Should you toss your license out the car window at the state line?

April 1, 1997
You can`t take it with you ... so goes the old saying. This applies not only to worldly possessions when a person departs this life but to dental hygiene licenses as well. Many hygienists find out that, when they move to another state, their dental hygiene license can`t go with them.

You can`t take it with you ... so goes the old saying. This applies not only to worldly possessions when a person departs this life but to dental hygiene licenses as well. Many hygienists find out that, when they move to another state, their dental hygiene license can`t go with them.

Get a few RDHs together and ask about relocation nightmares, and what do you hear? The story of careless movers and grandmother`s broken crystal? The family accidentally leaving behind the beloved family dog?

No, you`ll hear really horrible stories about retaking dental hygiene board exams. For instance, your only clinical patient is denied, and you have no backup or all the "out-of-staters" take boards on a different day from the natives and enjoy high failure rates...

Cathleen Terhune Alty, RDH

...One hygienist, Susan Kummer, responded to an October 1996 RDH survey about licensing by credentials by pointing out, "We have hopes in relocating soon to Arizona. I looked into obtaining an Arizona license only to throw away the paperwork. The amount of time to fill out the forms, get past college transcripts, letters of recommendation, the expense to travel to Arizona to take the boards that included the completion of a prophy on a patient of your own finding plus full mouth radiographs was enough to make me sit down and cry with frustration."

"It`s very costly," writes Michele Evans of Utah. "I have taken three different regional boards. Not only is it costly but it`s hard to find a patient if you`re new to an area."

"I think there are a lot of military spouses who are hygienists and are sick of taking boards. If national licensure ensued, there would be no shortage of hygienists," said an RDH married to a Marine.

The stories are enough to frighten anyone. "I have not moved because of the headaches!" says Laurie Janak of Denver. "I would like to try moving to another state for a few years, but I don`t want to take boards again."

Wouldn`t it be great if your past training and experience counted for something if you relocate to another state? How did the current system of relicensing get this way? Why is it so expensive? Who is in control of this process? And what is being done to change it?

You`re OK, I`m OK

First of all, some definitions are necessary. The terms reciprocity and licensure by credentials are two very different concepts. Reciprocity would mean that two states have an agreement to unconditionally accept another state`s licensees. In other words: "I take yours, you take mine."

Licensure by credentials is granting a licensee from another state a chance to prove their skills and performance to the receiving state by their past performance record instead of by clinical examination. In other words, "I`ll take you if you meet my criteria." The 30 or so states that accept some form of licensure by credentials look at the education of the applicant, past employment (number of years, number of other licenses), any disciplinary action taken against the applicant, continuing education credits, questioning under oath, and possibly background checks. This allows the state officials to thoroughly examine anyone who wants to be licensed in their state.

As you can see, reciprocity does not allow the state to have much of a say in who is licensed in their state where licensure by credentials does. The concept of "states` rights" is protected vigorously. Therefore, reciprocity is not a politically popular option.

The evolving tests

The current examination system has undergone various changes over the years. The written examination, required by virtually all states for licensure, is conducted by the Joint Commission on National Dental Examinations (an agency of the ADA). The clinical examination (which sometimes contain some written aspects) is administered by the regional testing agencies or individual state boards.

For a historical perspective, the national board was started in the 1920s as an effort to get uniformity into licensure. It was proposed to the ADA that the national board would follow the medical national board model, which consisted of three parts: part one and two were written, while part three was clinical.

Dave DeMarais, director of the Department of Testing Services at the ADA, said, "In 1933, dentistry accepted parts one and two but not the clinical part" to be the national board examination.

"The individual states didn`t want a national clinical examination because they believed they would no longer have a say in who is licensed; they believed that they would have no input," said DeMarais. "The state`s role is to protect the public and it appeared there would be no gatekeeper. So they compromised; there would be a national written test and a practical or clinical examination at the state level."

By the early 1960`s, dental hygienists wanted a uniform, written exam like the dentists had. According to DeMarais, the American Dental Hygienists` Association developed a structure for the exam and proposed that the ADA, through the national board, would perform and oversee the exam process.

Even today, individual states fiercely guard their ability to select who will receive a license. Each license granted is a state prerogative. However, in the 1970s, some states linked together via regional testing boards to make a common clinical exam. This isn`t to say that those states who joined gave up the right to give input into the qualifications of applicants. Instead, they came to an agreement in order to make the tests more uniform. There were other advantages to a regional board as well.

"In the past, we had our own board exam," said Sue Curry, administrative secretary for the Ohio State Dental Board in Columbus, "but there is much involved in the examination process. We went to a regional system because it was easier to manage."

