger question: Is it ethical to use human subjects for the purpose of discovering incompetence?
While examination failure rates don’t seem to be exceeding 80 percent, as they did for some schools early in the 1990s, even a 25 percent failure rate on the examinations translates into more than a thousand dental board patients receiving substandard treatment.
A commentary in the March/April issue of Dental Abstracts substantiates the practitioner survey. Titled "Dental Licensing Revisited,"2 a former dental board examiner confides that while he was "impressed with the dedication of individuals responsible for the design and administration of the exam," there was "significant" variability in the examiners, despite previous calibration exercises.
He also asserts that board examinations provoke a number of behaviors among the graduates being examined that are "less than professional and, at worst, unethical." Ascribing these behaviors to the need to pass at any price—many of these new graduates have already signed on with dentists as associates or have placed down payments on equipment, practices or both—the creation of the perfect board patient becomes an obsession that promotes unacceptable ethical behavior.
This former dental examiner questions the validity of the licensing examination. He notes that he is unaware of any instance in which an entry-level candidate at his institution failed the regional examination three times. Where, he asks, did their new skills come from? Most, if not all, of these candidates are graduates who have no way to remediate their deficiencies.
His solution: A single uniform clinical test given several months before the student’s graduation. This would allow for remediation if necessary. In a good/better/best rating, I’d rank his suggestion as "good." But it still doesn’t address the use of live patients during the clinical examination.
There was a time when the lack of uniform educational standards created vast differences in the quality of dental graduates. Many dental schools operated on a for-profit basis. Safeguarding bottom lines was more important than turning out quality students. No wonder that state licensing agencies sought to protect the health and welfare of their citizens by testing the clinical abilities of these dental professionals.
Those days are long gone. For years, the ADA, working with the Commission on Dental Accreditation, has established standards that ensure the highest-quality dental training in the world.
I have previously suggested that we place more trust in the accreditation process. Let our faculties determine the competence of the potential graduates and follow the leadership of the Canadian dental schools, which link the accreditation process with the licensing authority. Both groups formally participate in the dental schools’ on-site evaluations. And no further examination is required for licensure.
Why not adopt the Canadian model? Involving the licensing bodies in the accreditation process makes sense. But for entry-level dentists judged clinically competent by their faculties, I would add an examination consisting of interactive simulations (National Dental Board Part III). This patient-free examination would eliminate past ethical problems and could offer solutions to the mobility issues of the already licensed.
To date, the licensure debate has focused on initial entry and mobility. No longer. The explosion in technology and the globalization of the world’s economy already are expanding that horizon.
Consider the practice of tele-dentistry. Licensure issues have already surfaced in that area, with 20 states requiring health practitioners to have a full license if they participate in Internet practices. The global issue of dentists freely moving from country to country has surfaced in the discussions of the European Economic Community and the North American Free Trade Association.
It’s time to resolve the issues surrounding licensure. While any solution depends on the states’ agreeing on a common policy, that requirement should not be a rationale for inaction. The ADA’s activity in this area should step up from "encouragement" to aggressive jawboning. There is just too much at stake to accept the present slow "progress" as the pathway to an eventual solution.
