Wednesday, December 11, 2013

First True Emergency

Statistically speaking, the odds of a life threatening event occurring in a dental office is very rare.  The last time I read an article on the subject, I believe the average TRUE emergencies experienced in a general dentists career was something like 0.8.  This means not everyone will see even ONE over a 30-40 year time span.  Well I’ll be damned, but I’m only out 1.5 years and have had the privilege of a real “OH SHIT” moment just this past Friday.

I’ve had some time to process the emotions involved and feel pretty good about posting this on ye olde blog.  If nothing else, so I can remember the event with clarity although I think I will probably remember this forever.

A true emergency is NOT vasovagal syncope (fainting).  A true emergency is when there is a real threat to life that needs to be managed until the Calvary arrives or the problem remedied in-house.

Here is the situation.  I have just consulted a patient who needs a referral and am walking through the office to write one up.  As I’m meandering through, I notice an assistant essentially sprinting towards the front with a look of purpose and abject terror.  I b-line the direction she had come from and find a mother clutching her 7-week old baby in her lap.  The mom is entering the early stages of hysteria and I immediately can see why – the baby is blue.  Like Violet from Willy Wonka and the chocolate factory blue.

This is that moment in life which really determines who you are in a crisis.  I have always been confident in a controlled setting, but have secretly feared that if someone truly needed help in an emergency, that I would shy away and spectate. 

I don’t know exactly what went through my head, but I do remember acting and sequencing.  I entered the room and scooped the baby away from mom, sat down and had the baby supine in my lap, head close to my core for assessment and immediate airway management.  Why do we turn blue?  When we are not getting enough O2 – simple as that.  How do we not get enough O2?  Air is either not being processed by the lungs or it is obstructed from getting to the lungs.

The baby is conscious and moving arms about.  Chest is rising sporadically.  He is making clear choking and snorting sounds.  Baby is conscious, I skip checking for pulse.  I immediately head-tilt and chin lift and ask mom – “Has he had anything to eat or access to any object he might try to eat.”  NO.  Child is 7 weeks old, all soft diet, was strapped to mom all morning, no access to foreign body.  So while he appears to be choking on something, it isn’t a toy car or food particulate.

Observation: It is bone-chillingly cold outside and baby has tons of snot visible in his nostrils.

9-1-1 has already been called by the assistant, I ask for O2, and it is brought about with a passive air mask.  Head-tilt chin lift has not resolved blue coloration and breathing difficulties.  Passive O2 is also not helping.  I ask for a hand-mirror and proceed to jam it down the little guy’s throat.  Depressing the base of his tongue and pulling it down and forward.  Voila, baby lets out loud cough starts crying and turns pink in about 10 seconds.  Paramedics arrive and I hand the infant off to the pros.

My current cause is that the infant was choking on his own secretions.   A 7 week old infant is such a smushy and compressed human, that the airway can EASILY be compromised.  Whether or not my dx is correct is yet to be determined.  All we know so far is the baby was hospitalized with some sort of virus.  I hope to learn the exact cause in the next few weeks.

This happened about 740AM, so now I have the rest of the day to take care of.  I moved forward and returned to talk with my patient about the referral.

The entire office staff has been non-stop bragging about me and congratulating me and giving me all this hero talk.  Quite frankly, while I feel phenomenal that the situation turned out OK, it is sort of embarrassing to get all these accolades.  All I did was manage an airway for 4 minutes and help clear an obstruction.  The assistants who calmly called 9-1-1 and got everything I asked for quickly and efficiently all played an important role.  The mom herself managed to stay (somewhat) calm and answered every single question I asked her immediately.  Everyone played their part well and the outcome was positive.

Here is what I would do differently:

1 – Positive pressure O2 rather than passive (we have an ambu bag hook-up, but I did not specifically ask for it)

2 – Surgical suction up the baby’s nose to clear some of the mucous.

3 – Use mirror for tongue depression faster

Several of my colleagues suggested the baby equivalent of the Heimlich maneuver which is turning him over on his stomach and giving him two strong back slaps.  This may have worked, but I went with the mirror head because all signs pointed to a collapsed airway and not a foreign obstruction

What I am happy with:

1 – My demeanor was calm and collected throughout.  My mind processed the event and made the right decisions.  I would like to have arrived at the need to depress the tongue sooner, but I probably was doing it within 30 seconds of sitting down (time completely vortexed and distorted for me).

