BILL ANALYSIS                                                                                                                                                                                                    







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        |Hearing Date:June 21, 2010         |Bill No:AB                         |
        |                                   |1524                               |
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                      SENATE COMMITTEE ON BUSINESS, PROFESSIONS 
                               AND ECONOMIC DEVELOPMENT
                         Senator Gloria Negrete McLeod, Chair

                         Bill No:        AB 1524Author:Hayashi
                        As Amended:June 14, 2010 Fiscal:    Yes

        
        SUBJECT:   Dentistry: examination requirements. 
        
        SUMMARY:  Repeals the clinical and written examination administered by  
        the Dental Board of California and replaces that examination with a  
         portfolio examination  of an applicant's competence to practice  
        dentistry to be administered while the applicant is enrolled in a  
        dental school program.

        Existing law:
        
        1) Establishes the Dental Board of California (Board) to license and  
           regulate the practice of dentistry in California.

        2) Provides that dentistry is the diagnosis or treatment, by surgery  
           or other method, of diseases and lesions and the correction of  
           malpositions of the human teeth, alveolar process, gums, jaws, or  
           associated structures; and such diagnosis or treatment may include  
           all necessary related procedures as well as the use of drugs,  
           anesthetic agents, and physical evaluation.

        3) Requires examinations by the Board to be sufficiently thorough to  
           test the fitness of the applicant to practice dentistry, and  
           requires questions and answers to be written in English.

        4) Specifies that the subjects in which the applicant shall be  
           examined shall be those subjects as the Board may from time to time  
           prescribe in accordance with curricula provided by dental schools  
           within California, and that dental schools shall be informed two  
           years in advance of any proposed changes in the list of subjects to  
           be provided on the examinations. 






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        5) Requires each applicant for dentistry licensure to successfully  
           complete the written examinations of the National Board Dental  
           Examination of the Joint Commission on National Dental Examinations  
           (NBDE); an examination in California law and ethics administered by  
           Board, and one of the following:  A clinical and written  
           examination developed and administered by the Board; or a clinical  
           and written examination administered by the Western Regional  
           Examining Board (WREB).

        6) Authorizes the Board to issue a license to practice dentistry,  
           without requiring the taking of the state exam, to applicants who  
           are currently licensed to practice dentistry in another state, and  
           who meet specified clinical practice and other requirements.


        7) Provides that when an applicant for a license has received a  
           grading of 85 percent or above in any given subject on the state  
           exam, he or she shall be exempt from re-examination on that subject  
           in subsequent examinations.

        8) Provides that, notwithstanding a general statutory prohibition  
           against imposing additional prerequisites on unsuccessful  
           examinees, applicants who fail to pass the state exam after three  
           attempts must take 50 hours of remedial education for any of the  
           three subjects which the applicant failed in his or her last  
           unsuccessful examination.

        9) States that occupational analyses and validation studies are  
           fundamental components of licensure programs.  

        10)Requires the Department of Consumer Affairs (DCA) to develop, in  
           consultation with boards, programs, bureaus, and divisions under  
           its jurisdiction, a policy regarding examination development and  
           validation, and occupational analysis.  Provides that this policy  
           shall address, but shall not be limited to, the following issues:

             a)     An appropriate schedule for examination validation and  
               occupational analyses, and circumstances under which more  
               frequent reviews are appropriate.

             b)     Minimum requirements for psychometrically sound  
               examination validation, examination development, and  
               occupational analyses, including standards for sufficient  
               number of test items.

             c)     Standards for review of state and national examinations.





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             d)     Setting of passing standards.

             e)     Appropriate funding sources for examination validations  
               and occupational analyses.

             f)     Conditions under which boards, programs, and bureaus  
               should use internal and external entities to conduct these  
               reviews.

             g)     Standards for determining appropriate costs of reviews of  
               different types of examinations, measured in terms of hours  
               required. 

             h)     Conditions under which it is appropriate to fund permanent  
               and limited term positions within a board, program, or bureau  
               to manage these reviews.

        11)    Requires every regulatory board and bureau, and every program  
           and bureau administered by the DCA to submit to the director on or  
           before December 1, 1999, and on or before December 1 of each  
           subsequent year, its method for ensuring that every licensing  
           examination administered by or pursuant to a contract with the  
           board is subject to periodic evaluation.  Requires the periodic  
           evaluation to include: (a) a description of the occupational  
           analysis serving as the basis for the examination; (b) sufficient  
           item analysis data to permit a psychometric evaluation of the  
           items; (c) an assessment of the appropriateness of prerequisites  
           for admittance to the examination; and (d) an estimate of the costs  
           and personnel required to perform these functions.  States that the  
           evaluation shall be revised and a new evaluation submitted to the  
           director whenever, in the judgment of the board, program, or  
           bureau, there is a substantial change in the examination or the  
           prerequisites for admittance to the examination.

