I had an interesting conversation with an orthodontic resident Monday at the AAO Annual Session. A couple of friends of mine and I were sitting at a table catching up when a senior resident approached and asked if they could “get my advice on something”. Of course I agreed and the resident asked me what I thought about doing ortho out of a GP office and how much of a percentage of production they should pay the GP to do that. I said that I would never pay a percentage of production to a dentist as that is a good way to get the boot once they see what you’re doing AND because it’s fee splitting in some cases. I went on to explain that short term it can be ok to practice out of a GP office (and I know people who have done it a long time but that’s the exception) but it usually devolves over time because the dental staff resents you invading their space and other dental offices won’t refer to you. The orthodontists sitting with me agreed and offered their insight but then a funny thing happened… The resident said, “No, you don’t understand. I will be going in on the GP’s non-patient days so none of that applies to what I’m doing.”
This is when I knew the convo would get interesting. I said to the resident, “So, you have three orthodontists here who have practiced between 14 and 20 years and have done reasonably well and have the benefit of decades of screw ups and failure and you walked up and asked for advice but you’re now saying that you know better and we don’t understand? Look, I’m happy to help you but if you already know what you want to do and how why don’t we just stop right here?”

The resident assured us that they wanted our advice and proceeded to explain that they “Had to be in the GP offices because the guy selling the office they were going to buy decided to delay the sale 9 months so they needed something to do until then.”

I asked why they were so focused on this one area? Had they done a demographic survey and found an awesome spot? Was the office they were buying really awesome? They told us that They “couldn’t move out of the area because their spouse’s family wouldn’t let them” and I mentioned that this may not be the soundest business reason to practice in a certain area but they assured me it was.

Now I’ll admit that I’ve had this conversation many times in the past – tried to explain that living and working somewhere because of family is a personal decision and that you cannot backfill business reasons for it if it’s the basis for your decision – and I know the futility of such discussions so I let it go.

Next the resident explained that there were two practices in the area. One was doing 1100 starts a year and the other 81 starts a year. I asked which they were buying (though I already knew the answer) and then learned it was the 81 start practice and that the seller had another practice 25 miles away (the same seller who was delaying the practice sale). To our experienced ears this sounded suspicious and we collectively tried to tell them so but the resident would hear nothing of it and told us they knew what they were doing because they knew the area well. We asked why the resident would buy such a small office instead of finding a larger one or doing a startup and they explained that “they could buy this office for a lower price” which left us amazed and shocked and a little amused while fearing for the resident’s wellbeing.

The resident went on to say they were moonlighting at a large corporate practice and that the office manager at that practice said they would “send the resident all their patients once they bought the 81 start a year practice.”

“Right now they are sending all of those to the 1100 start a year practice but that will change when I get there. That’s 150-200 starts a year right off the bat”. To which we collectively responded in turn, “That’s awesome as long as the manager is authorized and able to do that, the existing orthodontist’s reputation is not strong enough to override the OM’s recommendation, the corporate practice doesn’t bring in an orthodontist and the OM retains the job indefinitely.” The resident explained, as politely as they could manage and with great consternation, “That we just didn’t understand the situation and that there was no way this OM would lose their job any time in the foreseeable future.”

At this point I finally realized that the conversation was pointless (yes, I’m very slow) as it is very difficult to add anything to a cup that is already full so I changed tactics and just agreed with everything the resident said.

“That sounds like a great idea” I said not really listening as they went back over the GP office model, the practice purchase and the flood of patients they would get from the other office as if they were explaining it to children. When they finished, I said to my colleagues, “I totally agree with them, don’t you?” They readily agreed shaking heads and gesticulating while suppressing laughter. This seemed to satisfy the resident. We thought they might have caught on to the fact that we were appeasing them in order to end the convo but we are not altogether sure they did – and if they did realize it, we are sure this was no deterrent to the plan.

So why tell such a silly little story?

