Licensure and Licensing Examinations
Hakli olmak değil hakliliğini surdurmek onemlidir.
The rather worthy fact is not being right but to stay right.
A license is a privilege—a conditional privilege—granted by the state for the benefit of the people over whom it has jurisdiction.
In order to be licensed, one has to satisfy certain requirements. These requirements include specific licensing examinations. All U.S. licensing jurisdictions require passage of the respective National Board Examination for dental or dental hygiene license applicants. Most jurisdictions also require passage of a recognized state or regional practical clinical examination. Although these examinations are prominent, there are also other requirements. Most jurisdictions require completion of a predoctoral accredited dental education program or documented completion of equivalent education. Many also require a passing score on a state- and profession-specific jurisprudence examination and that the applicant be of good moral character. And most jurisdictions require payment of an administrative fee.
As part of applicant evaluation, many states now routinely query state and federal databases of professional sanctions as well as criminal and civil actions. Some may additionally require character references or letters of recommendation; however, in the absence of contrary evidence, good character is generally assumed, and if all other qualifications are met, the applicant is licensed. Once licensed, it is incumbent on the licensee to behave in ways that justify the trust that society has placed in him or her. Notorious or illegal behavior in one’s personal life that may have no direct relationship to professional practice or clinical skill can bring into question one’s character and may result in limitation, suspension, or even revocation of one’s professional license.
National Board Dental Examinations
For dentistry, all U.S. licensing jurisdictions now require passage of the National Board Dental Examination (NBDE). For dental hygiene, there is a single examination, the National Board Dental Hygiene Examination (NBNHE). For dentistry, the examination currently has the following 2 parts: Part I, covering the basic sciences, is usually taken sometime during the first couple of years of an applicant’s dental education program and Part II, covering the clinical sciences, is usually taken sometime later when the applicant has had more clinical experience.
Both Parts I and II of the NBDE have sustained recent changes to make them more integrated and clinically relevant. A portion of the items on Part I now consists of scenarios or “testlets” that provide a clinical context for related basic science questions. And a portion of the items on Part II now consists of a series of questions taken from multifaceted clinical cases. These changes reflect a general trend toward greater integration in dental education and testing.
A plan to create a new, fully integrated examination for dentistry is now underway. Though the exact timing is unclear, the result is as follows: a single Integrated National Board Dental Examination (INBDE) that students will take before the end of their predoctoral dental education will someday be a reality. All communities of interest, including students and their education programs, will be informed about the upcoming changes in the NBDE examination well in advance of the changes being implemented. Furthermore, at some point, disseminated information will likely include sample items and, possibly, a practice examination that candidates will be able to take in preparation for the new integrated examination. Undoubtedly, there will be a period of time when both Part II and the new INBDE will overlap and be offered in parallel so that students who have taken Part I will have a choice and can take either Part II or the new INBDE. Constantly updated information, including answers to frequently asked questions about the progress of development and implementation of the new integrated examination, can be found on the Joint Commission’s Internet website.*
Any attempt to cheat or manipulate any National Board Examination would be unwise. Item remembering or “brain dumping” schemes have frequently backfired for candidates whose examination results are then withheld and who could be required to wait a year or more before being allowed to retest. Furthermore, evidence of involvement that surfaces, even years later, can retroactively impact the license of a licensee.
Nowadays, the National Board Examinations are administered under strict surveillance at secure testing centers. Candidates who misunderstand the test center’s scheduled or unscheduled break policy or who have inadvertently carried contraband items such as a mobile phone or a lucky talisman into the secure testing area are often surprised when they later learn that their scores are being withheld because of a testing irregularity. And then they may need to file an appeal with the Joint Commission and wait for a period of time before being allowed to retake the examination. These are not always conscious violations but are sometimes just the result of carelessness or ignorance. The resulting hassle is not worth the risk. Candidates are advised to pay close attention to all testing regulations and instructions. They should not harbor a cavalier or too casual attitude when taking any National Board Examination.
Candidates are generally eager to do whatever they feel may be necessary to pass the examination. It would be well for the examination to test basic science foundation knowledge and clinical science understanding that practitioners need to know and for candidates to remember that they are working to master understanding of this information to skillfully treat the patients they aspire to serve.
Practical Clinical Examinations
Why do we also have clinical examinations?