        12)    Indicates that the evaluation may be conducted by the board,  
           program, or bureau, the Office of Professional Examination Services  
           of the DCA, or pursuant to a contract with a qualified private  
           testing firm.  States that a board, program, or bureau that  
           provides for development or administration of a licensing  
           examination pursuant to contract with a public or private entity  
           may rely on an occupational analysis or item analysis conducted by  
           that entity.  Requires the DCA to compile this information, along  
           with a schedule specifying when examination validations and  
           occupational analyses shall be performed, and submit it to the  
           appropriate fiscal, policy, and sunset review committees of the  





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           Legislature by September 30 of each year. 

        This bill:

        1) Repeals existing law provisions requiring that the examination to  
           practice dentistry be sufficiently thorough to test fitness of the  
           applicant to practice dentistry, and the requirement that the  
           questions and answers be in English; and general provisions  
           relating to examination subjects.

        2) Repeals the requirement that a dentistry applicant complete and  
           pass a clinical and written examination developed and administered  
           by the Board and replaces it with a  portfolio examination  .

        3) Requires the portfolio examination specified in item # 2) above to  
           be conducted while the applicant is enrolled in a dental school  
           program at a board-approved school in the state.  Requires the  
           examination to utilize uniform standards of clinical experiences  
           and competencies.  

        4) Requires an applicant to additionally pass a  final assessment  of  
           the submitted portfolio at the end of his or her dental school  
           program.  

        5) Provides that before any portfolio assessment may be submitted to  
           the Board, the applicant must remit a $350 fee, to be deposited  
           into the State Dentistry Fund, and a letter of good standing signed  
           by the dean of his or her dental school or delegate stating that  
           the applicant has graduated or will graduate with no pending  
           ethical issues.

        6) Requires the Board to independently monitor and audit the  
           standardization and calibration of dental school competency  
           instructors at least biennially to ensure standardization and an  
           acceptable level of calibration in the grading of the examination.   
           Requires the board to audit each dental school's competency  
           examinations.

        7) Requires the Board to oversee all aspects of the portfolio  
           examination process, but shall not interfere with the dental school  
           authority to establish and deliver an accredited curriculum.   
           Requires the Board to determine an end-of-year deadline, in  
           consultation with the current board-approved dental schools, to  
           determine when the portfolio examinations shall be completed and  
           submitted to the Board for review by its examiners.






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        8) Requires the Board, in consultation with the current board-approved  
           dental schools, to determine portfolio examination competencies and  
           the minimum number of clinical experiences required for successful  
           completion of the portfolio examination.

        9) Provides that the Board shall require and verify successful  
           completion of competency examinations that were performed on a  
           patient of record at a board-approved dental school, including but  
           not limited to: 

                a)        Comprehensive oral diagnosis and treatment planning.  


                b)        Periodontics. 

                c)        Direct restorations.

                d)        Indirect restorations.

                e)        Removable prosthodontics.

                f)        Endodontics.

        10)Clarifies that an applicant must successfully complete Part I and  
           Part II of the NBDE written examinations.

        FISCAL EFFECT:  According to the Assembly Appropriations Committee:

        1)No direct state fiscal impact. By eliminating one exam-related  
          workload and replacing it with a new framework of similar magnitude,  
          the costs of this bill are absorbable for the Board. There are  
          indications this bill may lead to a reduction in workload after  
          initial implementation. 

        2)The Board is supported by special fund licensing revenues charged  
          for initial and renewal licenses.  Under current law, approximately  
          1,200 dentists become newly licensed and more than 40,000 are  
          granted renewal licenses in California annually. This bill requires  
          applicants for initial licensure to pay a one-time $350 fee. 

        COMMENTS:
        
        1. Purpose.  According to the  Dental Board of California  , the Sponsor  
           of this measure, this bill would streamline the licensure process  
           for California dental school graduates by eliminating the  
           requirement of a clinical examination administered by the board.   





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           It points out that the current clinical examination is administered  
           over three days, costs each applicant over $2,000, and requires the  
           participation of a volunteer patient provided by the student.   
           Supplying the patient has been especially problematic for dental  
           students, as finding an appropriate test subject raises practical  
           and ethical issues.  Additionally, concerns have been raised about  
           the reliability judgments made about candidate performance in these  
           one shot examinations.  The Board points out the new examination  
           requirements proposed by this bill will provide a higher  
           probability that candidates who successfully complete the process  
           will meet minimum competency standards, while also providing  
           greater protection and safety to consumers.    


