The ADEA Compendium of Clinical Competency Assessments: A Potential Pathway to Licensure

Steven W. Friedrichsen, DDS

ABSTRACT The profession of dentistry benefits broadly from a licensure process that assures the public that the practitioner is prepared to provide contemporary oral health care. The American Dental Education Association Compendium of Clinical Competency Assessments (ADEA Compendium) is being purposely developed as a valid and reliable assessment of clinical competency and gauge of student readiness for practice or entry into advanced dental education. The ADEA Compendium can serve as a transformative pathway to licensure.

The profession of dentistry would benefit from the increased involvement of practicing dentists and hygienists demonstrating an interest in transforming the dental profession’s licensure processes. The most prevalent licensure pathway involves the use of a single-encounter, procedure-focused, high-stakes, patient-based clinical examination — the licensing exam that most practicing professionals are familiar with. Historically, the most interest in change has come from the dental education community including students preparing for licensure examinations as well as educational program faculty and administration.

This paper points out the value of broad-based support for changes to licensure for dental professionals, identifies key drivers involved in support of change, highlights selected efforts undertaken within the profession to engage in change and provides a detailed portrait of the American Dental Education Association (ADEA) Compendium of Clinical Competency Assessments (ADEA Compendium), an emerging new assessment and licensure model. The ADEA Compendium has evolved from the collaborative efforts to bring transformative change to the dental licensure process. The ADEA Compendium offers advantages over the existing licensure exams, meshes with changes in dental education assessment and can provide a valid and reliable assessment of readiness for practice.

Effects of Dental Licensure on the Profession

While the personal immediacy of concerns over the licensure process declines for most dentists and hygienists once they successfully obtain their license, there are compelling reasons for the entire profession to sustain an interest in the dental licensure process and the transformative changes that are needed. [1] If dentistry wants to sustain its status as a self-governing profession, be universally regarded as ethically centered and advance changes that reduce increases to the cost of dental education, it will require a broad-based interest in moving to 21st century licensure pathways. The predominant examination process affects the profession as a whole, not just dental education and candidates for licensure. [2]

STATUS AS A PROFESSION

Dentistry takes great pride in its status as a respected profession. Maintaining dentistry as a profession involves, among other qualities, a significant commitment to self-governance even in an era of increasing external accountability. The privilege of self-governance embodies the responsibility to ensure the public is served by the profession’s providers through a process that includes initial licensure. It is important that the licensure pathway satisfies all entities and is an authentic qualification to practice on behalf of the public.

The current licensure examination process is focused on procedural competency, rather than the full scope of skills required for professional practice. In reviewing licensing board disciplinary actions, Chambers found procedural competence is a less frequent source than practice management and personal issues. [3] There are similarities in medicine; Papadakis et al. looked at disciplinary actions by medical boards and found a strong statistical association between disciplinary licensure actions for unprofessional behavior and similar prior activity in medical school. [4] Incompetence, the physician equivalent of a dentist’s technical errors in this study, were found to be a minor component of disciplinary actions.

ETHICS AND PROFESSIONALISM

Much has been written about the value of the ethical foundation of the dental profession. Dentistry’s ethical foundation is buttressed by state dental practice acts, which almost universally prohibit payments and incentives to patients, often require timely and appropriate care, support comprehensive evaluation of patient needs and place the patient’s needs ahead of the practitioner’s interest.

Under the current licensure exam model, most candidates pay patients a substantial amount of money to sit for the examination. Many of the participants are not patients of record. Care can be delayed for months if the patient has an “ideal board lesion” (lesions often no longer recommended for irreversible restoration in contemporary practice) or need just a few more clicks of calculus to qualify as a periodontal patient. [5–7] Any one or all of those actions would likely be found to violate the state dental practice act under which the candidates seek to be licensed.

