Center for the Future of the Health Professions Sept. 2022 digest
Posted: August 25, 2022
This month, The Center for the Future of the Health Professions will post another monthly op-ed column for 2022. Our columns represent strong, informed, and focused opinions on issues affecting the health professions’ future. As mentioned previously, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce to effectively plan for a sustainable future and make the best use of available resources.
This month features a discussion of requirements for dental residency training for licensure in the U.S. In the U.S., each state has requirements regarding the criteria a dentist needs to meet to get a license to practice. For some states, it is lumped into the initial licensure category, and for some states, it is a different process called a specialty licensure application.
This brief article is authored by Leonard Goldstein, DDS, PhD, assistant vice president for clinical education development in the office of academic affairs at A.T. Still University (ATSU). Dr. Goldstein came to ATSU from the New York Institute of Technology College of Osteopathic Medicine. As director of clerkship education, he was responsible for developing and monitoring the rotations for 600 medical students annually. His previous administrative positions include serving as an assistant dean for graduate program development, medical director of a hospital-based temporalmandibular joint (TMJ)/facial pain center, and program director for a master of science program in forensic examination.
Dr. Goldstein has presented multiple papers on clinical education at national conferences and is the author/co-author of more than 60 publications in pain management, forensic dentistry, and TMJ dysfunction.
We look forward to your comments.
Randy Danielsen, PhD, PA-C Emeritus, DFAAPA
Professor & Director
The Center for the Future of the Health Professions
A.T. Still University
A requirement for dental residency training for licensure in the U.S.
Licensure by residency in the dental profession was limited to two states, Connecticut and New York. In 2003, New York state enacted legislation that allowed graduating dentists to participate in a one-year post-graduate residency in place of the clinical portion of the licensing exam. In 2007, it became mandated throughout the state. This was a dramatic paradigm shift for the dental community, and overall opinions vary widely on the topic. Since New York state enacted the PGY-1 residency as a pathway to licensure, the following states have also made it a pathway to licensure, but not a requirement for licensure:
- California
- Colorado
- Minnesota
- Ohio
- Washington
Before discussing the pros and cons of licensure by residency, I would like to share how this became law in New York state. During the early 2000s, I was a member of the Council on Dental Practice and Hospital Dentistry for the New York State Dental Society. The Council felt that it was necessary to require a PGY-1 for licensure. Our recommendation had nothing to do with the North East Regional Dental Board Exam (NERB). However, the executive director of the New York State Dental Society was angry that a substantial number of New York students failed the clinical portion of the NERB each year. So, he lobbied the New York State Legislature and had a law passed and signed by the governor that a PGY-1 would be utilized instead of the clinical portion of the NERB. Then, he had the law passed that said the PGY-1 would be a requirement in New York state for licensure in dentistry. Unfortunately, on a national level, states look at New York’s law and always see it as doing away with the exam, which was not our council’s idea or intention.
Arguments against licensure by residency
Historically, the one-time board exam is seen as the ultimate competency determination. Since it has been the “gold standard” for so long, talks of eliminating this path to licensure have met with considerable opposition. There are no procedures to qualify attending dentists and no way to get an accurate assessment due to a possible bias of the close relationships between residents and residency directors. Another argument against licensure by residency is that there is no specific curriculum for all residency programs. Each program may have its strengths and weaknesses, but there are no specific criteria that residents must consistently pass in order to graduate from the program. Also, there are no procedures in place to qualify attending dentists. Remember, faculty members and supervisors become evaluators of the same individuals whose development they have been fostering.
Arguments for licensure by residency
A novice dentist may be able to expand his/her skills and experiences to become competent and even an expert in a year of supervised practice. It takes out the variable that comes with a one-moment-in-time examination of a live person, where nothing is standardized. The one-time exam on a live patient presents many variables that may result in an untoward occurrence with little or nothing to do with the student’s clinical abilities. There are many factors outside the student’s control; often, these are reasons for failure. Also, there is no test for critical thinking or other characteristics needed to be a competent dentist. These things can be assessed and improved through coaching in a year-long program. The one-time clinical exam relates to essential learning of technical procedures, not more significant levels of learning.
Downfalls in the current system of dental education are widely known and tolerated. Instructors are at a premium, and students complain that the instructors in the clinic are not always there, so opportunities for advancement are often missed. In addition, since many schools require specific procedures and competencies to graduate, patient care is often modified to fit the need of the requirements. It may not always be in the best interest of the patients. Similarly, treatment may often be delayed or postponed while waiting for the exam date. We can debate whether this is ethically acceptable in the practice of dentistry.
With these arguments noted, we can see how a residency education can overcome them. Comprehensive care is the norm in hospitals and health centers, where most dental residencies are located. The one-time clinical exam is not a barometer of the dentist as a whole and has no bearing on how the dentist will practice. There is no way through the snapshot test to assure the student’s chairside manner or how the student may work in a team setting. In a residency, however, this is paramount!
Conclusion
Licensure by residency is a very acceptable way to determine competency. It provides for a more thorough observation and assessment over a long time. However, residencies need a uniform, standard set of guidelines that each program must utilize to determine readiness for licensure. The time has come again for the American Dental Association (ADA) to re-evaluate a nationwide movement towards licensure by residency.