1. LICENSURE—HOT TOPICS American Student Dental Association Western Regional Meeting November 5, 2011 Dr. Ronald P. Lemmo American Dental Association Brittany Bensch Dean American Student Dental Association

2. © 2010 American Dental Association, All Rights Reserved Licensure-Related Acronyms CDEL- Council on Dental Education and Licensure NBDE- National Board Dental Examinations ADEX - American Board of Dental Examiners CRDTS - Central Regional Dental Testing Service CITA - Council of Interstate Testing Agencies NERB - North East Regional Examining Board SRTA - Southern Regional Testing Agency WREB - Western Regional Examining Board

3. © 2010 American Dental Association, All Rights Reserved History of Licensure  Since 1902 profession discussing one national exam  In 1928 three part exam proposed  In early 1930s states begin use of NBDE I and II  In early 1970s many individual state boards moved to one of four new regional testing agencies

4. © 2010 American Dental Association, All Rights Reserved History of Licensure  In 2003 NERB implements the Curriculum Integrated Format (CIF)  In 2004 the clinical testing agencies try (again!) to develop one exam to be used by all  In 2005 ADEX is established using the CIF Also, fifth regional testing agency-CITA is established

5. © 2010 American Dental Association, All Rights Reserved History of Licensure Today –  NERB, NV, FL and HI administer ADEX Exams  Five regional testing agencies and four independent states administer a total of six different exams.

6. © 2010 American Dental Association, All Rights Reserved Regional Exam Participation ADEX - 26 member states, but 40 states accept results (NERB, HI, FL, NV) CRDTS - 17 member states and 20 other accepting states CITA - 6 member states and 18 other accepting states NERB - 18 member states-no information available on other accepting states SRTA - 6 member states and 26 other accepting states WREB - 15 member states and 21 other accepting states

7. © 2010 American Dental Association, All Rights Reserved History of Licensure Since 2002, States have authorized alternative pathways:  PGY-1 – NY, CT, MN, CA, WA  OSCE – MN  Portfolio – CA

8. © 2010 American Dental Association, All Rights Reserved History of Licensure Ultimate authority –STATE LEGISLATURE State Board implements the state laws with authority granted by state legislature Want change? Best to work with state dental association

9. © 2010 American Dental Association, All Rights Reserved History of ADA Activities  1997-2001 -- Invitational Licensure Conferences  2001 -- Resolution 114H-2001 established ADA Task Force on the Role of Patient Based Examinations; the Task Force met 2002-2004  2004 – CDEL adopts recommendation that a graduate of an accredited dental education program should be able to take a single clinical examination that has national acceptance—ultimately led to establishment of ADEX.

10. © 2010 American Dental Association, All Rights Reserved History of ADA Activities In 2005:  Resolution 23H-2004 established the ADA National Clinical Licensing Examination Consensus Committee.  ADA developed proposal for the National Commission on Clinical Dental Licensing

11. © 2010 American Dental Association, All Rights Reserved History of ADA Activities An Ideal Clinical Exam Process Be an activity involving an independent third party within the educational process Allow for assessment of the full continuum of a candidate’s competence Instill public confidence Evaluate competence within the context of a treatment plan that meets the patient’s needs Provide valid data for outcomes assessments as required by the accreditation process Be provided at a reasonable cost to the candidate

12. © 2010 American Dental Association, All Rights Reserved History of ADA Activities  2005-2008 -- ADA met informally with individuals from some clinical testing agencies in effort to keep lines of communications open  2008-2009 -- Communications from the ADA presidents to state boards of dentistry encouraging implementation of ADA policy on acceptance of results of any state or regional clinical examination.

