Almost done and lost

[drseplo]

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Title says it all. I'm reaching the end of my time in dental school with less than a year to go. I've been considering my options and been seriously considering some sort of GPR in order to expand my clinical skills. I feel comfortable with the skills I've obtained in surgery, prosth and restorative but do lack confidence in endo. However at the same time I have very little limitations and would love to see what kind of advice some of you SDNers would have! I will be 26 when I graduate, single, no debt (no service obligations of any kind) and a sizable chunk of change in the bank (about 150k give or take). I've considered going straight into ownership but I have reservations as to how good of an idea that would be unless of course I find a practice with an owner willing to mentor and stay on for a year or so. Ultimately my goal is to own a couple practices and focus on the aspects of dentistry that make happy (surgery and prosth). I will have taken CDCA and really have no limitations in terms of where to work.
Thanks in advance!

 

[TanMan]

Title says it all. I'm reaching the end of my time in dental school with less than a year to go. I've been considering my options and been seriously considering some sort of GPR in order to expand my clinical skills. I feel comfortable with the skills I've obtained in surgery, prosth and restorative but do lack confidence in endo. However at the same time I have very little limitations and would love to see what kind of advice some of you SDNers would have! I will be 26 when I graduate, single, no debt (no service obligations of any kind) and a sizable chunk of change in the bank (about 150k give or take). I've considered going straight into ownership but I have reservations as to how good of an idea that would be unless of course I find a practice with an owner willing to mentor and stay on for a year or so. Ultimately my goal is to own a couple practices and focus on the aspects of dentistry that make happy (surgery and prosth). I will have taken CDCA and really have no limitations in terms of where to work.
Thanks in advance!

Don't worry about endo. Endo is pretty easy with the new(er) file systems out there. Waveone Gold + lots of irrigation + good activation system (Endoactivator, US, EDDY, PIPS) + BC Sealer/single cone = easy endo = easy money. Work for a high volume practice for a year to get your endo/system practice down, then buy an office. If you perf, there's always RRM. If it fails, there's retreatment and apicos. If that fails, ext/implant/bridge

If the only aspect of dentistry that you're unsure about is endo, take a weekend endo + apico/microsurgery course. Why would go through an extra year? That's an extra year in the prime of your life and lost future income. You'll never get a year back in your 20s ever again. You are at the prime of your life where you can eat whatever you want, do whatever you want (as long as you don't get someone pregnant), and physically meet any challenges that come your way.

 

[drseplo]

Don't worry about endo. Endo is pretty easy with the new(er) file systems out there. Waveone Gold + lots of irrigation + good activation system (Endoactivator, US, EDDY, PIPS) + BC Sealer/single cone = easy endo = easy money. Work for a high volume practice for a year to get your endo/system practice down, then buy an office. If you perf, there's always RRM. If it fails, there's retreatment and apicos. If that fails, ext/implant/bridge

If the only aspect of dentistry that you're unsure about is endo, take a weekend endo + apico/microsurgery course. Why would go through an extra year? That's an extra year in the prime of your life and lost future income. You'll never get a year back in your 20s ever again. You are at the prime of your life where you can eat whatever you want, do whatever you want (as long as you don't get someone pregnant), and physically meet any challenges that come your way.

Would it be unwise to buy a practice straight out? I know several people from this years graduation class that did just that and it's something I've been considering.

 

[Vicviper]

Especially with no debt, I'd say do a AEGD/GPR to expand your skills and comfort level, especially if you are interested in then looking into practice ownership. It's really hard to find someone willing to associate with who will mentor you in a meaningful way now unfortunately. Also unfortunetly, people are graduating dental school with less and less experience. I interview people from big name schools that have done 20-30 direct restorations and say they feel "comfortable" with fillings. Everyone is different, that's for sure, but especially if you're looking to take over a practice within 1-3 years of graduating, it may be very helpful to have a jump start with your experience level - just be sure its a program that does things you actually want to do / gain experience in - one of my faculty in dental school told me that at his AEGD/GPR, he sewed more lips back together than crown preps.

 

[drseplo]

Especially with no debt, I'd say do a AEGD/GPR to expand your skills and comfort level, especially if you are interested in then looking into practice ownership. It's really hard to find someone willing to associate with who will mentor you in a meaningful way now unfortunately. Also unfortunetly, people are graduating dental school with less and less experience. I interview people from big name schools that have done 20-30 direct restorations and say they feel "comfortable" with fillings. Everyone is different, that's for sure, but especially if you're looking to take over a practice within 1-3 years of graduating, it may be very helpful to have a jump start with your experience level - just be sure its a program that does things you actually want to do / gain experience in - one of my faculty in dental school told me that at his AEGD/GPR, he sewed more lips back together than crown preps.

What kind of case load would you say would bring you up to an acceptable experience? I will be graduating with about 150 direct restorations, 20 indirect, 100+ extractions. I feel relatively comfortable for restorative and somewhat with crowns.

 

[Faefly]

 

[TanMan]

Would it be unwise to buy a practice straight out? I know several people from this years graduation class that did just that and it's something I've been considering.

If you had the capital and cash reserves to start out, why not? This highly depends on the individual, their financial circumstances, and speed/sales ability. If the person had the capital, good at selling/patient interaction, and sufficiently fast/skilled, then they can buy outright or start a new practice. If I came from better circumstances and had the financial resources (and assuming I stayed in dentistry), I would started right out of dental school, ramping up my office and working at other offices.

What kind of case load would you say would bring you up to an acceptable experience? I will be graduating with about 150 direct restorations, 20 indirect, 100+ extractions. I feel relatively comfortable for restorative and somewhat with crowns.

Number of procedures doesn't matter. The number of procedures that you have done are insignificant to the amount that you will do in private practice. What matters more is how fast you executed the procedures, whether they held up or fell apart, and did you hurt the patient in the process. Last I counted in my practice (not including my associateship), I've done 16k fills, 3k+ indirects and endos, and a bunch of extractions (haven't counted). Is there room for improvement? ALWAYS. I always stress this among graduating dentists and new dentists who ask for advice... You have to always think about what you're doing and how you can improve (speed and quality). Sometimes you have to step back and study your workflow. There are inefficiencies and when you identify them, you must find a way to address those inefficiencies within yourself and your staff.

