Changes in ABO certification: A scenario-based format
With the combination of: (a) external challenges and changes in the certification process by the American Board of Orthodontics (ABO); (b) internal changes in almost every orthodontic office as a result of computerization; (c) confrontation from the government with HIPAA and OSHA requirements and limitations; and (d) the need for better time/motion efficiency to address improved delivery of orthodontic services, the forces for change combine to be far stronger than the forces for maintaining the status quo.
In an article by Robert M. Diamond, he observed that: “Significant change will never occur in any institution until the forces for change are greater in combination than the forces preserving the status quo … the forces for resisting changes are extremely powerful” (September 8, 2006).
As an institution, orthodontics has survived those challenges, and in the process, we have begun to reinvent ourselves as practitioners, researchers and educators. Our post-graduate orthodontic programs have improved in ways that will enhance educational growth, development and learning to all graduate students. It has not been an easy task nor has there been universal acceptance of its progress, but it has resulted in major revisions to all postgraduate orthodontic programs.
The lead taken by the ABO has been quite dramatic and refreshing to the profession, even though these changes have been hard to swallow by us “seasoned diplomates.” It is essential that we do not engage in the debate of whether the changes are the right ones or even if we all agree on the changes — what is most important is that we embrace the changes and move forward together to assure the survival of this unique institution of orthodontics.
All of us have made great strides forward with improving the quality of the orthodontics services that we provide for our patients. It is apparent that we will continue to move in directions that secure a place of distinction for our profession.
Peter Senge, PhD, senior lecturer at the Massachusetts Institute of Technology, pioneer in the field of learning organizations and author of “The Fifth Discipline” (1990), identified two specific types of learning:
- Adaptive learning: When organizations fail to keep up with the accelerated change of today’s social and business environment, they will die. The ability to adjust is the key to survival. Adaptive learning is about coping. It is the first stage of moving toward a learning organization.
- Generative learning: By contrast, generative learning is about creating. It requires a new way of looking at the world, a new way of looking at patients (what do they need), a way to manage better and lead (fostering learning instead of controlling). Generative learning requires looking at the systems that control events and not just reacting to events or adjusting to trends.
Leadership and change come from creative tension. While we have not yet reached the generative learning stage, we are now posed for the move into it. This requires trust and loyalty but also means giving up personal agendas and opinions for the good of the entire organization. Creative tension is the difference between the vision (where we want to be) and current reality (where we are). Creative tension can be resolved in two ways, by: (a) raising current reality or (b) lowering the vision. With creative tension, we can learn to use the energy it creates to move current reality toward the vision. It is our choice how we respond; we have often selected routes of resisting change as the least threatening.
Ethical leadership in orthodontics is essential for presenting solid core values to residents in order for them to be properly prepared to become orthodontic specialists as well as leaders in the field; it must be addressed with enthusiasm and fervor in order to ensure that the orthodontic health-care needs and the protection of human rights for our communities and society are protected (Tartakow).
As noted in chapter two, Marshall and Oliva (2006) suggested social justice in education required powerful societal support that concerned the values, mission and leadership for transforming society. In order for ethics of identity for affirmation of difference and social transformation to be instilled in orthodontic residents, educational institutions and hospital training programs are morally obligated to demonstrate principles and practices that support, respect, and sustain different identities, as well as transform prevailing social patterns (Appiah, 2005).
Today, orthodontic education and orthodontics in general as an industry is suspect and may well have lost some of the unique trust and luster that it has held since the late 1940s. The cries for accountability, affordability and accessibility are the mantra for professional and educational reform. Many of our educators, clinicians and researchers are ill-equipped to deal with such unexpected and unanticipated challenges. The universal trust that was given by the American public to medicine and dentistry probably no longer exists; working together, we must find ways to rebuild that trust.
