Advice for graduation?

[DocLime]

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Seeking the wisdom of the many experienced dentists on here.

So I'm in my third year of dental school, my clinical skills put me at the top of my class. My grades are average Bs in every class across the board other than clinical classes. I really love GP and that's what I have always wanted to do.

I am fortunate enough that I am graduating with no debt, I founded a small company in college that I was able to sell to cover most of my tuition/living expenses.

With all that said, do you think I should pursue a AEGD? What kind of job should a new dentist be looking for these days? Associate? Look to buy a practice? Corporate? I'm really curious what my best option might be.

I really want to be the best GP possible. If that means devoting more time to residency then let it be so. But I'm hesitant because my professors are telling me that we get enough clinical time and that it's a waste.

Thank you for you input!

 

[schmoob]

Seeking the wisdom of the many experienced dentists on here.

So I'm in my third year of dental school, my clinical skills put me at the top of my class. My grades are average Bs in every class across the board other than clinical classes. I really love GP and that's what I have always wanted to do.

I am fortunate enough that I am graduating with no debt, I founded a small company in college that I was able to sell to cover most of my tuition/living expenses.

With all that said, do you think I should pursue a AEGD? What kind of job should a new dentist be looking for these days? Associate? Look to buy a practice? Corporate? I'm really curious what my best option might be.

I really want to be the best GP possible. If that means devoting more time to residency then let it be so. But I'm hesitant because my professors are telling me that we get enough clinical time and that it's a waste.

Thank you for you input!

Don't worry about what others say (including me). Do what you think will best help you achieve your ultimate goals.

 

[2TH MVR]

You're in a unique position with no debt. That gives you many options that your classmates may not have. If you enjoy the learning atmosphere (school) and want to learn/perfect/improve a certain clinical skill set .... sure.... an AEGD would make sense. I went to an AEGD 1st before going to ortho residency. During the AEGD ... I did rotations with the all the specialty depts and added to my skill set. It's kind of a job where you earn a little money.

The other option is to associate with a good, reputable dentist who is serious about being your mentor and establishing a future partnership. A good dentist with experience (clinical and business) will teach you many things above that of an AEGD. You associate for 6 months to determine if the marriage (partnership) is viable. I'm a firm believer that group (GPs and Spec) practices are the wave of the future if not the present. I would stay away from the dentist just looking for an employee. You're working, but with no future vested interest. Kind of like working in Corp.

As always is the case on a forum .... this is just my humble opinion. Good luck with your choice.

 

[Chipotlegonewild]

I would go buy a practice fresh out of the gate.

If you are already comfortable with the clinical side, why do you need more schooling?

Why associate and limit yourself to $150k, when you can purchase a cash flowing practice and make $200k+ right out of the gate.

 

[DocLime]

I would have recommended specializing but then saw your average B gpa... why not open up or buy a practice right after graduation and beef up on CEs? your clinical skills won't be as good as specialists' anyway

I want to take a large amount of CEs to expand my skills as a GP, I just don't feel very confident buying my own practice in terms of the business side of things and managing overhead.

You're in a unique position with no debt. That gives you many options that your classmates may not have. If you enjoy the learning atmosphere (school) and want to learn/perfect/improve a certain clinical skill set .... sure.... an AEGD would make sense. I went to an AEGD 1st before going to ortho residency. During the AEGD ... I did rotations with the all the specialty depts and added to my skill set. It's kind of a job where you earn a little money.

The other option is to associate with a good, reputable dentist who is serious about being your mentor and establishing a future partnership. A good dentist with experience (clinical and business) will teach you many things above that of an AEGD. You associate for 6 months to determine if the marriage (partnership) is viable. I'm a firm believer that group (GPs and Spec) practices are the wave of the future if not the present. I would stay away from the dentist just looking for an employee. You're working, but with no future vested interest. Kind of like working in Corp.

As always is the case on a forum .... this is just my humble opinion. Good luck with your choice.

I think going associate sounds like a good plan at this point. The question is just how to go about finding one that is a good match for me.

I would go buy a practice fresh out of the gate.

If you are already comfortable with the clinical side, why do you need more schooling?