Just an example, if I'm doing 4 back to back interproximals, how can I improve that procedure?

- Need a ring system that I can stack back to back for 4 interproximals (I could do tofflemeier superfast, but I prefer broad contacts, doing tofflemeier would make it supereasy, but often have issues with food trap). Doing one restoration at a time will kill your efficiency. If you can assembly line the restorations, you save a lot of time. Etch/bond all at the same time, then start filling, once you have one or two filled and you can cure a restoration without affecting the other, start curing and move down the line.
- Incremental curing v. bulk fill? I cut a 5mm segment of straw and tested various bulk fills for handling characteristics, cured it with fast curing light, checked hardness with explorer, hammered it against plywood
- Curing light: Output intensity, curing depth, and speed, tested them on incremental v. bulk fill
- Why am I waiting for the curing light to move from tooth to tooth, I need 2+ curing lights that can cure fast and skinny enough to fit 2 premolars/anteriors. I haven't mastered 4 curing lights yet, but I don't think we can fit 4 curing lights in the mouth all at once.

There's a bunch more besides material and equipment choice. It's also minimizing unnecessary movements and materials. Fills are predictable. Extractions, not as much, made a lot more predictable with a surgical handpiece.

Those are some of the things that run through my mind when I think about how can I go faster. That would be my question for you... how fast can you execute these procedures at a clinically acceptable level and how much faster can you go?

 

[drseplo]

also, the original post is def a humble brag post, but that's ok.

I wish, to tired and worn out to do that plus dental school has stuffed humble pie down my throat. Just wanted to make clear my circumstances.

 

[drseplo]

If you had the capital and cash reserves to start out, why not? This highly depends on the individual, their financial circumstances, and speed/sales ability. If the person had the capital, good at selling/patient interaction, and sufficiently fast/skilled, then they can buy outright or start a new practice. If I came from better circumstances and had the financial resources (and assuming I stayed in dentistry), I would started right out of dental school, ramping up my office and working at other offices.



Number of procedures doesn't matter. The number of procedures that you have done are insignificant to the amount that you will do in private practice. What matters more is how fast you executed the procedures, whether they held up or fell apart, and did you hurt the patient in the process. Last I counted in my practice (not including my associateship), I've done 16k fills, 3k+ indirects and endos, and a bunch of extractions (haven't counted). Is there room for improvement? ALWAYS. I always stress this among graduating dentists and new dentists who ask for advice... You have to always think about what you're doing and how you can improve (speed and quality). Sometimes you have to step back and study your workflow. There are inefficiencies and when you identify them, you must find a way to address those inefficiencies within yourself and your staff.

Just an example, if I'm doing 4 back to back interproximals, how can I improve that procedure?

- Need a ring system that I can stack back to back for 4 interproximals (I could do tofflemeier superfast, but I prefer broad contacts, doing tofflemeier would make it supereasy, but often have issues with food trap). Doing one restoration at a time will kill your efficiency. If you can assembly line the restorations, you save a lot of time. Etch/bond all at the same time, then start filling, once you have one or two filled and you can cure a restoration without affecting the other, start curing and move down the line.
- Incremental curing v. bulk fill? I cut a 5mm segment of straw and tested various bulk fills for handling characteristics, cured it with fast curing light, checked hardness with explorer, hammered it against plywood
- Curing light: Output intensity, curing depth, and speed, tested them on incremental v. bulk fill
- Why am I waiting for the curing light to move from tooth to tooth, I need 2+ curing lights that can cure fast and skinny enough to fit 2 premolars/anteriors. I haven't mastered 4 curing lights yet, but I don't think we can fit 4 curing lights in the mouth all at once.

There's a bunch more besides material and equipment choice. It's also minimizing unnecessary movements and materials. Fills are predictable. Extractions, not as much, made a lot more predictable with a surgical handpiece.

Those are some of the things that run through my mind when I think about how can I go faster. That would be my question for you... how fast can you execute these procedures at a clinically acceptable level and how much faster can you go?

Would it be frowned upon to work at one office and own your own?

How quickly does speed ramp up once out of school? This is one of the reasons I've considered first doing a year of PP then going and purchasing my own. But then again like it's been mentioned it would be a waste of a year in terms of getting ahead.

 

[TanMan]

Would it be frowned upon to work at one office and own your own?

How quickly does speed ramp up once out of school? This is one of the reasons I've considered first doing a year of PP then going and purchasing my own. But then again like it's been mentioned it would be a waste of a year in terms of getting ahead.

It would be frowned upon, but as they say... shamelessness. You do what it takes to survive. You don't disclose it to your employers and as long as you're not violating any contracts or taking their clients, there should be no issue.

Speed ramps up depending on the individual. The advantage of working at a corp office while starting up... money and it's better to mess up at a corp office than your own.

 

[321931]

Edit see second post

 

[321931]

What kind of case load would you say would bring you up to an acceptable experience? I will be graduating with about 150 direct restorations, 20 indirect, 100+ extractions. I feel relatively comfortable for restorative and somewhat with crowns.

I do about that many indirect in two weeks. 150 direct? Maybe a month. Extractions I don’t do anymore but if you work in an affluent area people don’t lose their teeth as often so it’s a wasted ability.

You graduated with that caseload in a span of 2 years clinical...

Get a good year or two in a job or gpr where you can cut teeth with your eyes closed on any nervous big tongue difficult cheek can’t open and hard to get numb patient. Once you can do that with confidence then buy a practice. Then master your first practice and buy the second and third.

 

[TanMan]

What about bank loan for someone who doesn’t have any debt as the OP?

How would you decide where to open?
You recommend services like DoctorDemographics for this?

You recommend any of the CE that is about practice management? I.e. Breakaway seminars, etc?

- I don't like bank loans because they have plenty of restrictions, reporting and compliance requirements.
- Decide where to open based on a objective and subjective analysis. Objective numbers are important, but also understanding (subjectively) your demographic and needs/deficiencies of the region.
- I don't know that service does.
- I think most practice management "gurus" are scammers. If anyone knows of a good one, let us know.