COST

Many members of the profession are aware and concerned that the cost of dental education programs continues to escalate at an unsustainable rate. The current examination process incurs significant direct and indirect costs to candidates and schools. Most dental administrators would note that the indirect costs are orders of magnitude higher when faculty and staff time allocated to the various measures preparing for the licensure examinations are considered. Indirect costs include dedicated curriculum time aligned to and focused on preparation for the examinations, conducting screenings for board patients, providing mock exams to acquaint students with the testing format, closure of the clinic or imposing significant restrictions on the treatment facility to conduct the examination, etc. Transitioning to emerging licensure models can help reduce both direct and indirect costs for students and educational institutions.

READINESS FOR PRACTICE

It is a logical expectation that a newly licensed dentist or hygienist will have the basic requisite patient care skills needed of an associate, employee or potential owner of a practice. In short, the process for granting a license should indicate a minimum level of competence and readiness for practice. Many current licensure systems do not offer that minimum assurance because they lack the validity and reliability necessary to accurately evaluate the basic clinical skills. [8–11] More importantly, the licensing examinations do not address the broad scope of knowledge, skills and attributes necessary for the practice of dentistry. [12,13] Although not frequently articulated, the most accurate evaluation of the readiness of dentists and hygienists primarily resides with the educational institutions. No single evaluation at a point in time can match the multiplicity of evaluations, evaluators and variety of methodologies obtained from accredited educational programs. [14]

Change Drivers

The drivers for change in dentistry have built slowly but appear to have reached a tipping point. The impetus, efforts and rationale for change exceed the stability of the status quo. Key drivers have been an increasingly strident student voice, continuous advances in oral health care, changes in the care delivery model and transformations in dental education that reflect the other drivers of change within the profession.

STUDENT VOICE

A significant driver for change is an increasingly active student voice. The students who are in essence the primary consumers of the licensure exam process have capably pointed out the deficits in the process. [15] Their concerns include examination variables that while decisive are not necessarily reflective of the candidate’s clinical skills, the lack of validity and reliability related to evaluation of clinical skills, the cost of the exam and the ethical challenges inherent in patient selection, delay of treatment, payment to patients and even patient procurement services — essentially commoditizing the patient’s treatment needs. The student position opposing the single encounter, patient based procedural exam resonates with others who have long advocated for changes to the licensure system. [1,11,16–18] There are equally strong student concerns related to the interstate portability of their licensure. It is notable that the students believe that retaining an evaluation of psychomotor skills is still a valued component of the licensure process.

Dental education program faculty and administrators recognize the same exam challenges as the candidates as well as the direct and indirect institutional resources required for preparation, execution and follow-up for the licensure examinations. [19] To provide students with the best preparation for the exam, many institutions will provide a mock examination process, essentially doubling the time and investment. More importantly, educators recognize that the evaluation of technical skills using a limited number of procedures is not representative of the complex array of knowledge, skills and attributes required to be competent as a new licensee prepared for contemporary dental practice or entry into advanced dental education programs. [2] Moreover, they recognize the time, energy and focus on preparing for and passing the current licensing exam would be better utilized in emphasizing and cultivating other aspects of dentistry within the time constrains of each program’s curriculum.

ADVANCES IN ORAL HEALTH CARE

As the profession has evolved, there are changes in the expectations for newly licensed practitioners that are not reflected in the existing examination process. The single-encounter, patientbased, procedurally oriented examination remains focused on psychomotor skills and procedure outcomes for minimally complex cases. The minimal or “ideal” lesions and cases most frequently selected for the licensure exam no longer represent the reality of contemporary oral health care. The complexity of care, patient needs and procedures available have expanded and will continue to expand in the future.

CHANGES IN THE PRACTICE MODEL

Today’s graduates need increased licensure portability beyond that typically available under the patchwork of laws governing licensing jurisdictions covering the 50 states, District of Columbia and U.S. territories. Notably, incremental progress has been made in the last decade in the number of states that accept other states’ licensure and broadening of the number of examinations accepted for licensure. At the same time, there are frequently stipulations requiring a number of years of practice that often hamper individual practitioners’ mobility at the time in their career when it is most needed. Conversely, there is often a limited time period when a state will consider a licensing examination as valid for initial licensure. Both of these time-based stipulations diminish licensure portability and therefore mobility for dental practitioners.

