Despite my idea that I wasn’t going to write more about it, I might as well record this thing for posterity. I’d like to describe in detail, both for myself, for my wife, for my future children, what it was like to survive “the worst hazing in all of medicine.”
The first thing you must understand is the way that licensing works. Licenses are doled out by states, and certain fiefdoms have been established around the US where you have to take a certain test to practice dentistry there. So, you do not receive your license, that is, your legal permit to do the job of a dentist, from your dental school. You receive it from the state in which you plan to work. Thus, upon graduation, you receive your school’s diploma and then you submit materials to apply for a license. I think that all of us working in Minnesota will apply for “Licensure by Exam”. That requires the following:
- Graduation from an accredited dental school. (I’ve covered this process).
- Pass “Minnesota Jurisprudence Exam” (know the laws governing you as a dentist — this is very straightforward).
- Pass written boards: “American National Dental Board Examination, parts I and II”. Three days of exams.
- Pass clinical boards. For us students, this can be CRDTS or Canadian boards.
Canadian boards are the NDEB.
Advantage: you don’t need to find patients to take the exam.
Disadvantage: devilishly difficult multiple choice questions. You can only practice in Minnesota with this one.
CRDTS stands for Central Regional Dental Testing Service.
Advantage: you can practice in 17 states after passing these boards.
Disadvantages are covered in the remainder of this essay.
I, along with the majority of my class, opted to take the clinical exam through CRDTS. In order to even qualify for the privilege of taking this 9 hour exam, you must do the following:
- Pay $1995 via cashier’s check. No credit cards. No simple checks.
- Find a dental assistant to work with you throughout the day. Pay them $350.
- Find a “perio” patient. This is someone who has periodontitis as a result of increasing pocket depth, calculus accumulation. I’ll give you an idea of the requirements for this patient: “The quadrant must have a permanent molar with a proximal contact (explorer does not pass freely between the contact) and a minimum of six natural teeth (any dental implants in the quadrant are not accepted). The 1-4 additional teeth, if needed, must be contained within one quadrant. At least 14 surfaces of qualifying subgingival calculus must be present in the Treatment Selection presented. At least 9 of the 14 qualifying surfaces must be on non-incisor teeth. At least 3 of the 9 posteiror qualifying surfaces must be interproximal on permanent molar(s).” Crowns on the teeth make the work hard, too. We mostly had folks in their 30s — they were old enough to have a lot of calculus, young enough not have a bunch of crowns.
- Find a “Class III” patient. They have a cavity of a certain size, shape, and location between their front teeth. The smaller the cavity, the better.
- Find a “Class II” patient. They have a cavity of a certain size, shape, and location between their back teeth. The smaller the cavity, the better.
- Arrange to pay the patients for their time, in a sealed envelope, out of sight of CRDTS examiners. After all, CRDTS frowns on us reimbursing patients.
So, in January of this year, us D4s set up a weekend clinic and ended up screening almost 1500 people in order to get enough patients for boards. This evolved into the grueling process of “contributing to the general pool” and hoping you were assigned a good patient as a result of your hard work screening patients. Stressful, but manageable.
So, after the worst night of sleep ever, I began the 9 hour clinical exam on February 26, 2012. My first patient shows up (YES). If he hadn’t, I would have had to try to find a back-up patient, or risk failing. He’s the “perio” patient. Things go great. We clean the heck of out his teeth, perform the required exam, complete the required measurements.
My operative patient (from parts (4) & (5) above) is one guy, two lesions. That’s wonderful. He shows up. Yay again. Still on schedule, I begin to remove decay from his front tooth. I send in a few “modification requests” so I can remove all the decay. I remove more… and more… and more decay. Oh my God, we might hit the pulp of this tooth (you fail if you don’t notice this… happens every year to someone). I am sweating. I send in for another “modification request” — basically, this sheet saying “This is how I will be deviating from the ideal tooth-cutting that CRDTS requires. I’ve already shown you I can do the ideal, now I will tell you how I have to change that shape and depth so I can get all the caries (cavity) out.”
I’m behind schedule. I am almost, but not quite, panicking.
After an interesting discussion with a nice floor examiner (“you don’t really think you’ll need to place a cap on the pulp, do you?”), I regain my courage, and send this GIANT hole in the tooth over to be evaluated. It comes back fine! (If I had missed any decay, I would’ve failed.)
But. But but but. But I am frazzled and behind schedule.
The fill of this tooth is a STRUGGLE. I am just not working how I usually work. The materials don’t feel the same in my hands. I’ve got great isolation (not battling patient’s tongue or saliva), but I still can’t find a flow. Things take so long that I have to submit something that I KNOW doesn’t represent my work. I submit.
