Clinical Orthodontics

Jonathan Shouhed is a fourth-year dental student at Ostrow School of Dentistry, University of Southern California. (DTI/Photo Jonathan Shouhed)
Feb 15, 2013 | Orthodontics

State and regional board examinations of dental students’ performance, ethics and professionalism

by Jonathan Shouhed, USA

Do dental students treat patients holistically and humanely during dental competency examinations? As student dentists progress through their education, clinical skills are learned and then challenged during competency and licensure exams to make certain that the student is prepared to practice dentistry independently. State and regional board examiners detail the requirements and percentage value for caries preparation form, restoration anatomy and integrity, and the maximum length of time allowed to complete any procedure (including periodontal, endodontic and operative treatment) in order to achieve a passing grade.

Unfortunately, the emphasis on ethical and professional behavior during these exams is far less specific.

Beauchamp and Childress (2001) agree that dentists fulfill the criteria of professionals because they are specially trained and licensed, and they are committed to the provision of important health care services to their patients. As Tartakow (2010, p. 96) reported, “Certosimo cited five principles of ADA codes that included: non-malfeasance, beneficence, justice, veracity, and patient autonomy, [suggesting] that these were the obligations for all healthcare providers to make available in order to address the needs of patients and the profession.”

As defined by Rule and Veatch (2004, p. 45-46), patient autonomy, or the “patient’s right to make decisions based on his or her own values, principles or ideals,” can only be upheld if “the healthcare provider respects the patient’s rights to be adequately informed and acts accordingly.”

Rule and Veatch persisted that the principle of justice delineates the intrinsic worth and certain rights that every person possesses and that others are obliged to respect, signifying that no one patient deserves any more or less comprehensive treatment than another.

This ideology works in concert with the principle of veracity, which according to the AMA (Rule and Veatch, 2004) urges an individual to act honestly and without concealment regardless of benefit produced or harm encountered. These principles of social justice create a unique environment of honesty and respect in which fair treatment of patients is contextualized.

During dental competency examinations such as state boards, circumstances arise that can jeopardize these principles of practice. Through personal experiences and witnessed accounts of misconduct during practical exams, it is clear that ethics violations occur when a student is not mindful of his or her responsibility as a professional.

For example, the WREB Candidate Guide outlines the assessment of point deductions if a student fails to finish the procedure in the allotted time; completion more than 15 minutes late garners a score of “0.” As a result, student doctors may use improper isolation, etching time and instrumentation as ways to complete exams when time becomes limited.

They may also ask patients to limit questions regarding the treatment being received during the appointment, failing to follow proper protocol regarding informed consent in an effort to gain more “working” time. Under these circumstances substandard care can occur. This quandary, though, is not the only ethical gray-area on test day.

During the preparation and restoration evaluations, evaluators must review students’ work and may lower a score for any technical errors found during these checkpoints. This risk of losing valuable points can bring about the fear of forthright communication, which would directly result in error detection.

For instance, a student may be aware of a void in a composite restoration or an open margin on a provisional crown, but fail to present this to an evaluator. A sub-marginal restoration can be “corrected” by removing sound tooth structure or being “built-up” with adhesive resin. Concealment of errors even becomes a risk as a student can instruct a patient to “tap lightly” when occlusion is being checked.

These examples encompass the inherent conflict of interests involving the student’s desire to pass an exam and his or her obligatory honesty to the patient and the examination process itself, thus endangering ethical boundaries that are vital to the concept of being a professional.

While these examples may present complex scenarios, the response should not be to eliminate time constraints during exams or the examination process as a whole. Instead, ethical virtue can be assured on exam day with proper planning and execution.

For example, by explaining the risks and benefits of treatment to patients during a prior appointment, with full access to descriptions of the procedure, a patient’s true informed consent can be gained without pressure to do so during an exam. A patient’s rights to autonomy and making informed decisions are unalienable. No amount of time saved or advantage gained by a student justifies the failure to deliver a patient these basic rights.

A student must show preparation and confidence in clinical skills during an exam but must not attempt a competency exam for which he or she is unqualified. Proper case selection is vital to this concept. An example of this is the attempt of a potential graduate to complete a gold complete veneer crown preparation on a second molar with no distal contact and a gingival overgrowth in the area for a test.

Independent of skill and experience, a satisfactory crown preparation, gingival reduction, final impression and provisional restoration fabrication would be an ambitious task for any dental student to complete in a single appointment and brings about the potential for: (1) excessive patient discomfort, (2) poor treatment execution and (3) irreversible tissue and pulpal trauma. Had this patient’s treatment needs been assessed for clinical exam appropriateness with a faculty member prior to test day, the student may have been advised against performing a procedure that is not in the best interest of the patient. In addition to procedural responsibility, there are also personal obligations of the student doctor to professional behavior that protect the patient.

Above all other extrinsic factors, a student must value and protect his or her integrity as a doctor. He or she should always portray this decorum; that is, to pass exams based on merit and capability, not good fortune and concealment. The honesty with which doctors act engenders a trust between patient and doctor; honesty that has not been corrupted by selfishness and self-interest, the way Allan Bloom (1987) suggested modern honesty has, is central to this trust.

Bloom’s argument for a review of contemporary “honesty” during a time in which moral code is being eroded by knowledge of popular greed, is of particular importance to the medical field: a doctor’s commitment to selflessness displays profound strength of character, and makes him or her worthy of total trust. Continuing this tradition is pivotal to the esteemed reputation doctors possess.

Dharamsi et al. posited “dental and postgraduate residency programs must develop curricula with social justice and social responsibility as topics for educational training” (Tartakow, 2010, p.87). These ethical standards should be applied to the test taking process in order to prove true proficiency in the principles of medical and dental practice.

Brown opined that “only through critical reflection, lucid dialogue, and strategic praxis can programs be set into practice for future leaders regarding ethics, social justice, and the equity to grow in awareness and action” (Tartakow, 2010, p. 92).

Presently, a disconnect exists between the values of the medical profession and the standards to which students are held during performance examinations. Standards such as close attentiveness to others and procedural fairness, for example, have been lost in the student dentist’s overwhelming desire to pass a competency exam. It is this disconnect that brings about the potential for patient mistreatment. If students place personal interests aside, as contemporary bioethical standards demand, the implementation of ethical standards during exams can begin; the use of substandard practices during exams could then subsequently end.

In accordance with Brown, critical reflection, lucid dialogue and strategic praxis is interpreted to mean that patient well-being must become a priority to student doctors during exams and in the future as a practicing professionals. After all, including morality, humanity and ethics in a dental student’s education is not an option. It must be highlighted and emphasized throughout the four years, as a professional education cannot be considered complete without it.

Note: This article will be published in a future issue of Ortho Tribune U.S. Edition. A complete list or references is available from the publisher.


 

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