 

[drseplo]

- I don't like bank loans because they have plenty of restrictions, reporting and compliance requirements.
- Decide where to open based on a objective and subjective analysis. Objective numbers are important, but also understanding (subjectively) your demographic and needs/deficiencies of the region.
- I don't know that service does.
- I think most practice management "gurus" are scammers. If anyone knows of a good one, let us know.

So you would wait until one can pay cash for a practice then??

 

[TanMan]

So you would wait until one can pay cash for a practice then??

No. I would find a way to obtain/start a practice without excessive restrictions. I'm all for a startup since you don't need that much money to start, unlike purchasing a practice, which requires a lot of capital. Either find an easy to work with lender (one that doesn't have vendor restrictions, reporting/compliance requirements, or other BS) OR start real cheap if you're going the startup route.

You need to have your own practice as soon as you can. I just don't like the requirements that some lenders require, as it ends up costing you more in the long run.

 

[sb.tnh]

What kind of case load would you say would bring you up to an acceptable experience? I will be graduating with about 150 direct restorations, 20 indirect, 100+ extractions. I feel relatively comfortable for restorative and somewhat with crowns.

Those are very respectable numbers for a new D4. Would you mind sharing which school you go to?

 

[2TH MVR]

1. no need for the extra time in school; like others have mentioned ..... plenty of good CE out there.
2. Find the area where you want to start your dental career. Remember: Rural better than Urban, but then you are single .... so your needs maybe different than others. But this is step one. Then once in that area ...... find employment for 6-12 months. Get your feet wet. Best would be an associateship. You will learn more about running a private practice in an Associateship vs. Corp. Now you are PHYSICALLY in the area that you want to practice in. Much easier to locate dental practices for sale, consider a start up and/or network.
3. Assemble your team: practice brokers, dentist specific acct, equipment brokers, banks, etc. These people will be able to help once you buy or start your own practice.
4. Even after buying/starting your private practice ..... consider keeping your PT Associateship or Corp gig. Can't hurt until your practice is running full speed.

LOCATION is the biggest determinent on your future success.

 

[321931]

So you would wait until one can pay cash for a practice then??

No. Go call your nearest dental cpa, pay him by the hour and let him explain profit loss cash flow and now the numbers work out.

You def will appreciate the advice. Then you can form your own opinion if saving 10 years to buy a practice with cash is worth it or rather buying a good cash flowing practice, paying it off in 5-7 years with good bank terms while building equity maxing 401k and doubling your income is worth it.

 

[lemoncurry]

If I were in your shoes and doing it all over again, I would probably do a GPR and then buy a practice right after. Doesn't matter how badass you think you are in dental school, you're still slow in the real world. A GPR will help with your technical prowess as well as your speed so that you don't need 2+ hours to do a single crown. Unless you're running a skeleton crew at your new practice right out of school, IMO you're going to be losing money due to speed issues.

 

[TanMan]

I see HMO as good if you can upsell everything and your HMO clients have access to credit. Medicaid is state dependent and I am always concerned about RAC audits when it comes to medicaid. I'll add more on those two demographics later tonight/tomorrow.

 

[Roy Williams]

Especially with no debt, I'd say do a AEGD/GPR to expand your skills and comfort level, especially if you are interested in then looking into practice ownership. It's really hard to find someone willing to associate with who will mentor you in a meaningful way now unfortunately. Also unfortunetly, people are graduating dental school with less and less experience. I interview people from big name schools that have done 20-30 direct restorations and say they feel "comfortable" with fillings. Everyone is different, that's for sure, but especially if you're looking to take over a practice within 1-3 years of graduating, it may be very helpful to have a jump start with your experience level - just be sure its a program that does things you actually want to do / gain experience in - one of my faculty in dental school told me that at his AEGD/GPR, he sewed more lips back together than crown preps.

I find it hard to believe people are graduating with having only done 20-30 restorations. I've not even finished my second year yet and I've done probably around 20-30 already.

 

[2TH MVR]

I find it hard to believe people are graduating with having only done 20-30 restorations. I've not even finished my second year yet and I've done probably around 20-30 already.

You've done 20-30 restorations on live patients after 3 semesters in dental school?

 

[Roy Williams]

You've done 20-30 restorations on live patients after 3 semesters in dental school?

We started op at the beginning of 2nd year. So far I've done 15 direct restorations on live patients in our general dentistry clinic, and I've done around 10 or so direct restorations on pediatric patients + 3-4 stainless steal crown preps and placements on pediatric patients. At the start of second year we had one clinic slot per week. Now that we're in our summer semester, I have 4 clinic slots per week. This next week alone, I have probably 5-8 restorations planned. I usually try and do multiple per appointment.

Edit: Also, I have finished 5 semesters of dental school. We have fall, spring, and summer semesters. So technically I've finished 5 and am in my 6th (second year summer) right now.

 

[Vicviper]

Unfortunately you're the exception. I've spoken to more than one person from a very big name dental school that said they did their first Class II on a live patient on their board exams. I interview over a dozen people for my residency every year, and I always ask about how many restorations they've done, just to get a sense of current experience level. The average I hear is about 30-50 direct restorations that they're expecting to complete prior to graduation. Many of these people are beginning their 4th year, and have only done 10-15 restorations. Both of my current residents did three crowns to graduate, and maybe 30-40 restorations, and they went to a big name dental school. Some schools take 3-5 appointments of treatment planning and specialty consultation before you can actually start doing treatment on the patient - this, in addition to dwindling patient bases in some areas, is likely a significant cause of reduced experience in school.

On the other hand, about 10-20% of the time, I hear that they've done 100+ restorations, and they couldn't imagine anything less - you're in this camp, and it's a credit to your school. I did about 100 direct restorations in dental school, and felt like that was decent, but I would have liked to do more. Now, in my first two months of Residency I ended up doing that many, so there's that, haha.

Now here's the real crazy thing... you'd expect that if you did 3 crowns to graduate, and less than 40 fills, your preps wouldn't be great, and anywhere you'd go for residency would have to do a ton of standing over your shoulder work to get you up to par. In the last two years that I've had residents who graduated in situations like that, they've actually had beautiful, clean, nearly text-book ideal preps for direct and indirect. And because of that, you can focus on the real things you need to focus on in a residency - building speed, gaining experience, and increasing your confidence.