2 – staff in general did a great job, could have moved faster, but definitely acceptable

3 – Baby is OK!!!

So what should you young dental guns take from this?
Every single one of us should know how to manage an airway.  It is so easy to do, and so critical to life.
I credit my experience in the GPR greatly to my action as well.  This isn’t the first time I’ve seen a youngster turn blue, we had a few SPC IV Sed cases where this happened as well – that was in a very controlled environment though and with a lot more airway management equipment (not to mention a dental anesthesiologist to bail our asses out as necessary).  Each time I saw it happen, I either witnessed or performed the necessary maneuvers to remedy the situation.  These experiences were terrifying, but ultimately made me a better clinician.
Now just the day before this event, I received an asking price for a dental practice out in the western burbs.  Won’t even bother countering – asking price was in the stratosphere.  But I will get into that in my next post!
Hoping to get that up before the New Year - fingers and goes crossed!
If I don’t though, have a Merry Christmas and a Happy New Year!

Sunday, October 27, 2013

Being Proactive About Change

I will be the first to admit that the title of this post sounds like something you would see at some sort of business convention, but I use it as my own personal motivator.  Why you ask?  The quick answer, I am extremely resistant to change.  Most humans resist change because it results in uncertainty, something different, and something that cannot be predicted or controlled through past experience.  The end-result is often fear.  Not a lot of us enjoy fear, it is an unpleasant emotion that is best saved for the month of October watching slasher flicks on AMC.

So the title of this post has become one of my goals, a useful barometer in my ever-present development as an individual striving towards personal growth.  If you are like me, somewhat anti-social, timid, and more of a follower than a leader, you need to be proactive about change.  If I want to own my own dental office, nobody is going to hand it over to me, manage the details, and then steer the ship once control is finally attained.  I need to become a better leader, a better communicator, and simply a smarter individual in all things NOT related to dentistry.  Human relations and common business sense/strategy play an enormous role in this profession – a role that is not easy to learn or teach.

You need to set goals, both personal and professional.  You need to revisit and revise these goals regularly, you need to be realistic that change is inevitable, and it usually is arduous and slow.  I hate change; I love consistency, a guaranteed paycheck, no unknowns, and a routine I know.  This leads to something I hate even more than change – complacency.  The other associate in my current office represents what I don’t want to happen to me.  This person is a good dentist, well-liked by staff and patient alike, but is mired in complacency.  This person is unhappy, but fears change so much, that they are unwilling to make the move.  This person has been an associate for 7 years with no end in sight.  I hope they escape the cell of complacency because it is so much worse than taking the plunge and embracing risk/change.  That could be me.  It is like the story, ‘Christmas Carol,’ and I see the ghost of my future.  To be mired in fear so much that you are willing to be unhappy is far worse than dealing with the fear of the unknown.  In fact, in reflection, I realize that some of my most enjoyable memories have occurred following the leaps of risk and change.  So while I’m scared of change, I am learning to embrace that fear as something to draw upon and learn from.

So I wake up each day muddled in the complacency of my current situation, yet inspired by my drive to escape.  I’m not unhappy, but I’m also not content.  We are simply put, not making nearly enough money given our years of education/training and massive amount of debt.  It doesn’t help when I read an article about how the UIC chancellor got a 1 million dollar house for free just for taking the job.  What the hell is a chancellor anyways? Just a reminder of why I will never donate to my dental school.  Got a decent education, but the cost will never be justifiable to me – and it’s only getting worse.  So in order to make more money, we must own.  Is there risk?  Yes.  Could we make less money for a while?  Sure.  Will it be scary?  YES!  But do it we must.

So the first step towards ownership for me has simply been to network and stay in touch with people whose opinions I value.  Find a mentor!  My god, I can’t emphasize how important this is.  Having someone you respect, who is willing to talk with you regularly and help you evaluate situations and make life changing decisions is invaluable.  I have kept in touch with one of my attendings from the GPR and his advice has truly inspired me.  I also have maintained pretty decent contacts with several of my classmates and co-residents.  We have an email chain that provides for clinical discussion/debate which is a great learning tool.  Networking is also very important.  My wife and I have been more aggressive in attending local meetings and larger conferences.  Not only to you get CE – the importance of which is another topic altogether, but you meet people in your field.  Finding a good practice is usually best done through the grape vine and not a broker.  While you get mixed opinions for sure, if a practice is relying on a broker for sale, it is likely having difficulty selling due to reasons you may not figure out until you already have sold your soul.

