Setting the Direction for Licensure

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares key findings from a landmark report that describes the reasons change is needed in dental licensure and sets a pathway forward.

Monty MacNeil, D.D.S., M.Dent.Sc., 2018-19 Chair of the ADEA Board of Directors, has been concerned about the dental licensure process since his days as Academic Dean at the University of Connecticut School of Dental Medicine.

“I watched students struggle to prepare for their clinical licensure exams. The process influenced their decision-making and professional judgment, enticing them to make decisions counter to their contemporary training and good, evidence-based patient care,” Monty recalls. “I also saw the outcomes of those exams, and there didn’t seem to be any rhyme or reason when it came to which students were successful and which were unsuccessful.”

Eliminating the use of single encounter, procedure-based examinations on patients as part of the licensure process has been official ADEA policy since 2011. The American Dental Association (ADA) embraced this position even earlier, in 2005. And now, in partnership with the American Student Dental Association (ASDA), a joint task force of our three organizations—the Task Force on Assessment of Readiness for Practice (TARP)—has authored a landmark report that calls upon state dental boards to replace these exams with ethically grounded clinical assessments that provide a more valid and reliable measure of graduates’ readiness for practice.

“The ‘live patient’ exam always had a stigma around it, but it was the only game in town,” says Joe Crowley, D.D.S., ADA Past President. Thankfully, during the past decade, several pioneering states have been early adopters of alternative ways of assessing clinical competency for initial licensure. These include mandatory accredited advanced dental education, portfolios, curriculum-integrated format exams and the Objective Structured Clinical Exam (OSCE), first used for licensure in Canada. One state, Colorado, accepts all pathways to licensure.

To scale these efforts nationally, in 2016 the ADA committed to developing an OSCE for U.S. dental licensure, and our Association took on the task of creating a compendium of clinical competency assessments that would build on the California Hybrid Portfolio, which is now a recognized pathway to licensure in that state. Once these two new assessments are in place, the challenge will be to convince additional states to adopt them as pathways to licensure and eliminate the use of single encounter, procedure-based examinations.

That will be a heavy lift in states where vocal defenders of the status quo are still convinced that traditional clinical exams are the best way to protect the public, despite evidence to the contrary. (To debunk the myth of a connection between the skills tested on the exam and the infractions that lead dentists to face reprimands from their state dental boards, I highly recommend David Chambers’ study of disciplined dental licenses in the spring 2018 issue of the Journal of the American College of Dentists.)

In the meantime, our best strategy for convincing states to modernize the initial dental licensure process may be to start by focusing on the second goal articulated by the Task Force: license portability. The TARP Report urges states to update the laws and rules governing licensure by credentials so a license to practice dentistry in one state becomes “portable,” allowing dentists to practice in any state of the union.

“That’s really tough to argue against because U.S. dental graduates are all trained on the same standards and come from schools that are accredited the same way by the same accrediting body,” Monty says. “What is the distinguishing aspect from one state to another that would justify restricting license portability?”

The Federal Trade Commission (FTC) has raised similar concerns, and in recent years, the agency has argued against restrictions on professional licensure on anti-competitive grounds. A White House report takes a similar stance, and a separate paper from the Hamilton Project and The Brookings Institution comes to the same conclusion.

“When designed and implemented appropriately, licensing can benefit practitioners and consumers through improving quality and protecting public health and safety,” the paper states. However, licensing restrictions are often “inconsistent, inefficient, and arbitrary,” the paper adds, restricting mobility across states and increasing the cost of services to consumers.

Colorado made history in 2016 by deciding to accept all ways of assessing clinical competency (alternative as well as traditional) as pathways to Colorado licensure for dentists and dental hygienists. Currently, a small minority of states accept one or more alternative pathways, 10 states accept only two or three of the traditional regional exams, and four states accept only one exam. The Task Force calls upon dental boards in all states to go the way of Colorado until the report’s two larger goals have been met.

