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