Assemble your team:  While I haven’t officially retained anyone, I have been in contact with a few accountants, attorneys, and now lenders.  Most of these people will gladly meet with you for free – realizing that you are still poor as hell, but will eventually be able to pay them lots of money.  They are necessary for your success.  Find people you are comfortable with and that you can develop trust with.  Again, consulting your local colleagues, or mentor can give you a nudge in the right direction.  Network, network, network.  Sounds so funny saying that, as I’d prefer to spend my Saturday night watching an original Syfy horror movie (so bad they’re good), but  I realize that to get anywhere in this world – you need to get yourself out there and become recognized. 

Where are we right now?  It is the same as before work-wise, except that I am somehow managing to make EVEN less money in the private practice office due to an abysmal September.  However we have discovered through networking and meeting with other professionals (accountant in this case), an office that has potential.  It is located where we are targeting for a start-up and is 25 minutes from the area we want to buy a home.  The office itself is less than 5 years old with decent technology in place and the owner is planning to move out of state.  We met a week ago and it felt like being on House Hunters.  5-ops, hygiene driven at the moment as the owner doc is pretty laid back and slowing down.  We liked the space overall and the locale seemed nice.  Will be an absolutely horrible commute from Chicago, but I’m prepared to do that for a few years until we can actually afford a house.  The plan either way will be for me to set-up shop first while the wife keeps her associate position for a few more years and slowly phases out to our office as we theoretically grow large enough for a second dentist.  This affords us at least some financial security as her income will continue to be our lifeblood.  Although to be honest, even if I worked only 2 days a week building the practice as an owner, I would probably make more money than I currently am making 4.5 days a week working for other people.

I’ve signed the “non-disclosure” agreement which essentially means I can’t talk about the practice to anyone except my designated “agents.”  Whatever the hell that means.  I swear, lawyers are smart - invent your own new language using English words so that one must pay 400 dollars an hour to have it interpreted by the creator of the language.  Brilliant.

So I’m all over the place right now but the main point of this post still stands.  Embrace change – seek it out, or you will never escape the bonds of complacency – which is often a far worse fate then fear of change or fear of failure.  Even if you fail, you can learn from it, and dust yourself off for the next round.  This too is better than becoming frozen in time, depressed, and unmotivated as you drift through the motions, day in and day out.




Wednesday, September 18, 2013

The Fall Report

Although it is 80+ degrees for some reason, I still consider mid-September to be “Fall.”  The days are getting shorter, the clouds are hanging around more often, definitely fall-ish.  Now if that horde of hornets living up on my deck would finally die off, I’ll be a happy human.  Every time I wipe out one nest, I feel as if two more sprout up.

How is the professional life treating me you ask?  Still not great, but I feel like I have motivation and direction at last.  I figured I would work as an associate for 5 years in this office, build my skill-base, and then buy-out or transition into an existing practice.  However, I’ve quickly realized that I can’t wait five years.  Being an associate has many many benefits.  These benefits also come in tandem with many many frustrations.  The plus side is obvious.  You get to focus almost exclusively on your trade as a dentist.  Without the burden of managing an office and having employees, you can get the inexperienced jitters out of your system much smoother.

With all great things comes the downside.  You are an employee.  Always remember that.  It doesn’t matter if your contract is structured as an Independent Contractor.  You are still an employee.  Every other employee in the office knows this.  So naturally, your authority is limited.  You are not going to be able to dramatically change anyone’s behavior or any office systems already in place.  This becomes glaringly apparent if you work in an office that has been around for decades (like me).  Now every position is different, but as an associate, you WILL eventually max out your income potential.  If you want to hit that juicy median income of your average general practitioner, you must strike out and own.

So as my last post made clear, I am looking into ownership far earlier than expected.  I have spoken with both an attorney and accountant informally to simply network as well as get as much free advice as I can before they invariably start charging me.  The good thing about shopping around for other professionals is that they know this and are more willing to cut you a break at the beginning.  We are also meeting with a bank in regards to acquiring a loan towards practice financing.  Several major banks in this country have medical/dental specialist sub segments that exclusively cater to dentists and financing practice start-ups/buy-outs.  Much like with other professionals, we plan to meet with more than one.  This first meeting will occur early next month.

