Monday, December 31, 2012

Turn The Page, Wash Your Hands

On the eve of a new year and I just had to get one last post in.  I know, I know, the posting train has slowed to a veritable crawl, but such is life.  My PC did eventually succumb to the computer equivalent of Alzheimer’s.  It just stopped remembering how to open any application, and the process of buying a new one is rather expensive.  I was in no particular rush either as we usually just use an ipad or our phones for internet stuff in the house.  However, typing up blog entries just doesn’t feel right unless I’m at a trusty desktop.  So here I am, new PC (with crazy windows 8) at the ready.
So I read my last post and found it to be extremely negative.  I don’t want to be ‘that guy’ so I’m attempting to look more on the positive side.  I do tend to use this blog as a mental venting source every once in awhile, but I don’t want that to be all it’s good for.  I honestly feel my overall pessimism is from being a Chicago sports fan.  Let’s face it, our teams generally suck.  And when they tease you with glimmers of hope, they choke it away in the last month of the season.  I’m looking at you both Bears and White Sox.  But this is not a sports blog, so I digress.  I haven’t had much dentistry in my life these last 6 months which I can use as an excuse for limited posting.  Yet, these past months have felt more busy and full of life moments than most do.  I got married in July, went to Maui for a 2 week honeymoon.  Hell, I finally left the country for the first time in my life.  We visited Taiwan and Japan for a 2 week tour in earlier this month.  The wife has a lot of extended family in Taiwan and we just went to Japan for the hell of it afterwards.  Being a creature of habit and routine, I figured this extensive trip would stress the crap out of me, but it ended up being really fun (minus the 2 week jet lag).

I did work temporarily in a public health clinic and was grateful to at least maintain some of my hand skills and dental brains.  But now, as we bring in the New Year, I finally appear to have a dental home for the immediate future.  I will be working in the same office as my wife.  As we plan to eventually own a practice together, I feel this will be an excellent trial period to see if we can get along professionally in the same working space.  If it doesn’t work out, better to find out before we sink 500k into a practice.  And there isn’t anything wrong with that either, there are plenty of married dentists out there that work in separate offices for the duration.  However, I’m hoping to be in the other category as the journey of business and ownership would be more palatable for me as a team rather than on my own. 

We hope to stay on as associates in the practice for the next few years while we improve our clinical and business skills whilst bringing the debt down.  Ultimately want to own a practice within ten years.  Ideally like to be transitioning within five.  We do have one practice in mind at the moment owned by two dentists (also married).  We met them during Dental School and have kept in touch, seems the timing for their retirement may work out perfectly with our own timetable for ownership.  There is interest in both camps, but obviously things can change, but it’s nice to at least have a possibility.  I would prefer to transition a practice rather than buy one outright.  But we may end up doing that if we can’t find the right fit.

So the year of 2013 should be the one where we finally can start saving money and increasing our loan slaying.  We’ve also spent a lot on vacation, the wedding and the holidays over the last year, so it will be nice for a low key year where we can develop a routine and start putting money away for our eventual migration from the city proper.

It still feels weird not having the ‘next grade’ to go to in terms of education.  No more tests, no more class, no more paying tuition!  Start my first associateship on Wednesday!

I have no more to say folks; I look forward to relaying dental focused entries again in the coming months.  Granted, job hunting was viable topic, but it is also not really that exciting as there is just so much waiting involved coupled with bursts of excitement and/or frustration.  I will look back on these past 6 months happily in the future as a time of self-discovery, patience, and humility.  Everything works out in the end, just seeing that happy ending sometimes is tough.

Happy New Year everyone!

Monday, November 5, 2012

The Current State of Blah

When I got into dentistry, every person in the field that I shadowed/spoke with was so excited about my decision.  They all claimed it was perfect timing.  I would be graduating just in time for all those baby boomers to retire and sell their lucrative practices to me.  If I had known this was total BS, I may have chosen a different career path.  Well, not really.  I do think this job in itself is awesome.  I truly enjoy being a dentist; however, the actual state of our profession for young dentists is absolutely atrocious at the moment.