Why associate and limit yourself to $150k, when you can purchase a cash flowing practice and make $200k+ right out of the gate.

Nervous about the business side of things and overhead management. Also as the saying goes "You don't know what you don't know". I feel confident in clinic, but there may be cases that come to me that I couldn't solve without the mentor-ship of an older, more experienced dentist OR GPR experience.

 

[Screwtape]

You are definitely asking the right questions but unfortunately its hard for strangers to give you the right answers. I am a recent grad so that may give you some context about what I say here. Anyways based on your comments here I would recommend two options.
First would be an excellent GPR/AEGD. Now this is assuming you can get in. Good GPR/AEGDs generally look for top third, yes there are exceptions. Not all GPR/AEGDs are created equal. There are bad ones, great ones, and everything in between. It is on you to research the programs, talk with directors, talk with current and past residents, and possibly even visit the program before interviews. Most programs don't have everything and none are perfect. But it is up to you to prioritize what you want out of a residency and then find one that meets those priorities, or comes closest to it. A good GPR/AEGD aligned with your goals can very much be worth it.
The second option would be to find an associateship where serious mentoring is a selling point from the owner doc. This can be tricky. Many owner docs mention mentoring during interviews but at the end of the day they are paying you to work and produce. So sometimes the whole mentoring aspect is oversold and under delivered. Corporate gigs generally are not there for mentoring. Yes they usually provide a decent amount of $$$ for CE's, but based on your comments I don't think you would thrive in that environment. As I mentioned above the mentoring aspect of an associateship can be tricky. Most times you only have the word of the dentist, there is no "mentoring clause" in a contract. There usually is no track record of past associates to talk with (sometimes there is, but they may not want to talk to you). But if you can find a great associateship with a great doc (you don't want to learn from a poor clinical dentist) who is willing to do some serious mentoring, well then thats a great option. But that can be difficult to find. You will learn more of the "private practice" style dentistry and be more versed in the business side than your residency trained counterparts. You will also get paid more for that first year. More uncertainty compared to AEGD/GPR in regards to experience though. Also you will most likely only be learning from one doctor compared to several at an AEGD/GPR. GPR's also provide you with the opportunity of hospital privileges. But thats a minor point for most people.

As you can see I lean towards a good GPR/AEGD but I do think there are associateships out there that are great and pay you more. Again, its on you to find them. It all boils down to two things-- Figuring out what you want for your first few years after graduation and then finding the opportunity that will get you there.

A GPR/AEGD does make you more marketable compared to a new grad. So in reality you could pursue both of the options I mentioned just with a residency first followed by a good associateship. Best of luck.

 

[cacajuate]

Nervous about the business side of things and overhead management. Also as the saying goes "You don't know what you don't know". I feel confident in clinic, but there may be cases that come to me that I couldn't solve without the mentor-ship of an older, more experienced dentist OR GPR experience.

Then do the reverse associate-ship model. Buy a practice from a dentist and have him work as an associate working fewer days. Purchasing an existing practice has a the staff that knows the systems already, they will point you in the right direction.


If you don't have a senior doc to hold your hand, you just punt the pt to the specialist. I guarantee that 3-6 months in the real world, you aren't going to be needing someone holding your hand all the time.


trying to convince this whole generation of dentists that we need to get into ownership, so we don't all end up working for a corporate entity.

 

[Swole DMD]

you have 2 years to teach yourself practice management, HR, acquisition etc.. youre going to want to know it one day anyway, AEGD or not.. also, who is to say the dentist that hires you is any good at managing overhead, running a business etc? and how will you know if the dentist hiring you and the practice is a good fit and even has room for an associate? I suggest reading, podcast, CE so you can accelerate that learning curve when you come out of school... just my 2 cents and Im a 2nd year so this is all just theory on my part

 

[Greyangel6]

I admire what you're doing! Really! I'm barely surviving with clinical requirements as a D3 let alone having time to think about stuff like this. I'll check back to this thread to see more opinions on this topic.

 

[Swole DMD]

I admire what you're doing! Really! I'm barely surviving with clinical requirements as a D3 let alone having time to think about stuff like this. I'll check back to this thread to see more opinions on this topic.

