The Point/Counterpoint discussion that appeared in January JADA is a valuable opportunity to discuss potential modalities in evaluating entry-level competence prior to granting initial licensure for the practice of dentistry. Dr. Hindin’s letter, however, is substantively inaccurate and seems to [show] an unfamiliarity with the licensure examination administration and development process. The examining community has a long-standing protocol of evaluating the processes used for that assessment.
The construct for a check and balance between the profession, educational institutions and regulatory agencies was developed and refined by William J. Gies in his landmark report.1 The system originally articulated by Gies has undergone continual refinement and improvement. The methodologies used in arriving at the assessments utilized for evaluation of initial competence are not arrived at "willy-nilly" by "political appointments" but, rather, through a complex process that involves independent measurement specialists and accepted methodologies. Integral to this process is continued, ongoing review of all components of the examinations.
Content validity is determined by appropriate occupational task analysis in dentistry, with cross analysis with examination content, to ensure that those competency areas in dentistry that meet the accepted levels of criticality are tested. Content experts, comprising educators, examiners and others, determined the weighting of the various criteria components in determining the scoring rubrics.
Standardization and calibration exercises of participating examiners are carefully carried out to ensure high interrater and intrarater reliability levels of the participating examiners. The examining pool utilized by testing agencies consists not just of members of state boards of dentistry, but also of many educators and appointed consultants with specific expertise.
The licensing examinations that have evolved over the years have transferred appropriate clinical components from patients to alternative testing methods, whenever possible. However, evaluation of the literature by testing specialists (psychometricians) has not found, up to this point, an appropriate alternative for the total elimination of patients in the licensure examinations in dentistry and dental hygiene.
Doctor-patient interaction and human variability in treatment are essential components in the evaluation of the candidate’s ability to independently translate his or her dental education into acceptable patient care. This reality was the impetus behind the National Board of Medical Examiners’ reinstituting a patient-based component into the U.S. Medical Licensing Examination, the national licensure examination in medicine.
The involvement of patients in the examination process is accomplished with careful attention to informed consent, to ensure that patients understand the testing process in which they are involved. The testing community has carefully scrutinized the ADA’s Agenda for Change2 in the evolution of the examinations and, as a result, has instituted changes in the examination process. Testing agencies have made great strides in moving the examination components into the academic year. Through this change in examination timing, important issues of patient treatment are addressed. The patient participating in the examination should be the patient of the dental student taking the examination.
The independent performance required on the examination is little different from the independent performance required by the dental school in the completion of a competency. Therefore, any ethical considerations would be similar. Unacceptable performance on the examination results in treatment being stopped, and then continued at a later date under faculty supervision.
The trend of moving the examinations into the academic year has afforded increased opportunities for remediation prior to graduation and examination retake.
The examining community has always condemned the very rare unethical behavior on the part of students during the conduct of the examination. Delaying appropriate care for patients purely for examination purposes is never appropriate. All care provided to any patient should be provided within the appropriate standard of care, including sequencing an acceptable timetable for delivery.
AADE and the examining community have always been open to discussion and interaction with the stakeholders, patients, communities of interest—the ADA, American Dental Education Association and the American Student Dental Association (all of whom participate in their positions as a result of a political process)—and other voices representing components of the profession, to continue the improvement in the reliability and validity of the examination process utilized for initial licensure in dentistry and dental hygiene. Both the interactions and the tensions among these communities affect the checks and balances that are the basis for the continued improvement of the system.
In the end, the testing community’s ultimate responsibility is to carry out the statutory and regulatory mandates of the 53 licensing jurisdictions; that is, [to ensure] that only competent individuals obtain a license to practice dentistry so that the health, safety and welfare of the public is protected.
Examinations are only a small component of the focus of AADE. As the national organization representing the state boards of dentistry in the United States, the majority of AADE’s attention is involved with the myriad issues that state boards deal with after licensure has been obtained, and with innovative suggestions for solutions that are dynamic and responsive. I would invite all segments of the profession to register for and attend our annual and semiannual meetings to learn more about the complex regulatory issues facing our profession.
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