Firstly, the cost of becoming a dentist is unrealistically absurd.  I went to a freakin’ state school, was a resident of said state, had my parents PAY for housing, and still left with 250,000 in debt.  My wife is from New Jersey, so her out of state tuition was about 500,000.  Do the math people, with the friendly interest rate of 6.8%, we will essentially be paying back well over a million.  A MILLION!!!!

But hey, dentists are rich right?  They make tons of money right?  WRONG.

ESTABLISHED practices that are OWNED by a dentist make money (usually).  New graduates make very little in comparison.  Now money is all relative I suppose and if some dude who manages a McDonalds read this, he would tell me to shut the hell up.  The amount of money I make is a lot more than most people, this is true.  However, most people aren’t crippled with 5K in loan repayments every month either.  They also didn’t spend an extra five-years after college to earn that debt reward.  We essentially are paying for two houses at the tender ages of twenty-eight.  What’s tougher is that the job market (particularly in Chicago) is non-existent.  Nobody wants to retire, and nobody wants to hire.  New grads are essentially shoe-horned into corporate dentistry which is a topic for another day.

The extreme debt also makes it nigh impossible to buy/start your own practice.  No bank is going to loan you 500k-1mil when you already owe the government 750k.  And hell, I would probably go insane with that much debt.  This leads me to a quote one of our instructors said in school.  “As a dentist, you are always going to be in debt, you just learn how to manage it.”  Depressing…but seems true at this point.

You know what else nobody tells you? How much money it costs to stay a dentist after you graduate – having lawyers bleed you for incorporation/contracts. Paying for your license, malpractice, paying for CE, paying for paying, everyone wants a piece of you because you’re a dentist and you’re supposedly wealthy.
Now my original job was lined up nicely, I was going to come back from my honeymoon and start in August. Basically, we couldn’t come to terms on a contract. The reason we couldn’t, was because the owner did not understand the concept of negotiation but led me along like he did. The original contract had me as an Independent Contractor which essentially lets your employer skimp on paying any of your taxes. Most contracts for associates have you as an independent contractor and I understand this. I figured it couldn’t hurt to ask though, so I inquired if he would be willing to make me an employee instead. He offered NO resistance whatsoever to this suggestion and even asked me to have a contract drawn up. So after shelling out hundreds of dollars for a lawyer to do just that, he calls me up and tells me has another applicant in mind who IS willing to be an independent contractor and I would need to take the original contract to be on ‘level playing ground. 
Horseshit good sir. Horseshit. I forgot to mention that he told me point blank he was not interviewing anyone else. So was I applying other places during this 4-week negotiation-nope. So I bowed out. Frustrating as hell, but an excellent learning experience. I learned that most dentists don’t know anything about business. They just do whatever their lawyers or accountants tell them to do. I can’t blame them either, I know nothing at this point myself but I definitely hope to learn.  

This was all back in September so I’ve been scouring the lands trying to find another opportunity ANYWHERE. Nobody replies to classifieds, I have been mailing my resume to tons of local doctors in hopes of finding a lead. Nothing. Zero. Zilch.

OK, it is rough, but I am also complaining more than necessary.  We aren’t being starved out or anything, but we really aren’t able to save or plan or do any of the things most young married couples get to do.  Kids?  Hell no, can’t afford that.  Buy a house?  Same thing.  Now obviously this will change in the coming years, but these are issues I wish I had been more prepared for.  I did five extra years of education so that I could enjoy a career and have a life outside of work, it seems like that isn’t on the table currently.

But hey, my life mantra is that “everything will work itself out in the end.”  And guess what, it seems to be happening.  The office my wife works at is owned by an older doc who wants to cut back.  This equals job opening for me.  The place is established and successful.  We aren’t really interested in buying-into it because it's on a larger scale than we are currently interested in, but it will be a great place to learn both the clinical and business ends of dentistry.  It also pays better than any other office I have looked at.  I start in January 3-days a week (plus more when the head doc is on vacation). 

