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.