Assessment
Attitudes and Perceptions of U.S. Dental Students and Faculty Regarding Dental Licensure Ahmad Abdelkarim, DDS, MS, PhD; Donna Sullivan, PhD Abstract: The aim of this study was to assess the attitudes and perceptions of U.S. dental students and faculty members about National Board Dental Examination (NBDE) pass/fail reporting, an Integrated NBDE, clinical examinations, licensure process and strategies, and validity of licensure. A survey instrument consisting of ten statements with response options on a five-point Likert scale and a free-text comment section was developed and distributed through SurveyMonkey. A total of 411 students and 186 faculty members from ten U.S. dental schools participated, with an estimated response rate of 17%. Faculty and student responses were compared using the Mann-Whitney U test. These students’ and faculty members’ attitudes and perceptions were similar. Both groups showed mixed attitudes about NBDE scores as pass/fail, rather than numerical scores. The Integrated NBDE solicited mixed opinions and concerns that it would be complicated and stressful because students would be challenged to memorize information from earlier years. However, a single national clinical examination was highly preferred by both groups, preferably with simulated rather than real patients. Other strategies, such as background checks and continuing education requirements, were supported by both groups. Most of the licensure process strategies and policies were supported by both student and faculty respondents in the dental schools surveyed. Dr. Abdelkarim is Assistant Professor and Chair, Department of Orthodontics, University of Mississippi School of Dentistry; and Dr. Sullivan is Professor, University of Mississippi School of Medicine. Direct correspondence to Dr. Ahmad Abdelkarim, Department of Orthodontics, University of Mississippi School of Dentistry, 2500 N. State Street, Jackson, MS 39216-4500; 904-314-5353;
[email protected]. Keywords: dental education, dental licensure, licensure exams, National Board Dental Examination, clinical examination, live patient examination Submitted for publication 4/3/14; accepted 6/7/14
D
ental licensure grants permission to practice dentistry to dentists who meet a state’s requirements. The public policy goal in licensure is to protect the lay public from unqualified health practitioners. Dentistry is a profession that has stringent licensure requirements including dental education, the National Board Dental Examination (NBDE) Parts I and II administered by the Joint Commission on National Dental Examinations (JCNDE), usually a clinical examination, and other requirements, such as a background check. Also, the dentist as a professional is expected to continue his or her education with a continuing education process. Since the NBDE was first established under a standing committee of the American Dental Association (ADA) in 1929, there have been no changes to its strategies of providing and conducting dental examinations to issue a certificate of qualification to successful candidates.1 However, there have been changes in some aspects of the NBDE. In the past,
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exam scores were reported to all candidates, whereas since January 2012, the raw score is reported only to failing candidates.2 This may affect admissions to graduate specialty programs because their directors considered NBDE scores in selection of residents.3 Therefore, the pass/fail score currently in use may now complicate the graduate acceptance process. The JCNDE’s future plans for the NBDE are to replace both parts with a single exam, which will likely be called the Integrated National Board Dental Examination (INBDE).4 This one-step examination currently exists in Japan, where a single written exam process, comprised of 330 questions, is required— unlike the two parts of the NBDE (with a total of 900 questions) currently in use in the United States.5 An additional piece to the NBDE is the clinical examination, which is administered by a third party. There are currently five major clinical testing agencies in the United States. Hence, there is a call to combine these examinations into one standard-
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ized and uniform national clinical examination. The clinical exam process currently requires live patients. Live patient examinations present an ethical dilemma to the candidates because they are not yet licensed and have no faculty supervision during the examination process.6-8 This could also be perceived as unfair to the patients who are recipients of irreversible dental procedures by an unlicensed individual whose acquisition of a license rides on the specifics of the examination outcomes. Ranney et al. argued that the use of patients during examination process might be unethical because patients are subjected to irreversible dental procedures.9 Dental procedures done during an examination process might result in damage to oral structures because a combined decision making process (usually conducted by the student and a supervising faculty member) was not used. Therefore, clinical examinations are faced with several challenges. Some states waive the clinical examination if the applicant completes at least one year of postdoctoral education. Acceptance of completion of this additional education in lieu of a clinical examination is a trend that the majority of dental school deans now approve.10 Currently, some states do not require a clinical examination for licensure, but instead applicants have to complete an accredited postdoctoral dental program of at least one year in length. Therefore, the clinical examination component is not consistent among the state boards of dental examiners. Also, the clinical exam is unlike the national NBDE, which is administered by one agency (the JCNDE). Dental students are future dental licensees, trained by experienced practitioners in accredited dental schools in the United States. Currently, opinions of dental students and faculty members may shape the licensure process in several ways. For example, they can state their opinions at meetings of the House of Delegates or their Council during meetings of the American Student Dental Association (ASDA) and the American Dental Education Association (ADEA). It is important to continue to discover the attitudes and perceptions of these two groups in order to refine decisions made by other stakeholders such as the ADA, licensure agencies, dental schools, and accreditation agencies. Dental students and faculty members do not share the same roles, needs, or interests; therefore, their differences may create different perceptions about licensure. Consequently, the purpose of this study was to investigate the attitudes and percep-
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tions of dental students and faculty members at dental schools regarding dental licensure. The null hypothesis stated that there was no difference in attitudes between the two groups towards current and proposed changes in dental licensure. The goal of the survey was to provide insight to policymakers and authorities who may seek the opinions of dental students and faculty members regarding current and proposed issues in dental licensure.