While state licensing laws are well-intended and founded in the need to ensure competent care for the public, their variability and unintended consequences of various stipulations lead to a reduction in mobility and constraint that has drawn significant attention outside dentistry. The licensing of dentists and dental hygienists has been cited in recent publications as unnecessarily restrictive and potentially protectionist of the profession rather than the public. [20–22]

CHANGES IN DENTAL EDUCATION

The dental education assessment and outcomes processes are evolving toward measurements that are reflective of increased understanding and new knowledge about how learning occurs. [23,24] Dental education is supportive of migrating the licensure examinations away from high-stakes, procedurefocused assessments and must mirror that same philosophy in their evaluation of student competency as well. As dental schools move closer and closer to true competency-based approaches to student evaluation, there will be a natural evolution toward systematically developing a panel of assessments that view competency globally rather than completing a checklist of procedural examinations. The ADEA Summit on the Future of Assessment in Dental Education (Feb. 6–7, 2019) established the case for continued change in the dental education assessment processes moving away from a preponderance of procedural skill evaluations and toward health outcomes and other “… competencies that are critical for person-centered, team-based care.” [25]

Dental Profession Change Initiatives

Multiple independent efforts over several decades yielded small and incremental change but neither substantive nor transformative change to the licensure system. The last few years have seen notable attempts at transformative change as well as concerted collaborative efforts. Both the collaborative efforts and the transformative approaches have helped build a momentum that moves toward 21st century licensing practices.

The two notable examples of transformative change were the adoption of the Canadian OSCE for licensure in Minnesota (MN OSCE) and the California Hybrid Portfolio Examination (CA Portfolio). Both the CA Portfolio [26] and MN OSCE [27] serve as case studies in transformative changes in licensure. In these two states, the dental board, dental association and dental school(s) worked jointly, building mutual trust and cooperation to support the changes.

In addition to the transformative changes at the state level, recent multiple interlacing efforts by national organizations collectively provided significant impetus for changes. The ADEA, the American Dental Association (ADA), the American Dental Student Association (ASDA) and the American Dental Hygiene Association (ADHA) each played a role in helping to move change forward. Their willingness to work collaboratively toward an analogous goal of transformational change of the licensure process helped accelerate the momentum more than any of the organizations could have accomplished working independently.

The ADEA has supported changes to the licensure process for a number of years and, with the ADEA House of Delegates’ unanimous support of Resolution 5H-2014, established the Task Force on Licensure, which provided a final report to the ADEA House of Delegates in March 2016. [28] The task force provided a series of recommendations that dovetailed with other national initiatives. One of the recommendations led to the workgroup that is developing the ADEA Compendium.

One of the most productive efforts was a joint task force of the ADA, ADEA and ASDA. The three organizations worked collectively and collaboratively from 2015–2019, spanning multiple yearly volunteer leadership transitions. The consistency of efforts ultimately culminated in support of the Report of the Task Force on Assessment of Readiness for Practice. [29] Included in the report was agreement to form the Coalition for the Modernization of Dental Licensure — a national coalition that would expand the base of support for licensure change and sustain valuable momentum. [30]

ADEA Compendium of Clinical Competency Assessments

The Report of the Task Force on Readiness for Practice proposed modernization of the dental licensure process by outlining three components: 1) completion of a DDS or DMD degree from a university-based program accredited by the Commission on Dental Accreditation (CODA); 2) passing the National Dental Board Examination; and 3) the successful completion of a reliable clinical assessment that does not require single-encounter, procedurebased examinations on patients.

The Task Force on Assessing Readiness for Practice Report specifically includes three examples, any one of which would meet the third licensure component for licensure: an Objectively Structured Clinical Examination (OSCE) including the Dental Licensure OSCE currently being developed by the ADA Department of Testing Services, completion of a CODA-accredited PGY-1 program or completion of a standardized compilation of clinical competency assessments designed to demonstrate psychomotor skills and practice relevant patientcare knowledge, skills and abilities, including the ADEA Compendium currently under development.