Because I’ve had this conversation literally hundreds of times. People who come to me asking advice but already knowing what they want to do. It’s a waste of time for them and for me and it reminds me of how much I knew and how confident I was in my way of thinking when I was a senior resident. I was the smartest I’ve ever been my last year of residency but the truth is that I didn’t know anything about anything. Worse than that is that I didn’t know what I didn’t know. Luckily for me I was scared and because of that I didn’t go home to the East Coast, I bought a practice in a little town in Arkansas – one that the owner financed for me.

The problem today is that the student debt numbers are much bigger (I owed 320k back in 2004 and that was a lot then but it’s below average now), the desirable markets are getting tighter, the competitors are multiplying and everyone believes they need really expensive stuff to be a “good orthodontist”. On top of that, orthodontists, orthodontic educators and organized orthodontics refuse to consider or even discuss that it may be time for orthodontics to change in a real way. You should hear all the wailing and moaning over Marc Ackerman and I being asked to speak at NewConn in 2019 (and I’m sure it will only get louder as more people know about it). What the hell is so frightening about hearing an alternative view of the orthodontic world? Given all that is going on shouldn’t we at least consider our options instead of trying to suppress anyone who doesn’t toe the party line?

I beg residents and recent graduates to take a step back and consider what you KNOW. If you don’t you’ll have to learn everything the hard way – through failure and disaster – just like I did! The problem being that the stakes are much higher these days and the margin for error is far narrower.

Orthodontics is a great profession and if dummies like me can make it then you can know with certainty that you can too. You just have to be smarter about it and consider more options with an open mind than I did when I graduated in 2004.

18 thoughts on “Senior Ortho Residents Are The Smartest People On The Planet!

  1. Haha! This reminds me of a conversation I had with you 10 years ago when I was just getting out of residency…and I knew everything I needed to know. Why would I let some guy with a weird accent who talks fast dissuade me? What does HE know?
    Fast forward 10 years, and my only regret is that I had asked more people, been willing to listen, and do what they were saying. If only.

  2. Bravo!

    In the US, we’ve lost what it means to be a constant learner. This is especially discomforting to see in postsecondary education. By teaching students to pass tests, we teach them nothing and prepare them poorly for the real world and its challenges.

    I don’t see this trait in our European and Asian-Pacific clients. In their training, most were given oral exams, not multiple choice or fill in the blank queries to be memorized. They understand the more you learn, the more you realize how little you know.

    Unfortunately for you and I, and most orthodontists reading this blog, we had to learn all of this the hard way, through scrapes, scars and bruises in the real world. We’re slow but we finally grasped the paradox that failure equals success.

    The resident you describe will unfortunately have to acquire the same scrapes and bruises over many years.

    Two articles of interest.

    One from someone much smarter than me, author Mark Manson:
    https://markmanson.net/paradoxes-that-are-true

    One recent post to private clients and members of The Burleson Report:
    http://www.burlesonorthodontics.com/articles/On_Being_Wrong.pdf

    See you and Bridget in Kansas City soon!
    – Dustin

    1. In agreement with what you said, Malcom Forbes has summarized it beautifully: “Education’s purpose is to replace an empty mind with an open one.”

  3. Hey Dr. Burris,

    My experience as a resident definitely mirrors what you say. Many, maybe even most, other residents talk about practicing on the east or west coast, and the ones that want to compromise only go so far as moving to a place like Austin, TX…since Austin is apparently some underserved area…

    I’m definitely seeing the trend here. I hope I can stay open minded enough.

    May you provide any links to demographic survey or street traffic monitoring resources? I keep asking in residency about this, but I mostly just hear back “use Bentson Clark or McGill”. Maybe that’s the best route, but I want to be in more command of the search process and develop my own sense of location valuations as I grow. If that’s the wrong way to go, I would love to know that as well.

    Anything you can offer would be appreciated. Thank you.