        2. Background.  

             a)     Licensure Requirements for Dentistry Applicants.  The  
               Board regulates over 38,000 dentists in California, and five  
               approved dental schools in the state, namely, the University of  
               the Pacific School of Dentistry, UCSF School of Dentistry, Loma  
               Linda School of Dentistry, UCLA School of Dentistry, and the  
               USC School of Dentistry.  The examination requirements for  
               dentistry licensure are as follows: 1) passage of Part I and  
               Part II of the NBDE; 2) passage of the California law and  
               ethics examination and 
             3) passage of  either  the clinical or written examination  
               administered by the Board  or  the WREB.  Additionally, an  
               applicant who has completed a minimum of 12 months of a general  
               practice residency or advanced education in general dentistry  
               program approved by the ADA's Commission on Dental  
               Accreditation is also eligible for licensure.  

             The clinical and written examination administered by the Board is  
               offered two to five times a year.  Currently, the examination  
               subjects include Endodontics, Removable Prosthodontics  
               Evaluation; Periodontics; Class II Amalgam Restoration; Class  
               III or IV Composite Resin Restoration; and Simulated Fixed  
               Prosthetics.  The  Endodontics  examination is a written,  
               50-multiple choice questions that test the candidates ability  
               to diagnose, treatment plan, interpret radiographs and  
               critically evaluate treatment, strategies for pulpal and  
               periapical pathoses as well as systemic conditions. The  
                Removable Prosthodontics Evaluation  , conducted in a laboratory  
               setting, tests the candidate's knowledge, understanding and  
               judgment in the diagnosis and treatment of complete dentures,  
               partial dentures and implants.  Candidates evaluate cases in a  





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               laboratory station-based examination providing answers to 50  
               multiple-choice questions.  The  Periodontics  examination  
               consists of three parts: clinical examination and diagnosis;  
               scaling of a patient; and a written examination comprised of 54  
               multiple-choice questions based upon projected slides.  The  
               candidate must provide a patient for both the clinical  
               periodontal examination and diagnosis and scaling portions of  
               the examinations.  If a patient is deemed unacceptable, it is  
               the candidates' responsibility to provide another patient who  
               is acceptable.  Specific patient requirements are included for  
               Class II amalgam restoration, Class III or Class IV composite  
               resin restoration.  The  Simulated Fixed Prosthetics  examination  
               involves a typodont or a model of the oral cavity, including  
               teeth, gingival, and the palate, that is mounted in manikin.   
               This examination tests for partial denture, and crown  
               preparation.

             Since candidates provide their own patients, there are general  
               requirements that apply to these patients, including completion  
               of a medical history, and the taking and recording of blood  
               pressure.  Additionally, candidates are required to furnish  
               their own instruments, handpieces, typodonts, and materials  
               necessary to carry their assignments to completion.  

             b)     State's Requirements for Examination Validation and  
               Occupational Analysis. Occupational analyses and exam  
               validations are critical components of appropriate and legally  
               defensible licensure programs.  Both types of reviews help the  
               State ensure that the standards for entry into professions are  
               consistent with the skills required in those professions.   
               Section 139 of the Business and Professions Code also expresses  
               the policy of the State that any licensing examination provided  
               in California for purposes of licensure must be evaluated and  
               reviewed to assure it has been appropriately validated and has  
               had an occupational analyses conducted that meets both the  
               legal requirements and testing standards of California.  

             Examinations recognized and used by State licensing boards must  
               also meet the requirements of subdivision (a) of Section 12944  
               of the Government Code to assure that they do not have an  
               adverse impact on any class by virtue of its race, creed,  
               color, national origin or ancestry, sex, age, medical  
               condition, physical disability, mental disability, or sexual  
               orientation.  

             c)     Study on Alternative Pathways for Initial Licensure for  





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               General Dentists.  On February 9, 2009, a private entity  
               submitted to the Office of Professional Examination Services of  
               the DCA its final report on the Board's consideration of  
               alternative pathways to initial licensure.  This study focused  
               on four alternative pathways to licensure and identified the  
               best option for the Board pursuant to specified criteria.  