TABLE Sample Rubric for ADEA Compendium — Preparedness for Patient Care SEE TABLE IN THE FULL ISSUE OF THE JOURNAL

The remainder of this paper outlines the development, current status and rationale for adoption of the ADEA Compendium.

ADEA Compendium Development Process

ADEA formed the Compendium of Clinical Competency Assessments Workgroup in January 2018 to develop a clinical competency assessment that was in concert with the recommendations from the ADEA Task Force on Dental Licensure. [28] The ADEA Compendium (APPEND IX A) was also expected to align with collaborative licensure reform efforts of the ADA, ADEA and ASDA.

The workgroup (APPEND IX B) began with four overarching aspirational goals and developed consensus around a group of concepts that were used to frame the development of the clinical competency assessment and implementation process. The four overarching goals provided to the workgroup included developing a clinical competency assessment system and process that:

■ Provides licensure upon graduation.

■ Eliminates the high-stakes, single-encounter, patientbased clinical exam.

■ Increases the portability of initial licensure to all licensing jurisdictions.

■ Decreases the burden of the licensure process for the students and programs.

With the goals in mind, the workgroup began with discussions that led to consensus on the following framing concepts:

■ All dental education programs already have a curriculum-wide assessment plan to assure that the programs are in compliance with the CODA standards. A small segment or “thin slice” of the overall assessment plan could replicate the areas evaluated on clinical licensing exams (APPEND IX C). The workgroup initially recommended the six areas of clinical care used by the CA Portfolio as a starting point.

■ As a transformational approach to licensure, key elements of the CA Portfolio aligned with the planned goals for the ADEA Compendium. The use of calibrated faculty, employing a standardized rubric format and a common reporting method as well as the ability to achieve licensure upon graduation were the elements of greatest interest to the workgroup.

■ Strongly support the use of a competency assessment model that builds validity and reliability based upon multiple evaluations over the course of time by multiple evaluators. [31]

■ The Association of American Medical Colleges Core Entrustable Professional Activities (EPAs) used by the medical profession provide a structured approach to evaluating the preparedness of students to complete activities (procedures) independently. The EPAs measurement scale of independent performance could be tailored to dentistry and used as a gauge of this component of readiness for practice. [32–35]

■ It was logical to start with a prototype rubric that expanded the assessment to include four domains of clinical care for a more authentic representation of the knowledge, skills and attributes expected of a practice-ready student. The four areas were: ● Preparation for patient care. ● Patient and appointment management. ● Procedure. ● Professionalism and communication.

■ An established process and associated mobile application were evaluated that could facilitate rapid data entry and automatic population of a dashboard permitting real-time monitoring of student progress. The workgroup felt the software and process could be modified for use in the ADEA Compendium. [36]

The workgroup worked conscientiously over the course of 2018 to refine and build a system of clinical competency assessments that were based on the framing concepts. The workgroup also developed a process for the integration of the ADEA Compendium competency assessments system within dental education programs. The workgroup balanced the elements of the assessments system with the anticipated integration process to support achieving the original workgroup goals.

In conjunction with their internal development, the workgroup used an iterative process, presenting successive drafts of the assessments system and proposed process to a variety of groups and individuals both inside and outside dental education to obtain feedback and suggestions for improvement. The workgroup also conducted formal focus groups at the ADEA annual session and exhibition in March 2019. Following each review by outside groups as well as the focus groups, the workgroup used the feedback to modify the assessments system and integration process.

ADEA COMPENDIUM ASSESSMENTS SYSTEM

The ADEA Compendium assessments system was crafted using three foundational evaluation components (APPENDIX D).

Blended together, the three components provide a comprehensive view of each student’s performance and evaluate their progress throughout the normal learning trajectory toward clinical competence and readiness for practice or entry in advanced dental education programs (FIGURE 1 ).

