COVID-19 Pandemic Is Here, Airplanes Crash, and the Profession Has an Educational Dilemma

It has been said that “one should beware when the camel's nose is beneath the tent.” The camel's nose is a metaphor, of course, for a situation where the permitting of a small, seemingly innocuous act will open the door for larger, clearly undesirable actions.Recently (January 2018), the American Dental Association (ADA) took action to support its policy calling for the elimination of patients from the dental licensure examination process. The ADA requested that the Council on Dental Education and Licensure direct the development of a Dental Licensure Objective Structured Clinical Examination (DLOSCE).The ADA DLOSCE would be a written exam (much like the OSCE-administered exam in Canada) that excludes the assessment of clinical skills completed on a live patient. Written tests are an effective way to find out what level of knowledge has been acquired. No part of the OSCE assesses the applicant's clinical skills or patient management.The Western Regional Examining Board (WREB) dental examination is a highly developed and respected clinical examination that is already accepted by about 44 states for licensure. Most dental schools also test students for clinical competency with patients at some point. The issue, however, is whether schools' testing and determination regarding candidate readiness is sufficient to eliminate a third-party, high-fidelity, patient-based assessment. There is a small but consistent number of candidates who, despite graduating from an accredited program, are still unable to demonstrate acceptable competence when working independently. These students are unable to perform a simple restoration on a patient even after multiple attempts. Dental schools are either (a) knowingly graduating a small number of non-ready candidates, relying on an independent, third-party clinical exam to “apprehend” them, or (b) unknowingly allowing this small number of candidates to get through via an insufficient assessment of minimal competency… which is more disturbing. It is especially disturbing this year, as the COVID-19 pandemic has caused most dental schools (just weeks before graduation) to close classroom lectures and provide only limited care to patients. Clinical competency examinations may be severely compromised or eliminated entirely. These issues make existing clinical board exams very important in keeping a small number of candidates (about 3%) from practicing until they are able to demonstrate minimal clinical competence on a patient.The WREB operative dentistry clinical examination includes the following topics: local anesthesia and pain management, moisture control and soft tissue management, communication and patient management, disease management and removal, instrumentation with material handling skills, and anatomic/functional skills. If dental schools are not testing students with live patient clinical examinations, then who can be trusted to protect the public? One might even ask: What is the point of having examinations at all, especially if the number of failures is so small? Consider the following: most people trying to board airplanes are not terrorists, but the millions of people trying to board go through elaborate security procedures every day. Are these procedures 100% foolproof and perfect? No, but scrapping them for no screening at all would reduce public safety. And if the COVID-19 pandemic means dental students are unable to complete their clinical requirements or their clinical competency examinations, how will dental schools certify student readiness to practice dentistry? The educational dilemma is worsened because outside testing agencies (like the WREB) will likewise have similar difficulties giving clinical examinations if the COVID-19 pandemic persists.In education, most will agree that “trust is the coin of the realm.” The public would like to trust our educators, and the following questions might help with understanding the educational dilemma:The ADA is an immensely powerful and influential lobby. The deans of dental schools have a vested interest in getting their students a dental license to practice and will undoubtedly also have great influence. Without a doubt, both will argue vigorously for the development and implementation of OSCEs. That said, the public should be wary. Poorly tested pilots, poorly tested airplanes, and dentists who are inadequately tested on live patients can be hugely dangerous to the public.These are strange and challenging times for dental educators.

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