New States: License by PGY-1

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I had heard there may be 10 new states in the process of accepting PGY-1 for licensure in addition to NY, CT, MN, WA and CA. The main state I'm particularly concerned with is Massachusetts. Can anybody confirm this information? I called the MA State Dental Board and they said it is "being discussed" but wouldn't tell me anything more. I'm planning on doing a GPR starting July 2013, so I'd be looking at this taking effect in 2014. Any additional information is appreciated. Thank you.

Wow, that's good news. Had not heard that but years ago it was mentioned that other states would do this. You may want to stay tuned to ada.org because they always update licensure news, or some of the major dental magazines, etc.

Anyone else heard anything about this?

Massachusetts Needs a PGY-1 Option for Licensure
Bruce Donoff

The American Dental Association (ADA) House of Delegates voted to eliminate live patient clinical exams in the year 2000. Canadian dental graduates take an objective structured clinical examination (OSCE) for licensure. Several states have changed their dental practice acts to permit licensure by mentored experience of a general residency or specialty. Dental students have led the fight, with some results, to eliminate a practice—live patient exams—that perpetuates unprofessional and potentially illegal activity.

All that led me to ask applicants for oral and maxillofacial surgery residency at the Harvard School of Dental Medicine (HSDM) in November 2006 the following question: “When you return to school next week, your dean will ask you and all your senior classmates to a meeting. He or she will tell you that all of the U.S. dental school deans have decided to not permit live patient-based exams to be given at their schools in the spring of 2007. What would be your reaction to this?” Most said they would jump for joy, some asked for clarification of their own position, but a few asked, “How will we know if we are qualified to be dentists?”

“Unbelievable,” I thought, and I asked these applicants whether the faculty had been observing, evaluating, and teaching them, and providing feedback and judgment on their competency for several years. They answered “yes” but were a bit perplexed by the thought of such a change. The truth is, we all often do not see things the way they are, but the way we are and the way we see things depend on where we stand. That is the student’s dilemma, the practitioner’s dilemma, and the profession’s dilemma. The need for a postgraduate year (PGY-1) for dental education is not, however, about licensure. It is about producing the best dentists for the 21st century who can build on the great traditions of the dental profession.

The number of states adopting PGY-1 or advanced education in general dentistry (AEGD) changes in their practice acts is increasing. These dental residents will treat a greater number of patients with more complicated health problems and from lower socioeconomic groups; they will interact with their medical colleagues more; and they will have direct oversight by practitioners, who are overseers and not just graders. The unexpected result might be real change in dental education and the profession.

Change in the endgame—residency—will lead to change in the game—dental school—and maybe even in the pregame—the college-preparatory admissions requirements. The result will be better-educated and better-trained dentists, and, ultimately, a profession that improves the public’s health and well-being.

I am a practicing optimist, and I truly believe that reasonable people can come together outside of their own organizational silos to reach a solution. John Kenneth Galbraith once said: “Faced with the choice between changing one’s mind and proving there is no need to do so, almost everyone gets busy on the proof.”

This has been the examiners’ response to challenges about the efficacy, accuracy, and relevancy of an exam that they champion. It has also disappointingly been the experience that the three deans of Massachusetts dental schools have had over the last two years in convincing the Board of Registration in Dentistry (BORID) to permit PGY-1 as an alternative to live patient exams for licensure. Dr. Arthur Dugoni, former dean of the University of the Pacific Arthur A. Dugoni School of Dentistry, stated in a recent letter to the Journal of the American College of Dentists, “It has taken over five decades to realize and understand that patients, in a one-time evaluation, are being dehumanized, exploited, and used for purposes that do not satisfy the fundamental tenets that exist for licensing—namely, protection of the public and continued competency of the profession.”1

Storytelling often has an impact beyond cogent sensible arguments for change. Let me share two such stories. In 1996, the New England state dental association presidents and executive directors held a meeting to discuss the issue of internship or PGY-1 programs in dentistry as an alternative to live patient exams. There was general agreement that the need for an internship was minimal, given the excellence of dental education. At that time, I asked each dentist present what he or she did after graduation. Every single one answered similarly: “I was in the Army [or Navy, or Air Force] for one or two years. It was the best experience of my life.” They were each affirming the positive impact of their PGY-1 experience in the military without even knowing it.