As an interesting side note, Ohio suspended its dental hygiene clinical board examinations in 1990 when the state discontinued participating in the Northeast Regional Board exam. For three years, any dental hygiene student who graduated from an accredited program and had taken and passed the national board exam was granted an Ohio dental hygiene license.

"The dental hygienists were very happy with this arrangement and the schools preferred it!" said Curry.

The downside was that any graduate hygienist who wanted to practice in another state had to take that states` clinical exam anyway. The Ohio dental board returned to the regional board format after working out differences with the Northeast Regional Board.

"We understand your frustration," said Cynthia Barrett, RDH, executive administrator of the Central Regional Dental Testing Service Inc. (CRDTS) in Topeka, Kansas. "No one wants to be put through the hoops again. Many states do offer licensure by credentials, but not all."

Barrett says they have informally talked with other regions and are very committed to a uniform exam or an equivalent exam. But it is very difficult to get agreement on the content, exam administration, or philosophic differences (for example the CRDTS uses a mannequin for endodontic testing where other regions do not).

Barrett also stresses how they try to improve the exam every year. "We do a thorough analysis of the exam and examiner performance. The exam from the year before is taken apart and scrutinized: where is the heaviest failure rate? Is there something in the exam that contributed to this, or is this a skill they should have and they just didn`t do well on it? We learn a lot from this, and, let`s face it, you can`t lose when you learn."

Linda Paul, executive director of the Western Regional Examining Board in Phoenix, said, "Although slow to massive change, in the last 10 years we have seen phenomenal positive movement, although none of it is as fast as you want it to go."

The regional boards have in the past worked together briefly and are continuing to try to work out some common licensure issues that allow more uniformity in the regional board examinations. For example, in 1995, the Northeast Regional Board and the Central Regional Testing Service joined together to give an exam. If dentists passed this clinical exam, they were eligible for a license in 30 different states instead of the usual 15 or 16. The regional boards currently exchange some examiners. But they still have some differences to iron out in their philosophies and administration which can greatly affect the outcome of an exam. But the regionals seem positive about their past projects.

"It`s a good concept and we look forward to working on another similar project," said Barrett from CRDTS.

"The Western Region would welcome more projects like this," said Paul of the WREB.

Ten states and two licensing jurisdictions, however, do not utilize these regional boards (California, Florida, Alabama, Mississippi, Puerto Rico, Hawaii, Virgin Islands, Nevada, North Carolina, Indiana, Delaware, and Louisiana), choosing instead to administer their own clinical testing.

Many of these states require a clinical exam to be taken prior to licensure.

When asked why they choose not to join a regional board, Mr. Audie B. Wilson at the Florida Board of Dentistry said, "For peace of mind that our consumers in Florida are getting the utmost in care, we only feel secure that we provide a test. We understand the concepts of reciprocity and credentials, but our standard of care may be different here than in another state. We don`t want to take that chance."

As for the cost of examinations, Linda Paul at the Western Regional Examining Board (WREB) said, "We`re a private, non-profit corporation. Our only income is from candidate fees. We pay examiners who come from Alaska to Texas, so we have the most expensive travel fees. We have a very small administrative staff of eight full-time employees and one part-time employee, so we have low overhead. Any money left over from exam fees is used for exam development and research to make it better. Fifty percent of the U.S. is covered by the Western Board, so we have a lot of territory to cover. It is worthwhile for us to bring in examiners from all the states we represent to keep it fair."

In a press release, WREB reports testing almost 19,000 dental and dental hygiene candidates with an average passing rate of 81 percent. In 1996, 2,530 candidates were examined and an average of 84 percent received passing scores. If they pass the Western Regional, candidates can apply for a license in any one of the 10 member states without having to take another clinical exam. The WREB is currently "conducting a practice survey of dental hygienists to evaluate the appropriateness of the procedures tested on the exam." Results will be available sometime this year.

A cooperative spirit

The future of clinical examinations appears to be greater cooperation between different regions, and the ADA is working to facilitate licensure issues with everyone.

"We have a strong interest in pursuing licensure issues," says Lois Schuhrke, director, Center for Educational Development and Research at the ADA.

The Association`s leadership became increasingly interested in licensure issues over the past few years and they created an ad hoc licensure committee to examine the issues.