The ABO’s mission is to establish and maintain the highest standards of clinical excellence in orthodontics. Its mission statement clearly defines four objectives:
- Evaluate knowledge and clinical competency of graduates from accredited programs;
- Re-evaluate clinical competency of a diplomate's career through recertification;
- Contribute to the development of quality graduate, postgraduate and continuing education programs in orthodontics; and
- Contribute to certification expertise throughout the world.
In 2007, the ABO certification process went through many significant changes in criteria: (a) the number of cases required for presentation; (b) specific malocclusions; (c) precise time when a case can be presented; (d) the Initial Certification Examination was offered for the first time to orthodontists graduating in 2007 from a CODA (Commission on Dental Accreditation) accredited orthodontic program, and who have successfully passed the ABO written examination; (e) current board-eligible orthodontists — the Option I and II pathways were to be completed by 2008 but if this was not possible, there would be a transition pathway available; and (f) a recertification process, that was both voluntary and involuntary.
Board certification was based upon the highest standards of knowledge and clinical skill, and all diplomates were expected to maintain and enhance such standards. According to the board, 38 percent (or more than 3,000) of active AAO members from the United States and Canada were board certified. In its 76 years of existence, the ABO has never exceeded 28 percent, averaging approximately 24 percent as board-certified members of all AAO orthodontists.
In 2017, the ABO elected to research and observe other dental and medical specialty boards to ensure adherence to best practices. Currently, clinical examinations of four American Dental Association's dental specialty boards are completely scenario-based. While creating a degree of expertise and proficiency that all orthodontists should aspire to attain, the ABO believed it was essential and imperative to conduct an “up-to-date” certification examination.
According to Chung, Tadlock, Barone, Pangrazio-Kulbersh, Sabott, Foley, Trulove, Park and Dugoni: “The board's extensive evaluations, combined with research of best practices, support the decision that a new design is needed to give an examination that is fair, valid and reliable, while increasing accessibility. To facilitate the development of a new examination design, the ABO contracted with Castle Worldwide (Castle), a certification and licensure testing company with 30 years of experience in the science of psychometrics and training development” (2018, p. 322).
The new scenario-based examination format is not intended to make it easier; it’s standards will remain the same high quality. “The ABO believes that in today's climate a shift is needed to develop an examination that facilitates participation by all, while creating a measure of proficiency and expertise that most specialists should aspire to attain” (Chung, Tadlock, Barone, et al., p. 322).
The new examination will no longer require patient cases but will include four sections: (a) Data gathering and diagnosis, (b) Treatment objectives and planning, (c) Treatment implementation and management, and (d) Critical analysis and outcomes assessment. It will also continue to examine case outcomes of the scenario-based examination by taking into account cast and radiograph evaluation, case management form, the discrepancy index and cephalometric superimpositions and analysis.
The written examination will not change; it will use the same layout and design of multiple-choice questions based upon clinical and biomedical sciences, in addition to orthodontics. Once the examinee has successfully completed a CODA-accredited orthodontic program of at least 18 months duration, he or she will be eligible to take the ABO written examination. The recertification process will remain the same, requiring a commitment to lifelong learning, continued clinical improvement, proficiency and self-evaluation.
Change is never easy; it is, however, vitally important for the survival of our profession and the integrity of each one of us. It is only through education that civilization can be advanced and problems solved. There are no teachers … we are all learners. Once we begin to compromise our thoughts and become complacent, we become a product of mediocrity. Epistemic access to the future has unending possibilities. As the 17th century French philosopher René Descartes stated: “… under your velvet glove … Cogito ergo sum” is roughly translated as “I think therefore I am.”
The directors of the American Board of Orthodontics are a beacon of elegance and grace. They deserve much credit for their perseverance while swimming upstream in a sea of complexity with no shallow end but indeed, some unpopular opinions and resistance … my hats off to all the directors!
- Nothing in the world can take the place of persistence.
- Talent will not: nothing is more common than unsuccessful men with talent.
- Genius will not: unrewarded genius is almost a proverb.
- Education alone will not: the world is full of educated derelicts.
- Persistence and determination alone are omnipotent.
(NOTE: References are available from the publisher.)