I am working part-time in a public health clinic right now, filling in for a dentist on maternity leave.  I’m actually enjoying it more than I expected (namely because the staff is fantastic).  Public health is a whole other can of worms though that we will not broach today.
I guess the frustrating part is that I don’t feel the residency helped me at all in terms of finding a job.  However, I still wouldn’t change my original stance.  I feel the learning I did in that short year will translate positively into my clinical interests, strengths and goals as I develop throughout my career.
So 2013, the year I actually start a solid, not transient job – hooray!  2012 has been tough these last few months – but it has thickened my skin and made me stronger and smarter.  I realize now that dentistry is a lot like any other job.  You still have to pay your dues and work the trenches as a newcomer.  And hey, having so much time off these last few months has helped me develop important life skills such as cooking and exercising regularly.  I have probably never lived so healthily in my entire life.  Of course now that I am getting older, this is far more necessary as my metabolism can no longer support fast food every week.

So to all the aspiring young pre-dents out there.  This post is not intended to scare you away.  This profession still is great and has so much to offer.  However, it would be wise to have your expectations tempered just a bit so that reality doesn’t crush your skull in after graduation.  If you don’t have family in dentistry, and aren’t willing to move ANYWHERE in the country, finding a good job takes time.  Most associateships don’t work out either, it’s like dating – awkward, fun, frustrating all at once.  You need to spend within your means as well.  I still drive the same POS I had in college and I’m fine with that.  All the extra money goes into slaying the debt monster before he devours me whole.

And I’m spent.

Wednesday, September 12, 2012

The GPR – Good Idea or No?

Three months out of my completed GPR gives me plenty of time to retrospectively evaluate its worth.  However, I probably won’t be able to truly evaluate the future perks until I get a solid job.  I will discuss the job search in a later post but to sum it up – I have nothing long-term locked in at the moment.  Getting married and going on a honeymoon slowed things up considerably, but my recent contract negotiation which has essentially exploded into nothingness is what really set me back.  I was also na├»ve enough to think that the office I was in negotiation with was not interviewing anyone else whilst negotiating with me.  Seems a bit tatty of them, but hey, won’t make that mistake again. 

But that is a story for next time.  I know I already covered the basic GPR itinerary, so I won’t repeat myself (too much anyways).  The program was exactly 12 months long with an optional second year for those interested.  At my particularly program, they probably get one second year every couple of years.  My group had one such second-year or “chief” resident.  This was both a blessing and a curse.  On the one hand, the second-year provides a great deal of guidance for a lot the first-time experiences (particularly being on call, handling hospital consultation/emergencies.).  On the other hand, the second-year gets a TON of complicated cases and pretty much cherry picks all the good stuff from the previous group.  To put this in perspective, the year before mine placed about 20 implants as a group.  I did not get to restore a single one.  That’s right; I restored more dental implants in dental school.  That is a major con right there.  Our second-year guy was pretty cool though, and I did work with him on multiple occasions for both implant placement and extraction of thirds.  These experiences were extremely positive and I took a lot out of them.

So what is the main purpose of a GPR?  In my mind, it is for someone who wants to be a general dentist, but isn’t sure exactly where to focus.  As a GP, it is really not possible to be great at everything.  That is why specialists exist, to take care of the tough cases that you just don’t have the experience to mess with.  When I graduated dental school, I had no idea where my true strengths/interests were.  I needed more time to figure out where I wanted to focus my continuing education, what strengths I would have in my practice.  One year later, I can tell you I have a strong interest in implant placement/restoration, conscious sedation, and minor perio surgery.  I can tell you that while I don’t particularly love endo, I no longer throw up in my mouth a little when one walks in the door.  Will I be doing a lot of molar endo?  Doubtful.  Can I get it done given the time?  Sure. 

The same can be said for third molars.  I can get most teeth out quite easily now, even the hard ones come out too given the time.  The big thing you learn is time though.  If it takes me one hour to take out 4 impacted thirds when an OS can do it in 20 minutes, then it should be referred.  Simply because it isn’t particularly fair to the patient or in their best interest to be getting cranked on for three times the necessary amount of time.  But again, the GPR has given me such a broad scope of experience with removing thirds that I have a much greater idea of my limitations then I had coming out of school.  The month I spent at cook county was invaluable in developing speed and just seeing a shitload of cases.  The more you see/do the greater your experience, the better you are.