This licensure committee determined the ADA`s role in licensure should be as a catalyst and facilitator for change, encouraging communication and cooperation between testing agencies. As an outgrowth of this committee, the ADA has hosted an ongoing series of meetings between the four regional testing agencies (Western Regional Examining Board, Central Regional Dental Testing Service, Inc., Northeast Regional Board of Examiners, Inc., Southern Regional Testing Agency, Inc.), the 12 independent states who do not subscribe to regional testing boards, the American Association of Dental Schools (AADS), American Association of Dental Examiners (AADE), and the American Student Dental Association (ASDA).

At this group`s meeting in March 1996, issues concerning the clinical licensure process were identified and discussed by the participants.

Over the course of the last year, the conference participants have developed 12 objectives for improving the dental licensing system. The group will meet again in March 1997 after taking these objectives back to their respective organization to see what the next steps will be.

This list of 12 objectives, titled, "An Agenda For Change In The Clinical Licensure Examination Process," contain many of the issues dental hygienists are concerned about, including test fairness and calibration, common content, minimizing use of human subjects in clinical licensure exams, improving appeals processes, and faster notification of examination results. All of this activity could be a very positive spinoff for dental hygiene.

While the testing procedures seem fairly straightforward on the surface, they are in fact very complicated and very technical. "How you score the exam is extremely critical," says Schuhrke. "How you administer it is as important as what`s in it. The ADA has resources to help clinical agencies as a group and is able to provide the forum for these groups to meet. The ADA has no interest in taking over the clinical exams and making it national. The ADA fully supports the states` right to license professional groups."

Of course, initial licensure isn`t as much of an issue for those already licensed as "freedom of movement," a term the ADA uses to describe the desire of licensed dentists and dental hygienists to move from state to state and still be able to practice.

"The ADA supports freedom of movement as a policy," said Schuhrke, "for dentists as well as dental hygienists." In fact, the ADA passed a resolution in 1990 that urges the state boards of dental examiners and the American Association of Dental Examiners to "develop mechanisms under which dental hygienists licensed in one state may be licensed for practice in another state in which they may now reside, with previous education, licensure, and clinical experience used as a substitute for current requirements."

In light of this resolution, it`s hard to point a finger at organized dentistry and say that it is preventing hygienists who move from practicing in their new state. Most dentists support hygienists` "freedom of movement" because they don`t want to discourage RDHs from practicing.

"With the current manpower shortages, dentists have a real interest in keeping dental hygienists in their career field, not away from practice," said Schuhrke.

The ADA is also interested in freedom of movement because of the growing number of female dentists. The association can see that as these professional women enter the workforce, they may be a part of a dual-income couple and may need to change their practice location due to transfers of their spouse.

"Our younger members need to be able to move, especially those who have a spouse with a career that requires transfers," said Karen Cervenka, executive director of the American Student Dental Association (ASDA). "Students wish to be able to practice wherever without having to jump through the hoops of a clinical licensure exam. They only want to have to take one." Cervenka says that the organization advocates changes to make exams more uniform and more humane, fair and comparable as possible.

Carolyn Gray at the American Association of Dental Schools (AADS) says their organization also is very interested in licensure issues. The AADS has several official policy goals, including freedom in geographic mobility for those dentists and dental hygienists who have graduated from an accredited program and have successfully completed the national board exam. Their long-term goal is to eliminate state and regional entry-level clinical licensing exams when a reliable means of evaluating a lifetime of professional competencies is established. The organization has drafted a set of competencies for graduates of dental schools which defines the skills, abilities and knowledge a dental school graduate should have to practice safely.

"We have taken a stab at defining competencies, not to dictate policies to dental schools but to be an educational resource to use as a part of their own education mission," said Gray. "We are in the early stages of planning dental hygiene competency requirements."

"We know these goals will take years to achieve," said Gray. "There are no easy fixes. But as a positive note, there is currently a climate of outreach that has never existed before. We are very committed to continuing pursuing these goals."

The ADHA declined to comment about any policy, recommendations or any other movement or impact they are making regarding licensure by credentials. With all of these other professional organizations working on this issue, it would be great to see what our own professional organization is planning.

So what can we do as a profession and as individuals to encourage our own freedom of movement?

"Work with the state boards of dentistry and professional associations," said Gray of the AADS.

"Work through your own association and own state dental board to make changes," says Barrett of the CRDTS.

"Hygienists are already involved through their involvement in AADE, AADS and the various state dental boards that have hygienists on them," said Schuhrke.

With this new spirit of cooperation and communication, maybe your prior dental hygiene experience really will count for something, and you`ll be able to take your license with you after all.

Cathleen Terhune Alty, RDH, is a consulting editor for RDH.

More freedom as a nurse? Maybe

Many dental hygienists compare their situation to nursing. "Why do the nurses have the freedom to move and hygienists don`t?" they ask. So I went to the nurses association to find out.

