Introduction
The objective of this study was to identify the board certification protocols that hospital and university-based postgraduate orthodontic programs have in place to prepare residents for the American Board of Orthodontics (ABO) certification examination.
Methods
An electronic survey was sent to the program directors of each of the 72 postgraduate orthodontic programs in the United States and Canada. The survey consisted of 49 questions about demographics, resident case assignment protocols, and ABO examination preparation methods.
Results
The response rate was 81%. Most programs were 30 to 36 months in length (72.7%). Many residents had a case load of 51 to 75 during their first year (50.9%), with an average maximum case load of 70 to 109. There was a positive correlation with both the number of cases that first-year residents start and the length of the program (Spearman correlation coefficient = 0.379; P <0.01) when compared with maximum case load. Approximately 72% of the programs do not offer a written mock board examination; however, 72% reported offering a clinical mock board examination. ABO cases are identified within the first 6 months of most programs. About 88% of respondents believe that residents take advantage of the banking system, and that over the past 5 years ABO Initial Certification Examination applications have increased.
Conclusions
Most program directors (89.1%) believe that their program length is sufficient for board preparation. Subjects tested in the written examination are integrated into the didactic curriculum and strengthened with ongoing literature reviews, with a passing rate over 90%. Clinical examination preparation varies, with most programs requiring a mock board examination for graduation. Total participation in both the Initial Certification Examination and banking has increased since 2010; better follow-up protocols are needed to track residents after graduation.
Highlights
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Most program directors believe their program length is adequate for board preparation.
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Clinical preparation varies, but most programs require a mock board examination.
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Participation in Initial Certification Examination and banking have increased since 2010.
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Better follow-up protocols are needed to track residents after graduation.
Currently, there is no standardized protocol in place at postgraduate orthodontic residency programs to prepare students for the initial American Board of Orthodontics (ABO) certification process. However, a refinement of the ABO certification process began in 2005, making it possible for orthodontic residents to attain initial certification and increasing the desire among residents to become certified. The Gateway Offer, implemented from 2005 to 2007, granted a 5-year ABO certificate to all interested practicing orthodontists who had successfully passed the written examination. During this time, a pilot study was conducted to determine whether residents were able to finish their cases with board-quality results. Once this was confirmed, a new Initial Certification Examination (ICE) was offered, starting with the class of 2007. This allowed residents to submit cases treated in their programs, promoting ABO certification early in their careers. In 2010, the “banking” process was introduced to allow residents to accumulate cases after graduation if they could not meet the case requirements during their program. The banking process is initiated after a candidate presents 3 cases; the total process must be completed in 10 years. An exemption request can be submitted for those initially presenting fewer than 3 cases with the understanding that 6 cases must still be completed in 10 years.
The Commission on Dental Accreditation (CODA), in its Accreditation Standards for Advanced Specialty Education Programs in Orthodontics and Dentofacial Orthopedics, standard 2-11, stated: “The program director and faculty must prepare students/residents to pursue certification by the American Board of Orthodontics,” but it is not up to the CODA or the American Association of Orthodontists to specify how that is accomplished. Because the ICE process makes board certification more attainable for recent graduates, it is the responsibility of each orthodontic residency program to develop its own protocol, employ knowledgeable faculty, and administer a program of adequate length to prepare its residents for the ICE process.
CODA accreditation standards require all directors of advanced specialty education programs to be certified by an American Dental Association recognized certifying board in the specialty. This action was the initial step in increasing the standards for ABO certification. Since then, there have been numerous revisions to the certification process. Surveys by residents in 2003 and 2007 showed that 81% to 87% of the orthodontic resident respondents planned to become ABO certified.
In addition to completing a CODA-approved orthodontic specialty program, an orthodontic resident must complete the following to become ABO certified: the ABO written examination, a board case oral examination, a case report examination, and a case report oral examination. A minimum of 3 to a maximum of 6 qualifying cases are completed by the candidate during residency and are used for the case report examination and the case report oral examination portion of the ICE process.
An update to the ABO initial certification process has made it possible for graduating residents to achieve board certification using cases treated under faculty supervision. This change has made it far more important to have certified faculty members with knowledge of the certification process and defined criteria for assessing case difficulty. The combination of shortages in recruitment and retention of orthodontic educators and a diminished desire by orthodontic residents to become educators has created a need for programs to develop a standardized protocol for teaching residents and keeping faculty up to date with the certification process.
The length of orthodontic residency programs is a hotly debated topic, and there is an ongoing discussion about whether 24-month programs are long enough to sufficiently educate an orthodontic resident in the didactic and clinical regimens necessary to be professionally competent. Some proponents of 3-year programs believe that the increase in program length would allow residents to treat more cases with better case demographics, thereby increasing their practical understanding before they take the ABO examination.
The current curriculum guidelines set by the American Association of Orthodontists for orthodontic residency programs are broad and allow for great variations between programs. Therefore, the objective of this study was to assess whether the board-certification protocols that are in place in hospital and university-based postgraduate orthodontic programs are adequate to prepare residents for the ABO certification examination. In addition, this information may identify methods to increase the number of residents becoming board certified through the ICE process.