Now all GPR programs are different, they all have a variety of rotations and patient population, so it is hard to quantify numbers.  For example, I was pretty disappointed in my prosthodontic experience overall.  I probably only did about 10-15 units of fixed in an entire year whereas most of my colleagues in private practice are doing that many per month.  But I did more endo than many of them combined.  I took out far more teeth, placed a number of bone grafts, placed an implant, the list goes on.  So while I gained extreme experience in certain areas, I was underdeveloped in others.  In only 12 months, you can’t expect to get it all.

One of the more unique experiences of my program was that every single Thursday of the year is dedicated to treating special needs patients.  This is also where we get the bulk of our conscious sedation experience.  2-3 residents per week would have 2 or 3 sedation cases (1.5 hr time blocks).  Whilst everyone else would treat other patients in 45 min blocks.  Now most ‘other’ patients would probably be good candidates for sedation as well but we just don’t have the numbers or time to treat all as such.  So we get by with restraint or oral seds.  It is tough work, truly.  It is similar to uncooperative pediatric dentistry except the patients can weigh 300 pounds and be far more violent.

The IV sedations themselves are an adventure.  Imagine trying to place your first IV on a patient that is thrashing their arms wildly and trying to bite you.  Pretty unnerving, but you get used to it.  The month we each spent in the anesthesia department in the hospital also really boosts the IV placing skills.  Another plus, albeit somewhat morbid is that since these patients are so uncooperative, we must take them deeper than would be ideal in a standard office setting.  You see, an ideal conscious sedation is just that, the patient is still conscious, although in a bit of a twilight.  The drugs we use also tend to produce amnesia so that is why you don’t remember that wisdom tooth appointment much at all.  A cooperative patient can respond to commands, and more importantly, breath on their own/protect their own airway.  In the special needs patient, we aren’t so lucky.  We must take them deeper, not enough to shut down their breathing, but enough to remove the response to verbal commands.  But as anyone who has worked in anesthesia before knows, this is a very vague and fine line at best.

This results in a lot of situations requiring airway management, either through nasal airway placement, positive pressure ventilation, or a simple head tilt chin-lift.  Seeing the O2 sat drop for the first time or your patient turn blue is absolutely terrifying.  However, seeing how to manage these situations was so absolutely vital.  Our anesthesia attending is always nearby and was one of the best instructors I have had from kindergarten through the end of my formal education.  He encouraged thinking over memorization, and never got flustered regardless of how much proverbial (or literal) shit was hitting the fan.  And that’s just it.  You need to stay calm in emergent situations.  Most dentists will experience one or fewer office emergencies throughout their career.  The rarity of it makes us lazy, unprepared, and that is when you read about some poor soul dying in a dental chair.  You need to keep up to-date, maintain your BLS/ACLS, and keep your staff ready.  Simple as that.  Most dental emergencies are so unbelievably easy to manage if you just stay calm and know your role.
So I have actually received my license in conscious sedation just this last month.  I feel quite comfortable with light sedation on healthy patients at this point and have done well above the minimum requirements for the license.  However, I do realize this greatly increases my liability and overall responsibility and is not something I take lightly.  If I can’t find the right office to perform sedations, I simply won’t perform them.