Lol never said I'm doing well in school 😉.. but I feel ya, I'm a 2nd year and we have started clinic 2X/week.. sometimes have a perio recall / adult prophy / simple restorative that you can find, or you assist another student or observe a resident.. but yea that 6-8hr a week would make a huge difference in studying time, keep grinding

 

[Swole DMD]

oh and check out.. Podcasts -->Shared Practices, Dentalpreneur, Dental Hacks, Howard Farran. Books --> Fred Joyal, Jocko Willink, Rich Dad Poor Dad, Mark Costes (Dentalpreneur guy - also an author), Dr larkin's mini-MBA (downloadable PDF, simple read, real short and to the point, great place to start)

 

[toyotasupra]

I know a handful of dentists with failed practices fresh out of dental school. But you seem business savvy, so you could probably give it a shot. Personally I’d be too chicken to start fresh out of school.

 

[TanMan]

Seeking the wisdom of the many experienced dentists on here.

So I'm in my third year of dental school, my clinical skills put me at the top of my class. My grades are average Bs in every class across the board other than clinical classes. I really love GP and that's what I have always wanted to do.

I am fortunate enough that I am graduating with no debt, I founded a small company in college that I was able to sell to cover most of my tuition/living expenses.

With all that said, do you think I should pursue a AEGD? What kind of job should a new dentist be looking for these days? Associate? Look to buy a practice? Corporate? I'm really curious what my best option might be.

I really want to be the best GP possible. If that means devoting more time to residency then let it be so. But I'm hesitant because my professors are telling me that we get enough clinical time and that it's a waste.

Thank you for you input!

Define "best GP" - Is it being able to tackle on all cases (super GP) or is it being the most profitable dentist. They are not one in the same. Once you define what you want to be, then you can choose the proper path.

If you're looking to maximize your profit, you need to gather enough capital to start your own office. Fastest way to make money is find a middle of nowhere associateship/mill that can bring you as many patients as possible and pay you a large percentage for all your production. Once you gather enough capital, open your own office and make lots of money $$. Invest wisely and you'll be the most profitable GP. Most of your money will not come from dentistry, but from the capital that you gain from dentistry. I am against buying a practice unless it is being sold at a bargain (think pennies on the dollar)

If you're looking to be a superGP, there's many paths. I've heard of combined perio-prosth programs that make you into a "bulletproof GP", or you could do an AEGD/GPR program (high variation in quality, you must do your research to make sure it is a quality program and not just a 5th yr of dental school), or corporate (if you care more about speed, than the extent of the procedures you are performing) supplemented with a bunch of CE's.

So... those are the two paths, I'm not sure what your aims are, but hope that helps you a bit. If you were to ask me what kind of job you should look for? The highest paying, highest volume, highest producing job out there. It will train you to be quick on your feet, treatment plan quickly, treat efficiently, and it's essentially a trial by fire. Sink or swim is the best way to gain speed. If you sink, then it means that you may not be able to adapt to changes in the clinical settings and you may need a more structured academic setting.

 

[cacajuate]

If you're looking to maximize your profit, you need to gather enough capital to start your own office. Fastest way to make money is find a middle of nowhere associateship/mill that can bring you as many patients as possible and pay you a large percentage for all your production. Once you gather enough capital, open your own office and make lots of money $$. Invest wisely and you'll be the most profitable GP. Most of your money will not come from dentistry, but from the capital that you gain from dentistry. I am against buying a practice unless it is being sold at a bargain (think pennies on the dollar)

I agreed with you all the way up into this point. I am going to assume that you are pro-start up and I'll agree it does have a bunch of merits but that last statement confuses me. Do you mind sharing your thoughts as to why you believe that?

 

[TanMan]

I agreed with you all the way up into this point. I am going to assume that you are pro-start up and I'll agree it does have a bunch of merits but that last statement confuses me. Do you mind sharing your thoughts as to why you believe that?

