New Clinical Licensure Testing: Coming to a State Near You?

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares news of a joint effort with the American Dental Association to change how dental professionals are assessed for licensure.

If you’ve ever talked with your colleagues about the clinical exams used for dental and dental hygiene licensure, you’ve heard this familiar litany of complaints: They are costly for students, often unfair to patients and fraught with potential for ethical compromise.

We’ve been hearing these grumblings for decades, but by and large, we’ve resigned ourselves to the idea that the way things are is the way they will remain. I’m happy to report that this grudging acceptance is giving way to new optimism. Change is visible on the horizon. Getting there is just a matter of time.

During the past 10 years, a few pioneering states have experimented with alternative ways to assess clinical competency for initial licensure—mandatory postgraduate training, portfolios, curriculum integrated format (CIF) exams and objective structured clinical exams (OSCEs). Most recently, Colorado opted to accept all of these alternatives as well as all of the traditional state and regional exams as pathways to licensure for both dentists and dental hygienists.

Colorado’s decision may be a bellwether of a nationwide shift away from the status quo and a major step toward license portability.

“It’s been a problem for dentistry for some time that state laws vary so much,” says Karen Hart, Director of the Council on Dental Education and Licensure at the American Dental Association (ADA). “When new and mid-career dentists want to move from one state to another, often they are required to retake the licensure exam, which includes demonstrating their skill on a patient. That’s burdensome, and according to available, albeit limited, published psychometric analyses of current patient-based licensure examinations, patient-based exams do not consistently and reliably determine an individual’s competency.”

ADEA went on record in 2011 opposing the use of live patients in licensure exams, and the ADA has held a similar position since 2005. With the increased migration of dentists across state lines in recent years, licensing reform became a top ADA priority, prompting that organization to invite ADEA to form the ADA/ADEA Joint Licensure Task Force—a recent development that should finally give isolated state-level experiments the fuel they need to scale up to a national level.

The Joint Task Force held its first meeting a year ago in August, and this February released a report with five recommendations:

  • Increase awareness and understanding of emerging licensure models.
  • Promote further development and piloting of alternative licensure models.
  • Increase understanding of the accreditation process.
  • Promote research and distribution of findings from alternative licensure models.
  • Publicly recognize and collaborate with others engaged in alternative licensure models.

ADEA and the ADA haven’t always seen eye-to-eye on every issue, but both organizations have fully endorsed the Joint Task Force recommendations. Even more importantly, both organizations have committed to concrete action to move the Joint Task Force recommendations forward. The ADA has established a steering committee to oversee the development of a Dental Licensure OSCE (DLOSCE), similar to the one currently used to license dentists in Canada and Minnesota. In parallel, ADEA will develop a template for a portfolio licensure exam along the lines of the one developed in California. These activities will advance our goal of creating valid and reliable assessments that states can use to test for clinical competency without involving patients. Over time, these alternatives might expand to include the use of manikins or haptics as the technology and economics of virtual testing evolve.

ADEA Immediate Past Chair of the Board Cecile Feldman, D.M.D., M.B.A., Dean of Rutgers, The State University of New Jersey, School of Dental Medicine, championed the idea of ADEA and the ADA coming together on common ground to improve the way U.S. dentists are licensed for practice. She serves on the Joint Task Force as Co-Chair and is the first to agree with my assessment that change is on the horizon, but she also points out that a long road lies ahead.

“The partnership between the ADA and ADEA was a natural,” she told me as we reflected on what has been achieved so far. “If you think of the licensing process as a three-legged stool, the testing and licensure folks are the other major piece of this. Whether they’re going to make some of the changes we feel strongly about remains to be seen.”

Indeed, at an April meeting of the American Association of Dental Boards, it quickly became clear that the ADA’s proposed DLOSCE remains controversial among the very dental boards that might ultimately be called upon to recognize it.

“The DLOSCE will take two to three years to develop,” Karen estimates, “and then we will have to advocate state-by-state for its adoption. In the meantime, we will work with state dental boards, state dental associations and dental schools on license portability so that all of the clinical licensure exams can be accepted by each state.”

Reaching these goals will require continued patience but also a sense of urgency. Our efforts are occurring at a time of heightened federal interest in occupational licensing. There has been a lot of discussion about just how much certification and licensure is really needed to protect the public, with the Federal Trade Commission devoting considerable energy to address this concern. In July, the agency’s Economic Liberty Task Force held its first public roundtable on the matter.

Given these pressures, I’m heartened by the strong partnership ADEA has formed with the ADA and the rapid progress we’ve made in a single year. As we move forward on achieving universal acceptance of a nonpatient-based licensure exam, we are inviting the American Student Dental Association to join us under the umbrella of a newly established Coalition for Reform in Dental Licensure.

Those of us who have been tackling this problem for decades know that it will take some time to convince everyone that change is not just possible, but in everyone’s best interest, including the public’s. There is a growing recognition that the issues dental boards handle on a routine basis have little to do with the dentists entering the profession and a lot to do with the behavior of dentists already in practice. Whether fraud, substance abuse, inappropriate prescribing or failure to meet standards of care, misconduct can arise at any point in a decades-long career. If licensure becomes more standardized, could more board resources be spent on curbing these behaviors? Maybe.

ADEA is planning to review the complaints that dental boards address to identify specifically which disciplinary actions occur most frequently in all 50 states and the District of Columbia. This research may reveal whether new dentists who gain licensure through alternative means are any more likely to be censured than their peers in states that use patient-based exams. If the answer is no, it will become harder to justify using patient-based exams or not letting licensed dentists and dental hygienists practice across state lines.

As Cecile has said, “The boards’ perception that these clinical exams are effective in preventing unqualified practitioners from entering practice—the two just aren’t related.” For those who disagree, this coming research should shed additional light on the matter and hasten the day when alternatives to live-patient licensure exams are implemented across the nation.

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