Most dental education programs have economic and logistic pressure to be efficient. Each is a unique system that functions something like a complex pipeline. They matriculate students, move them through the program, advance them from class to class, and urge them finish their requirements and graduate. Programs need students to graduate and leave, so the next class of students can advance and a new class of students can enter the program. A well-designed program efficiently delivers the necessary education and experience with carefully structured use of available resources and a detailed curriculum. For most programs, the surplus clinic facilities and faculty needed to accommodate remedial education or an extension of education time for any significant portion of the senior class are nonexistent. And by the time students have completed the prescribed program, debt has accumulated and they need to begin generating income. Regardless of the benefit or need, few are able to readily absorb the income delay and additional tuition that would be required for them to repeat a year of their education.
As a result, there are students who just slip by in some programs, or who, for practical reasons, are inappropriately advanced with the thought that catching up might be later accomplished. Despite Commission on Dental Education (CODA) standards regarding the implementation of certain competencies, exactly how these competencies are defined and verified are decisions left to the programs. Concerned faculty who hesitate to recommend a student for advancement may receive pressure from program administrators to somehow accommodate the student’s advancement. The economics and logistics behind this pressure are completely understandable.
In addition, nowadays there is legal pressure. In our litigious society, it can be difficult, troublesome, and expensive for a program to inform a student or his family that, after completing several years of training, he may not have what it takes to succeed and is being held back or released from the program. Besides expensive legal challenges the programs face when they attempt to implement and stand behind such decisions, they potentially face additional loss if the student is associated with a wealthy present or future donor.
All this is understandable. With the breathtaking expansion of knowledge, increasing complexity of technology, and expanding range of services dentists need to know about and be able to provide, predoctoral dental education programs nowadays perform a Herculean task. They do, every year, turn out thousands of top-notch graduates who are well prepared to enter the workforce and contribute to the profession. Though teaching is the program’s responsibility and learning is the student’s responsibility, not all students apply themselves with the same degree of focus. Despite having graduated, when independently tested, a small minority of students demonstrate that they are not ready to be licensed—not ready to deliver dentistry to the public in an unsupervised setting.
The number of graduates not ready by the end of their predoctoral training program is small, relative to the total number of graduates or applicants for licensure. The examination is criteria referenced and occasionally all the student candidates at some institutions satisfy the criteria and pass the examination on their first attempt. Sometimes those who do not pass appear to be well coordinated and seem to have good conceptual skills but, for example, fail to recognize gross caries remaining in their preparation. Some just need a little more experience. For others, the deficit may be something else. Overall, including candidates who repeatedly retake the examination, probably only about 5% of those who challenge the clinical examination ultimately fail. This statistic is fairly uniform across regional dental testing agencies. Most testing agencies can demonstrate that, in the absence of structured remediation, the probability of a candidate’s failing the examination increases with each successive failure. This fact contributes to the body of reliability evidence for these independent practical clinical examinations.
Like competency assessments, practical clinical examinations are imperfect. For example, they are not comprehensive but are limited by practical constraints. For example, some things are impossible or impractical to measure during the time interval of the examination. Assessment of ability in areas not directly measurable is generally inferred from the results observed for things that are evaluated. In spite of these limitations, independently administered practical clinical examinations may still be the most effective way for licensing agencies to determine things such as whether a candidate can recognize and appropriately handle dental caries, precisely use dental instruments in the oral environment, plan and organize clinical activity, effectively communicate with patients, and appropriately judge and effectively deal with the kinds of unexpected things that arise when practicing dentistry. To directly or indirectly assess these things, most licensing jurisdictions still rely on practical clinical examinations that include some patient treatment.
Of course it is possible for operator accidents or mistakes to occur during an examination just as they sometimes occur in teaching hospitals, dental education program clinics, or even in practice. During training, procedures are first simulated and then performed on patients. When students begin patient treatment, instructor supervision and procedural stop or “check-off” points are implemented to enable in-process feedback for the student and limit mistakes and potential patient injury. Nevertheless, despite these precautions, accidents occasionally still occur and can be expected to occur until the student has sufficient experience to make sound clinical decisions in real time on his own. If the educational program and student have done their jobs, then the candidate is deemed to have acquired this experience by the time he takes the licensing examination. If he has, involved patients are safe, and so will be the public on whom the candidates will be operating when he is licensed. If the educational program has done its job and the student is ready, then patient risk exposure is completely reasonable. We would not expect a candidate to fail the clinical certification and seriously damage a patient any more than we would expect a student pilot to crash the plane and injure himself or others during his solo test flight.
Remember, the examination is not testing patients, nor is it testing treatments; it is certifying—validating by independent assessment—candidate preparedness to practice independently. That is all. Candidates merely demonstrate the clinical skill they have acquired. There is, or should be, no experimentation involved.