             First, the study delineated specific  criteria or elements  of an  
               alternative pathway for initial licensure, as follows: 1)  
               oversight maintained by the Board; 2) built in system for  
               auditing the process; 3) does not require additional resources  
               from students, schools, or the Board; 4) must be instituted  
               within the current systems of student evaluation; 
             5) must be considered an examination that meets all professional  
               testing standards; 
             6) meets psychometric standards, relevant to current practice,  
               and designed for minimum competence; 7) designed to cover the  
               full continuum of competence; 
             8) evaluation of competence is within the course of treatment  
               plan for patients of record; 9) evaluators are regularly  
               calibrated for consistent implementation of the alternative  
               examination; and 10) has policies and procedures that treat  
               licensure candidates fairly and professionally, with timely and  
               complete communication of examination logistics and results.  

             The report identified and discussed the following four  
               alternatives to initial licensure:  
               1) Curriculum Integrated Format (CIF); 2) Objective Structured  
               Clinical Examination (OSCE); 3) the traditional portfolio; and,  
               4) the hybrid portfolio examination model.  The report  
               described each pathway in great detail, including the  
               disadvantages of each alternative and who currently utilizes  
               them, as applicable.  This analysis will only provide a general  
               overview of these alternatives.  First,  CIF  examinations are  
               administered to senior dental students beginning with the  
               simulated examinations (use of manikins) early in the senior  
               year and the restorative and periodontal examinations early in  
               the second semester of the senior year.  Secondly, the  OSCE   
               requires candidates to rotate through a series of stations in  
               which they must perform specific tasks.  Thirdly, the  
                traditional portfolio  would be a collection of verified  
               clinical experiences based on results of competency  
               examinations in diagnosis and treatment planning, periodontics,  
               direct and indirect restorative, prosthodontics, and  
               endodontics.  Lastly, the  hybrid portfolio examination  involves  
               hands-on performance evaluations of clinical skills as  





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               evaluated with the candidates' program of dental education.  

               The study concluded that the hybrid portfolio examination  
               satisfies the criteria identified by the Board, the California  
               Dental Association, and the psychometric consultants.  Since  
               this bill focuses on the hybrid portfolio examination, it will  
               be described in detail in this analysis.  The study pointed out  
               that the hybrid portfolio examination is a performance  
               examination which assesses candidates' skills in commonly  
               encountered clinical examinations.  It includes components of  
               clinical examination administered by the bureau/board or  
               regional examining entity; and the candidate's performance is  
               measured according to the information provided in competency  
               evaluations conducted in the schools by clinical faculty within  
               the predoctoral program of education.  The hybrid portfolio  
               would utilize the current structure used by dental schools to  
               assess minimum competence, where a faculty would observe the  
               treatment provided and evaluate candidates according to  
               consistent criteria developed as a consensus of key faculty  
               from all of the dental schools.  Additionally, each candidate  
               would prepare a portfolio of documentation that provides proof  
               of completion of competency evaluations for specific procedures  
               such as amalgam/composite restoration, endodontics, fixed  
               prosthetics, oral diagnosis, and treatment planning,  
               periodontics, radiography, and removable prosthodontics.   
               Moreover, the hybrid portfolio model requires documentation of  
               the test cases which are assembled in either a paper or  
               electronic format.  The faculty examiners would have to attest  
               to the ratings achieved by the students; and each procedure is  
               documented by type of procedure.

               As indicated above, the hybrid model relies on an assessment of  
               minimum competence, which would require that dental schools in  
               California have consistent methodology for assessing students'  
               clinical skills.  The report pointed out that during visits to  
               the dental school clinics and interviews with faculty, the five  
               dental schools in California are consistent in their evaluation  
               and assessment of student competencies, and that although these  
               dental schools had slightly different formats, the rating  
               criteria for their competency examinations were similar.  

             d)     Study on Portfolio Examination to Qualify for California  
               Dental Licensure.   In December 2009, the Portfolio Examination  
               to Qualify for California Dental Licensure, was submitted to  
               the Board. The study was done to support the formulation of  
               this bill, including the necessary competencies that would be  





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               used in the development of the portfolio examination.  This  
               study described the procedures used to define the competencies  
               to be tested in the portfolio examination, and provided  
               background research that may affect the implementation process.  
                Specific standards were discussed to ensure that the portfolio  
               examination can provide evidence that entry-level dentists  
               possess the minimum competencies necessary to protect public  
               health and safety.  

             First, the study described the portfolio examination model and  
               several distinguishing characteristics as previously mentioned  
               in section c) above.  The study also pointed out that the  
               portfolio examination model is designed to use the structure  
               for student evaluation that currently exists within the schools  
               to assess minimum competence.  

