Sarah K. asks:
“As a student who just graduated and took WREB, I was interested to find that we are the only profession, besides dentists themselves, who have to use a patient for our clinical boards. I also saw this topic in the recent ADHA magazine, but I am curious to know what other hygienists think, whether this is ethical for a patient to have them be checked by a student, then ask them to wait for treatment, have them checked by examiners (we had a patient who was checked by five or more), finally receive treatment, and then have them checked again. We then have to consider if the needed radiographs are retaken or not.
I know it’s important that hygienists are well tested and that we know what we’re doing, but is it fair or ethical to the patient? And is it fair to us as a profession? Nurses only have to do so many clinical hours and then take a written. Why don’t we?”
Debbye Krueger, RDH, BS, MAADH, responds:
Your point about comparing our profession to nursing has not fallen on deaf ears here! Registered nurses are the most closely equivalent profession to registered dental hygienists, in my opinion, and yet we enjoy so few of the same recognitions. When Tammy Byrd, a Past President of the ADHA, won her case against the South Carolina dentists through the Federal Trade Commission, she compared the education and training of RNs to RDHs and proved that RDHs had more hours of both education and training. I honestly feel that our lack of professional recognition is an issue of a turf war. Nurses are nurses, regardless of which state you live in. Sadly, the only organized group advocating for all dental hygienists is the ADHA, and the membership percentages are embarrassingly low. In my state, it is less than 10%. Hard to push for change, including where you use live patients on boards, when the folks you are dealing with are only too happy to point out that you truly do not represent the majority of your profession (I have heard this personally from State Legislators).
While at the last ADHA Annual Session in Nashville, Tennessee, the Kellogg Foundation had a panel dealing with such issues (yet another reason to be an ACTIVE member of your professional organization). When asked how they managed to achieve mid-level provider status in selected states, the answer was that it came from consumer demand, rather than professional battles. While the role of Community Organizer has been vilified in this country, it is indeed the most successful model for change. Partnering with organizations such as AARP, and other large groups, is an idea pregnant with possibilities. I would personally like to see us partner with physicians and be allowed to work in medical offices as well as dental offices. It would be interesting to hear the dentists’ arguments that we are not well enough educated to supervise ourselves. Would they also argue that physicians were not well enough educated to supervise us? As Margaret Mead once said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
Cynthia A. Chillock, RDH, EF, AP, responds:
Well, this is a hot topic and important, ethical questions. To carry your comparison even further beyond nurses, do surgeons need to remove a gallbladder to become licensed? What about oral surgeons, do they extract a tooth unnecessarily or resect a mandible? There is so much to consider.
I am currently full-time faculty and a 2nd-year clinic coordinator for a dental hygiene program, and this question comes up in academia on a frequent basis. If a dental hygiene program must be accredited and the student shows proficiency in skills, do we really need a board at all? Requirements are created to develop students who will be able to pass the board. But if those same requirements are in place, do the students need yet another test to show proficiency? As for the patients, they are checked a minimum of six times by examiners. Three must check them in and three check them out. That does not count what the student is doing while performing the procedure. And, if it is questionable regarding whether or not the patient qualifies, they may be checked by yet another examiner. One of my jobs is to create a “mock board” experience for the students in the last semester that is as close to the board as possible. The students are not approved to take the WREB until they have passed a “mock board.” If that is the case, why do they need a board in addition to the experience in school? As for x-rays, they are either diagnostic or not. If not, the student fails. There are no retakes for the board. However, that does not mean that the student has not taken multiple x-rays to achieve the perfect set to pass the board.
Without a board to pass, we would need some kind of uniform criteria for requirements across the country. That is not an easy thing to do, since we cannot even get Board agencies from multiple states to agree and create a national, clinical board. Until we have better uniformity in program teachings, I do not see eliminating boards as something that will happen in the near future.
Here is my two cents worth. Our students already do a computerized process to care exam that shows proficiency in critical thinking and treatment determination, along with a computerized national board. And, they most likely have taken a local anesthesia board to become anesthesia certified. That means dental hygiene students have to take four expensive boards to practice, so that they can then be supervised by another profession. Very interesting to me! With some of the computerized simulation labs I have seen in the nursing programs, why can’t we create a simulation with a mouth that has the appropriate level of calculus for removal on an inanimate model? Do we really need a live patient? This might satisfy both those who think we need to perform the procedure for a board, and those that think it is unethical to expose a patient to what some consider “cruelty” or “torture.”
Tracey Thompson McGonagle, RDH, responds:
Your question raises many interesting points, for both sides of the argument, actually. I think a board patient should be made aware that the process of care is unusual, given the circumstances (of a board examination).
The larger debate is if recent graduating hygienists from an accredited school should be required to take the clinical board exam. The ADHA has proposed Resolution 64H to eliminate human subjects from licensure. Cathy Elliott has written an interesting article about this in the May-June 2011 Access. It is a challenge to calibrate the clinical board exam. It is nearly impossible to standardize this exam using live patients, and there are also problems with calibration among the examiners.
I feel the clinical board exam does have merit. As a dental hygiene instructor, I see the pressure from the school to graduate students. The “final” check is this exam. A student can be successful in the written areas but not be able to perform clinically. This exam is the only way to check this. New York is substituting the traditional clinical exam for dentists with a “post-grad” year after graduation, called the PGY-1. Minnesota is offering the PGY-1 as a choice for licensure, as well as the traditional exam.
I wish there was only one national clinical board allowing your license to be valid in all fifty states. This would make it easier for hygienists to move and find jobs in other areas of the country. It would minimize the number of clinical boards to be taken, thus requiring fewer “live” patients overall.