Of Professional Policy and Equity

Those who have served in the leadership trenches of the California Dental Association, including service as a delegate to the American Dental Association House of Delegates, will agree on at least one important observation, which prevailed once again at the recent ADA House of Delegates session in Kansas City.

Due to the diversity in the demographics of the profession, the geography of California, and to many workforce-related factors, California is often the first district of the American Dental Association to see the need for change in organized dentistry’s policies. New programs, policies, or resolution of problems are necessary to meet the changing needs of the profession and the public.

We have seen this reality as an ever-present challenge to each recent California delegation as it prepares to seek changes that are believed to be in the best interest of not only California dentists, but also the profession at large. California delegates frequently have been frustrated when delegates from other districts have remained unconvinced that a problem facing dentistry in California requires a change in ADA policy or a new program. Since CDA membership represents 18 percent of the total ADA membership, it would seem that colleagues in organized dentistry in other states might be more receptive to resolving issues that could have implications to members or potential members in their state. In our experience, that has not been the case.

Of considerable concern to this observer were some of the arguments advanced in support of maintaining the status quo at the recent House of Delegates. For example, a modification of ADA guidelines on licensure sought by the California delegation, which would have encouraged consideration of credentialing and mobility of foreign-trained graduates, failed to be approved. A major argument advanced by those opposing new language that would allow mobility of practitioners who had a clean and safe record of practice for a minimum of five years was that such a change would lower the traditional educational standards of the dental profession. The notion behind this specious or deceptive argument seemed to be that graduation from an accredited dental school (or the lack of it) in the practitioner’s past was a more important evaluation criterion than a dentist’s record of practice and postgraduate achievements in dentistry during his or her career.

In the fast-changing dental profession of today, after five, 10, or 20 or more years of practice, it is unlikely that the school of graduation is any longer a valid criterion for assessing a dentist’s reputation or record of practice. Yet, 55 percent of the delegates defeated the California resolution that sought to modify ADA policy to favor the mobility of a qualified practitioner from California or any other state who had passed National Boards Part I and II, had passed a state or regional licensure examination, and had practiced with a good record for a minimum of five years. Denying the freedom of movement to qualified foreign-trained graduates with a good practice record is neither equitable nor a fair standard in the United States of America today. A foreign-trained dentist now practicing in California (or Hawaii) is unable to move to another state, even though that state recognizes licensure by credential, unless one of two things occurs:

1. The practitioner leaves practice and goes back for a supplementary predoctoral education program of at least two years at an accredited U.S. dental school, OR,

2. A state changes their regulations to permit credentialing based upon a qualifying practice record of five years or more. (This was the modification of ADA policy under consideration at the House.)

For now, let’s put the frustration that CDA delegates experienced in a strong attempt to educate other colleagues on this issue aside and look at the real impact of the ADA guidelines or policies on licensure.

ADA guidelines on licensure have traditionally placed state’s rights to determine licensing standards ahead of any association policy considerations. The ADA Board of Trustees, to whom many delegates look for development of their attitudes and positions on various issues, has recognized accredited dental education as the standard for initial licensure and for licensure by credential. ADA policies allow "state boards sufficient latitude to fulfill their legal duty to determine appropriate educational qualifications of applicants for dental licensure from other jurisdictions."

Thus, even the current ADA policy that provides for licensure by credential is not enforceable in states; and the changes sought by the CDA delegation, even if they had been approved by the House, would probably not have changed the inequity previously described -- at least immediately.

The net effect of ADA policy, when it comes to licensing can be best described as an instrument useful in bringing about a change in attitude -- both within the profession and eventually within state legislatures and regulatory boards. Policies can "encourage" and "urge" change but cannot mandate it within state jurisdictions. An attitudinal change could take years in some states, as there are so few foreign-trained dentists in some locales that legislators or boards are unlikely to feel the need to make a change. At a time when unity and inclusiveness are widely discussed throughout the land, these disparities in professional and public policy are unfortunate. This is the pessimistic view.

On the positive side, the efforts of the CDA delegation this year to educate other constituencies was productive and hopefully advanced the cause. Even the House reference committee that studied the matter recommended adoption of an amended version of the CDA proposal. That was a major sign of progress.

This issue will be back. More colleagues must be educated to the need to achieve equity in licensure for all of the practicing profession. A new attitude will build within organized dentistry that will eventually convince state legislators and regulators that revised licensing guidelines are essential to providing improved access to care.