A Review of the Ethics of Patient-Based Licensure Examinations

DISCUSSION

One of the challenges in designing this literature review was the knowledge that an effective search strategy on the topic of the ethical implications of patient-based dental licensure examinations would detect a large range and quality of articles. It was anticipated that publications would span a breadth of form and rigor, ranging from traditional manuscripts addressing the topic in a dedicated, comprehensive manner, to others where it was a secondary or even lesser focus, to expressions of individual opinion in the form of editorials, short letters, or statements. To assist and focus the review process, a PICO question was formulated to guide the search strategy which included the definition of inclusion criteria and other analysis items. Care was taken to be as inclusive as possible in the selection of endpoint articles while excluding items that did not sufficiently address the central topic. Importantly, the strategy facilitated the recognition of two subsets of articles, Objective/Referenced (Subset A) representing manuscripts with greater scientific or academic construct/style, and Subjective /Narrative (Subset B) which were more opinion-based, supported by few or no references, etc., yet providing sufficiently structured input and reflection to warrant consideration.

The two inclusion criteria that proved most challenging to satisfy were that an article a) specifically addressed the PICO question and b) devoted at minimum of 400 words (e.g., 2-4 paragraphs), indicative of sufficient focus on the topic of ethics and patient-based licensure examinations. In addition, determining whether the articles had been peer-reviewed often proved elusive, especially for editorials and invited submissions; articles where uncertainty existed were not immediately excluded but remained in consideration for selection.

This review of the literature revealed that significant ethical concerns have existed about patient-based licensure examinations both for dentistry and dental hygiene since at least 1985.¹¹ The first article was a 1985 debate in the Journal of the American Dental Association in which four contributors offered contrasting viewpoints on the subject.¹¹ This is noteworthy as the 1926 Gies Report is often cited as the first such report; this review found that the concerns in the Gies Report were about fairness and validity of the examination process rather than ethical issues; consequently, the Gies Report did not fulfill the inclusion criteria for this literature reveiw.²

There are several salient points within the data displayed in Table II and Figures 1-3 that extend beyond the outcomes reported in the results. The inclusion/exclusion process identified seventeen articles in the Objective/Referenced category compared with twelve in the Subjective/Narrative category. The difference between these two categorical groups was sometimes striking, with articles in the former category generally having a stronger scientific and analytical character and those on the latter category tending to be more conversational in style and based on opinion rather than supporting evidence. The two articles that did not note any ethical issues with patient-based examinations were in the Subjective/Narrative category. Most articles that did report ethical concerns linked these concerns not only to the patent/test subject but also to the test candidate and/or the public-at-large. Authors of the articles in the Objective/Referenced category that expressed an ethical concern about patient-based examinations and the general public most frequently based the concern on the reported low validity and reliability of these examinations in assessing clinical competency and therein the questionable effectiveness of this methodology in protecting the public.

As shown in Figure 1, all four major principles of health care ethics were referenced across the twenty-seven articles where ethical concern was expressed. Autonomy, or the duty of the dental provider to respect a patient’s right to self-determination and confidentiality, was the principle most frequently cited. Also cited were the principles of beneficence (do good, where the provider has the duty to promote the patient’s welfare), justice (the duty to treat people fairly) and nonmaleficence (do no harm). Consistent with this reporting, the ethics reference most frequently cited was the ADA Principles of Ethics and Code of Professional Conduct.⁴⁰

This review found a paucity of support for the continuance of patient-based examinations (Figure 2), This reasoning extended beyond the frequency of expression that ethical problems were associated with this type of examination (Figure 3). A secondary reasoning was that this type of examination was no longer necessary due to the emergence and increasing acceptance of alternative forms of competency assessment not requiring that patients serve as test subjects. The three alternative assessment methods with the greatest current recognition by states are manikin-based simulations, objective-structured clinical examinations (OSCE), and portfolio review.¹⁰ In addition, several states recognize completion of a one-year postgraduate residency training, or PGY-1, as an experiential alternative to a licensure examination.¹⁰ The COVID-19 pandemic accelerated these changes across the US as the delivery of patient-based examinations became difficult. During the pandemic period, over 40 states modified their regulations to recognize one or more of these alternative methods. Relative to dental/dentist licensure, as of June 1, 2024, 49 of the 50 US states, along with the District of Columbia, have changed their licensure rules to permanently recognize one or more alternative pathways that do not include or require the completion of a patient patient-based examination.¹⁰ Only one state, Delaware, continues this singular requirement.¹⁰