That leads me to my final major assessment of why the GPR was great.  Dealing with dental emergencies.  Not the kind where the patient is having a stroke in your chair, but the kind where you get paged at 3am because some drunk asshat fell on his face.
The ER is an absolutely unique place – particularly in the middle of the night.  Now I can say that fortunately, through six weeks of primary call and 7 weeks of secondary, I only had to physically drive to the hospital in the middle of the night once, which all things considered, ain’t that bad.  However, we would constantly get stuff during the day or random calls from patients over the weekends.  A valuable tidbit of info I learned – Pain is NOT an emergency.  Does pain suck?  Yes.  Can it lead to an emergency?  Yes.  Will dental pain likely lead to an emergency overnight?  Unlikely.  Most calls are from people who put off seeing the dentist, maintaining a state of delusion that if they don’t do anything, it will go away.  We are all guilty of doing this at some point or another in all walks of life.  The problem is, outside of generalized sensitivity, specific tooth pain is indicative a problem that will NOT go away.  And unfortunately, the longer you wait, the worse it will get.  A true dental emergency is for someone with a rampant infection that is threatening their airway, or someone involved in some form of trauma.  At the beginning of the residency, I had trouble differentiating the different types of emergencies or how to delegate/handle the situation.  Let’s face it, if every dentist went in to the office for every emergency phone call, we would be working 8 days a week.  Most ‘emergencies’ can be handled with simple reassurance, or pain control (assuming this is a patient of record).
Well I’ve kinda rambled all over the place here.  I could go on and on but the core value is what’s important.  The GPR is only one year – the amount of experience/learning you garner is absolutely through the roof.  The program itself counts towards 150hrs of continuing ed, which honestly isn’t even enough all things considered.  At only one year, you are not really sacrificing much income.  Most of my colleagues didn’t really get rolling until a good 4-5 months following graduation.  So yea, you don’t make a dentists salary given the hours you put in, but at least you get tons of experience for your troubles, and can defer your loans.

So now, if I can find the right fit for me as an associate, all this training will hopefully pay off.  Up next, the job hunt.

Saturday, September 8, 2012

A Phoenix Perhaps?

Oh my, well.  Where to begin?  If you actually pay attention to this little corner of internet heaven, then you may be asking where the hell did this guy go?

By all accounts, if you are going off my last post, it would appear that I was slain at Cook County.  My burning ruin, left smoldering on the cold, unwashed floors.  You would be wrong though!  I simply got lazy, uninspired, busy, distracted, insert adjective.  Not an excuse, just a reality.  Life moves along at a steady clip, and while I still have plenty of time to myself, I use that time differently than a few years back.

Speaking of moving fast, how about that GPR?  Over before it began.  An entire year, one of the fastest of my life leaves me finally understanding what my dad means when he says it just goes faster each and every year.  Hell, I’ll be dead before too long at this rate.

I WILL make a detailed post about the GPR at some point.  I simply cannot do it justice right now.  I will say it was 100% worth the time/effort/lack of $$$.  At least it feels that way now.   The unfortunate reality is that unless I find a PERFECT fit to utilize my skill-set, I will probably end up doing fairly standard dentistry until I can finally open my own office.  That feels like centuries away right now…what with the massive pile of debt sitting at my doorstep.

But I digress!

A quick year-long summary which is fitting considering how fast this year has gone:
1) Completed the GPR successfully on June 30th, 2012
2) Attained my license in conscious sedation with intent to utilize
3) Improved in pretty much every aspect of dentistry (did more root canals in first month than all of dental school).
4) July 2012, got married….to a dentist….gross.  Remember when I was saying how class-cest was a bad idea.  Damn that crow tastes good.
5) Slow start to job hunt due to wedding/honeymoon
6) 2-month part-time gig as a mercenary dentist in a public health clinic begins in October
7) What felt like a sure-thing part-time job in a decent west-suburban office has crumbled over the last few weeks due contract negotiation, details forthcoming.
8) I still live!

I can’t promise anything, but seeing as the job hunt is taking about 5x longer than I expected, I may as well use my time to relate the experience.  Hell, this stuff is just as important to the dental nerds reading the blog as passing classes was.  Getting a job in a major metropolitan area is not difficult.  Getting a GOOD job is.

And the great thing about being married to a dentist is that her income keeps us afloat so that I don’t need to rush into a bad situation.  I WILL find the right fit.  You could also argue that the bad thing about being married to a dentist is that we owe the government about 750,000k in loans and that we really need the dual income sooner rather than later.


Ok enough, I need to finish reading a contract that I’m about to sign for the 2-month mercenary job.  Oh and mercenary could also be replaced with the word temp, I just think it sounds way better.

Sorry for not responding to emails, at this point it seems silly to reply to something 9 months old.  So I can just cop out and give a blanket apology.  I WILL TRY TO IMPROVE!


Sorry for the dramatics, being a fan hurts sometimes.