Licensure by Portfolio: Our Experience in Prospect and Retrospect

Iris Nam, DDS; John Won, DDS, MS; Greg Olson, DDS, MSD; and Edwin L. Christiansen, DDS, PhD

ABSTRACT Loma Linda University School of Dentistry’s pathway to California licensure by portfolio began in 2016 with eight candidates. Designated faculty were calibrated to assess and guide candidates. Portfolios substantiating clinical accomplishments were required as were clinical experience and successful completion of the California Portfolio Examination. Participation demanded organizational skills, commitment and motivation. Four students transferred out and four students completed the program. Postportfolio surveys confirmed the greatest challenge was finding appropriate competency cases.

The Commission on Dental Accreditation stipulates that qualification for dental licensure in the U.S. requires that a candidate successfully matriculate from an accredited dental school, pass parts I and II of the National Board Dental Examination and demonstrate clinical competency in a live-patient examination administered and overseen by a state or regional testing agency. [1]

In lieu of clinical licensure examination, certain states mandate or permit one postgraduate-year residency from an accredited institution. Postgraduate-year residencies are mandated in Delaware and New York but are optional in Minnesota, California, Colorado, Ohio and Washington. 1 The Curriculum Integrated Format also leads to licensure and is available through examining agencies collaborating with participating dental schools. [2]

Pathways to California Licensure

California has four pathways open to qualified dentists: licensure by credential, by residency, Western Regional Examination Board (WREB) exam and licensure by portfolio (LP).

Licensure by credential is available only to practicing dentists licensed in another state. A minimum of 5,000 hours of active clinical practice are required over a period of five consecutive years during the seven years immediately preceding application. 3 Two years of maximum credit is allowed for a completed residency. Unfulfilled clinical years may be met by contracting to teach or practice in a setting specified by the California Business and Professions Code. 3 Licensure candidates are required to prove nonfailure of the California licensure exam or the WREB clinical exam within the five-year period immediately preceding application. [3]

Following receipt of candidates’ application and proof of eligibility, a license may be issued within two weeks. [3]

Licensure by residency requires a minimum of 12 months in a general practice residency or advanced education in a general dentistry program. [4] Also required are passing the California Law and Ethics Exam and fingerprinting. [4]

The WREB is the most common option selected by candidates for licensure. A common thread of requirements exists for most pathways to licensure: graduation from an accredited dental school, passing National Dental Board examinations, passing WREB exams, passing tests of dental law and ethics and undergoing required fingerprinting. [5] Fees for WREB may vary with the chosen test site in any given year. [6]

Enrollees for LP build portfolios to substantiate efforts and accomplishments throughout their dental education. Students’ expanding portfolios are subject to evaluation by designated faculty in accordance with guidelines established by the Dental Board of California. Standardized minimum clinical experience and successful completion of the California Portfolio Examination are required and cover seven competencies in six clinical domains. The remaining requirements are the same as the WREB. [6] A summary of comparative costs for all licensure pathways is shown in the TABLE .

TABLE Itemized Cost of California Dental Licensure SEE TABLE IN THE FULL ISSUE OF THE JOURNAL

Strengths and Challenges of Licensure by Portfolio

Challenging the LP pathway may represent the most significant and comprehensive evaluation of a student’s clinical skills during their dental education. [7] It is assumed that by requiring a measured minimum of clinical experiences, as well as demonstrated competencies in each domain, there is a strongly perceived probability that candidates will have been prepared and qualified to treat patients within the boundaries of established standards of care.

Seven competency examinations administered to LP pathway participants cover more areas of dental expertise than a single comprehensive clinical dental board examination. Additionally, it is anticipated the LP path will broaden traditional dental foundations of didactic and clinical skills by providing more opportunities for assessment and improvement. Presumably, the cost of a dental education may be lowered if one factors out traditional, relatively high testing fees.

Drawbacks to Loma Linda’s LP offering were anticipated, chief of which appeared to be the cost in time, effort and money. Each cost challenged the administration’s decision to develop, refine and implement a new curricular path, one requiring testing by competent faculty examiners (CFEs) who underwent specialized training and calibration. Loma Linda was well aware that the LP option would place unique demands on an already robust curriculum and require significant investments of time and resources.

Though the LP guidelines provided by the Dental Board of California are clear and detailed, each participating school is tasked with implementing the LP program in harmony with its unique circumstances and resources.

Calibrating CFEs is one example of the challenges that faced the program organizer and faculty. From students’ perspectives, participation demanded greater than average organizational skill sets, undivided commitment and unflagging motivation, the lack of which may result in some electing to return to a traditional route of graduation and licensure (e.g., WREB). [8,9]

Progress or Problem?

Discontent with clinical testing has been growing for more than 20 years. Now a few administrators, faculty and students are calling for the elimination of live-patient testing. [10] Countering this argument, other voices remind dentistry of the norm that has dictated policy for decades – that operative competency testing on live patients represents an assessment of students’ graduation-readiness, serving as a rite-of-passage [emphasis added].

