The Examination Enigma: Ethical Considerations for Dental Board Exams
Live Patients vs. Manikins in Dental Board Examinations
The dental profession, much like the world around it, is in a constant state of transformation, continually evolving and adapting to innovative technologies, methodologies, and societal norms. As the profession moves forward, we must continually confront fundamental questions that challenge our traditional practices. This is true not just of our own clinical practice and leadership, but also when it comes to evaluating the aptitude and readiness of the next generation of oral health professionals.
Among these challenges is a pressing question: Should we continue with the longstanding tradition of using live patient board exams, or should we transition towards a seemingly safer, more controllable, and more equitable approach using manikin-based exams?
In this commentary, I want to explore these ethical considerations and (I hope) shed some light on the profound implications of each choice as well as the potential moral dilemmas that lie beneath the surface of these assessment techniques. My goal is to spark a conversation centered on ethics in dental education that can ultimately guide us toward a more balanced, equitable, and patient-centered approach.
Patient-Centric Ethics
First and foremost, the philosophy of healthcare ethics focuses on patient well-being. The Hippocratic Oath obliges us to "do no harm." The ethical question, then, arises in the context of live patient examinations: are we compromising this basic tenet for convenience in assessment?
During a live patient board exam, the student works within the assessment parameters while balancing the needs and treatment considerations of the human being treated. Given the immense pressure of the testing environment, it’s possible that sub-optimal care delivery, unintentional patient discomfort, or potentially adverse outcomes can occur. Also, the exam context could potentially distort the student's focus from patient care toward performance. The ethical burden of using human beings as 'test subjects' is a significant concern.
For patients, there are risks associated with undergoing a dental procedure via the board exam framework. Specifically, in many instances, patients are offered discounted or free dental care in return for their participation. This 'benefit' can disproportionately attract lower-income individuals, inadvertently exploiting their economic vulnerability. This presents an ethical dilemma in terms of social justice and equitable treatment.
Diagnosis and Treatment Timelines in Live Patient Examinations
Adding another layer to the ethical complexity is the practice of diagnosing dental decay for a board exam and then postponing treatment until the date of the exam. This raises additional ethical considerations: the right to timely treatment and the concept of beneficence, a key principle in medical ethics that obliges healthcare professionals to act in the best interest of the patient.
Timely Treatment and Patient Rights
Once a dental disease is diagnosed, the standard of care dictates that treatment should commence as soon as possible to prevent further progression. Delaying the necessary treatment due to the scheduling of a board examination might put the patient at risk of experiencing unnecessary pain, discomfort, or complications.
It’s not unreasonable to argue that this delay is akin to using the patient's disease for the benefit of the student's examination rather than focusing on the well-being of the patient. This prioritization of educational benefit over patient care may directly conflict with the principle of primacy of patient welfare, which states that the health and well-being of the patient should always be the primary concern of healthcare providers.
The Principle of Beneficence
The principle of beneficence holds that healthcare providers have a duty to benefit the patient. By delaying treatment in anticipation of a board examination, it could be argued that this principle is being violated. Dental decay, if left untreated, can progress rapidly, leading to severe pain, tooth loss, and even systemic infections. By waiting to treat the diagnosed condition until the board exam, this duty of care may be violated, resulting in unnecessary suffering for the patient.
Informed Consent and Autonomy
It’s also important to note that the principle of patient autonomy requires that a patient be fully informed about their condition and available treatment options before deciding on their care. If a patient is asked to delay treatment for the convenience of a board exam, it is crucial that they understand the implications of this delay, including the potential progression of the disease and associated complications. Transparent communication and respect for patient autonomy are essential.
Learning Considerations and Manikin Exams
So what can be done?
Manikin-based board exams present a viable alternative that circumvents these ethical quandaries. By shifting the exam setting to a controlled environment with manikins replacing live patients, we can eliminate the risk of harm or discomfort to real individuals.
Manikins offer a reliable and consistent testing environment. This allows every student to be evaluated under the same conditions, thereby ensuring fairness. Moreover, manikins enable students to demonstrate their skills without the worry of causing patient harm.
Of course, there is a flip side. Manikins cannot fully simulate the human oral environment, patient anxiety, or unexpected clinical challenges. So the examination results may not fully reflect the candidates' ability to handle real-world scenarios — which raises another ethical question. Do manikin exams adequately prepare future professionals for the realities of their profession?
In this debate, it seems there may not be a perfect answer, but that is no reason to stop seeking improvement.
Striking the Balance: Clinical Competency and Patient Safety in Board Exams
It seems to me that we should aim to strike a delicate balance: ensuring rigorous clinical competency assessment during the board exams, while upholding our duty to patient safety and well-being. The moral and ethical dilemmas that we grapple with are not easy ones.
Is it acceptable, in the context of a high-stakes board examination, to potentially compromise on replicating real-world scenarios to mitigate the risk of patient discomfort or harm? Or, alternatively, should we challenge students to navigate the complexities and realities of the dental profession, including direct patient interaction, even given the above ethical concerns with live patient board examinations?
We need to seek a balance.
A Balanced Approach for Dental Board Exams?
With the above-outlined ethical considerations in mind, we might want to consider a comprehensive assessment model that eliminates the potential harm of traditional board exams. Perhaps we could combine the advantages of both live patient and manikin-based assessments and cater to the critical needs of competency evaluation and patient safety.
Part 1
In this model, the examination could be divided into two distinct segments. The first part would involve an intensive evaluation of technical skills on manikins, simulating real-life clinical scenarios in a controlled, risk-free environment. This would allow the board to assess a candidate's technical acumen, attention to detail, and ability to work under pressure without any potential harm to real patients.
Part 2
The second part of this model would take a more progressive approach. Instead of having students perform procedures on live patients under stress, candidates could be asked to compile a portfolio of their work throughout their dental school career. This portfolio could include case reports, radiographs, treatment plans, and patient feedback from real-life patient experiences under real-world, non-exam conditions.
The portfolio would provide a snapshot of the candidate's clinical capabilities, patient management skills, and ability to handle complex dental cases. It would offer examiners a longitudinal view of a candidate's skills and competencies, mitigating "performance pressure" associated with traditional exams and eliminating the risk of harm to patients during a high-stakes assessment.
Ensuring Equity
Last but certainly not least, serious effort should be taken to address potential socioeconomic bias related to access to high-quality manikin technology. This could involve forming partnerships with technology providers, introducing subsidies, or implementing innovative solutions to ensure equity.
Final Thoughts
The debate between live patient and manikin board examination in dentistry is a complex issue involving ethical considerations about patient safety, educational effectiveness, and social justice. There’s no straightforward solution, but a balanced approach might be the best path forward. As we continue to evolve our methods of assessment, it's critical to keep care for the patient, quality, and equity at the forefront of our decision-making.
What do you think? Should dental board examinations be conducted with live patients or manikins? What about a balanced approach involving manikin exams and a clinical “portfolio”? Shoot me an email at zbrian (at) unc.edu or connect with me on LinkedIn and let me know what you think!