I am definitely pro startup. For me, there are advantages for a startup v. purchasing an office. A startup can definitely be cheaper than a practice purchase, but some people may say that you have immediate cash flow coming from the office. While that may be true, we need to look at where that production is coming from. Is it from recalls or treatment? The turnkey part of the office is the recalls which is self-sustaining. I had to lookup one of my old posts, since I can't seem to think clearly right now, but essentially, monthly recall income should be greater than your practice debt servicing, otherwise, you are just working to pay the other guy off. You should have to do virtually nothing at the practice (which is essentially recalls) and still come out even or ahead. Otherwise, you're indirectly working for the dentist who sold you the practice (assuming goodwill = 0). Second, a productive practice would have exhausted most of the treatment in the office already, so you're in an uphill battle either redoing treatment/finding new caries (which patients may find suspicious, especially if they trusted the old doc before) or having to market to a new population. Third, the practice you are purchasing has the old staff there. Old staff usually have bad habits, and depending on the terms of practice transition, you may end up having to get rid of some or all staff if they are stubborn, unable to adapt/improve, or think they are better than you. In some states, that can be difficult due to labor laws, especially if they are older or considered a protected class. What's the point of buying a practice if you have to retrain the staff the way you want to, rather than starting from a blank slate.

Now, what do I consider a bargain? At a minimum, the purchase price should be lower than buying all the equipment and buildout to be considered a bargain (at market value, not new value). Looking at it from a business standpoint, you need equipment and labor. The equipment costs, new or used, vary greatly. When buying an office, the equipment is usually older, and your maintenance costs will be higher and chance of replacement is higher.

As I discussed previous about labor, there are some potential legal issues if you're in a pro-employee state, but even then, getting rid of half the staff can hurt the morale of the remaining staff. Staff morale is important, because they are the sales engine that drives your practice. I would prefer to start with a clean slate, new staff, new/refurbished equipment, cheap buildout.

Last, patient retention with the new owner. A lot of the value comes from the production derived from these patients. If your patient pool drops because of the loyalty and/or distrust of the new dentist, then you're essentially buying a depreciating asset. I know that a lot of dentists will "stick around" to assist with the transition, but that goes back to the potentially complacent and inefficient staff that will feel empowered with the presence of the previous owner. I do assume that everyone has their own practice style, but I find that potential employees that have a lot of experience are a lot harder to train to your style of dentistry.

Anyway, my responses are all over the place, I'm tired, if you can't understand what I said here, I'll be glad to clarify. I'm pro-startup because I see it as a faster way of making money with less capital and more control of your practice variables. Marketing, clinical speed to be able to deliver all the dentistry your marketing brings, and your personality are your major key to success. I don't like the idea of borrowing money to purchase an office, since it feels like I'm just investing in a note/bond that I have to work for. I could do that without having to deal with buying/running an office. I paid for my office with cash though, so my perspective could be different from other startups.

 

[cacajuate]

I am definitely pro startup. For me, there are advantages for a startup v. purchasing an office. A startup can definitely be cheaper than a practice purchase, but some people may say that you have immediate cash flow coming from the office. While that may be true, we need to look at where that production is coming from. Is it from recalls or treatment? The turnkey part of the office is the recalls which is self-sustaining. I had to lookup one of my old posts, since I can't seem to think clearly right now, but essentially, monthly recall income should be greater than your practice debt servicing, otherwise, you are just working to pay the other guy off. You should have to do virtually nothing at the practice (which is essentially recalls) and still come out even or ahead. Otherwise, you're indirectly working for the dentist who sold you the practice (assuming goodwill = 0). Second, a productive practice would have exhausted most of the treatment in the office already, so you're in an uphill battle either redoing treatment/finding new caries (which patients may find suspicious, especially if they trusted the old doc before) or having to market to a new population. Third, the practice you are purchasing has the old staff there. Old staff usually have bad habits, and depending on the terms of practice transition, you may end up having to get rid of some or all staff if they are stubborn, unable to adapt/improve, or think they are better than you. In some states, that can be difficult due to labor laws, especially if they are older or considered a protected class. What's the point of buying a practice if you have to retrain the staff the way you want to, rather than starting from a blank slate.