Recently, the American Student Dental Association (ASDA) published a position paper against [writers’ emphasis] live-patient testing: “Members of the ASDA … stand firm in our conviction that the practice of using human subjects in clinical licensing examinations is flawed and unethical” [11] [citation modified]. Considering current curricular debate, Loma Linda, moving thoughtfully and cautiously, determined that LP provides a viable option to live-patient testing. [12]

The Loma Linda Experience

Loma Linda embraces a philosophy and tradition of preparing graduates to be best positioned for service learning. Our faculty strives to enable students to pass licensure examinations in pursuance of productive careers serving as oral health care providers at all levels of society. Thus, with these guiding principles, we moved forward.

Loma Linda's Response

METHODOLOGY

Immediately following the official decision to incorporate LP into the curriculum, a search was set in motion for a faculty member to organize and coordinate the process. The coordinator’s first steps were to review relevant published materials and open a channel of communication with the Dental Board of California — an action that proved essential throughout the process. Loma Linda’s LP program coordinator communicated with licensing specialists in the dental licensing and examinations department at the Dental Board of California, receiving assistance and guidance on “building” the program. Licensing specialists, available by phone and email, were prompt to provide valuable oversight of the logistical and technical requirements of the process. Materials developed by California dental schools in conjunction with the dental board were particularly helpful for us as we outlined the methodology for calibrating participating LP faculty. Detailed information was provided describing the process of having our portfolio graders approved by the dental board. Moreover, licensing specialists visited our campus for direct, interactive Q&A sessions.

Upon agreement of the plan for our infant LP program, we moved ahead. Identifying and recruiting faculty competency graders was the next step. To our advantage, competency examinations preexisted the LP project in the divisions of general dentistry, endodontics and periodontics, which smoothed the intramural transition to LP to metrics in these departments. It was decided to retain existing examination and grading protocols (each with unique features) within qualifying departments. Faculty examiners were calibrated in accordance with published guidelines of the California Portfolio Examination. [13]

Calibration exercises were conducted within the division of general dentistry in the sections of operative dentistry and removable prosthodontics. Guidelines were given to faculty competency graders for review ahead of meetings that followed. Grading rubrics were scrutinized to assure faculty were “reading from the same page” and grasped the core requirement of each step. After intradepartmental calibrations, all three departments met to review the specific details of administering and grading competency examinations. A list of graders and their credentialing information was submitted to the dental board from the Office of the Dean. After approval, competency examination graders met regularly to review issues and updates.

Eight candidates joined the LP program when it launched in 2016. Their identities were submitted to the dental board and each was assigned an ID number. The project coordinator met with the candidates on several occasions to review program details and requirements and collect information on issues and challenges. The coordinator served by establishing protocols of the competency examination, guiding candidates and faculty as needed, leading out in faculty calibration and serving as a liaison between LP candidates and grading faculty members.

Shortly after the project launched, candidates began challenging the California Portfolio Exam. Delay of testing was believed to be due to difficulties encountered in identifying patients who met the specific testing parameters.

Parallel with establishing the program, a redundant record was organized by creating subfolders for graders, candidates and calibration. Google Docs was chosen for its versatility and live document status, which was readily edited and shared among approved users. In addition to electronic documentation, the entire document was hard copied for storage at a secure site in the division of general dentistry — a precaution to ensure against electronic failure.

CHALLENGES

By far, time spent grading was the greatest challenge facing LP faculty. It is estimated that faculty examiners spent 30 hours’ grading time per candidate during the entire program.

For the LP candidates, their greatest challenge was timely identification of appropriate treatment cases for portfolio competency examinations. Because school policy does not allow students to directly select patients from the general pool, some candidates had difficulty finding appropriate cases.

OUTCOMES

The LP program commenced with eight candidates, each in the first quarter of their senior year. They were unable to begin taking competency examinations until the second quarter as most of the first quarter was consumed by organization and preparation. Though all eight candidates underwent examination, two chose to leave the program in the third quarter, opting for the approaching WREB examination. Both candidates were scheduled to report for military service shortly after graduation and stated they could not afford to risk having to remain beyond graduation to complete remaining LP requirements. Two additional candidates opted out in favor of the WREB because of their uncertainty of finding the required number of competency cases. In the end, four candidates finished the program and submitted completed portfolios to the dental board for licensure.

In postexperience surveys, all candidates confirmed that their biggest challenge was the difficulty finding appropriate competency cases in a timely manner but added that the minimum-clinicalexperience requirement posed no challenge.

LP STRENGTHS, WEAKNESSES AND LESSONS LEARNED

Important lessons were learned during our efforts to implement the LP pathway at Loma Linda:

■ Students’ familiarity with the process was helpful.

■ Having an existing, robust competency-based clinical curriculum accelerated the most difficult aspect — reliable and valid measurement. Not needing to reinvent the method for grading the portfolio competency exams was a significant bonus.

■ Competency exam graders selected for portfolio grading were more easily calibrated. Scoring results showed excellent agreement.

