The Un-Ethics of a Live Patient Exam – Samuel Lee (Harvard ’18, District One Events Committee Member)

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As a 4th year student, I am strongly against the live patient exam of CDCA or WREB – on many levels. However, the largest problem I see is with the ethics of the exam. During my white coat ceremony, I took an oath. This oath was crafted by many of my classmates and was shaped around the Hippocratic oath. One main tenant is that we do no harm to our patients. Live patient exams inherently create an environment in dental schools that directly contradicts this principle. The exams are comprised of a portion in which a student sits and practices on a patient performing several different types of dental restorations: a class II restoration and a class III restoration. In order to complete this restoration, one must first diagnose the necessary lesion by taking bitewing and periapical radiographs.

Now, the hardest part, the perfect lesion. You need one that is, as goldilocks would think, not too big… not too small… just right. This perfect lesion must be right at the DEJ. This is the delineation between the enamel (the hardest part of the tooth) and the dentin. If the lesion is too small, the tooth is not likely cavitated and would not be clinically indicated for a restoration. If the lesion is too large, there is a possibility that the lesion could extend to the pulp and create pulpal involvement.

The hunt for the perfect lesion creates the ethical quandary that many dental students face. If this lesion is indeed perfect and meets right at the DEJ or just barely short of it, do I: A) discuss with the patient that this active disease lesion would qualify for my licensure exam that is in March (even if March is several months away), which means we are waiting to treat active disease or B) discuss with the patient that they currently have active disease occurring in their oral cavity and that we need to treat this now? Let’s take a moment to stop and ask ourselves. I have active disease in my patient’s oral cavity – do I treat it now, foregoing the opportunity to have this lesion for my licensure exam, risking that I’ll find another perfect lesion, or do I ask this patient to wait to have their tooth treated until my licensure exam?

This is going on throughout the country. Not only am I, a student, contemplating this ethical quandary, but many faculty members are as well. As a third year, my faculty would not think twice about this perfect active disease lesion needing treatment because it is indeed, active disease. They would instruct us to treat it. But, as a fourth year, with my licensure exam in several months, “this would be a good licensure lesion. Think about holding on to this,” one instructor mumbles. This is an instructor, who is also a licensed practitioner, discussing with their student and future healthcare provider to wait to treat active disease because of the licensure exam.

I’d like to leave you with this last thought about this irrational double standard that future dentists are held to.

Imagine if a live patient licensure exam was in place for a medical physician to graduate from a surgical residency. A surgeon would need to find this perfect lesion. Too small, no we can’t operate. Too large, we need to operate immediately. Just right, let’s see if it will stay the same size in a couple months for me to operate in order to challenge my licensure exam. Does the circumstance change that much? Is the surgeon’s situation really that different? Or is it because a surgeon looking for a mass could be life or death for a patient while for a dentist it’s well… just a tooth? These are the questions we should be asking.

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