I still think it's a shame dental schools are charging more and more for less and less experience. These are things that most people would never really understand / know when you are applying to schools. And, when you're in school, most people don't really interact much with people from other dental schools, so you think it's totally normal to only do 30-40 restorations, or in your case, you think it's totally normal to do 20-30 restorations by your second year - which is great by the way!

 

[Noah Littell]

Regarding the dental specific CPA questions.. it is instrumental to find one that you can grow with long term and ideally start vetting while in residency to build trust. Like anything, if you need a dental cpa in an acute situation ie the opportunity to buy/start a practice, you will do yourself a disservice. Example: if you find this great opportunity and super excited and pay a cpa a few grand to review the financials, and if that cpa you just met tells you anything short of go for it, you will naturally dismiss him her and find a 2nd opinion for affirmation of what you want to do regardless of the condition of the practices books.

 

[P7898]

We started op at the beginning of 2nd year. So far I've done 15 direct restorations on live patients in our general dentistry clinic, and I've done around 10 or so direct restorations on pediatric patients + 3-4 stainless steal crown preps and placements on pediatric patients. At the start of second year we had one clinic slot per week. Now that we're in our summer semester, I have 4 clinic slots per week. This next week alone, I have probably 5-8 restorations planned. I usually try and do multiple per appointment.

Edit: Also, I have finished 5 semesters of dental school. We have fall, spring, and summer semesters. So technically I've finished 5 and am in my 6th (second year summer) right now.

Them NC schools are fire

 

[321931]

Regarding the dental specific CPA questions.. it is instrumental to find one that you can grow with long term and ideally start vetting while in residency to build trust. Like anything, if you need a dental cpa in an acute situation ie the opportunity to buy/start a practice, you will do yourself a disservice. Example: if you find this great opportunity and super excited and pay a cpa a few grand to review the financials, and if that cpa you just met tells you anything short of go for it, you will naturally dismiss him her and find a 2nd opinion for affirmation of what you want to do regardless of the condition of the practices books.

In my opinion, a dentist should be able to evaluate and get a jist of what the practice cash flow/financial condition is before consulting a CPA. A CPA is just to double check your homework.

Paying a few grand to review everything that looks alright that comes your way...is just throwing money away. Save the money for the ones that are standout winners and you really have a hunch is a good practice. That's where meeting with a CPA prior and learning about cash flow, s corps, taxes, what can be taken off, added back, cut costs really helps. All these things you learn through dental-town and or cpa's sorta teaching you as you go.

In the end, it's going to be your practice, your books, your money. YOU need to know as an individual what all that means, because it's not the CPA's practice- it's your practice.

 

[DrJeff]

In my opinion, a dentist should be able to evaluate and get a jist of what the practice cash flow/financial condition is before consulting a CPA. A CPA is just to double check your homework.

Paying a few grand to review everything that looks alright that comes your way...is just throwing money away. Save the money for the ones that are standout winners and you really have a hunch is a good practice. That's where meeting with a CPA prior and learning about cash flow, s corps, taxes, what can be taken off, added back, cut costs really helps. All these things you learn through dental-town and or cpa's sorta teaching you as you go.

In the end, it's going to be your practice, your books, your money. YOU need to know as an individual what all that means, because it's not the CPA's practice- it's your practice.

I think that ultimately the decision about whether or not to have a CPA look at the books prior to making an offer has to do with the combination of what one's financial aptitude/comfort level is at while looking at the numbers, one's comfort level with the deal on the table, and the amount of trust that one has in the potential seller. What level of "risk" is one comfortable with and is that worth the $$ spent on having a CPA look at the books prior to the sale going through?

Unfortunately there are some deceptive practice owners out there who will try and take some steps with their books if they really want to sell, to make things look better than they actually are. If you combine that with someone who may not have done their proper financial due diligence ahead of signing a deal, then the buyer may be in for a bit of a rude awakening once the seller leaves. In the few cases I have heard of in my local area where things like this happened, it was a situation where the seller was 100% out of the practice the second the deal was signed.

Anecdotally it seems like a seller is less likely to try and "hide" some bad numbers if the seller is going to be staying on for some period of time post signing the sale agreement and thus still has some proverbial skin in the game of the practice

 

[321931]

I think that ultimately the decision about whether or not to have a CPA look at the books prior to making an offer has to do with the combination of what one's financial aptitude/comfort level is at while looking at the numbers, one's comfort level with the deal on the table, and the amount of trust that one has in the potential seller. What level of "risk" is one comfortable with and is that worth the $$ spent on having a CPA look at the books prior to the sale going through?

Unfortunately there are some deceptive practice owners out there who will try and take some steps with their books if they really want to sell, to make things look better than they actually are. If you combine that with someone who may not have done their proper financial due diligence ahead of signing a deal, then the buyer may be in for a bit of a rude awakening once the seller leaves. In the few cases I have heard of in my local area where things like this happened, it was a situation where the seller was 100% out of the practice the second the deal was signed.

Anecdotally it seems like a seller is less likely to try and "hide" some bad numbers if the seller is going to be staying on for some period of time post signing the sale agreement and thus still has some proverbial skin in the game of the practice

Well from what I've seen is that when it comes to financials- a dentist doesn't know their left hand from their right hand. They are just that bad. When I hear about associates producing 100k a month...I just die inside...go ownership! If you can produce 100k, you will kill it in private practice.

What I'm saying is that one should be comfortable enough to sniff out the bad practices, and the good practices- and if a good practice is found- then start paying a CPA to really go through the books.

You would be crazy to buy a million dollar purchase without a CPA digging through the numbers. But you shouldn't be so financially illeterate that you have to have a CPA evaluate every single practice opportunity...because thats expensive, and number 2, you should be able to discern the ones worth really digging into, and the ones that aren't.

 

[AONLINE]

Unfortunately you're the exception. I've spoken to more than one person from a very big name dental school that said they did their first Class II on a live patient on their board exams. I interview over a dozen people for my residency every year, and I always ask about how many restorations they've done, just to get a sense of current experience level. The average I hear is about 30-50 direct restorations that they're expecting to complete prior to graduation. Many of these people are beginning their 4th year, and have only done 10-15 restorations. Both of my current residents did three crowns to graduate, and maybe 30-40 restorations, and they went to a big name dental school. Some schools take 3-5 appointments of treatment planning and specialty consultation before you can actually start doing treatment on the patient - this, in addition to dwindling patient bases in some areas, is likely a significant cause of reduced experience in school.