    1. I did a google search of “free demographic information by location” and found tons of options. Local chamber of commerce, post office delivery info and real estate agents showing commercial listings are also good sources of free info. When you actually look at a commercial space the prospectus should come with demographic information in 1, 2, 3, 4 mile increments as well as traffic flow info. Another way to get traffic flow info is to find a billboard near where you are interested in and call and ask for that info from the people renting out the billboard. I used OrthoSynetics’s demographic research program because it can account for lots of things I’m interested in like income, number of people per household, average age, local school info (most programs out there can do this) and then compare that to what they know of offices they work with that are successful. When we did the research in Orange Co FL, I chose where I wanted to be because of the population density and the stats about the population within 4 miles of desired location. Once you find a promising area you just keep looking around at what is available in that area and re-examine the specific location once you have a site in mind. You can also compare the numbers the real estate agents give you with the demographic survey (they don’t always match up as the real estate agency is interested in renting the space primarily). In our case we chose a 5000 square foot space when we really just needed 2500-3000. This might sound crazy but in the area we wanted to be (because of the demographics) there were only 1000 or 5000 sq foot spaces available. You can check out our office at https://www.facebook.com/SmileyFaceOrlando/ or MySmileyFace.com if you want to see what we are doing here in Orlando. Let me know if you have other questions. As a general rule of thumb, whatever everyone else is doing or suggesting you do when it comes to the business of orthodontics is to be viewed suspiciously. If it were as simple as that then the vast majority of orthodontists would have more business than they can handle… Logically, all things being equal you should be suspicious of any advice you get and try to err on the side of listening to practitioners who are successful over those who tend to whine and cry about how difficult life and practice are. FWIW
      Free advice is worth what you paid for it! 🙂

      1. Man, that was a badass response…way more than I usually get to that question. Thank you!

        I’ll definitely heed your advice about taking advice. I try and ask as many questions to as many orthodontists as I can and obviously I take way more value in the advice of successful orthodontists. I’ve heard of some orthodontists who struggle and just and then blame the “type” of patient they get and that just sounds crazy to me.

        Another big question I have yet to be answered was which practice business models fit which demographic bases. My general observations in residency are that downtown offices are much different than suburban offices. Lots of people want to come out and just start a really high tech office regardless of location or the demographics of their patient. But I’m not sure if this is the right strategy. To me, the office should match the location, and not just your personality. But I don’t yet know how to match the offices to the locations. I’d imagine your practice model of cheaper faster tx does well in an area with low to moderate incomes..as opposed to an area with a higher % of wealthy adults, but I really have no idea and I may be too presumptuous with these assumptions.

        I wish I could just ask you every business question I have haha. That probably sounds like a real suck-up comment but business just seems to be a more minor focus in residency yet I would imagine it becomes everything once you get out.

        1. This is the stuff I like to talk about. It’s hard work challenging the status quo and the orthodontic group think that prevails, there are lots of ways of doing things, I certainly don’t have all the answers and few listen but it’s worth the effort to watch the successes. I can’t tell you how many residents and recent graduates have come to visit my office in the past to discuss this stuff in detail – if you want to talk about all your questions that’s one of the best ways btw – and I expect there will be many more visitors now that I’m in Orlando instead of Arkansas. I’m also talking with Carestream about putting on a one day course for residents talking about how to select a location, design, build, equip, market and run a pracrice. Basically I want to do the course I wish I had when I was in school. Hopefully it will become a reality.
          As to your questions about type of patient there should only be two types from an orthodontists’ POV – those who have braces and those who don’t know they want them yet. If we are not at capacity (we are not) why would we ever judge any patient? If we judge patients as the wrong type then what do you think that does to the way we treat them and thus likelihood of them starting? It’s a self fulfilling prophecy! If a patient decides not to start how can we automatically assume that the problem lies with them? This is a stupid way of thinking but almost all orthodontists think this way. Search the term “those people” here on OrthoPundit and you’ll see I’ve talked about this once or twice. As to your question about type of practice and location that’s actually pretty simple. Basically IT DOESN’T MATTER WHAT WE WANT OR THINK as orthodontists. It only matters what consumers want and think. In the old days your professors tell you about you could do whatever you wanted and make a reasonable living but these days unless you go to nowhere USA when you get out you’ll have to wise up and offer a product and a price point that consumers actually want if you expect to have any patients. This is a big topic and I’ve written on it before – search the word “modulate” and a useful article will surface. Good questions. Keep asking not only me but everyone the how’s and why’s that don’t make sense. I got beat up in dentals school and residency for doing so, I got beat up by my dental peers for doing so in AR and the AAO and I continue to get beaten up by those who approach me in person, at talks, on the blog, over the magazine and about our book… being a pariah is tough but it’s better than following blindly and it’s worked out pretty well for me thus far. Kanye said it best, “There’s leaders and there’s followers…”
          Come visit in Orlando sometime and bring your classmates if you can. If you keep asking questions you’ll figure it of. Have a great weekend.