When it comes to license portability, Joe tells me he sees the proverbial “light at the end of the tunnel. I truly believe many of today’s D1s will be practicing in states with license portability.” Monty is also optimistic: “I think state boards are recognizing that there is a concern at the federal level about these issues, and they will be hesitant to amplify that further.”

Monty’s optimism also springs from the unprecedented level of unity achieved by the Task Force organizations. “There is a strong opinion across the country that change is necessary, and it’s not a fringe opinion,” he says. “It’s across the practicing community, it’s across the educational community and it’s across the student/trainee community. That’s very powerful and very hard to ignore.”

And ignoring this consensus will soon become even harder. News of the Task Force report was well received in the trade press.

What’s next?

  1. ADEA will develop a compendium of clinical competency assessments that are valid and reliable in demonstrating that our graduates are competent to enter practice.
  2. The ADA will complete development of its dental licensure OSCE and begin testing the new exam in late 2019. Several schools have already expressed a strong interest in taking part in the pilot, and more details will be available by the time of the 2019 ADEA Annual Session & Exhibition in March.
  3. At the same time, the newly established Coalition for Reform in Dental Licensure will begin creating an infrastructure to advocate for change across the states. Representatives from ASDA, the ADA and ADEA have already been chosen.
  4. The Coalition is currently reviewing the perceived readiness of various states to consider changes in their initial licensure and portability rules. The next step will be to establish state-focused coalitions to advocate for change in 2019.

The experience in Colorado has shown that students, residents and fellows are incredibly effective in the advocacy arena, and I anticipate that as informed advocates who stand ready to “vote with their feet,” they will play key roles in the next phase of this endeavor across the states.

As ADEA Chief Policy Officer Denice Stewart, D.D.S., M.H.S.A., points out, “ADEA, ADA and ASDA have come out against the single encounter, procedure-based examinations on patients. These exams place a significant burden on students, schools and programs; they are expensive, time-consuming and stressful. If students can choose any pathway to licensure, they may be less likely to choose traditional exams.” Once that occurs, we will likely find ourselves at a tipping point, where states still following a 20th-century licensure model will feel greater pressure to change.

The Task Force report makes one other observation that is vital to consider if we hope to hasten the pace of change. The handful of states in which new and additional pathways to licensure have been adopted share a common attribute: a high degree of trust among the state dental board, the state dental association and the dental schools located within the state. That trust was built on long-standing relationships and also on knowledge—of how and why education works, and how CODA accreditation ensures that a competent dentist is the end result of a dental education. Much of that knowledge was gained through exposure—something ADEA members can encourage by inviting dental board members to observe accreditation site visits and other important events in the life of a dental school.

“The more we can get representatives of state boards and licensing agencies to come to our schools, to see what we’re doing, the more trust that develops,” says Cecile (Ceil) Feldman, D.M.D., M.B.A, Dean of Rutgers, The State University of New Jersey, School of Dental Medicine, who has spent considerable time advocating for licensure modernization. “Developing trust is not just about them coming to our schools. It’s also about educators going to their meetings. We need to remember, they’re not trying to create obstacles for our students. They have a very significant and serious role to play and we need to appreciate their side of things.”

When I spoke with examiners last year for an earlier column on this topic, they expressed a number of valid concerns about the licensure process, including a desire for third-party oversight of licensure assessments conducted in dental schools. Members of the Coalition have expressed their openness to third-party engagement, and Ceil agrees that this would be a welcome development.

“I’d love to see some meetings where we sit down and think jointly about what kind of assessment documentation would give state boards and examiners confidence in what dental schools are doing,” she says. Given developments related to licensure at the national level, it’s urgent that we do so.

“Just as all politics is local, all licensure is local,” Ceil points out, “at least until the FTC or some other group steps in.” She hopes it won’t get to that point, believing it’s better for our community to find our own solutions than to have them thrust upon us. I agree, and I’m confident we will be able to find common ground with the state boards and the examining community, just as we have with ASDA and the ADA.

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