This literature review provides additional context at a time when significant reflection is occurring within the dental professions on the process of licensure to practice. The formation of the CMDL illustrates that many in the dental professions believe that significant improvements are necessary and possible.⁹ The four major associations representing the dental professions share resolutions calling for an end to patient-based licensure examinations.^4-8 The following are pertinent excerpts from these policies and resolutions:

American Dental Association, current policies (1954-2023) state the “elimination of patients in the clinical licensure examination process is strongly supported to address ethical concerns, including those identified in the ADA Council on Ethics, Bylaws and Judicial Affairs statement entitled Ethical Considerations When Using Patients in the Examination Process (Reports 2008:103). State dental societies and dental boards are urged to work toward acceptance of valid and reliable clinical assessments that do not require single-encounter performance of procedures on patients.”⁴

American Dental Hygienists’ Association, policy statement (2018, #1S-18/1-08) states that the “ADHA supports elimination of the patient procedure-based, single encounter clinical examination for candidates who are graduates of Commission on Dental Accreditation (CODA) accredited dental hygiene programs and who are eligible to take the National Board Dental Hygiene Examination.”⁸

American Dental Education Association, House of Delegates Resolution 5H-2014 “recommends the elimination of the human subject/patient-based components of clinical licensure examinations and the adoption of an alternative and validated process for the clinical assessment of candidates for licensure.”⁷

American Student Dental Association policy number L-1 “recommends elimination of patient-based examinations for initial dental licensure.”⁶

These resolutions align with and reinforce the recommend-ations made within the majority of articles in this literature review. The articles present compelling ethical reasoning for the elimination of traditional patient-based examinations by all states. Further, the development of alternative assessment methods, now recognized and employed by a number of state dental boards appear to have rendered patient-based examination unnecessary and obsolete. Beyond the ethical imperative, there is evidence that some of these alternative assessment methods have greater validity in differentiating between competent and incompetent candidates furthering the need to sunset patient-based examinations in favor of newer, improved, and ethically sound methods.³

This literature review and its findings should be of interest and importance to state dental boards and related regulatory agencies overseeing professional licensure. The availability of alternative methods to assess competency and readiness for practice points to the very serious question of whether patient-based licensure examinations should be permitted to continue either as part of a required or possible pathway in any state. The authors of the many articles in this literature review advocating for cessation of this licensure methodology would undoubtedly suggest the time has come for all states to take this corrective action.

How might this be accomplished? First, as previously described, it is important to recognize that substantial progress has been made over the past decade toward reducing the recognition of patient-based examinations and their active use in licensure.¹⁰ Relative to dental/dentist licensure, of the 49 states that offer alternative licensure pathways, 36 states no longer actively describe or promote alternatives that require the completion of patient-based examinations. However, even with these changes, only one state, Connecticut, to date, has changed its statutes to prohibit the use of this method in initial dental licensure. Fourteen state dental boards (Alaska, Delaware, Georgia, Louisiana, Mississippi, Missouri, Montana, North Carolina, Oklahoma, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming) continue to function under statutory or regulatory provisions specifying that a single-encounter, procedure-based patient examination is required for dental licensure. One state (Delaware) continues to grant initial dental licensure only upon the completion of a patient-based examination.

The national movement toward acceptance of alternative assessment methods for initial licensure has been slower, overall, in dental hygiene. A notable exception is the recent change in California where graduates of CODA-accredited and Dental Hygiene Board of California (DHBC)-approved programs may gain licensure based on program completion and are no longer required to take a clinical examination. However, many states continue to retain the requirement of a patient-based licensure examination. One might conclude, therefore, that patient-based examinations are far from retired and vacant from the landscape of dental and dental hygiene licensure. For this to be achieved, the following steps appear necessary: 1) States where statutes or regulations still exist that require candidates to pass patient-based examination for dental/dental hygiene licensure take prompt legislative or related action to eliminate this requirement in favor of alternative assessment strategies, and 2) All state dental boards, in consideration of future graduates, prohibit the use of, or otherwise cease recognition of, licensure processes that require the completion of single-encounter, procedure-based patient examinations. These actions would allow state dental boards to review and update their licensure processes to ensure compliance with prevailing ethical standards and employ the most valid and reliable methods available. The result will be a better served and protected public and allow the dental and dental hygiene professions to better exemplify the ethical standards to which they aspire.