    1. I’m glad you didn’t meet me when I was a resident. No telling how harsh you’d have been to me – I knew EVERYTHING when I was a senior resident but luckily I’ve gotten dumber every day since.

  4. Thanks for sharing the story Dr. Burris.. I have recently started reading your work and find it very helpful. If the resident reminds you of yourself, I think he’ll do well and find his way :). I actually wish I had a little more courage to follow my instincts getting out of residency. I took everyone’s conventional advice and followed it, too scared to try something different. All worked out fantastic, but I’m no Burris or Burleson. 🙂

    I am sure that guys like you that are helping change the course and direction of Orthodontics were probably viewed the same way as you view this ‘new kid’. So my request: don’t discourage or be condescending because they disagree with you, and continue giving them advice even if they’re not listening… Cause after the mistakes it’ll sink in much better. Thanks again for all the content you provide.

    1. Thanks so much for commenting. Can you point out where in this piece you think I was discouraging or condescending?

  5. Haha!! First I really appreciate you taking the time to reply! U da man! I was a little reluctant about using that verbiage and I was sure you didn’t mean it that way… ( I wish I knew how to send you my comment in private because I did not want to come across as being rude). So my apologies in advance.

    But, I felt like the heading ‘Ortho residents are smartest people on the planet!’ Def has some sarcasm built in. 🙂

    The picture you built about you nodding your head in ‘fake’ agreement to end the conversation… while your colleagues ‘gesticulating and holding back laughter’ has a little negative tone built in. I have to agree it makes for a fun read and you are telling a story. But overall I pictured a sarcastic tone in that conversation. I maybe totally wrong in doing so… In any case, please keep on writing, I look forward to reading more of your views. Thanks again for your response.

    Also, will you be doing the ‘Straighter’ course in 2018?

