Clinging to dinosaurs

March 1, 2012
I recently attended a seminar and became engaged in an age-old discussion about licensure.

by JoAnn R. Gurenlian, RDH, PhD

I recently attended a seminar and became engaged in an age-old discussion about licensure. It seems as though the debate continues about the need for restructuring the dental hygiene licensure process, particularly as it relates to the clinical examination of dental hygienists. Remarkably, I had a similar discussion in the 1980s. Really, some things never change.

It appears that, for some individuals, creating a national clinical examination is an important consideration. All dental hygiene students could be tested in the same manner. They would be able to relocate and become licensed without having to be re-examined. That certainly seems like a positive outcome, but not likely to occur right away given the current rules and regulations for each state.

Another point of view under discussion is to abolish the clinical exam once and for all. The argument here is that it is unethical to use humans for this testing purpose. Also, only dental and dental hygiene students have to take a clinical examination as part of licensure. Physicians, nurses, and a host of other health-care providers are not subjected to this type of examination. They complete a written examination only. One might wonder if a doctor can prescribe medication, place and remove sutures, perform surgery, and diagnose without taking a clinical examination, why should dentists and hygienists go through that extra step?

What does the clinical examination do for the profession and consumers? Well, to be honest, nothing. Some will claim that this examination protects consumers from incompetent practitioners. Others will state that it ensures clinical competence and a standard of care that will be provided by these future practitioners.

All of these considerations aside, the fact is there is no evidence to support the use of a clinical examination. No studies demonstrate that the exams are valid and reliable. No studies demonstrate that this examination ensures competency. No studies demonstrate that a standard of care will be employed in practice settings. Unfortunately, these facts — or lack of evidence supporting the use of clinical examination — are completely ignored by those who require them.

Who benefits from the clinical examination for dental hygiene licensure? Perhaps the organizations that conduct the examinations are the beneficiaries. After all, students pay a substantial fee to take the examination. One might argue that there are significant costs involved in organizing these clinical exams; thus, the fee. It seems unlikely that these groups are operating at a loss. One can envision these associations protesting loudly if the clinical examinations were stopped.

The state board members might be concerned that there are no assurances that the graduates being licensed are adequately tested. This clinical examination is one means by which they justify granting a license.

Is there a good answer for this situation? Rather than resorting to the same old, same old, now might be a good time to consider real solutions to this dilemma. What are we striving to achieve? If the answer is assurance of competency, one could remember the fact that competence is established when a student graduates.

Students spend a majority of their education performing clinical skills. They cannot graduate or pass their clinical courses without demonstrating effectiveness. Students cannot progress from Dental Hygiene I to IV without passing a series of process and product examinations. Some schools even require students to pass these exams at a proficiency level of 80% or greater. Students are required to treat medically complex patients and those with varying degrees of periodontal conditions. Is this effort meaningless in terms of licensure, or is there merit to considering graduating from an accredited dental hygiene education program sufficient?

Another option might be to have recent graduates complete a mentorship program similar to what new teachers must do. With this program, a graduate would mentor with an experienced dental hygiene practitioner for a given period of time, perhaps presenting cases that demonstrate proficiency using the dental hygiene process of care of assessment, diagnosis, planning, implementation, evaluation, and documentation. Upon successful presentation of a given quantity of cases to the mentor, this new graduate would be certified.

An alternative might be to have prospective licensees present a case to the dental hygiene committee of the state boards for review and discussion. The student can apply for his or her license, take the jurisprudence exam (if required), and meet with the dental hygiene committee to discuss the case.

Doing the same thing just because it is the way it has always been done is not the answer. Disregarding the facts about the clinical examination is inappropriate. It is long past the time when dental hygienists should have resolved this issue. It is remarkably unfair to ask our colleagues in dentistry to make the determinations about what is best for dental hygienists and the public. We need to ask our professional associations to take the time to hold forums to seek alternatives, and we need to arrive at a resolution that recognizes the education and proficiency of dental hygiene graduates.

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