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Delegates move forward on national licensure exam

Delegates move forward on national licensure exam
Dr. Kennedy

Orlando, Fla.—The 2010 ADA House of Delegates underscored its commitment to developing a national clinical licensure examination that evaluates candidates in accordance with Association policies on live patients.

The action follows a year-long study by an ADA workgroup and some new innovations in state licensure. In passing Resolution 42H-2010, the House initiated a request-for-proposals process 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.”

“The House has said, in clear terms, a new examination process must be developed,” said Dr. Samuel B. Low, the ADA 17th District trustee who was recently appointed chair of a new workgroup brought together by Res. 42H-2010.

“There is no doubt there is a schism between the examining community, the academic community and practicing community on this issue, but we are going to have to start collaborating so that we can achieve the best of all worlds: that is, live patient examinations, quality psychometrics, and a written exam that deals with ethics and treatment planning,” said Dr. Low. “I truly believe we can do this.”

Image: Dr. Low

  Dr. Low

The idea of having one national exam that assesses clinical competence of dental graduates dates back to the early 1900s. What’s new are alternative methodologies for evaluating competency for initial licensure and concerns over the ethical treatment of patients, such as the growth of “patient brokers,” or business interests that identify “ideal” patients for testing services and sell those services to students.

“What we need is an exam that meets the needs of everyone,” said Dr. Brian T. Kennedy, chair of the Council on Dental Education and Licensure. “That could be a portfolio-style assessment that is truly curriculum-integrated, one that evaluates more competencies and allows for outside objective evaluation that would protect the public, and one that avoids putting students in a situation where there is patient brokering for a snapshot, high-stakes exam.”

A new workgroup will oversee the development and announcement of the RFP process in 2011 and consideration of the received proposals in 2012. In addition to Dr. Low and Dr. Kennedy (the ADA representative to CDEL), the group includes Dr. Edward J. Vigna, ADA 10th District trustee; Dr. Patrick M. Lloyd (the American Dental Education Association representative to CDEL); Dr. David Perkins (the American Association of Dental Boards representative to CDEL); Dr. Christopher Salierno, ADA New Dentist Committee; and Brittany Bensch, American Student Dental Association.

The House of Delegates re-visited the issue of a national exam in 2009 with the consideration of Resolution 26S-1-2009, which called for the House to direct CDEL to study the development of a Part III examination of the National Boards that would evaluate clinical competency, ethics and professionalism in keeping with the ADA policy, Eliminating Use of Human Subjects in Board Examinations. That workgroup was chaired by Dr. William R. Calnon, now ADA president-elect; and included Dr. Charles H. Norman, ADA 16th District trustee; Dr. Kennedy; Dr. Lloyd; and Dr. Perkins.

With representation from the practice, education and examining communities, the workgroup held frank discussions of issues related to dental licensure.

“I don’t think there was an opinion that was not voiced and not voiced strongly,” said Dr. Kennedy. “We took this issue apart from every angle we could trying to find common ground and move things forward. In the end, we agreed that if the concept of a national exam is to be viable, it would have to address the concerns of all parties. The ADA can facilitate that process.”

(Read more about the 26S-1 workgroup at

The workgroup studied the perspectives and policies of the licensure community, as well as dental educators and students; the history of dental licensure; alternative initial licensing methods now in use; and California’s recently enacted legislation making the state the first in the nation to create a dental school-based portfolio examination process.

Many are watching California as the state unveils a new licensure process that gives dental students the option of taking a school-based licensure exam that allows them to build a portfolio of completed clinical experiences and competency exams in seven subject areas over the entire course of their final year of dental school.

(Read more about the legislation at

The workgroup zeroed in on portfolio-style assessments, which are conducted using patients of record, as a methodology that shows great promise and supports policies on the ethical treatment of patients, said Dr. Kennedy. Portfolio assessments could also address the examining community’s concerns over the lack of fidelity in simulation alternatives that do not involve live patients.

The strength of Res. 42H-2010 is that it’s a compromise resolution, added Dr. Low.

“With a portfolio-style assessment, you still have a live patient but not in a scenario where the patient can be used for a particular objective and possibly never seen again,” said Dr. Low. “I think that is why the House reinforced the elimination of live patients but also sought a compromise that enables the dexterity of dental students to be tested.”

A secondary challenge facing the workgroup is whether states will accept one national exam.

“States have the right to accept any examination or methodology for initial licensure that they choose,” said Dr. Kennedy. “However, if we can come up with something objective that allows for independent evaluation and meets state boards’ regulatory obligations to protect the public, we can move toward broader acceptance.” He likened a national exam to licensure by credentials, which was initially met with some resistance but is now accepted in 46 states.

“This will be an evolutionary process,” said Dr. Kennedy. “If it’s something that makes sense, is economically feasible and can be ethically accomplished, the states have no objective reason not to consider its implementation.

“As more states utilize the process,” Dr. Kennedy continued, “there will be less rationale to administer a less comprehensive examination process with all the problems we know to be associated with it.”

Developing and administering an exam has high start-up costs and ongoing administrative costs for dental boards, schools and students. “The request for proposals will give us a more accurate estimation of the financial implications,” said Dr. Low.

The workgroup will begin its meetings in 2011.