Preparation of International Dentists for U.S. Dental Schools
(This article was originally written for publication to benefit international dentists)
When international dental graduates elect to pursue training and practice opportunities in the United States, they find fewer pathways available now than in previous years. The largest impact recently was initiated by the closure of several licensure-by-examination programs, particularly in California. The challenging California Restorative Technique Examination provided the international dentist with the means to achieve parity with U.S.-trained dental students, but solely in that state. There were approximately 300 international dentists per year that were achieving licensure in California through this avenue through most of the 1990s and until 2008. Now that this avenue to licensure is no longer available, more international dentists will pursue dental school admissions on an advanced placement basis to those U.S. schools with the program, and this has increased enrollment competition greatly. ADEA helps to manage admissions to dental educational programs by providing a centralized resource and application framework for certain types of educational pursuits, now including advanced placement programs.
The nature of advanced placement programs varies greatly from school to school. In most, the successful applicant will be merged into the undergraduate student body during the third year. This assimilation of the international dentist during the clinical years usually takes place after an in-house preclinical review program, lasting from weeks to months. On the other hand, some schools have well-established independent, stand-alone international programs, where the clinics, classrooms and faculty are separate from the traditional student facilities.
While the accreditation guidelines that schools must follow tend to enforce a uniform standard of training, it must be considered that an independent international student program could actually achieve a higher standard due to the motivation of more mature and experienced students. Also the faculty members that find satisfaction teaching these programs tend to be those that enjoy working with more mature and eager (and demanding) students. It is refreshing to find students who want to learn as much as possible!
More schools each year consider international dentists for advanced-standing admissions, yet the competition is still keener than ever. There are a variety of ways that schools find to sort the applicants and identify the most qualified individuals. Records from schools overseas and letters from their faculty, when available, are a formality and don’t really help in the selection process, unless the school is very well known. U.S. letters of recommendation from a recognized source can, of course, be especially helpful. Performance on National Board Dental Exams, particularly Part I, is a key factor for many schools. This factor will become less important when the exam is changed to a pass-fail grading option, but more schools may then give their own basic science examination during an on-site interview – it will be interesting to see how this develops. Performance on the TOEFL exam is important, but most applicants have little trouble with this, particularly those whose dental training was in English.
For many schools the primary determinant of acceptance is the on-site evaluation – which comprises several parts, the most important are the practical examination and the personal interview. The practical examination, unlike any other examination attracting candidates from around the country, is competitive. A regional dental licensure exam is NOT competitive – everyone can pass if they meet the requirements. But, at the schools, only those who do the best work are considered. You have to do better than other applicants.
The personal interview is when the admissions staff can get to know who you are. What are they looking for in the personal interview, and what are YOU, as an applicant, looking for? We tend to forget about this second part, but, interestingly, the school may also be evaluating you by the kind of questions you ask them! Your most important question would be related to the amount of clinical experience you can hope to get from their program.
One of the most interesting issues today is the changing demographics of applicants from overseas, and the average level of skill and comprehension displayed as they start the interview process. Many are found recently to have had an educational experience that leaves a lot to be desired. As applicants to an advanced-standing program they are being evaluated to see that they match the knowledge and skill level of a third-year traditional student, but many are severely deficient. The deficit is not necessarily in knowledge of basic sciences or even in clinical sciences, but in the relationship between “theory and practice”, if you will. Even the task of performing common preparations on a typodont often displays a fundamental lack of comprehension about how restorative procedures are designed to meet the demands of materials and engineering principles, and as well, a lack of understanding about how a preparation can be done safely, quickly and efficiently. And most applicants have never done a cast restoration on a patient. While we all should learn, ultimately, dentistry from our patient experiences, there has to be a solid foundation of knowledge and insight upon which to build these lessons.
Make no mistake, an experienced educator can look briefly at any preparation done by a dental candidate and tell much about what they understand and don’t understand, beyond what they can do with their hands and a bur! If you want to make a good impression, it requires more than just practicing hand skills.
Many dental school advanced placement applicants seek to remedy their practical deficiencies prior to on-site examinations. Is it possible to significantly improve these skills with necessarily brief but intensive programs? Yes – provided that there is enthusiasm and dedication and a certain background level of ability and comprehension. When the original background is found weak in these fundamental areas, it takes longer and it takes more dedication on everyone’s part. The inculcation of true values in conservative dentistry is an intellectual, logical, scholarly, but also fundamental and emotional process. Some educators make it their life’s work to provide this depth of training to their students, but precious few.
So where does that leave you? If you have relatively strong National Board Part I score and good Toefl you could well get invited to interview. If there is a practical exam, do you know what is on it? Is it on a hand-held typodont or a manikin? Is the manikin positioned in a standard reclined position in a dental chair, or it is at some unnatural angle? As strange is it may seem, it also has to be asked if you will be allowed to use a mirror. Do they provide the typodont, or do you use your own? Is your typodont, if needed, in reasonable condition, such as not to compromise your work or their ability to grade it? What kind of typodont is required, (generally either Columbia or Kilgore)? Do you know the difference between these and how the preparations may be more challenging on one compared with the other? Do you know when certain types of preparations may be indicated for particular patient conditions, (some schools may give you a case description rather than a specific preparation assignment)? What burs are going to be the best to use for certain preparations – do you know which work well for patients but aren’t really practical in a typodont? Does the school require retentive grooves for a class II amalgam preparation? The more you know the better your chances of competitive success!
As you pursue advanced-standing admissions you will find a considerable network of other candidates that share information – remember that this is a competitive examination, but social networks can still be a big aid. Schools will not necessarily tell you as much as you would like to know. Pay attention to these resources as much as you can. If you live near a school, go visit and see if you can talk to a faculty member, particularly if teaching in a stand-alone program. Try to make arrangements to meet with students that are currently attending the program – they can tell you much about the way the program works, how many patients they have, and what the practical examinations are like. Start early! Many overseas dentists will need months of work, after NBDEI, to get their performance up to a level that will be a credit to them on practical exams or school review programs. This additional training should be with highly qualified and experienced individuals or institutions, and there are options available.
Ultimately the fundamentals that you bring as you join a U.S. dental school program will determine much about what you are equipped to get out of that program. The faculty may not have enough time to teach you the difference between “good enough” and “optimal” during crowded clinical sessions. If your goal is to do your best now, to do better than most, and to achieve more satisfaction as you traverse your career – get started as soon as you can. Find a way to seriously supplement your training while you (may) have the time to do this at your leisure. Admission into a U.S. school does not guarantee that you will always be doing the best dentistry you can – but you can set the stage for successful admissions, and also for optimal learning throughout your educational and practice careers if you take advantage of any opportunities to learn at the earliest possible date.
So the international dentist has a clear pathway toward U.S. dental practice. This initially, in most cases, will require some intensive supplemental training in the more skill-intensive areas of general dentistry. Those that follow this route can expect an easier time achieving admissions to advanced placement programs, a more effective educational experience once in the program, and to have a more satisfactory practice career as a lifetime learner. Everyone will benefit – the student, the U.S. dental school, and, ultimately, the patients.