13. © 2010 American Dental Association, All Rights Reserved History of ADA Activities 2009 --Resolution 26S-1 2010- Resolution 42H

14. © 2010 American Dental Association, All Rights Reserved ADA House Past Actions Related to Clinical Exams and Part III  100-1991 Development of a Part III Clinical Examination for Dental Licensure  77-1992 and 100-1992 Development of a Standardized Clinical Part III  49-1993 Part III National Clinical Dental Licensure Examination All were defeated by the House

15. © 2010 American Dental Association, All Rights Reserved ADA House Past Actions Related to Clinical Exams and Part III Resolution 26S-1-2009. Resolved, that the American Dental Association House of Delegates direct the Council on Dental Education and Licensure to study the development of a Part III examination of the National Boards that will evaluate clinical competency, ethics and professionalism, in keeping with ADA policy (Trans.2005:335) Eliminating Use of Human Subjects in Board Examinations.

16. © 2010 American Dental Association, All Rights Reserved Resolution 26S-1-2009 ISSUES IDENTIFIED BY ADA HOUSE OF DELEGATES:  CDEL and the JCNDE bylaws responsibilities do not include development of clinical examinations--would need House action to change them  Confusion as to the intent of the resolution and terminology such as “clinical competency,” clinical demonstration, clinical dexterity  Consideration of ADA policy on elimination of patients in clinical licensure examinations.

17. © 2010 American Dental Association, All Rights Reserved ADA House Past Actions Related to Clinical Exams and Part III 26S-1 Workgroup recommendation to House-- Initiate a Request for Proposals calling for the development of a portfolio style examination

18. © 2010 American Dental Association, All Rights Reserved ADA House Past Actions Related to Clinical Exams and Part III 42H-2010 Resolved, that a Request for Proposals (RFP) process be initiated calling for the development of a portfolio-style examination for licensure purposes designed to assess a candidate’s clinical competence with a third-party assessment that is valid and reliable psychometrically, including a complementary written/interactive examination to assess issues not deemed adequately addressed in the portfolio model, such as ethics and professionalism, and be it further Resolved, that a new workgroup composed of two representatives from the Board of Trustees, three from the Council on Dental Education and Licensure (one appointee each from the ADA, ADEA and AADB), one from the Committee on the New Dentist, and one from the American Student Dental Association be appointed to oversee the development and announcement of the RFP process in 2011 and consideration of the received proposals in 2012, and be it further Resolved, that appropriate progress reports be made available to both the 2011 and 2012 House of Delegates.

19. © 2010 American Dental Association, All Rights Reserved The RFP for a Portfolio-Style Exam Concepts in the RFP Be Ethical and professional Have Oversight by the state licensing jurisdiction Assess clinical competencies Be Psychometrically sound Be Cost effective and feasible Have a Built-in system for audit Have Mechanisms to assess outcomes Enable portability Have a Remediation process

20. © 2010 American Dental Association, All Rights Reserved ADA Licensure Policies ADA has several policies to support mutual acceptance of exams. Acceptance of Successful Completion of State or Regional Licensure Examinations by State Boards of Dentistry (1998:725) Acceptance of Results of Regional Boards (1992:630; 2001:468 Standardization of State Dental Examinations (1992:629) Guidelines for Licensure (1976:919; 1977:923 1989:529; 1992:632; 1999:938; 2000:401; 2003:340)

21. © 2010 American Dental Association, All Rights Reserved ADA Licensure Policies Eliminating Use of Human Subjects in Board Examinations (2000) Resolved, that the Association supports the elimination of the use of human subjects in the clinical licensure examination process by 2005, and be it further Resolved, that the Association transmit this policy to all clinical testing agencies.

22. © 2010 American Dental Association, All Rights Reserved ADA Licensure Policies Eliminating Use of Human Subjects in Board Examinations (2000; 2005) Resolved, that the Association supports the elimination of human subjects/patients in the clinical licensure examination process with the exception of the curriculum integrated format within dental schools, and be it further Resolved, that the Association encourages all states to adopt methodologies for licensure that are consistent with this policy.