FIGURE 1. ADEA Compendium of Clinical Competency Assessments System. SEE FIGURE IN THE FULL ISSUE OF THE JOURNAL

The current modified areas of clinical care assessed in the ADEA Compendium include diagnosis and treatment planning, periodontal therapy, endodontic therapy, restoration of teeth and replacement of teeth. For each of those five areas of clinical dentistry, students are evaluated in four domains: preparedness for patient care, patient and appointment management, procedure and professionalism and communication. Student evaluation of each domain includes whether they met or exceeded expectations as well as their level of independence.

The ADEA Compendium assessments system is organized in a format similar to the original rubric. For each clinical area assessed, there are four domains to be evaluated. The TABLE represents one domain of the rubric. The educational program can modify or tailor the criteria to their particular institution. For each of the four domains, the faculty evaluates the student on whether they exceeded, met or did not meet their program’s expectations. A program’s expectations are summarized as the criteria listed under each domain heading.

In addition to evaluation of the encounter as described, the ADEA Compendium assessments system includes a measure of student independence based on a scale modified from the EPAs. The workgroup modified the Chen and Ottawa independence scales used in the EPAs [32] to provide a relevant scale for dental education. Students entering their clinical education would be expected to need guidance, oversight and intervention. As they progress through their clinical education, the typical learning trajectory leads them toward completion of the patient encounter with lessening faculty intervention, eventually including the ability to independently provide care that meets or exceeds the program’s expectations.

Finally, in the feedback corrective actions column, the faculty assist with the student’s learning, professional growth and formation by providing feedback, corrective action items and comments of either a positive or formative nature.

The ADEA Compendium competency assessments system is designed to allow each program the flexibility to define the elements that contribute to each of the required four domains. Similarly, the program defines the criteria required to meet or exceed their expectations. For the purposes of standardizing the ADEA Compendium, student performance will be reported in the defined categories. As part of the ADEA Compendium integration process, faculty and students will be calibrated on the use of the assessment in the areas of encounter evaluation, the independence scales, recording of evaluations and data submission.

The workgroup supports a definition of competency that is in alignment with the structure of the EPAs. Students should be able to independently perform the procedure at a level that meets or exceeds the institution’s criteria on multiple occasions. Depending upon the individual school’s patient population, some of the areas proposed for the ADEA Compendium may necessitate a blend of patient and simulated procedures to arrive at the multiple independent evaluations. It is anticipated that the changes in dental disease and demographics will eventually be reflected in changes in the exam components for dental licensure.

ADEA COMPENDIUM INTEGRATION PROCESS

As indicated earlier, the workgroup engaged in both the process of developing the ADEA Compendium assessments system as well as the adoption and integration process for dental education programs (see FIGURE 2 at cda.org/ADEA). Internally, the workgroup was assembled with members who understood the complexities of adopting and using new systems in dental education. The workgroup also used the feedback from the iterative development process to refine the utilization process.

A consistent theme in the review of the various drafts by groups outside the workgroup and especially prominent in the ADEA focus groups was the desire to move toward the ADEA Compendium assessments system broadly within their dental education programs. The sentiment expressed was a desire to move toward the ADEA Compendium assessments system for all areas of clinical education and to then simply report the “thin slice” to third parties who would then use that information for the clinical licensure purposes. The ADEA Summit on the Future of Assessment in Dental Education demonstrated significant alignment with the ADEA Compendium assessments system and utilization process. [38]

The integration process for the ADEA Compendium is planned to start with programs submitting their assessment plan to a centralized service similar to other centralized academic services. The program’s assessment plan will be reviewed to ensure it meets the criteria for each clinical area. The program’s assessment plan will also be used to customize those areas of the assessments system in the mobile application for use by the program and establish the centralized data cache for the student outcomes.

Once modified, the faculty, staff and students will be calibrated on the data entry process as well as the elements of the rubric. The ADEA Compendium evaluation could be directly entered into a field on a mobile application and is designed for efficient entry of the evaluation. The entry can be input as an existing institution’s current grading scale or it can be derived from identification of keywords. Keyword utilization assists with automatic development of specific areas for improvement or demonstrated ability.

