JADE

Congratulations on the new issue of JADE.

I am especially appreciative of the focus on the use of human subjects. Since my appointment as a full-time faculty member at NYU Dentistry in 1977, I have been directly involved with licensing examinations. One of my first assignments was to prepare foreign-trained dentists to pass these examinations, which were initially on manikins — allowing these foreign-trained dentists to then challenge the patient-based examinations without any additional CODA approved education. In the very early 1980s, New York State added a requirement of one year of clinical education which subsequently went to two years. Since that time, requirements have changed a great deal, with most states now requiring a CODA approved education culminating with a diploma in order to apply and take a licensing examination.

What hasn't changed is the requirement for human subjects in these exams. I have been extremely vocal on the issue, arguing that the use of human subjects for testing of dentists for licensure is hypocritical, unethical, and in my opinion, truly malpractice in many ways. I am glad that some of us continue to fight.

Unfortunately, as more and more professionals realize the absurdity of the use of human subjects, it is not the testing agencies that are to blame. It is the state boards of dentistry. As long as state boards mandate the use of human subjects, nothing will change. I believe that testing agencies can provide a valuable safety net, not so much for the patients, but more as a check and balance among the different educational institutions. For example, CDCA now requires a manual skills test on a typodont, which affords an independent assessment of hand skills. We must remember that a dentist is really a medical professional specializing in the oral cavity. Unlike many other medical professionals, we are unique in that not only do we diagnose a condition, but we must also be able to treat it medically and in many cases surgically; this is unlike the neurologist versus the neurosurgeon paradigm or the cardiologist versus the cardiac surgeon paradigm. Dentists diagnosis the tooth infection and must treat it medically and surgically. We not only need to fill a cavity, but may need to provide endodontic treatment, and/or extract a tooth and perhaps even place a suture if all else fails.

With this as background, I fully support the elimination of human subjects in the testing of dentists for dental licensure. From personal experience and observation dealing with testing candidates from all over the world and from nearly every one of the 5 different testing agencies, the number of unethical practices that have occurred is truly disappointing. For example, I know for a fact that one candidate completed a Class III restoration where the patient was dismissed and then an hour later — when the examiners realized they failed to record the grade for the preparation — the patient was brought back to the exam, the restoration that had just been placed was removed, and the preparation graded. The good news here was that the candidate replaced the restoration and passed the exam.

On another occasion a patient was rejected for treatment for the operative portion of the examination and was resubmitted the next day by another candidate and accepted.

There was a case with one of the testing agencies where a candidate who failed the manikin portion of the exam twice in the fall of the senior year was allowed to challenge the patient portion of the examination before trying to pass the manikin portion the third time. Should that candidate pass the patient portion and then fail the manikin portion again, that candidate must retake the entire examination. If this is not the strongest indicator of a failure to protect the public, I don't know what is!

I know of patients who are warehoused for months in order to have the "ideal" board lesion.

I know of patients who are told not to brush their teeth so that they will have swollen gums to insure adequate pocket depths.

I know that one testing agency now licensing hygienists requires candidates to administer anesthesia to patients to demonstrate their injection techniques. These patients receive no other treatment!

I know of a candidate who started preparing the wrong tooth but was able to hide the mistake by placing a rubber dam.

I know that one testing agency REQUIRES a preparation design that is contrary to the teaching of many of the dental schools.

I know that one testing agency allows a candidate to treat only one surface of a tooth with decay even though another surface also has decay that should be treated but is left untreated.

I could site dozens more!

Now that we have the ADA, ADEA, ASDA and probably most of the dental schools and dentists in the United States in favor of eliminating the use of patients in dental board examinations, the push has to be to the state boards. A number of state boards, including New York, California, Minnesota, and a few others, have developed other pathways for licensure. That push must come from the deans of the dental schools reaching out directly to each of the congressional members of the legislature of their respective states. Change will not happen without that occurring. If our representatives can see and understand the arguments that have been brought forth in your publication, change could happen.

I applaud the efforts of the ADA in trying to develop an OSCE TYPE national examination; however, I think that an evaluation of hand skills using typodonts should continue as part of any independent evaluation and licensure process. I agree that the current system of testing using human subjects provides an inordinate amount of stress. Using typodonts — while still likely stressful, as it too would be a high-stakes examination — allows the candidates to retake the examination after a few months when additional training by faculty can occur.

Dentists constantly work under stress. And of course, new or recent graduates who treat a patient in a practice for the first time, or perform a procedure that they have not performed either recently or at all in their dental education, feel a level of stress. Even an OSCE or any written test would be stressful as well.

I appreciate the opportunity to share my insight and experience.

Dr. James Kaim