Now, what do I consider a bargain? At a minimum, the purchase price should be lower than buying all the equipment and buildout to be considered a bargain (at market value, not new value). Looking at it from a business standpoint, you need equipment and labor. The equipment costs, new or used, vary greatly. When buying an office, the equipment is usually older, and your maintenance costs will be higher and chance of replacement is higher.

As I discussed previous about labor, there are some potential legal issues if you're in a pro-employee state, but even then, getting rid of half the staff can hurt the morale of the remaining staff. Staff morale is important, because they are the sales engine that drives your practice. I would prefer to start with a clean slate, new staff, new/refurbished equipment, cheap buildout.

Last, patient retention with the new owner. A lot of the value comes from the production derived from these patients. If your patient pool drops because of the loyalty and/or distrust of the new dentist, then you're essentially buying a depreciating asset. I know that a lot of dentists will "stick around" to assist with the transition, but that goes back to the potentially complacent and inefficient staff that will feel empowered with the presence of the previous owner. I do assume that everyone has their own practice style, but I find that potential employees that have a lot of experience are a lot harder to train to your style of dentistry.

Anyway, my responses are all over the place, I'm tired, if you can't understand what I said here, I'll be glad to clarify. I'm pro-startup because I see it as a faster way of making money with less capital and more control of your practice variables. Marketing, clinical speed to be able to deliver all the dentistry your marketing brings, and your personality are your major key to success. I don't like the idea of borrowing money to purchase an office, since it feels like I'm just investing in a note/bond that I have to work for. I could do that without having to deal with buying/running an office. I paid for my office with cash though, so my perspective could be different from other startups.

Thanks, for detailed answer. That definitely is a different perspective than what I have been hearing and its good to hear it.


Staying with the start up idea. What are your must haves? Do you spend any money on some of the newer technologies? CBCTs, intraoral scanner, 3d printers? I feel that dentistry is heading that way quickly and is it worth the investment early to stay some what ahead of the curve? What do you feel is the ideal op size? I realize that this is location specific but what do you feel is an appropriate price to spend per op? For total office? Let's keep the argument for a office for a fresh grad or few years out since that will be the majority of the audience on this site. Like I said, I know its location specific but lets just say stick with average range of prices.



edit: thought about this some more and specifically about the part recalls covering debt service. When I thought about it more, one of the main factors that I would be looking at would be the value of EBITDA. I wouldn't choose to buy a practice that had a low enough EBITDA to not cover the debt service. The only reason that I see recall number is important is to get a feel of how many active pts there are.

 

[TanMan]

Things that are needed (that I can think of at this time):
- Electric Handpieces: Cut faster, cuts procedure time, increases efficiency (probably number one must have in all your treatment rooms) and extra coarse/aggressive cutting burs for more efficiency
- CEREC: Saves on impression material, temporaries, chair time, number of visits; literally prints money
- Piezo scalers: For me, they seem more efficient in hygiene than magnetostrictive, but it may be a matter of preference
- Intraoral cameras: no need for fancy ones, 20 dollar ebay ones work well, and you can buy 20-30 of them, in case some break. Pictures are worth a thousand words and increased treatment acceptance
- Statims: Fast turnaround in sterilization. No need to wait for sterilization. You should have at least 2, in case one breaks. They do have a higher rate of repair (usually gasket/seal replacement needed)
- WaveOne system: Most efficient endo system I've used. Almost idiot-proof. Pretty much WL w/ 10 file + Apex Locator then instrument with Waveone. If I can't get a 10 file down, I can usually go down with a Waveone file, but you may have to replace the file as it will get dull due to calcification/cutting action.
- Digital Xrays: Very very important, but high capital costs. For a cheap startup, you can go with the older generation such as the Gendex eHD's. You can snag a sensor for 1k usually. When you get busier, you can upgrade to the top of the line.
Things that I have, but I wouldn't say I absolutely need:
- Lasers: Diode is nice for troughing, I don't even need cord. If your office is a slower paced office but lots of perio, the Periolase is a great addition (relatively easy perio surgery), Er:Yag laser is great for root canals (PIPS). I have all three, and I'd rank it as Er:Yag, Diode, Periolase. However, this has to do more with my procedure mix more than anything else. A Perio heavy practice would probably rank it in reverse. I know Er:Yag lasers are sometimes touted as drill-less alternatives, but I would never advertise that. You'll attract the wrong kind of patients.
Things I'm not sold on:
- CBCT: I'm not sold on it in a GP's office. My office is not desperate enough to venture into sleep apnea, nor do I want to tackle difficult implant cases. I'm also concerned about liability in what we scan on the CBCT. Also, getting paid for CBCT is difficult in medical and dental billing, regardless of what the sales rep tells you. If you're going to do extensive cases or full mouth reconstruction or all on 4,5,6,etc..., then you may consider one. However, from personal experience, my hourly return and risk is not worth pursuing these types of cases.
- 3d printers: I don't know much about 3d printing, but the question is how do I monetize 3d printing in the context of dentistry, and how long does it take to produce a model, etc...