Feedback has consistently supported one uniform system within an institution rather than a separate one for clinical licensure. The use of a separate database for clinical evaluations assures that student assessment information is discrete from the patient’s electronic health record for legal purposes. The ADEA Compendium is designed to have minimal impact on a program’s criteria for meeting their clinical care expectations and an existing numerical or qualitative measure can be indexed to the ADEA Compendium scale. The role of the faculty is to provide evaluations longitudinally throughout the student’s clinical education program.

The students’ goals throughout the ADEA Compendium integration are well-aligned with an expected learning trajectory. Students learn to consistently provide care that meets or exceeds their program’s expectations in the four domains of the ADEA Compendium with gradually increasing levels of independence. Once the student and faculty are confident of the students’ ability, the students are expected to complete the procedure independently. Faculty evaluate the procedure at the steps determined by their school to assure that it both meets expectations and that the student is performing independently. Faculty have the option to intervene if needed and the student would then need to attempt the procedure independently at another time. Competency in a clinical discipline is demonstrated by completing multiple procedures that meet or exceed expectations without the need for faculty intervention.

The students’ outcomes are submitted to the testing agency or licensing body depending upon the state’s rules and regulations. When used for licensure, students who complete the ADEA Compendium, pass the National Board Dental Exam and graduate from a CODA-accredited program would complete other state procedures (jurisprudence, infection control, etc.) and be issued a license.

The ADEA Compendium workgroup anticipates that implementation would include oversight such as approval of faculty as compendium evaluators, recalibration of faculty and periodic evaluation of the school’s records/process. Oversight measures could be provided from the centralized service or testing agencies or implemented by the states.

Conclusion

The entire profession of dentistry is bolstered by an initial licensure process that authentically represents students’ readiness for practice or for entry into advanced dental education. The predominant clinical licensure exam process poses significant ethical challenges, incurs extraordinary direct and indirect costs, does not align with changes in dental education or dental practice and does not possess sufficient validity and reliability. Modernization of the clinical licensure process requires transformative changes that should be broadly supported throughout the profession.

The ADEA Compendium is currently under development and could be an instrument of change in the dental licensure process. The ADEA Compendium is a combination of purposeful design, offers appropriate educational program flexibility, uses evaluation by calibrated faculty and streamlined reporting within a standardized format. As a result, the ADEA Compendium will achieve the following: 39

■ Provide a process of valid and reliable assessment of clinical competency that is completely integrated within the clinical education experience.

■ Produce standardized ongoing demonstration of student performance and faculty calibration to achieve clinical competency.

■ Serve as a pathway for licensure upon graduation using accepted, valid and reliable assessments of readiness for practice.

The ADEA Compendium integration process is planned to allow educational programs to integrate with minimal disruption of existing assessment processes. At the same time, the ADEA Compendium is designed to bring maximal value in support of dental education’s role in assessment of student competency while retaining third-party oversight of the process.

There is an established axiom in education that “assessment drives student behavior.” With the ADEA Compendium, students are assessed on the full range of knowledge, skills and aptitudes needed for appropriate patient care, not just the technical skills of a procedure for licensure. The assessments system incentivizes students to learn to provide care independently that meets or exceeds their institution’s criteria.

The ADEA Compendium of Clinical Competency Assessments can serve as a transformative 21st century approach to the clinical licensure process that represents the dental profession’s commitment to the public we serve.

Appendices — see full issue of Journal

Appendix A. Compendium definition

Appendix B. ADEA Compendium Workgroup

Appendix C. CODA Standard 2 Educational Program

Appendix D. ADEA Compendium Foundational Evaluation Components

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THE AUTHOR, Steven W. Friedrichsen, DDS, can be reached at sfriedrichsen@westernu.edu.

AUTHOR

Steven W. Friedrichsen, DDS, is a professor and the dean of the Western University of Health Sciences College of Dental Medicine. He is the chair of the ADEA Compendium of Clinical Competency Assessments work group. Conflict of Interest Disclosure: The views and opinions expressed are those of the author and do not necessarily reflect those of the American Dental Education Association. The author is one of six who hold the patent and trademark for iFF, a mobile formative feedback application. The commercialization of iFF does not result in financial remuneration for the author.