On the other hand, about 10-20% of the time, I hear that they've done 100+ restorations, and they couldn't imagine anything less - you're in this camp, and it's a credit to your school. I did about 100 direct restorations in dental school, and felt like that was decent, but I would have liked to do more. Now, in my first two months of Residency I ended up doing that many, so there's that, haha.

Now here's the real crazy thing... you'd expect that if you did 3 crowns to graduate, and less than 40 fills, your preps wouldn't be great, and anywhere you'd go for residency would have to do a ton of standing over your shoulder work to get you up to par. In the last two years that I've had residents who graduated in situations like that, they've actually had beautiful, clean, nearly text-book ideal preps for direct and indirect. And because of that, you can focus on the real things you need to focus on in a residency - building speed, gaining experience, and increasing your confidence.

I still think it's a shame dental schools are charging more and more for less and less experience. These are things that most people would never really understand / know when you are applying to schools. And, when you're in school, most people don't really interact much with people from other dental schools, so you think it's totally normal to only do 30-40 restorations, or in your case, you think it's totally normal to do 20-30 restorations by your second year - which is great by the way!

Thanks for sharing your perspective. To share the experience at my school, after a year in clinic most people have done 40-50 direct restorations, so I expect them to graduate with about 100. I started clinic over a month ago and I was able to do 8 fillings so far, so I think those numbers are very attainable. Most people graduate with 6-8 crowns.

 

[TanMan]

What are your thoughts on a medicaid/hmo heavy business model for a private practice?

Totally forgot about the post. Medicaid works well if you are one of the first ones with massive volumes and incentives to drive medicaid patients into the door. You have to triple and quadruple book for medicaid, as their show rates are quite unpredictable. You also have to know your state's medicaid program pretty well so you know what procedures to do, what to send out, their auditing process, etc... You don't want them clawing back any money and since it's government, you don't want to be made an example of during election season. You also have to find legal ways to attract these patients and if it means renting or buying a bus to get these patients into your door, giving away school supplies, etc... then you have to do all that if your state law allows you to do so. Know your state law well so you don't get into trouble. Medicaid patients love free stuff. You have to understand the culture of the people you are serving, in certain demographics, kids run the household, or the mom, or the dad. If you understand who run the household, you know who to target.

For HMO patients, you have to be very good at selling non-covered procedures. The "upsell" is the only way you can monetize these types of patients. HMO patients are there, because most of the time, they are looking into the cheapest plan for 2 main reasons, either they cannot afford better insurance or they were cheap to begin with. Both are not good criteria for patients. If they don't have money, then they need to have good credit so that the burden of financial risk is shifted to the lender. If they are cheap to begin with, you have to upsell like a car salesman. I've seen porcelain upgrade fee, fees for impressions, graft on every site, arestin on every site, infection control fees, etc... Most of these mills will unbundle the procedures. If you are in a poor population, you need to open up access to credit (do not do in house financing, as the risk is on you, rather than a 3rd party). If you are in a cheap/tight with money type of population, you need to sell or learn to refuse to do procedures without these upsells. Certain demographics are worse than others and you have to learn to pick your battles.

Thankfully, I don't have to deal with any of this, but this is my insight from working at the mills.

 

[DrJeff]

Totally forgot about the post. Medicaid works well if you are one of the first ones with massive volumes and incentives to drive medicaid patients into the door. You have to triple and quadruple book for medicaid, as their show rates are quite unpredictable. You also have to know your state's medicaid program pretty well so you know what procedures to do, what to send out, their auditing process, etc... You don't want them clawing back any money and since it's government, you don't want to be made an example of during election season. You also have to find legal ways to attract these patients and if it means renting or buying a bus to get these patients into your door, giving away school supplies, etc... then you have to do all that if your state law allows you to do so. Know your state law well so you don't get into trouble. Medicaid patients love free stuff. You have to understand the culture of the people you are serving, in certain demographics, kids run the household, or the mom, or the dad. If you understand who run the household, you know who to target.

For HMO patients, you have to be very good at selling non-covered procedures. The "upsell" is the only way you can monetize these types of patients. HMO patients are there, because most of the time, they are looking into the cheapest plan for 2 main reasons, either they cannot afford better insurance or they were cheap to begin with. Both are not good criteria for patients. If they don't have money, then they need to have good credit so that the burden of financial risk is shifted to the lender. If they are cheap to begin with, you have to upsell like a car salesman. I've seen porcelain upgrade fee, fees for impressions, graft on every site, arestin on every site, infection control fees, etc... Most of these mills will unbundle the procedures. If you are in a poor population, you need to open up access to credit (do not do in house financing, as the risk is on you, rather than a 3rd party). If you are in a cheap/tight with money type of population, you need to sell or learn to refuse to do procedures without these upsells. Certain demographics are worse than others and you have to learn to pick your battles.

Thankfully, I don't have to deal with any of this, but this is my insight from working at the mills.

100% agree with TanMan on all of this.

Frankly, if possible (and the way the "insurance" industry and push towards government run healthcare seems to be heading in this country now unfortunately) try and avoid treating as much Medicaid as possible. Medicaid treatment is more about treating a pre-set algorithm, where that "algorithm" is a warm body very likely with the mindset that if it isn't covered (meaning "free" to them) that it isn't needed. It gets incredibly frustrating as a provider to see a molar with a broken cusp that you know needs a crown you know that medicaid won't authorize (it costs them too much) and that the patient won't agree to pay for the crown since "it isn't covered" and you end up with the choice of dismissing them as a patient or placing the MODBL amalgam (since most medicaid plans don't pay for posterior composite in adults, and at least in my home state of CT, which has one of the "better" adult medicaid plans in the country, I can't place composite unless the patient self pays for the entire filling (and the state can an periodically does chart audits to make sure that what is being billed for is actually being done and then they will fine you for any instance they find where the treatment in the mouth doesn't coincide with what is in the chart) ). To top all of that off, in my practice at least, the medicaid reimbursement rates are roughly 50% of my regular fees for kids and around 25% of my regular fees for adults.