Besides equipment, I think your staff is more important than anything else in terms of efficiency and workflow. The culture of the office is set by the tone and speed of the dentist.

How many ops to start? Probably 6 with future ability to double to 12 would be ideal. A cheap startup with 5-6 rooms? A little above 100k, maybe 120k. If I were to do a rough estimate of chair + delivery system + handpiece, I might say you can go as low as 5-6k, but don't quote me on this, as I'm just doing a rough mental estimate. This 100-120k does not include cost of CEREC. Some tips to reduce your cost: Don't use a dental contractor, use a general contractor, cheap laminate flooring (or VCT) with home depot laminate countertops. Overhead plumbing, avoid breaking ground. Chairs, no lights, no cuspidors, rear delivery on all. Compressor, go buy an industrial compressor and outfit with dessicator and dryer. Vacuum, look for a used one on ebay. Computers - Dell refurbished when combined with coupons can really lower your IT costs. Pano - go digital, but refurbished.

Let me know if you have any other questions, this was just another unorganized brain dump.

 

[TanMan]

Thanks, for detailed answer. That definitely is a different perspective than what I have been hearing and its good to hear it.

edit: thought about this some more and specifically about the part recalls covering debt service. When I thought about it more, one of the main factors that I would be looking at would be the value of EBITDA. I wouldn't choose to buy a practice that had a low enough EBITDA to not cover the debt service. The only reason that I see recall number is important is to get a feel of how many active pts there are.

EBITDA is important and unfortunately, the information we gather are snapshots in time. My bigger concern would not be the latest EBITDA, but what variables can affect your production. At a given point, your EBITDA may be enough to cover your debt service, but based on what I mentioned above, patient retention is important to determine whether the current earnings would drop to not be able to cover debt service. Past performance may not necessarily be indicative of future performance in a practice transition (as with any investment). Before jumping on board, make sure you know as much of the variables as possible such as the payer mix and any insurance/policy changes that may affect your future income.

Recall can help to measure active patients, but for me, it is more of a measurement of whether I can afford the debt service from the practice income alone without any other source of income and extra effort. Essentially, I'm assuming the worst case scenario in that my treatment production = 0 and how far the existing patient pool will drop.

Why does recall income differ from treatment income? Recall income is essentially free money and low-labor/time requirements. Anyone can generate recall income, even the most incompetent dentist. Now, treatment income has a lot more challenges. First, do you agree with the previous treatment plan that the previous dentist made. If no, do you say anything or just do the treatment? Second, is the patient willing to go forward with you, as the treating dentist? Third, depending on the complexity of the treatment, are you able to execute the treatment plan efficiently or do you predict a lot of problems?

It's not just about looking at the snapshots of data, but looking at the variables which could affect your production. Trends can give another insight to the overall health of the practice, but a major event such as the sale of a practice can have an effect on your practice production. Also, it depends on the goodwill that the previous dentist made and how easily you want to acquire or distance yourself from that goodwill (i.e negative goodwill from a really really bad dentist with a poor reputation v. a dentist with such a great reputation that no dentist could hold their own against).

 

[Swole DMD]

This is the best thread that has ever blessed SDN

 

[babykk]

A share need me now, thank pro !!