Material and methods
After we received approval from the A. T. Still University Institutional Review Board, an electronic survey (Qualtrics, Provo, Utah) was created. An e-mail link to the survey was sent to the program directors or chairpersons of each of the 72 postgraduate orthodontic programs in the United States and Canada, requesting their anonymous participation in the survey. The e-mail link was personalized to each program so that follow-up e-mails and calls could be sent only to those who had not previously responded and so that multiple responses were not allowed.
The survey consisted of 49 questions using a logic section format in which only applicable questions, based on previous responses, were asked to respondents. These logic sections included director and program demographics, resident case assignment protocols, and ABO written and clinical examination preparation methods. All questions were multiple choice, although some questions allowed users to enter additional comments.
Over a 3-month period, 2 e-mail requests were sent, followed by a final e-mail request to each person who had not yet responded. Four e-mail addresses were bounced back, bringing the total number of surveys sent to 68. Fifty-five programs participated in the survey, resulting in an 81% response rate. Survey data were compiled using Excel (Microsoft, Redmond, Wash).
Statistical analysis
Descriptive statistics, including means (standard deviations), ranges, and counts (percentages), were calculated. Spearman correlation coefficients (r s ) were calculated to estimate the strength of the relationships between program characteristics and outcomes of interest. The criterion for statistical significance was P <0.05, 2-tailed. SPSS software (version 23; IBM, Armonk, NY) was used to analyze the data.
Results
Of the 55 respondents, 85.5% were male, and 14.5% were female. Approximately 87% of the directors who responded reported their board certification status, and 33% were board examiners. Most programs were 30 to 36 months in length (72.7%), and a majority had 4 to 6 residents per class (65.5%). The number of residents accepted per year was positively correlated with the number of full-time ABO certified faculty members (r s = 0.364; P <0.01), suggesting that the larger programs employed more full-time ABO certified faculty. Most directors thought that their program length was sufficient for residents to complete ABO cases (89.1%), and 72.7% of programs offered a combined MS/certificate degree. A majority of both full-time and part-time faculty members were board certified ( Table I ). The most common reason provided for why faculty members were not board certified was: “It was not stressed during their residency,” followed by “inadequate patients” and “not interested.” “Stricter ABO case requirements at the time of graduation” was the least common reason. Some respondents stated that board certification was a requirement to teach in their program, so this question did not apply to them.
| Characteristic | % of respondents (n) | |
|---|---|---|
| Sex | ||
| Male | 85.5 (47) | |
| Female | 14.5 (8) | |
| Age range (y) | ||
| 36-45 | 20.1 (11) | |
| 46-55 | 20.1 (11) | |
| 56-65 | 25.3 (14) | |
| 66 and over | 34.5 (19) | |
| ABO certification status | ||
| Certified | 87.3 (48) | |
| Noncertified | 12.7 (7) | |
| Full-time (FT) clinical faculty members | Total FT faculty | FT ABO certified faculty |
| 0-2 | 21.8 (12) | 58.3 (32) |
| 3-4 | 49.1 (27) | 30.9 (17) |
| 5 and over | 29 (16) | 10.2 (6) |
| Part-time (PT) clinical faculty members | Total PT faculty | PT ABO certified faculty |
| 0-10 | 40 (22) | 76.2 (42) |
| 11-20 | 38 (21) | 16.3 (9) |
| 21 and over | 10.8 (6) | 7.2 (4) |
| Are you an ABO examiner? | ||
| Yes | 32.7 (18) | |
| No | 67.3 (37) | |
| Length of postgraduate orthodontic program (mo) | ||
| 24-29 | 25.5 (14) | |
| 30-36 | 72.7 (40) | |
| Over 36 | 1.8 (1) | |
| Number of residents per class | ||
| 1-3 | 12.7 (7) | |
| 4-6 | 65.5 (36) | |
| 7-10 | 20.0 (11) | |
| 11 and over | 1.8 (1) | |
| Degrees offered | ||
| MS only | 7.3 (4) | |
| Certificate only | 16.4 (9) | |
| MS and certificate | 72.7 (40) | |
| Other | 9.1 (5) | |
Many residents had a case load of 51 to 75 during their first year (50.9%), with most cases being started in the second month of residency (47.3%) ( Table II ). The average maximum case load ranged from 70 to 109, with this number reached by the second year of residency. There was a positive correlation with both the number of cases first-year residents start and the length of the postgraduate orthodontic program (r s = 0.379; P <0.01) when compared with maximum case load. In other words, a longer program is associated with more cases started, hence a larger case load.