A lot of my free time is now spent reading up on the non-clinical aspects of dentistry.  Books on leadership, communication, practice transitions, etc.  Not only is it a nice break from constantly reading articles on clinical dentistry, but I am absorbing an enormous amount of information – namely because I am really underdeveloped from a business standpoint.

I currently work 4.5 days a week and while my income is still laughable for a general dentist (and given my 9 years of post-HS education), it has become less laughable than it was last year at this time.  My wife is still bringing home way more bacon than me, but as a progressive and mature adult human, I am super excited about this because she keeps us going financially while I have fuddled around for the last year.  She still is pretty underpaid for how many hours she puts in – but I can’t say she is unfairly paid as an associate dentist.  Combined, we make enough to maybe consider ourselves one whole dentist.  I realize our income potential is quite high over our careers, but knowing this and getting there are two very different ideals.

I did get a job offer from one of the local corporate dental chains.  I would make double what I do now, but I just couldn’t pull the trigger.  To be unable to practice comprehensive dentistry every day of the week would simply drive me insane.  I do care about financial growth and stability, but I don’t consider my wealth as the definition of who I am.  Don’t get me wrong, I like nice things just as much as the next guy, but I thankfully don’t find myself craving social status types of items.  We are living somewhat below are means.  Most of our money is spent on travel, which we do sporadically.  And finally having a somewhat less laughable income on my end has allowed us to begin significantly saving money.  The student loans still sit, but we have stabilized and will continue to chip away, hoping to whittle them down 100% over the next 10-15 years.  The idea of taking out another 500K to finance a practice is daunting, but at the same time, it’s just a number.  I never physically walk around with it in my pocket.  The practice is established with numbers crunched to accommodate repayment well before the bank even approves.  Dental practices rarely ever fail.  And I’ve see some pretty incompetent dentists in my short career doing just fine and dandy.   If they can somehow get by, then I feel like I’ve got a good chance to excel.  Not that I’m god’s greatest gift to dentistry or anything, but I actually care about the quality of my work.  I know I’ve had bad days, but I learn from my mistakes, constantly strive to improve and am never satisfied with what I know.  I feel like these traits will push me to higher peaks over the next 35 years.

So much like the Chicago Bears this season, I am cautiously optimistic about the future.  I know there are plenty of frustrating times ahead of me, but I also see a lot of happiness and contentment as well.

While I’d be lying if I said my post-education world was what I expected it to be, I’d also be lying if I said I wasn’t a pretty lucky SOB with a great life.

Cheers to all.

Wednesday, July 31, 2013

One Year In

I finished my first full year as a “general dentist” at the end of June.  I know it has been MONTHS since my last appearance but I assure you, I am very much alive.  So how are things you ask?


Yea, unfortunately 12 months post residency, my professional life is still meh.  I am much better off than I was last fall (unemployed!), but really it isn’t THAT much better.  I work in two offices.  One is a long-time standing general practice with 2 owner docs and 3 associates.  The other is a Federally Qualified Health Center (FQHC) which caters to low-no income families.  I started in the private office in January and just started in the FQHC in July.  By the way, for you die-hard fans, this is the same FQHC I temped in last fall.  They finally made room for a second dentist and I was invited back for 1.5 days a week. 

The general practice office is still three days a week and if I have anything to do with it, will soon be zero.  Six months have elapsed and I still have a schedule with more holes in it than a moldy piece of Swiss cheese.  The office is predominantly PPO (Over 90% of the patients), and I am paid exclusively on collections (40%).  You see the 40% and think, that ain’t half bad.  Well, as I have found out at a painfully slow pace, the yearly collections in this office is under 90%.  UNDER NINETY PERCENT.  I have never heard of such a poor yield.  The fact that we take all these dogshit PPOs also cripples the ability to charge an even ‘average’ fee.  I’m sorry, but only 400 bucks for four wisdom teeth?  Are you kidding me?