As a dentist, if you're treating medicaid (and even more and more these days with any dental insurance plans) you in essence are giving up a great degree of your clinical autonomy in favor of an algorithm that is pre-determined by an insurance company. In particular with a medicaid population, what I have also noticed is that often when (or more likely unfortunately IF) a person gets off of medicaid and onto a private insurance, that mindset of "if it's not covered (free), I don't need it" doesn't go away, and that then can equate into the patient feeling like you're all about the upselling and not about what is the "recommended" (only by the insurance company perspective) treatment. This is really becoming more and more of a "problem" as more and more people think that centralized, often government run, healthcare is a "better" thing because it will be either along the lines of the rtalking point of "less expensive" or "free"

With my practice lifespan having spanned the last just over 20 years now, I've gone from where I started off which was an era of way more dentist driven choices for what treatment is most appropriate for the patient based on actually clinical findings to the current system where its morphing into more of a data driven treatment path where the individual characteristics are made to be fit into a pre determined pathway that the patient in essence has to accept. It is a vastly different way to look at things, and one that frankly sure feels like what is often the most important thing IMHO we learn in dental school, our diagnostic and treatment planning skills, are less important than out abilities to enter certain treatment codes into the patients treatment plan/health record.

Folks are going to hear a plethora of talking points about healthcare delivery systems in the next roughly year and a half ahead of the 2020 elections. One needs to take the time to understand not from the outside looking in, but from the perspective of someone with gloves on and their fingers in patients mouths actually providing care, not just analyzing data about care treatment, what actually is a "better" system to allow you to treat your patients in the best way, and then advocate and educate for that among your patients and various folks who garner the most votes on election day and set policy that effects your livelihood

 

[Cold Front]

Don't worry about endo. Endo is pretty easy with the new(er) file systems out there. Waveone Gold + lots of irrigation + good activation system (Endoactivator, US, EDDY, PIPS) + BC Sealer/single cone = easy endo = easy money. Work for a high volume practice for a year to get your endo/system practice down, then buy an office. If you perf, there's always RRM. If it fails, there's retreatment and apicos. If that fails, ext/implant/bridge

If the only aspect of dentistry that you're unsure about is endo, take a weekend endo + apico/microsurgery course. Why would go through an extra year?

Are you saying that Endo residency, cost and as a specialty is not justified? I have been having this debate with general dentists and some ended up going back to school to do Endo residency after practicing for 5-7 years. Now they are facing the prospect of additional debt, and uncertainty with Endo evolving towards general dentists.

 

[TanMan]

Are you saying that Endo residency, cost and as a specialty is not justified? I have been having this debate with general dentists and some ended up going back to school to do Endo residency after practicing for 5-7 years. Now they are facing the prospect of additional debt, and uncertainty with Endo evolving towards general dentists.

Do endo if you really want to, but not because of financial benefits. The specialty, just like any specialty besides OS, can be done by a GP with enough experience and training. I don't know how anyone can go back to residency after working for 5-7 years, unless they were totally unproductive with their professional careers OR they really love that part of dentistry that they want to specialize into that field. Even if you want to do only one field of dentistry, you can always be Dr. _______, Practice limited to ___________. I can't see myself ever going back to school and I'll probably in a state of self-loathing everyday I'm there.

 

[FutureDent020]

Are you saying that Endo residency, cost and as a specialty is not justified? I have been having this debate with general dentists and some ended up going back to school to do Endo residency after practicing for 5-7 years. Now they are facing the prospect of additional debt, and uncertainty with Endo evolving towards general dentists.

There is plenty of Endo that GP’s can do. But there is also a lot of Endo that GP’s shouldn’t be doing. And when it fails / or as I say “didn’t respond to their treatment” majority send it to the endodontist for retreatment/ surgery. Don’t let anyone fool you. It’s rare to find GP’s doing retreatments and micro surgery. There will always be plenty of need for endodontists unless more psuedo documentaries come out and finally destroy us. And like Tanman said, don’t do it for the financial gain, but if you love it and are good at it, a financial gain should easily follow.

 

[321931]

Are you saying that Endo residency, cost and as a specialty is not justified? I have been having this debate with general dentists and some ended up going back to school to do Endo residency after practicing for 5-7 years. Now they are facing the prospect of additional debt, and uncertainty with Endo evolving towards general dentists.

I dunno, I think there is still a need for Endo in general. I personally gave up doing all specialty procedures because I don't find the stress worth it. When you are doing 1 mil+ and endo turns out to be .05% of that 1 mil....and its the hardest most stressful procedure that you dread on the schedule- I refer out.

Now I don't worry about post op flare-ups, missed canals, broken files, and inadequate shaping cleaning.

To me its not worth it when an endodontist does the job 1000% better, and more efficient.

When you own your business- the thing you want is repeat patients. Doing an endo- having it flare up post-op- and or 6 months later still have a fistula- and then referring to a specialist- is a good way to lose a patient and their family. Endo/OS- the two biggest procedures that can result in lawsuits/board complaints. I don't even bother with them anymore. Not worth my time, and the % gross in the practice is negligible. Zero stress.

 

[TanMan]

I dunno, I think there is still a need for Endo in general. I personally gave up doing all specialty procedures because I don't find the stress worth it. When you are doing 1 mil+ and endo turns out to be .05% of that 1 mil....and its the hardest most stressful procedure that you dread on the schedule- I refer out.

Now I don't worry about post op flare-ups, missed canals, broken files, and inadequate shaping cleaning.

To me its not worth it when an endodontist does the job 1000% better, and more efficient.

When you own your business- the thing you want is repeat patients. Doing an endo- having it flare up post-op- and or 6 months later still have a fistula- and then referring to a specialist- is a good way to lose a patient and their family. Endo/OS- the two biggest procedures that can result in lawsuits/board complaints. I don't even bother with them anymore. Not worth my time, and the % gross in the practice is negligible. Zero stress.