Fast-forward to the Massachusetts Dental Society (MDS) Board of Trustees meeting on November 19, 2003.2 Dr. John Cassis, then director of the Boston University School of Dental Medicine (BUSDM) AEGD Program, presented on the benefits of a PGY-1 program. Then BORID, represented by its chair, Dr. Fred Mackler, and Dr. Robert DeFrancesco, discussed BORID’s opposition to residency programs being used in lieu of a standardized test. They based their argument on the lack of independent third-party evaluation, thereby compromising the elimination of those individuals not qualified to practice dentistry competently. The curriculum integrated format (CIF)—whereby the dental examiner goes into the dental schools to perform a clinical license evaluation while a student works on a patient— which reduces the burden of a single exam at graduation time, was suggested as a compromise.

The MDS Board voted to support the resolution by the ADA at its 2000 House of Delegates, which stated that the clinical examination for initial dental licensure may also be met by the successful completion of a postgraduate program, at least one year in length, that contains competency assessment in general dentistry or in an ADA-recognized dental specialty, and that is accredited by the Commission on Dental Accreditation (CODA). The MDS Board also voted to support CIFs at the area dental schools.

That was 10 years ago. Nothing ever came of the first action, and the second has led to little real change but great curricular time and resources spent in examining students. The notion that faculty cannot judge the competency of students but that examiners can by virtue of their being independent third-party evaluators is flawed.

At its June 20, 2006, meeting, the MDS Board of Trustees engaged in a panel discussion on alternative pathways to licensure and change in licensing regulations with BORID.3 Dr. Robert De- Francesco, BORID chair, and Dr. Lawrence DiBona represented BORID, and the dental schools were represented by Dr. Dominick DePaola (the Forysth Institute), Dr. Spencer Frankl (BUSDM), Dr. Lonnie Norris (Tufts University School of Dental Medicine), and myself (HSDM). As a participant, I recall how often BORID’s responses were influenced by the fact that BORID members are Northeast Regional Board (NERB) examiners. This issue of conflict of interest has not received sufficient attention.

In August 2010, Drs. Jeffrey Hutter (the Forsyth Institute) and Lonnie Norris, along with myself, asked for an opportunity to present a formal request to BORID for an option of a one-year CODAaccredited PGY-1 program to serve as a basis for licensure. After three meetings with BORID and rigorous discussions, the request remains in a spiral of inaction. This is a clear case of stonewalling, as my discussion with dentists from all over the state suggests broad support of this option for licensure.

Even if the live patient exam is a good practice that benefits the public, the payment of patients to appear for exams degrades it and treats it according to a lower mode of valuation than is appropriate for a profession. More than one superb dental student has failed the exam because a patient did not show up. Each candidate running for the presidency of the American Student Dental Association in 2012 had licensing reform as a number one priority. Organized dentistry and the examiners have looked at multiple iterations of exams, ranging from portfolio exams— where dental students build a portfolio of completed clinical experiences and competency exams in subject areas over the entire course of their final year of dental school, with oversight by dental examiners— done in schools (promoted when the California Dental Association and the Western Region Examining Board began to compete for students) to simulation. Haptic simulation is very close to successfully testing whether students can remove all the caries in a lesion, which board examiners have told me is the main purpose of the live patient exam. The bottom line is that examiners do not think that anyone but independent third-party evaluators can judge the competency of graduates.

Conclusion

Changing minds may not be easy, but changing a belief system is next to impossible. The advantages of a PGY-1 year in caring for a more diverse group of patients, enhancing the repertoire of the young dentists, and making them better practitioners is acknowledged by almost everyone in dentistry, except the examiners. It is mandatory in New York State and optional in California, Connecticut, Washington, and Minnesota, and it should be enacted without further discussion by BORID. Every effort to move this forward only results in a plan by examiners to maintain control and power.

Dr. David Chambers, editor of the Journal of the American College of Dentists, said it all recently when he wrote, “The arguments that the boards are unethical [in terms of live patients] and psychometrically indefensible have been made, heard, and ignored. We should ask instead that the examining community return to the original challenge of defining and assessing the competence of the entire profession to deliver oral health care to current standards. Their logical partner in this business is the schools, not the testing agencies.”4

The single biggest obstacle to greater implementation of a PGY-1 year and other state initiatives is the paucity of states recognizing this pathway to licensure. Students will continue to choose traditional clinical licensure exams in the short term to ensure portability of their licenses.

Even if there was some wisdom in a one-shot live patient test of mechanical skills under artificial circumstances, the option of a PGY-1 year that is fully CODA-accredited, with dedicated program directors and faculty who are not dental school–based or academics, must be enacted in Massachusetts. Our graduates deserve this, our patients deserve this, and the profession will be stronger for it. ■