The Greek philosopher Heraclitus is credited for stating that the only thing that is constant is change. Businesses that think they can survive today using the same strategies they used 30 years ago are doomed to the same fate as Woolworths, Blockbuster, Kodak, and Polaroid. Modern technology has only quickened the pace at which businesses must adapt. Just look at how fast Uber changed the taxi industry.
From my private practice in Rio Rancho, New Mexico, I have witnessed the evolution of orthodontics over the past 25 years. The introduction of clear aligners by Invisalign in 1997 gave general dental practitioners a tool that made them feel comfortable treating many of their orthodontic patients “in house.” Additionally, short-term orthodontic companies and “advanced” orthodontic continuing education courses for general practitioners have blurred the line between orthodontists and dentists who provide orthodontics. The biggest challenge faced by the American Association of Orthodontists and its members in 2017 is that many patients do not understand the difference between dentists and orthodontists.
When I graduated from the University of Iowa in 1991, I was challenged by my mentor, Dr Samir Bishara, to become certified by the American Board of Orthodontics (ABO). It was his contention that certification would help me become a better practitioner by teaching me to evaluate my clinical outcomes using criteria developed by the board. Accepting Dr Bishara’s challenge, I became ABO certified several years after graduation and found it to be a valuable learning exercise. But unlike most other medical and dental specialties, the majority (currently 60%) of orthodontists never become board certified. Consequently, the current system of voluntary certification has unintentionally created a division within the specialty. Although prohibited by the ABO Code of Ethics, it is not uncommon for board-certified doctors to promote themselves in a way that suggests that their skills are superior to their noncertified colleagues.
Young orthodontists have a different mind-set and face different challenges than I did when I came out of my residency. They have more debt and face more competition (both from inside and outside the specialty). Many work for corporations that, for the most part, do not encourage or pay for them to participate in organized dentistry. New doctors value their online professional relationships more than face-to-face meetings, and fewer of them volunteer to serve in leadership positions. They are unanimous, however, in their belief that the ABO should refocus its efforts on differentiating orthodontists from dentists rather than pitting us against one another.
The stated mission of the ABO is to “elevate the quality of orthodontic care for the public by promoting excellence through certification, education, and professional collaboration.” I submit that there is a way for the ABO to accomplish this mission and team up with the American Association of Orthodontists to carry out its responsibility of educating the public. The change I propose would involve a major paradigm shift and require the biggest change in the ABO certification process since its inception. Implemented correctly, however, the restructuring could both strengthen the specialty and make the ABO more important than ever. My proposal requires that all graduates of accredited orthodontic programs (past, present, and future) be certified by the ABO to be recognized as orthodontists.
The key to this proposed change is that all graduates of accredited orthodontic residency programs must be certified by the ABO. All currently practicing orthodontists who graduated from accredited residencies would necessarily receive board certification retroactively; all future orthodontic residents would be evaluated for certification after graduation from their residency programs. Granting board certification retroactively to all current orthodontists will be the hardest part of this proposal for currently board-certified doctors to accept. I understand their feelings, since I was certified under the old system myself. Without this important step, however, there would remain a division among practicing orthodontists that would still confuse the public.
To be clear, I am not suggesting that ABO certification should be granted merely for graduating. I am proposing that upon graduation from an accredited residency, all doctors would be required to pass reasonable board examinations similar to what we’ve done for years in general dentistry. Upon dental school graduation, all dentists must pass a written national board in addition to a regional clinical board to become eligible to be licensed by their states. Working with orthodontic educators, the ABO could develop and administer standardized written and clinical boards that evaluate the training and competency of graduates desiring to be recognized as specialists. A written board has been in place for years. A clinical board consisting of diagnosing and treatment planning the pretreatment records and then evaluating clinical outcomes from the posttreatment records could be developed that is more easily administered than the current system, which requires doctors to return to St Louis several years after graduation.
Recertification, nearly universal in the medical field, is the second important part of this proposal. Regular recertification would ensure that doctors stay current in our field. If the mission of the ABO is to elevate the quality of orthodontic care, this proposal could actually provide a better vehicle for accomplishing that than we’ve ever had before. As with general dentistry, the board could develop a recertification process based upon reasonable continuing education requirements reported at given intervals. Advancements in technology are creating methods of education and evaluation that could greatly simplify the recertification process. Continuing education could take many forms and might even increase attendance at our professional meetings. In the end, the goal of recertification would be to encourage orthodontists to keep learning and growing throughout their careers.
ABO certification of all true orthodontists would unify the specialty and give the public the clearest definition of an orthodontist that we have ever offered. In a sense, the ABO could become the “gatekeeper” for our specialty. Although this may not seem important or necessary now, it will not be long before nonresidency-trained doctors will be able to legally advertise as “orthodontic specialists” by merely attending for-profit continuing education courses. Consider how a court recently ruled against the Texas State Dental Board in a case involving other self-proclaimed specialists.
Modern challenges require modern solutions. They also require that we swallow our pride and acknowledge that the world is changing, and so must we. The orthodontic specialty faces challenges from seemingly all sides. ABO certification of all orthodontic residents at graduation and then recertification thereafter could unify the profession, better educate the public about our credentials, and keep us all better educated and up to date throughout our careers. I understand that not all will agree with this proposal, nor will it happen overnight, but let the discussion begin!