Although I would agree that repeat patients are good patients, it all depends on the business model. If the emphasis is on recalls and crown&bridge work, then not doing endo would work. For offices that thrive on limited exams, emergencies, and same day treatment, endo is extremely important, especially when bundled with buildup and crowns. Most tooth related problems (besides caries with no pulp issues) have two paths, rct or ext. Ext value is low, patient function afterwards without a bridge or implant is lower v. saving the tooth which has a higher value to the patient/dentist. However, I would argue that a business model dependent on recalls gives a good passive income stream, but much of the present value/lifetime value is extracted without the endo.

That's why you have to learn the whole chain of single tooth repair. If the rct doesn't work, do a retreat. If the retreat doesn't work, do apico. If apico doesn't work, do the extraction or intentional replantation (which you can do at any point of failure) w/ bridge or implant as an option if you extract.

 

[2TH MVR]

If the rct doesn't work, do a retreat. If the retreat doesn't work, do apico. If apico doesn't work, do the extraction or intentional replantation (which you can do at any point of failure) w/ bridge or implant as an option if you extract.

Not questioning your philosophy or experience, but personally I would want a positive prediction on the efficacy of a proposed treatment rather than multiple (expensive) attempts at saving a tooth. Again .... this is another example of a treatment sequence that most likely pisses patients off and adds to the distrust some patients have for the dental community.

Wouldn't a patient with a questionable tooth want to see an endodontist and perhaps be treated with as few procedures as necessary?

 

[Cold Front]

I don't know how anyone can go back to residency after working for 5-7 years, unless they were totally unproductive with their professional careers OR they really love that part of dentistry that they want to specialize into that field.

Money!

Some general dentists are not satisfied with general dentistry income, and don’t want the headaches of practice ownership and managing staff. So they try to go back to school to make higher income... and not necessarily that they love the specialty itself, even at the cost of getting into more debt.

 

[321931]

Money!

Some general dentists are not satisfied with general dentistry income, and don’t want the headaches of practice ownership and managing staff. So they try to go back to school to make higher income... and not necessarily that they love the specialty itself, even at the cost of getting into more debt.

Which is absolutely stupid considering ownership puts everyone on the equal playing field of money. Did you know for the amount of work to make the same amount as an associate- you will about 50% less. If you work the same amount as an associate (production wise) you would actually make 100% more. Those are incredible numbers.

Doesn’t matter if you are a GP, endo, omfs, whatever, at the end of the day it’s about overhead collections marketing hours days associates rooms whatever.

 

[Cold Front]

I think there is still a need for Endo in general.

Someone has to do retreats, difficult cases general dentists can’t do or would not want to touch. Like you said, there is plenty of work for general dentists, specially in good times when the economy is doing well. So in a sense, it’s better to be general dentists today and avoid additional debt of going back to school.

 

[Cold Front]

Which is absolutely stupid considering ownership puts everyone on the equal playing field of money. Did you know for the amount of work to make the same amount as an associate- you will about 50% less. If you work the same amount as an associate (production wise) you would actually make 100% more. Those are incredible numbers.

Not every dentist understands the economics of dentistry, or are completely oblivious about the potentials that is stirring in front of them. Just shows being a dentist and a dentist with a business acumen are two separate things. A lot of people get into dentistry and expect “financial success” comes with the profession as a default. Until they get a rude awakening after they finish dental school and then try to double down on that strategy by trying to specialize. Hard work + being business savvy is the true potential.

 

[FutureDent020]

Which is absolutely stupid considering ownership puts everyone on the equal playing field of money.

True, but immediate GP ownership isn’t a viable option in many desirable cities and locations.

 

[TanMan]

Not questioning your philosophy or experience, but personally I would want a positive prediction on the efficacy of a proposed treatment rather than multiple (expensive) attempts at saving a tooth. Again .... this is another example of a treatment sequence that most likely pisses patients off and adds to the distrust some patients have for the dental community.

Wouldn't a patient with a questionable tooth want to see an endodontist and perhaps be treated with as few procedures as necessary?

You would be surprised at how much people would pay to try to save a tooth with a guarded prognosis. If they are made aware of the options before going through retreats and beyond, some may opt to just extract and some will do anything to save the tooth. Dentistry is about percentages, if the patient cannot accept a high chance of failure on a guarded tooth, then the best route is pull the tooth out. However I also inform them that implants can fail too and if they fail, you may be out of options.

 

[FutureDent020]

You would be surprised at how much people would pay to try to save a tooth with a guarded prognosis. If they are made aware of the options before going through retreats and beyond, some may opt to just extract and some will do anything to save the tooth. Dentistry is about percentages, if the patient cannot accept a high chance of failure on a guarded tooth, then the best route is pull the tooth out. However I also inform them that implants can fail too and if they fail, you may be out of options.

Completely agree with this. Although I think it was your implication that a GP should and could be the one doing the retreatments and apicos which was in question. If it’s a retreatments or apico with a guarded or questionable prognosis, and the patient is eager to invest and save the tooth, as a GP I would feel more comfortable referring out to an Endodontist. And I assume 9/10 GP’s would feel the same

 

[TanMan]

Completely agree with this. Although I think it was your implication that a GP should and could be the one doing the retreatments and apicos which was in question. If it’s a retreatments or apico with a guarded or questionable prognosis, and the patient is eager to invest and save the tooth, as a GP I would feel more comfortable referring out to an Endodontist. And I assume 9/10 GP’s would feel the same

If the GP is comfortable and has the skills and training to do retreatment and apicos, why not? I've seen patients go down that path with the endodontists as well. When things don't heal properly or remain symptomatic, they'll either go down the same line I mentioned or watch the tooth with post ops prn. Patients are upset when they don't understand the variability of the human response to the procedures we perform, but if they accept that we can try our best to save the tooth and it doesn't work, then there are other options for them to pursue. It is the attempt to intervene that they are paying for, not necessarily results, especially if the prognosis was not good to start off. If what nature provided us doesn't last a lifetime, why should they expect that something manmade would last a lifetime.

Edit: We even have endodontists doing implants now. I have nothing against endodontists, I think they are great at what they do... but I don't think they are the only ones who should be allowed to do endodontics.

 

[charlestweed]

I've met a lot of general dentists who get burned out from working non-stop for 8 hours a day, 5 days/week at the corp offices. To avoid getting fired, they have to do the procedures that they don't like and treat the patients who don't pay them well (ie HMO, medicaid patients). Many of them wish they could go back to school to specialize but they couldn't because they didn't have good enough grades or because of their family situations.

