Live Patient Licensure Exams: Beneficial or Unethical?
Reasons against single-encounter live patient license exams:
Unethical patient care
Single-encounter live patient license exams are exactly that: a single encounter. In all areas of healthcare, especially dentistry, we hold ourselves to the responsibility that we will treat each patient with the best comprehensive care we can offer. However, for single-encounter exams, patients are often neglected afterward, meaning they never receive necessary follow-up care. In 2016, 23.9% of patients who had follow-up appointment needs were never cared for.
Single-encounter live patient exams also encourage treatment coercion. According to ASDA’s White Paper on the use of human subjects in clinical licensure examinations, 13.7% of dental students knew of a situation where patients were coerced into a treatment they did not necessarily need or want. Coercing a patient into consent for treatment can have a negative impact on patient compliance, trust, and, most importantly, the patient’s care experience.
2. Encourages unethical operator/student behavior
Circling back to ASDA’s White Paper, 8% of dental students knew of another student who purposefully created a lesion for an exam. As oral health providers, we should prioritize our patients’ health and safety, including those we see for licensure exams. This means finding a way to best prevent operator malpractice and causing harm to a patient. Especially as we welcome High Point University’s dental school projected to have more than 150 dental students per class, it is our responsibility to anticipate and proactively prevent patient risk of suffering unnecessary treatment and harm by dental students desperate to pass a single patient encounter evaluation.
3. Ineffective and insufficient evaluation
Single encounter live patient license exams function on the assumption that all procedures in each category (i.e., posterior restorations) are the same. However, this is not the case. Every patient is unique, as are their oral health needs and disease. This means that, for example, one patient’s posterior restorative needs will not look the same as another. Therefore, it comes into question – how can we evaluate two different students effectively when they are working on different patients with different needs? Even if two students are executing the “same procedure”, a Class II restoration on a mandibular premolar is very different than a Class II restoration on a maxillary third molar. Such variety in patient care and needs is something that we, as providers, cannot control. However, students should not be penalized or benefited because they were given a much more difficult or easy task. Because of this, it is clear CITA (Council of Interstate Testing Agencies) live patient encounter evaluation cannot be standardized, leaving too much of the passing grade up to circumstance and subjectivity. In other words, many dental students are left searching for patients and hoping to be “lucky” enough to find the “ideal patient”. Licensure should never be about luck; it should be about proficiency.
High costs for students
Licensure is expensive. Specific to North Carolina, the live patient exam costs $1500 the first time, and another $1500 for every retake after a failed attempt. Building on the point that grading is already subjective, this leaves the dental student at a higher risk for having to retake parts of the exam and spend upwards of $3000.
Cost of CITA: https://m.citaexam.com/dds/clinical-exam-cost/3
Assuming a dental student passes all parts of their patient licensure exam the first time, there is still the obstacle of patient compensation. The patient is aware that the dental student is desperate to have them show up for the exam because a no-show is a failing grade. This shifts the relationship power dynamic heavily toward the patient, giving them full control over if, what, and how much they want to be compensated for showing up for the dental student. In ASDA’s White Paper, 61% of dental students paid their patients to be present for the exam. 61% of dental students is more than half. In North Carolina alone, that means an average of 85 dental students will pay their patients every year for their license exams, and this number will only rise as we expand our dental education community to High Point. With dental school costs rising and license exams already demanding $1500 minimum, dental students are under extreme financial pressures and should not have to face additional barriers to earn their license. Our dental license needs to be earned and not paid for through unethical methods such as bribery and patient coercion.
Financially disadvantaged or underrepresented students at further disadvantage by having to retake/being blackmailed by patients for having to pay for accommodations/compensation/etc.
This furthers the inequality within the profession if students are unable to provide the financial compensation that is demanded from patients or given by other students to secure a patient.
Reasons for manikin license exams:
Eliminates possibility of unethical patient care
Manikin license exams, unlike live patient encounters, eliminate the possibility of unethical patient care. With manikins, dental students can demonstrate their mastery of clinical skills without risk of harming the patient or bribing them into receiving care they do not want. In addition, manikins will not require the same follow-up care that live patients do. This prioritizes patient safety because it guarantees that no patient seen for a license exam can be neglected. It is also important to note that a manikin exam does not mean the student will not demonstrate treatment plan mastery. The student can still show the appointments they would schedule for their manikin as if it were a live patient, but now they can do so without risk of harming anyone.