■ The patient pool was sufficiently diverse and plentiful to provide necessary clinical experiences, though a few candidates expressed concern about finding necessary procedures in a timely manner, which may have exaggerated students’ anxiety.

■ Ten to 12 months (minimum) is a reasonable period for completing one’s portfolio.

■ We believe that having two or three additional months would have allowed students to complete their portfolio.

•Valuable time was spent instituting rather than implementing the LP program.

■ Though competency-based examinations and faculty calibration existed prior to launching LP, interdepartmental calibration required more time to develop. Relative compartmentalization of specialties and departments created significant barriers to the flow of information and communication.

■ Another symptom of “compartmentalization” was suboptimal communication and recordkeeping. Such issues were managed with interdepartmental meetings.

■ One way to improve competency grading and record-keeping is by centralization of faculty calibration results and LP student grading, rather than by division; this should be implemented.

Looking Ahead

Administration and LP faculty were pleased when the first four students graduated. Having collected data pertaining to increased demands of time and effort imposed on an (already) overworked faculty, we are aware that more efficient, collaborative efforts are crucial for recruiting and accommodating LP candidates.

Valuable lessons and insights were gained over the course of initiating the LP pathway. Most students agreed the process was rigorous but reported less stress during competency assessments.

Another benefit was the opportunity afforded faculty to reinforce our unique core values regarding patientcentered care — values we espouse.

Conclusion

Debating the format and the existence of dental board examinations seemingly dominates discussions on dental licensure. Throughout the U.S., a menu of licensure options is being weighed: some for acceptance, while others, traditional and historical, may be rejected. The debate is caught, for now, in the evolving ratiocinations of curricular specialists, educational psychologists and philosophers. Though the future of dental licensure may be turbulent, Loma Linda remains certain that the interests of students, patients and faculty are best served by greater personal investment and professional fulfillment offered by licensure by portfolio. n

REFERENCES

1. American Dental Association. State licensure for U.S. dentists. www.ada.org/en/education-careers/licensure/state-dentallicensure-for-us-dentists.

2. American Dental Association. Licensure pathways. www.ada. org/en/education-careers/licensure/licensure-dental-students/ licensure-pathways.

3. Dental Board of California. Licensure by credential. www.dbc.ca.gov/applicants/licensure_by_credential.shtml.

4. Dental Board of California. Licensure by residency. www.dbc. ca.gov/applicants/licensure_by_residency.shtml.

5. Dental Board of California. Application for licensure based on passing the WREB examination — general information and updates. www.dbc.ca.gov/applicants/wreb_exam.shtml.

6. Western Regional Examining Board. Dental exam schedule. wreb.org/dental-candidates/dental-exam-schedule/.

7. Gadbury-Amyot CC, McCracken MS, Woldt JL, Brennan RL. Validity and reliability of portfolio assessment of student competence in two dental school populations: A four-year study. J Dent Educ 2014 May;78(5):657–667. doi: 10.1002/j.0022- 0337.2014.78.5.tb05718.x.

8. Davis MH, Ponnamperuma GG, Ker JS. Student perceptions of a portfolio assessment process. Med Educ 2009 Jan;43(1):89–98. doi: 10.1111/j.1365-2923.2008.03250.x.

9. Spicuzza FJ. An evaluation of portfolio assessment: A student perspective. Assessment Update 1996 Nov–Dec;10(2):4–13. doi.org/10.1002/au.3650080604.

10. Elliot C. The debate on the elimination of live patients in clinical licensure examination. www.thefreelibrary.com/ The+debate+ on+the+elimination+of+live+patients+in+clinical+li censure...-a0179977425.

11. American Student Dental Association. Use of human subjects in clinical licensure examinations. www.asdanet.org/docs/ advocate/issues/asda_white-paper_licensure_web_final. pdf?sfvrsn=a0a868dd_18.

12. COMIRA. Alternative pathways for initial licensure for general dentists, submitted to the Office of Professional Examination Services California Department of Consumer Affairs. Feb. 9, 2009. www.dbc.ca.gov/formspubs/pub_portfolio_final.pdf.

13. Dental Board of California. Portfolio examination candidate handbook. www.dbc.ca.gov/formspubs/portfolio_handbook.pdf.

THE CORRESPONDING AUTHOR, Iris Nam, DDS, can be reached at inam@llu.edu.

AUTHORS

Iris Nam, DDS, is an assistant professor, division of general dentistry, at the Loma Linda University School of Dentistry. Conflict of Interest Disclosure: None reported.

John Won, DDS, MS, is an assistant professor and head, division of general dentistry, at the Loma Linda University School of Dentistry. He is a fellow of the American College of Prosthodontics. Conflict of Interest Disclosure: None reported.

Greg Olson, DDS, MSc, is professor and chair, pediatric dentistry, at the University of Texas Health Science Center at Houston. Conflict of Interest Disclosure: None reported.

Edwin L. Christiansen, DDS, PhD, retired from Loma Linda University in December 2019. He was a professor in the school of dentistry and an adjunct professor in the school of medicine. Conflict of Interest Disclosure: None reported.