Not every general dentist is good and fast at peforming a variety of procedures. Some are good at fillings but are terrible at endo. Some are good at doing endo but are terrible at making dentures. I think this is why some dentists, who have practiced a few years and know their limitation, want to go back to school to specialize.....so they don't have to deal with the procedures that they are not good at.

Spending 1-2 hours to place 1-2 implants a day as a periodontist OR spending 2-3 hours to do 1-2 molar RCT a day as an endodontist and making more than (or the same as) what an associate GP makes for working 8 hours/day are also the reasons why some are willing to spend money and 2-3 extra years of schooling. Who doesn't want to work less and make more?

 

[Cold Front]

Many of them wish they could go back to school to specialize but they couldn't because they didn't have good enough grades or because of their family situations.

Many general dentists get bored of dentistry after 4-6 years because of the learning curve starts to plateau. So boredom is not just from doing day to day procedures, but it also leads to boredom in their general life and finances. Then that’s when the “ESCAPE PLAN” cloud starts to hover over them... “WHAT IF...” slowly turns to “HOW SOON...” and then to “I’M READY” in a matter of weeks or few months. It’s the status quo of the job and income that becomes everything that fuels the subsequent decisions. The idea of looking a better job environment, or finding a good CE course to spice up the dental knowledge and make more income from that extra learning/training is not usually attractive to many dentists. Speciality to many is an answer with many “defaults” - higher default income, better life quality, a dose of happiness relative to the status quo and just an adventure all on its own. So when you start to suffer from the post-learning curve syndrome, the “ESCAPE PLAN” is a common option. I once asked my mentor in dental school why he practiced for 5 years as a solo practitioner and then closed his practice and went back to school to teach... he simply said “I was bored”.

 

[321931]

Many general dentists get bored of dentistry after 4-6 years because of the learning curve starts to plateau. So boredom is not just from doing day to day procedures, but it also leads to boredom in their general life and finances. Then that’s when the “ESCAPE PLAN” cloud starts to hover over them... “WHAT IF...” slowly turns to “HOW SOON...” and then to “I’M READY” in a matter of weeks or few months. It’s the status quo of the job and income that becomes everything that fuels the subsequent decisions. The idea of looking a better job environment, or finding a good CE course to spice up the dental knowledge and make more income from that extra learning/training is not usually attractive to many dentists. Speciality to many is an answer with many “defaults” - higher default income, better life quality, a dose of happiness relative to the status quo and just an adventure all on its own. So when you start to suffer from the post-learning curve syndrome, the “ESCAPE PLAN” is a common option. I once asked my mentor in dental school why he practiced for 5 years as a solo practitioner and then closed his practice and went back to school to teach... he simply said “I was bored”.

Ironically...going back to school is not only:
1) Hard- If you have been out 4-6 years- you probably have a family, settled down somewhere and made friends/maybe a house to. Moving the family across the country for Endo School is not an easy decision to make for yourself- and your family.
2) A very expensive and sometimes POOR financial decision
A) Lost opportunity cost and paying for school again.
B) Ownership levels the playing field for GP versus Specialist. If you choose to associate- then yes employee specialist will make more. But ownership is totally different, there many GP's that take in more income then specialists and vice versa.
3) Boredom. Ironically- you will become just as bored if not more bored. Doing a root canal day in and day out...after 4 years of doing it...is the same thing every single day. General dentistry can be jack of all trades- and in addition- you are most likely doing a family practice where the most important thing- is conversing with your patients. Specialists see patients once and then done. There is no building on that connection. You will also hit a plateau in terms of learning curve- because after the 10,000th root canal- guess what- boredom hits again.

I would only go back to school if I truly enjoyed the job. Do you hate everything about crown and bridge and endo makes you happy? Then yes go to endo. Do you hate conversing with patients all day and all you can think about is sedating and extracting teeth- then maybe go do OMFS.

Going back to school after being out is a very hard and expensive decision that shouldn't be taken lightly.

 

[TanMan]

I've met a lot of general dentists who get burned out from working non-stop for 8 hours a day, 5 days/week at the corp offices. To avoid getting fired, they have to do the procedures that they don't like and treat the patients who don't pay them well (ie HMO, medicaid patients). Many of them wish they could go back to school to specialize but they couldn't because they didn't have good enough grades or because of their family situations.

Not every general dentist is good and fast at peforming a variety of procedures. Some are good at fillings but are terrible at endo. Some are good at doing endo but are terrible at making dentures. I think this is why some dentists, who have practiced a few years and know their limitation, want to go back to school to specialize.....so they don't have to deal with the procedures that they are not good at.

Spending 1-2 hours to place 1-2 implants a day as a periodontist OR spending 2-3 hours to do 1-2 molar RCT a day as an endodontist and making more than (or the same as) what an associate GP makes for working 8 hours/day are also the reasons why some are willing to spend money and 2-3 extra years of schooling. Who doesn't want to work less and make more?

Yes, but spending 2+ more years of your life to specialize is a large hit on time. As I've said time and time again, if you live to be 50, that's 4% of your life out the door. Incurring more debt when you're already producing a relatively good amount of money in hopes that your average income increase compensates for the amount of time used and debt acquired.

If someone finds the need to specialize but wants to determine whether it's financially worth the gamble, I'd use the following parameters:

Find which percentile you're producing at as your time as a GP. This parameter will serve to determine what percentile you may produce as a specialist, assuming that your percentile ranking is based on speed/skill/business skills/luck. Second, determine the opportunity cost: Lost income over x years of specializing+ tuition/debt acquired (or if able to pay, lost interest/business income). Third, how many years do you plan to practice times the percentile income ranges of that specialty (If you were producing at the 75th percentile over the average of your years of working, you could assume you would do the same in that percentile as a function of years working).

Or, lets simplify the decision making process more... how much more money per year do you expect to make as a specialist? Does the amount of years you plan to work times the additional money per year outweigh the tuition/lost income and how long will it take to make the money back? What is the ROI of your additional training and educational expenses?

In my situation, there is no way I'd give up my GP position to specialize. I could not regain the money back in a timely manner to retire early.