             The study identified the six competency domains that the  
               competency examinations must include, as follows: Comprehensive  
               oral diagnosis and treatment planning; direct restoration;  
               indirect restoration; removable prosthodontics; endodontics;  
               and periodontics.  These domains were identified through  
               discussions with separate focus groups from the five dental  
               schools.   Additionally, to validate the content of the  
               examination, the study used the job analysis methodology.  The  
               study pointed out that job analysis data is typically obtained  
               through several sources, including interviews, observations,  
               survey questionnaires, and/or focus groups.  Separate focus  
               groups from the five approved dental schools were convened, and  
               their tasks included reviewing the topics to be covered in  
               competency examinations, explaining how their programs  
               currently conduct competency examinations, identifying major  
               competency and specific subcompetents within each of the six  
               competencies.  

             Moreover, the study discussed the need for a standardized  
               evaluation system that will be used to evaluate students'  
               performance in the competency examinations.  The study pointed  
               out that all of the five-Board approved schools must be  
               involved in the process so that the final evaluation system  
               represents rating criteria applicable to students regardless of  
               their programs.  Additionally, certain standards must be met to  
               measure success for all students.  These standards include that  
               the instructions presented to test takers must be sufficiently  
               detailed, the procedures for scoring or rating must be clear,  
               and the level of performance required for passing a test should  
               depend on the knowledge and skills necessary for acceptable  





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               performance in the occupation or profession and should not be  
               adjusted to regulate the number or proportion of persons  
               passing the test.  Additionally, the study identified the need  
               for examiner training and calibration to ensure that faculty  
               applies the same standards to students' performance.  The study  
               also pointed out the need to audit the process to determine if  
               schools are following the procedures established for the  
               evaluation system and calibration process, and that the Board  
               should oversee the auditing process and establish standards  
               necessary for public protection.

             The study found during school visits and interviews with faculty  
               that the dental schools did an exceptional job in calibrating  
               their examiners and were consistent in their methodology in  
               evaluating students' performance on competency examinations.   
               Furthermore, the processes used by dental schools for assessing  
               competencies were very similar. 

        3. Arguments in Support.  The  UC Schools of Dentistry  at  UC Los  
           Angeles  and  UC San Francisco  state that there are a number of flaws  
           in the current clinical and written examination administered by the  
           Board, including potential lapses in quality of care for patients  
           as test subjects, pressure induced critical errors by candidates  
           which may not occur in the normal setting and licensure based on  
           the passage of a single experience examination.  The UC Schools of  
           Dentistry point out that the portfolio examination proposed by this  
           bill is a much better method for evaluating clinical competency.  
        
        4. Author's Amendments:  
        
             a)     Examination requirements.  The Author would like to amend  
               this bill to reinstate Section 1630 which was inadvertently  
               deleted in this bill.  Section 1630 requires that examinations  
               of applicants for a license to practice dentistry must be  
               sufficiently thorough to test fitness of the applicant to  
               practice dentistry, and both questions and answers shall be  
               written in the English language.  

             b)     Schedule of Examination Validation and Occupational  
               Analyses.  To assure that the portfolio examination proposed by  
               this bill meets the state requirements specified in item # 2)  
               b) above, regarding licensing examinations, the Author would  
               like to amend this bill to add the following language:

             "  As part of the implementation of paragraph (1) of subdivision  
               (c) of Section 1632, the board shall review the portfolio  





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               examination to assure compliance with the requirements of  
               Section 139 and to certify that the examination process meets  
               those standards.  If the board determines that the examination  
               process fails to meet those standards, paragraph (1) of  
               subdivision (c) shall not be implemented.  The review of the  
               portfolio examination shall be completed no later than December  
               1, 2016 and submitted to the Legislature and the DCA.
              
         5. Policy Issue  :  Protecting the Integrity and Security of the  
           Portfolio Examination.  This bill would rely on dental schools to  
           maintain the integrity and security of examinations.  There have  
           been a couple of examination breaches reported of boards within the  
           DCA within the last few years.  For example, recently the Board  
           learned that the integrity of the Registered Dental Assistant Law  
           and Ethics written examination, which is one of several statutory  
           requirements that needs to be successfully completed to obtain  
           California registered dental assistant licensure, has been  
           compromised.  As part of the implementation of this bill, the Board  
           needs to ensure that the security and integrity of the examinations  
           are maintained by the dental schools, the Board must have  
           appropriate oversight mechanisms to ensure the integrity of the  
           examinations, and appropriate reporting mechanisms when the  
           examinations are compromise.
        

        SUPPORT AND OPPOSITION:
        
         Support:  

        Dental Board of California (Sponsor)
        Loma Linda University
        UC Los Angeles Dental School
        UC San Francisco Dental School


         Opposition:  None on file as of June 16, 2010



        Consultant:Rosielyn Pulmano