Methods A request to conduct this study was submitted to the Institutional Review Board of the University of Mississippi Medical Center. Exempt status was requested and granted. To address the aim of the study, a survey with a mixed-methods research approach (using both quantitative and qualitative data collection) was emailed to a convenience sample of ten U.S. dental school deans for distribution to their students and faculties. The deans forwarded the email including the link to the survey only once. The following dental schools participated in this study: Columbia University College of Dental Medicine, Harvard School of Dental Medicine, Loma Linda University School of Dentistry, University of California, Los Angeles School of Dentistry, University of Florida College of Dentistry, University of Louisville School of Dentistry, University of Mississippi Medical Center School of Dentistry, University of Tennessee Health Science Center College of Dentistry, The University of Texas School of Dentistry at Houston, and Western University of Health Sciences College of Dental Medicine. These public and private schools are located in various geographic areas in the country and vary in research activity, class size, and institutional age. The survey instrument consisted of ten statements designed to evaluate the attitudes and perceptions of students and faculty regarding four constructs: the NBDE, clinical examinations, licensure process, and strategies and validity of dental licensure. To better evaluate this quantitative data, respondents were also given the opportunity, via a free-text comment section, to expound on their responses in order to provide more detailed information about their perspectives. The survey instrument contained questions to measure each of the four study constructs. Review of the relevant literature helped in creation of the initial questions.1,3,6,10-14 The initial questions were then
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evaluated for content validity by five faculty members with experience in survey development to ensure that the questions measured the study constructs. The questions were then pilot tested with two students and three additional faculty members who were given the chance to provide feedback on the clarity of questions and overall structure. Modifications were made in the wording and overall format and structure of the survey accordingly. This information was used to create the final survey instrument for this study. The survey was conducted online through SurveyMonkey.com (SurveyMonkey, Portland, OR, USA). The survey first required respondents to self-identify as either a student or a faculty member. Afterwards, the statements were presented. Participants were asked to indicate their level of agreement with each statement. The dependent variable response was measured on a five-point Likert scale in which 1=strongly agree, 2=agree, 3=neutral, 4=disagree, and 5=strongly disagree. Participation was anonymous and voluntary, and no email addresses or identifiers were collected. To maximize privacy and confidentiality, participants were not asked about their institution or any demographic questions. Responses were stored in the SurveyMonkey.com website and then exported into a single SPSS file. Using a priori power analysis, the statistical power was set at 0.8, the effect size at 0.3, and the significance level at 0.05. This determined the minimum responses in each group to be 184 and total sample size of 368. To analyze the quantitative data, IBM SPSS software for Windows, version 19.0 (IBM Corp., Armonk, NY, USA) was used. Individual responses for both students and faculty were aggregated for each statement, and comparisons of the two groups were conducted via the nonparametric statistical Mann-Whitney U test. This test was used to investigate differences between the ratings of students and faculty for each statement. Our accepted Type I error rate (α) was 0.05 for all tests of significance. For analysis of the qualitative data, responses from the comment sections of the survey were exported from SurveyMonkey and collected in one Microsoft Word document. Comments were then coded to identify common themes presented by students and faculty. In the coding process, comment data were organized initially by general topic area (NBDE, clinical examinations, licensure process, and strategies and validity of dental licensure) and were then analyzed within each topic area to uncover
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common themes. A set of codes for subthemes was created, and all qualitative responses were analyzed and assigned codes where appropriate. Data arrays were also utilized to determine whether the individuals were in general agreement or disagreement with the statement on each topic. After all qualitative data were coded in this manner, passages that shared common codes were organized and compared between and against faculty and student responses.
Results Four hundred and eleven students and 186 faculty members responded to the surveys (597 total respondents for an estimated response rate of 17%). The students’ and faculty members’ responses on the statements by number and percentage of total respondents are shown in Table 1. In addition to the survey responses, a total of 244 comments on statements were obtained for analysis. Selected examples of these comments are shown in Table 2. According to the Mann-Whitney U test, these students and faculty members showed statistically similar attitudes on seven of the ten statements. There was a statistically significant difference between students and faculty members’ ratings regarding the preference for reporting the NBDE as pass/fail only (p