"First of all, nursing is a much older, licensed profession than dental hygiene," said a representative of the Michigan Nurses Association. "It`s very hard to compare the two." For example, nursing was independent of physicians from the beginning; they never had to wrestle their profession away from MDs. Their education system is vastly different from dental hygiene as well.

However, we did discover some similarities. The state practice acts for nursing used to differ from state to state, very much like in dental hygiene today. But over the course of many years, the requirements from state to state became more alike. Since the requirements were alike from state to state, it made sense to offer a national board exam instead of individual state licensure examinations.

But just because there is a national board exam, nurses do not have the total freedom to practice anywhere they choose with their current license. Each state has specific ways to acknowledge whether they will accept a previously-licensed nurse`s credentials. Each state will look at the licensing requirements of the originating state and compare what the receiving state requires. If the requirements are similar, licensure by credentials (licensing by evaluation of the person`s past training and performance instead of an examination) may be allowed. It is all at the discretion of the particular state, and it helps that nursing practice acts from state to state are nearly identical.

Scoring of the board exams also evolved over the years in nursing. In the past, the numerical value of your national board determined your employment possibilities: the higher the score, the greater the job offers. States that on average paid their nurses more demanded the nurses with higher board scores, whereas states with lower nursing salaries would take nurses regardless of board scores, as long as they passed the board. Problems arose with this system because if one nurse received an 80 on the test and another a 79, did that one-point higher score really indicate a more valuable nurse? The system changed to a pass/fail grade system rather than a numerical test score to alleviate this problem.

Other changes in nursing examinations involve the use of computerized clinical scenarios that make them more interactive and with no live patients.

"Here I always thought dental hygienists had it made," exclaimed one nurse I spoke with. "You guys get one patient at a time, get to sit down most of the time when working and you don`t have the life and death concerns we have everyday." As the old saying goes, I guess the grass is always greener on the other side!

In the October 1996 issue, RDH readers responded to a Dialogue survey about licensure by credentials. Here are some of the comments:

"Licensure by credentials is long overdue. Any dental hygienist who has graduated from an accredited school of dental hygiene, passed national boards and at least one regional clinical exam should be allowed to practice in any state."

"It would be great to not have to worry about taking a board everywhere."

"What is the point of a national board exam if there is no policy for national licensure?"

"Basically, teeth are teeth and prophys are prophys. Basic hygiene philosophies are the same everywhere."

"We need a strong voice for hygienists to get it through to the bureaucrats (dentists) that we, if nationally licensed and graduated from a fully accredited program should be employable anywhere in this country. It is absolutely ridiculous to be treated like morons."

Organized dentistry`s goals in resolving licensure issues

A conference of several dental organizations drafted a list of 12 objectives in November 1996. The list is titled, "An agenda for change in the clinical licensure examination process; Proposed objectives developed by participants in the invitational conference for dental clinical testing agencies." The docoment reads as follows:

"The American Dental Association should work in cooperation with the clinical testing agencies, the licensing jurisdictions, the American Association of Dental Examiners, the American Association of Dental Schools and the American Student Dental Association to facilitate improvements in the clinical licensure process. The following objectives should be addressed by these communities:

"1. Develop a common content clinical examination.

"2. Develop and promote the acceptance of guidelines for administration of a common content clinical examination and standardized examiner calibration.

"3. Work with testing agencies to involve the dental school faculty in the clinical examination process to the greatest extent possible and encourage dental school faculty to participate in clinical examiner calibration activities.

"4. Minimize the use of human subjects in clinical licensure examinations, but where human subjects are used, ensure that the safety and protection of the patient is of paramount importance and that patients are procured in an ethical manner.

"5. Develop and promote policies and procedures to make clinical licensure examinations more candidate-friendly.

"6. Develop educational processes for the candidate pool regarding clinical examination logistics and protocol, to assist the candidates in preparing for the examinations.

"7. Minimize the time needed to notify candidates of examination results.

"8. Improve and standardize the testing agencies` appeals process.

"9. Urge the American Association of Dental Schools to encourage all dental schools to offer remediation programs for candidates who fail the clinical licensure examinations.

"10. Promote further study of the pregraduation examinations by the clinical testing agencies and encourage the testing agencies and dental schools to work together to offer the pregraduation examinations.

"11. Promote the acceptance by all licensing jurisdictions of the National Board Dental Examination in lieu of a separate written examination on oral diagnosis and treatment planning.

"12. To address the profession`s concerns regarding the failure rates on clinical examinations, ensure that the examinations are valid and reliable measures of candidates` clinical competencies."