Keep in mind that after each submission (of the tooth hole, of the modification requests, of the final fill), you have to sit, alone, in your dental cubicle for 20-30 minutes while the patient is processed in an adjoining room. People have thrown up during this time. My entire body was frozen while I waited.
There is one thing that you don’t want to have happen and that’s this: the chief examiner (wearing a suit) visits you. They tell you, “you’ve done something outside the bounds of the test, and it’s time to stop the examination.” This happened to members of my class. So, I’m sitting there, desperately hoping someone in a suit doesn’t come by. They do not.
But, I receive an “instructions to candidate” form. The examiners have graded my fill, but they’d like me to change a few things before continuing. This is NOT, I repeat NOT good news. A very friendly floor examiner stops by, guides me through the changes, and I’m on my way.
But I am WAY behind schedule.
“Tell me when it’s 3:45,” I tell my assistant, as I blast into the next tooth. Cut, cut, refine, refine. Remove a little bit of decay (man this guy has deep decay), and I send it over for an evaluation. Time stops. I get ANOTHER “instructions to candidate” form. Holy shit. I’m in full-on panic mode. This nice floor examiner stops by, I make the recommended changes, I’m on my way.
I have NO IDEA how many points these “instructions to candidate” reduce my score by. All I can think is, I am no longer performing like a thinking, reasoning person. I am working like a caged animal trying to gnaw my leg off to escape. This is really really really really bad.
Somehow, God knows how, I pull it together and place the v-ring system to establish proximal contact with the posterior composite restoration. I burnish. I remember this moment vividly, because I said it aloud: “I shouldn’t have burnished.” This, I really believe, is the moment I saved the exam: some sliver of my human brain came back online and said “replace that v-ring system, and you’ll have a good contact.” I took the extra time to replace the v-ring system.
“I do NOT see any flash. Honestly, that margin is good.” I vividly remember saying this, as much for my own benefit as to just put out that positive thought into the air. My assistant agreed. I sent my patient over for his last check.
I could see that fill in my head and I thought… it is right. We began cleaning up. My patient comes back at 4:56 (the exam ends at 5), and I hand him his envelope of money. Right in front of a floor examiner. A different one from the happy ones before. An unhappy floor examiner.
“Wait wait wait. You are not done.”
“What. The. I’m… what? I’m… oh my God. I’m. What?”
Those are, quite literally, the words in my head at this point. I’m 9 straight hours in, I’ve had a part of a sandwich and maybe a bathroom break (I honestly can’t remember). I sputter to my assistant: “We, uh, I mean, we have to set up. There’s ANOTHER instruction to candidate.” She stood there in shock for a moment before she started setting up the cubicle again. At 4:59pm. The exam is supposed to end at 5.
The floor examiner looks at my fill for quite some time. I can tell that whatever the issue is, is minor. That doesn’t make the situation better. “See, right there.” He points at the mesiocclusal cavosurface margin toward the lingual of the tooth. “The material is a little high there.” I’m not even kidding, my hands were SHAKING at this point. I polished.
“Sir,” I heard myself saying, “I’m ready to have you take a look.”
He looks, sees another spot (not mentioned on the “instructions to candidate” form) and has me change it. I yank my loupes off and tell my patient “I’m going to be a little close to your head for a minute” and make the change. The floor examiner comes back again. I’m, quite literally, praying behind him.
“Okay, I’m going to be kind of mean here, but there’s just one more spot to adjust.”
My blood pressure has NEVER been that high. In a haze, all I can remember was me polishing and muttering, in some sort of panicked whisper voice I’ve never heard come out of me before: “I just don’t see it. Where is the spot he’s talking about? I just don’t see it. Where is it?” My hands are SHAKING. Bad. Like, the polishing bur is banging against the tooth I’m shaking so badly. I polish and have him check. I’m finally dismissed.
Strangely, the fact that he said “I’m going to be kind of mean” made me feel better. I realized that, if this were actually a big deal, then he would not have been so casual. I come home. Melt. Down.
Sobs wracked my exhausted frame as Mykala held me. “I’m sorry, I’m so so sorry. We can’t afford this…” is all I could get out, repeatedly. Though that final “instruction to candidate” didn’t seem to be a big deal, the others seemed to spell doom. Over the living hell that was the days of waiting for results, I thought about each part of each procedure that day constantly, and while doing so oscillated between “maybe I passed” and “there is no way I passed.” I only ever said the second one aloud, to myself. Usually while biking to clinic.
In what I consider to be a miracle, I passed. It feels amazing, because I know I have the clinical experience necessary to pass these boards, and to do good dentistry. That’s the next step, thank God.
Once, back in 2008, when I was about to start school, I saw a guy at the gym and he said his wife was nearly done with school. When I asked him how it was for his wife, he said, “Pure hell.”
Wow, he sure was right.