| Characteristic | % of respondents (n) |
|---|---|
| Average case load of first-year residents | |
| Up to 50 starts | 34.5 (19) |
| 51-75 starts | 50.9 (28) |
| Over 75 starts | 14.5 (8) |
| Time of incoming resident’s starting cases | |
| First month of residency | 27.3 (15) |
| Second month of residency | 47.3 (26) |
| Third month of residency | 20.0 (11) |
| Percentage of patients started and finished by the same resident | |
| 0%-30% | 32.2 (18) |
| 31%-60% | 21.7 (12) |
| 61%-90% | 45.0 (25) |
| Maximum case load of residents ∗ | |
| 60-89 | 32.7 (18) |
| 90-109 | 34.5 (19) |
| 110-129 | 12.7 (7) |
| 130 and over | 20.0 (11) |
| Maximum case load reached | |
| First year of residency | 5.5 (3) |
| Second year of residency | 76.4 (42) |
| Third year of residency | 12.7 (7) |
| Residents always accept new patients | 5.5 (3) |
| Length of program sufficient for residents to complete ABO board cases | |
| Yes | 87.3 (48) |
| No | 12.7 (7) |
| Ideal length of program | |
| 30 months | 5.5 (3) |
| 36 months | 5.5 (3) |
A resident’s maximum case load was negatively correlated with the numbers of both full-time and part-time clinical faculty members who are ABO certified (r s = −0.280; r s = −0.315; both, P <0.05), suggesting that the number of patients a resident can treat may be limited by the number of faculty present for supervision. There was also a negative correlation between the number of cases residents started in their first year and the time when incoming residents begin bonding their cases (r s = −0.304; P <0.05), showing that residents can bond more cases when they start during the first few months of their program.
A variable factor in residency programs is case distribution; programs attempt to ensure an equal distribution of various case types to each resident. Case distribution methods varied from Discrepancy Index score to Angle classification and random distribution. About 38% of respondents distributed patients based on “other” criteria, ranging from extraction need to degree of difficulty. Most cases were distributed by the clinical director (58.2%). Pretreatment Discrepancy Index scores were predominantly performed by the residents (89.1%).
A majority of programs begin examination preparation within the first year of residency, with 58.5% preparing during the first 6 months ( Table III ). Ongoing literature review is the most popular method of examination preparation (78.2%), and 47.3% of programs offer a formal in-house preparation course. Of those that selected “other” for the examination preparation method, 16% reported in the comments section that the curriculum is geared toward the examination, so an additional preparation course is not necessary. Approximately 72% of programs do not offer a written mock board examination. Although the majority of programs do not require a passing grade for graduation, 98% of programs reported a pass rate over 90%. Since the failure rate is low, many programs do not have a remediation plan in place, although 34% of programs prefer that the resident take the examination again before graduation.
| Characteristics | % of respondents (n) |
|---|---|
| When does the program begin preparing residents to take the written board examination? | |
| 1-6 months into the program | 58.5 (31) |
| 6-12 months into the program | 17 (9) |
| 13-18 months into the program | 17 (9) |
| 19-24 months into the program | 7.5 (4) |
| How does the program prepare residents for the written board examination? | |
| Program preparation course | 47.3 (26) |
| CD-ABO preparation course | 9.1 (5) |
| Literature review course | 78.2 (43) |
| Other (curriculum is geared toward examination) | 30.9 (17) |
| Does the program administer a mock board examination? | |
| Yes | 28.3 (15) |
| No | 71.7 (38) |
| Is it a graduation requirement to pass the written examination? | |
| Yes | 43.4 (23) |
| No | 56.6 (30) |
| What is the pass rate for the past 5 years? | |
| 76%-90% pass | 1.9 (1) |
| Over 91% pass | 98.1 (52) |
| What is the consequence for failing the written examination? | |
| Retake examination before graduation | 34 (18) |
| Take additional examination administered by program | 5.7 (3) |
| No remediation | 34 (18) |
| Other (not experienced) | 26.4 (14) |
In contrast to the written examination, about 72% reported offering a clinical mock board examination graded according to ABO standards, which includes the Cast-Radiograph Evaluation form and the Case Management Form, by calibrated faculty. ABO cases are identified within the first 6 months of most programs. The most common time frame to monitor ABO case progress is “quarterly” (21.8%), and it is incorporated into overall resident evaluations in 64.2% of programs. Case progress is evaluated by numerous methods in addition to the resident evaluations, including case presentations, discussions with attending faculty and self-evaluation by the resident. Outside ABO certified guests (70.9%) or in-house faculty (27.3%) explain the certification process to the residents. Residents present their completed cases to faculty (63.6%), coresidents (49.1%), and faculty panels (25.5%).
About 88% of respondents believe that residents take advantage of the banking system and that over the past 5 years, ABO ICE applications have increased ( Table IV ). The average percentage of residents who apply for the ABO ICE process immediately after graduation showed a positive correlation with the number of full-time clinical faculty members who are ABO certified (r s = 0.330; P <0.05); this may imply a push toward certification by the faculty members. “Not interested” and “insufficient number of patients” were the most common reasons that a new graduate did not pursue ABO certification, followed by “required classifications difficult to attain.” “Inadequate faculty support,” “international status,” and “other” (most commonly cited as “cost”) were the least common reasons. After graduation, the most common reasons that a resident did not complete the ICE, with the banking system in place, were “lack of long-term job stability,” “corporate environment not ideal for ABO preparation,” and “starting a practice/lack of patient pool.” The least common reason was “not interested.”