Eliminates possibility of unethical operator/student behavior
Conducting manikin-based licensure exams eliminate unethical operator/student behavior because a manikin-based exam can be fully controlled by the CITA testing service. This means that all teeth would be manufactured and distributed by CITA to dental students in their manikin, so situations in which students create extra lesions to fulfill requirements are impossible. Therefore, using a manikin not only eliminates provider misconduct, but it also upholds our core values as health professionals to prevent and protect patients from unnecessary treatment.
Standardized, hands-on evaluation that sufficiently evaluates students
Manikin-based exams offer a standardized evaluation method. Building from the previous statement that CITA can control the manikin dentition, having full control over the dentition each student works on is a major advantage. With full control, CITA can decide exactly which procedures at what complexity are sufficient to prove student competency and clinic readiness. In addition, it facilitates exam evaluation for the graders, allowing them to approach treatment objectively. This allows each grader to focus their energies on evaluating the student’s technique and form, rather than having to complicate grading with patient anatomy and health variations. This means that CITA benefits both the graders and the state. The graders benefit from a standardized grading approach that facilitates their experience. North Carolina benefits from the confidence that their dentists are clinically competent based on exact procedures defined by CITA as sufficient for clinic readiness.
More affordable for students
The manikin based CITA license exams are priced at $1525. While this may seem around the same cost as single-encounter live patient CITA exams, it is important to note that manikin exams are also standardized (as discussed previously). With standardized grading, there is less risk that a dental student will fail a CITA exam for subjective reasons or opinions that would otherwise not fail a student. However, even more beneficial is that manikin-based exams eliminate bribery. Without live patients that have the power to demand compensation, the 61% of dental students paying their patients each year will no longer have to set aside funds for this. While patient bribery is not applicable to everyone and is not something CITA can control, it is our responsibility to keep dental students safe and proactively prevent financial barriers such as these to focus on learning and dental proficiency.
Reasons for keeping patient-based exams:
Manikin exams are easier
Counter: It is difficult to say that manikin exams are “easier” than live patient exams because of the variability of live patient exams. For some dental students, manikin exams may be easier if their patient for their live exam had more advanced procedure needs than the manikin. However, it is also true that some dental students may think manikin exams are harder if their live patient had very simple procedure needs relative to the manikin. Either way, without clear, standardized evaluation methods, one test cannot be deemed easier than the other.
Counter: Whether the license exam is manikin or live patient, it is only a single encounter. Therefore, to further demonstrate clinic proficiency, dental students must graduate from an ADA accredited dental school that requires students to complete an extensive list of clinic requirements. These clinic requirements and evaluations are meant to further prove that a dental student is practice ready. Every student has better and worse days, but it is the consistent procedure proficiency on live patients in combination with a license exam that fully demonstrates their clinic competency. The many clinical requirements dental schools mandate should be more than enough to compensate for a single license exam that does not use live patients.
If manikin exams are easier than live patient exams, it is advantageous that manikin exams offer testing agencies such as CITA full control over what is tested. This means that CITA can advance the procedures required to earn a license, selecting more intense operative, endodontic, or prosthodontic needs for the exam.
Live patient exams are more realistic/on par with post-dental school settings
Manikins are becoming increasingly technologically advanced, as are the typodonts and dentition being used in manikins. Today, manikin systems in NC (North Carolina) dental schools have water, and plastic teeth can be made with decay and different layered materials to represent enamel, dentin, etc. License exams can utilize these
Makes licensure requirements more challenging for dentists who aren’t from NC who are coming to NC to seek licensure
Counter: CITA has extended licensure reciprocity
Additional comments:
As of August 2021, 18 more states moved to permanently accept a manikin license exam. We have ample data at our fingertips due to the COVID-19 pandemic that demonstrates manikin license exams are an effective testing and evaluation method. Manikin license exams offer extensive benefits for all parties involved, from the dental student to the graders and the patients. These benefits include, but are not limited to, patient safety, standardized assessment, facilitated testing experiences, and elimination of unethical provider behavior and financial barriers. If we want to continue to improve our profession, the best thing we can do is evaluate the evidence we have and initiate positive change. Implementing manikin license exams permanently in North Carolina is a policy- and evidence-based decision that will protect patients and best prepare dental students for practice. It is our responsibility as providers to prioritize our patient care and effectively evaluate future dentists’ practice readiness, and the decision to switch to a manikin licensure exam would be a proactive step in the right direction.
Live patients made it harder for dentists outside the state to get licensure in the state, but this benefit has been lost in part due to reciprocity laws with other states.
Other notes:
As of August 2021, 18 states moved to permanently accept a manikin licensure exam (ASDA (American Student Dental Association) Licensure Reform Webinar, Sep 2021)