23. © 2010 American Dental Association, All Rights Reserved ADA Licensure Policies Definition of CIF (2007) Curriculum Integrated Format: An initial clinical licensure process that provides candidates an opportunity to successfully complete an independent “third party” clinical assessment prior to graduation from a dental education program accredited by the ADA Commission on Dental Accreditation. If such a process includes patient care as part of the assessment, it should be performed by candidates on patients of record, whenever possible, within an appropriately sequenced treatment plan. The competencies assessed by the clinical examining agency should be selected components of current dental education program curricula. All portions of this assessment are available at multiple times within each institution during dental school to ensure that patient care is accomplished within an appropriate treatment plan and to allow candidates to remediate and retake any portions of the assessment which they have not successfully completed.

24. © 2010 American Dental Association, All Rights Reserved ADA House of Delegates ADA House of Delegates is the supreme authority on ADA policies.

25. ASDA’s Policy on Licensure Until a fair and ethical, reliable and reproducible, valid, and clinically relevant national common-content evaluation of minimal competence for initial licensure has been developed, and until all dental licensing jurisdictions of the United States and its territories accept such an examination, the American Student Dental Association supports the universal acceptance of all regional and state clinical licensing examinations.

26. © 2010 American Dental Association, All Rights Reserved Regardless of the examining authority or the jurisdiction in which the exam is administered, the American Student Dental Association believes that any clinical licensing examination intended to measure technical skill via a sequence of independent clinical tasks should: be a non-patient based examination emphasizing the recognition, diagnosis, and treatment planning of disease, in conjunction with the treatment of simulated disease by use of a typodont. be administered in the final year of dental school. provide opportunities for remediation, at the candidates’ dental school, prior to graduation. guarantee anonymity of candidates and examiners. be administered by examiners who have been calibrated to provide standardized and consistent scoring. not include a written examination that duplicates the content of the National Dental Board Examination Parts 1 or 2. be offered to candidates at the lowest reasonable cost possible.

27. © 2010 American Dental Association, All Rights Reserved While the American Student Dental Association supports continual improvement of existing examinations and collaborative development of a new examination, the association believes the following alternatives are preferable to the current licensure process: Initial licensure without an independent clinical licensing examination: Graduates of dental schools accredited by the Commission on Dental Accreditation should be eligible for initial licensure without taking any additional clinical examination. A portfolio-type clinical examination based on cases compiled during the final year of dental school: Such an examination should require a standardized catalog of required clinical procedures and the portfolio should be evaluated by an examiner independent of the dental school.

28. © 2010 American Dental Association, All Rights Reserved A non-traditional patient based clinical licensure examination: Although the American Student Dental Association does not support the use of live patients in traditional clinical licensing examinations, the association recognizes the potential for creation of an ethical, patient based examination. An Objective Structured Clinical Examination designed to evaluate a candidate’s diagnostic and treatment planning skills. Completion of a one year post graduate residency program: Completion of a postgraduate residency program that has been accredited by the Commission on Dental Accreditation and has a minimum duration of one year should be sufficient to substitute for the clinical licensure examination requirement in any jurisdiction. However, the American Student Dental Association opposes a mandatory postgraduate residency in any licensing jurisdiction. Taken from ASDA’s L-4 Policy

29. © 2010 American Dental Association, All Rights Reserved What is ASDA doing about it? Nationally: –Made the request that ASDA be a part of the RFP workgroup – 2 year appointment –Council on Licensure is working on a White Paper on the licensure examination process

30. © 2010 American Dental Association, All Rights Reserved What is ASDA doing about it? Locally: –With state dental associations –Working with the state legislators and dental boards YOU can be this voice!

31. © 2010 American Dental Association, All Rights Reserved Where does this leave us TODAY? YOU………ASDA have a VOICE and an OPPORTUNITY and an OBLIGATION

32. © 2010 American Dental Association, All Rights Reserved Final Thoughts…… Work with ADA component, constituent dental societies to determine common principles Advance ASDA policy through these relationships Engage State Dental Boards and legislators as needed

33. © 2010 American Dental Association, All Rights Reserved QUESTIONS THANK YOU! Dr. Ronald P. Lemmo rldds@aol.com Brittany Bensch Dean bensch@uw.edu