To any readers who are a bit miffed by insurance plans, allow me to summarize (I will likely have an entire post on this in the future).  I won’t deal with HMOs today.  So lots of people have PPO plans.  How do they work?  You usually get them through your employer, who will sign up for a plan to get a specific rate for his/her employees.  You pick your plan, cough up a monthly tab, and get your benefits.  Your average plan will cover 1500-2500 bucks annually.  They generally cover 100% preventative stuff.

So why do they suck?  Because they hamstring the dentist.  PPOs generally raise their fees about 0.5%-1% annually unless the dentist attempts to hardball renegotiate fees.  General inflation in America is 3-4% annually.  Do you see the problem?  The cost for dental materials, staff salary, office supplies, etc all increases with standard inflation.  The PPO does not.  So if you rely heavily on PPOs, you will begin to see a steady decline in office cash flow.  So how do you fix this?  Oh yea, cram as many patients into your schedule as you can.  I don’t care how good you are, you are going to be doing some shoddy dentistry when you are seeing 14+ patients daily (not including hygiene) just to make up for fee’s that you have no control over. 

Now of course the ideal world would be a completely fee for service (FFO) practice.  They do indeed exist, but realistically, most can’t get by without taking SOME insurance.  The key is to LIMIT it.  The inherent system is simply flawed.  Insurance companies are NOT dentists, yet they determine how much we should make.  It is not good. 

But I can dissect this stuff better in a separate post.  The jist of it has been implied.  So this family practice is essentially going under.  Office overhead is in the 70% range, the practice produces 2.5 million a year, yet is still struggling to break even.  So what has this yielded?  The wise and benevolent practice management firm that the owner docs seem to let run the show has suggested that they cut associate dentist compensation.  How they are doing it really doesn’t matter, but it essentially equates to about 60K gross pay for the oldest associate, 30K for my wife and 10K for me.  But hah, I make nothing as it is so what’s the diff.   The only reason I have stayed as long as I have is that the office is generally a positive work environment, I’ve learned a decent amount, I enjoy working with my wife (which bodes well for the future), and I was happy to have a stable work week finally.  But alas, all things tend to change.  I originally planned to stick it out here for at least a year.  Now I’m hoping to be somewhere else by then.  And a big part of me hopes that other place is owned by ME.  OH SNAP!

The real positive of this mess is that it is ignited a fire in my dormant self.  I originally thought I would slug it out as an associate for several years.  Hell no!  We are beginning the process of opening our own practice.  We still haven’t decided if we will buy one out, or start from scratch – but I have begun assembling the Justice League for Dentistry (i.e., my professional team).  This includes a lawyer, CPA, banker, demographics dude, medical contractor, oh my god there are a lot of them.

We are hoping to meet a bunch and find the right fit.  We aren’t rushing into anything, but the process has begun!  I’m pretty damn excited about it too.   Literally just started, but I hope to update as we go along, as this segment of my career will probably be pretty damn interesting for the new dentists coming forth.

So will I go bankrupt?  Make millions?  Die in a freak accident?  Find balance in all things life?  Stay tuned!

So yea, as far as this first year is concerned….



OKOK I know I’m bitching a bit excessively and I truly HAVE become a better dentist despite the lack of dentist-like income.  We aren’t starving or anything either, but the thought of having children or owning a house is much farther away than I would have expected for someone my age.  I still drive a car with no passenger door handle or driver side mirror.  I mean, I don’t need a Maserati or anything, but A/C and a non-ruptured washer fluid line would be nice.  We will get there eventually, but was the five extra years of school + mountain of debt really worth it?  Seeing as a do indeed like being a dentist, I’m still OK with it.  Lots of people make a decent living but absolutely hate their jobs.  I generally enjoy doing what I do at least.  So there’s some positivity!

Ask me again in a decade.

I will hopefully organize some posts about transitioning to ownership in the coming months/years.  I never saw myself as an entrepreneur, but the thought of building something from the ground up, and actually being in charge, and getting to do it MY way sounds so freaking amazing after working for other dudes that do so many things wrong.  Not that I am perfect or anything, but I’m looking forward to giving it the old college try.

Yikes I’m really rambling.  Sorry for the lack of coherence, but that is just how I roll!

Seriously though, I will try to get some thoughtful posts about this transition as it occurs.  Hell, it takes a long time to get rolling anyways so I should be able to find some time.

Good evening.