    1. Thanks for explaining. I have a few questions tho. From my point of view as the person who has the info someone else wants… I have someone come up and interrupt a conversation with me and two friends asking for advice, the three of us agree and give the requested advice but then are told we don’t understand, I stop the person asking for info and politely ask if they really think they know more than the three experienced and successful orthodontists they approached out of the blue and then suggest we end our conversation because it is obvious to me that they aren’t going to take any advice, the person refuses to take that advice as well and assures me they want advice, we give it to them again – twice more in fact – but are told we don’t that we don’t understand… What choice did we have but to agree in the hopes of getting them to leave us alone? We repeated ourselves and were rebuffed repeatedly. We didn’t ask this person for anything or for their company after all…
      Then I tell a story as it happened in an attempt to help others and implicate myself clearly as being just like this resident when I was a senior resident to make the point that senior residents need to pay attention as they have less margin for error than I did. AND I readily admit that I was no genius – that I just got lucky because I was too scared to be overconfident and that’s why I went to Nowhere, USA. Then I employ a time tested technique that I and other journalists use to get people to click on and read the article and you are saying that I shouldn’t have done any of this? How then, in your opinion, would you like me to deliver my extremely valuable and FREE advice to individuals who I do not know who approach me out of the blue? How would you have me post insightful stories in my attempt to help others that I don’t know and will never meet? I charge a nominal fee for full access to this site but the articles I’ve posted in the last week alone can make millions for anyone smart enough to pay attention. I’ve got a study group full of people who will readily admit that those who hang around with and listen to me make mega-bucks while making people smile and having tons of family time. Should I not have challenged Charlene White’s article and the mindset of average being good? Should I never question the AAO on the things they do (did you notice that AAO member registration was only 300 bucks or so this year btw?). Should I stop helping anyone or doing anything with anyone I don’t have a close relationship for fear of offending people? I’ve heard your complaints about how I do this but what is your solution? Upon what do you base your suggestions here? Do you have experience in mass communication or mentoring? Have you gotten exceptional results (positive and negative) that others want to know about on a grand scale? No matter what I say or do, someone will always know better even though they have never done and will never do anything like what they are giving advice on. Do you seriously assert that I can’t have thoughts and feelings and opinions and react to the stimuli given by those who are asking me a favor? Do you really believe there is a way to do anything that will not be offensive to anyone? Honestly I get many more of these info requests in private than I do in public – FB messenger, text, email, etc – and I spend a tremendous amount of time helping those who want to be helped. I cannot, however, help someone who already knows what they want to do and who wants me to agree with them. When I find myself in this situation then I have several choices – I can get up and walk away, I can flatly refuse to talk to the person, I can give my honest opinion and, when they tell me I’m wrong I can ask them upon what they base their knowledge (nothing is the answer and they get upset about this) OR I can agree with them until they go away. I chose the final option as this was the least confrontational and perceived as the kindest though it certainly is not (in my opinion). If I knew and really cared about the resident I would have grabbed them by the collar and shook them (metaphorically speaking) and told them I was terribly afraid for their future and that they needed to wise up. I did this very thing to a dear friend on Sunday in DC. It’s terribly risky and takes a lot out of me so I will only do this for those I love. The fact that you and most others in this profession believe that soft words and avoiding offense is kindness and caring when you know the person in front of you is deluded and needs help is very troubling to me. The only way people know they have options other than those they are familiar with is to have their core beliefs challenged. I used to be idealistic and willing to do this day in and day out in a group I ran called Young Docs and then Ortho101 but last year I finally realized that, not only do people not want my advice, objections and questions, they find them offensive and view any disagreement with their core beliefs as personal attacks. So be it. Since disengaging I have a lot more free time to do things I like with people I love. I’ll talk about, write about, speak about what I like with whom I like in the way I like and others are welcome to partake or not. I take advice on how to be more effective from those who are equally or more successful than I am. I ignore the advice of those who have done little to nothing and know very little. It’s that simple.
      Thanks again for your comment. The one piece of advice I would give all who read this article and these comments is this – if someone has something you want – info, wealth, stuff, time, whatever – it’s probably a good idea to approach them in the way they want to be approached and accept their value in the way they want to offer it. It just makes common sense and, more importantly, it works. Of course don’t do this unless you really want to hear what they have to say!
      Good luck to you. Have a great week.
      ben

  6. Ben,
    Thanks again! My sincere apology brotha! I have met you once and I was impressed that time, and even more with your current response.
    You are 100% correct I have never had to communicate on a large scale, nor can I relate to lot of the things you have accomplished. I regret implying you were discouraging, as I can understand why that would upset you, after you have helped many.
    I really do respect your work and content, and should’ve used better words. Thanks again for taking the time to respond. I hear your view, loud and clear!
    T

  7. No need to apologize. It is a discussion and a useful one at that. Please don’t read anything into my response other than an attempt to explain where I am coming from and why. I want orthodontists to do better and I work hard to help them do so. I can’t reach everyone or make everyone happy and that is very frustrating. If I were a better communicator perhaps I could make everyone happy but if I strove for perfection and waited for that then I’d never do anything. Such is life. Make peace with imperfection and move forward. Again it’s good that you shared your feelings on the matter so I could explain where I’m coming from. I heard you and I’ll keep working on doing better. Thanks.

  8. You mentioned earlier concerning demographic parameters such as “income, number of people per household, average age”…Do you have benchmark numbers you look for with these categories? Thanks in advance and thanks for valuing the truth over feelings.

    1. I do but they are not what other orthodontists would consider “good”. I like to be in high traffic commercial areas that are surrounded by tons of neighborhoods where median household income is, well, median. I avoid the top 10-20 percent of the socio-economic pyramid that most orthodontists covet in favor or serving the masses. I prefer the lower end of the spectrum than the 1%ers and have always sought to serve the underserved. It works well for me and I love what I do!

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