Wednesday, February 20, 2013

A Short Story (With Pictures!)

About two months into my current job and things are going swimmingly.  I’m still not busy enough, but slowly but surely, I’m building a patient base.  Luckily the practice is large, so I get all the emergencies to fill in the gaps.  Most emergencies are not particularly interesting, but I’ve been on a bit of a streak as of late.

So here is my story.  A certain Friday afternoon arrives with a middle-aged guy coming in at 2:00 for emergency tooth pain.  We close at 3:00 on Fridays and pretty much every specialist we refer to closes early on Fridays as well.

He is around 45 years old and is complaining of pain in #3.  Persistent for the last 3 days and really hurts when he eats. 

Hard to appreciate the divergent roots in this picture, but you can definitely see the fracture line going straight down the center of the crown.  He’s in a lot of pain and I have two options.
1 – refer to OS and give him pain killers to survive the weekend
2 – Extract the tooth myself
If you had talked to me right out of dental school, no way in hell I try to get that tooth out.  But here is why the GPR positively influenced me.  I decide to go for it.
For some reason, I thought I could get this tooth out in one piece (ohh silly delusional self).  So naturally, the tooth breaks down below the crest.  Fuck.  Now I’m flapping and removing bone with a handpiece and surgical bur.  Long story short, took me an hour to get it out and the sinus membrane was exposed at the base of EVERY root tip.  Fortunately, the membrane was intact and no communication was present into the sinus proper.
The GPR gave me the confidence to attempt this extraction, but more importantly, it gave me the skillset to get out of trouble and analyze the procedure more critically than I would have straight out of school.
What went well:
-Entire tooth removed, all tips accounted for
-no sinus exposure (close though!)
-pain management during procedure and post-op was excellent
What could have gone better:
-Should have flapped/sectioned immediately, controlled tooth breakage is far superior to forceps-induced.  This in turn, would have allowed me to spare more of the alveolar bone as well.
This was my first “oh crap” moment in private practice.  When the crown snapped off, I realized I was in a hole and it was going to require some patience and persistence to climb out.  Great thing is I didn’t panic, everything worked out OK, and the site is healing up as expected at this point.
So that brings me to the very next patient I saw the following Monday.  Emergency comes in complaining of tooth pain.  Young African American male with no medical complications.
Both #1 and #2 need to go.  I felt like this was my chance for immediate redemption.  This time, I adapted from my previous experience and made the correct choice.  I immediately flapped, troughed, and sectioned #2.  #1 was a standard forceps extraction.  Including anesthesia and suturing, I was done in 20 minutes, a marked improvement over Friday afternoon.  No post-op issues, area healing well at follow-up.
This isn’t a ‘brag’ post or anything.  Plenty of general dentists could get these teeth out as well, but I was just really pleased with the immediate turnaround.  I mean, that sort of thing is so rare, to get a chance to do a nearly identical procedure the very next patient and see such improvement in management just made me smile. 
So I’m the extraction guy in our office and I’m ok with that.  I am still waiting to really get rolling with some more prosthetic cases, but the bread and butter stuff is working out fine.  Being out of the game for a few months really didn’t diminish my skillset at all, I feel confident and comfortable with the basics.  Do I still get frustrated?  Yes.  Do I still need time to think and dissect a larger restorative case?  YES!  Am I still learning and getting better every day?  Hell yes!
The only real complaint I can come up with at this point is a lack of consistency on when I get paid.  Supposed to be the 1st and 15th of every month…but is currently the 20th of February, and I still haven’t seen that 15th paycheck.   Not the end of the world, but definitely annoying and making paying back loans and keeping my credit card balance at zero far more difficult to keep up with.  We are getting by and I only expect things to improve after I really establish myself at this office…but it is still rough going financially.  Go figure right?  A husband/wife dentist combo is living paycheck to paycheck.  Can’t wait for that phase of our lives to end, hope it’s sooner rather than later.
Three days a week of work is still not enough, but it seems like the potential to grow is good and I will ultimately get more time in this practice. The question becomes should I find another job for the interim.  The plus side to that would be increased income and exposure to a different work environment.  The con would be difficulty in changing days/hours as my workload at the primary office increases.  We shall see how things develop.
And I’m spent.  Going for a ton of CE at the midwinter meeting…hopefully I learn.