Wednesday, February 19, 2014


You’ve graduated Dental School….FINALLY.  You have amassed 250,000 dollars in student loans (probably even more by the time you poor newbies read this), and are raring to go. 

Now what?
There are several routes to go following graduation.  The decision really comes down to your desires, dreams, and goals.  Finding out what is right for you may take time and lot of frustration, but you will figure it out.
What are the options?
1.  Work for someone else
       a. corporate dentistry
       b. private practice
       c. Public Health

2.  Buy an established practice

3.  Start a practice from scratch

4.  Teach

5.  Quit dentistry and start-up a new career (probably impossible unless you had a butt-load of financial help and low debt service.)

Different personalities will go different routes.  Many routes will interweave with each other and offer opportunities to jump to another option.  For example, working as an associate for an older doctor for five years and then buying him out and becoming the owner. 

I really can’t help you figure out what to do, all I can do is relate how I came to my decision and go from there.  So if any of you greenhorns out there are interested in starting a practice from scratch – this new blog series should pique your interest.

How did I get here?  I graduated dental school in 2011 and completed a 1 year GPR on July 1st 2012.  I next struggled to find a steady job and only had temp work for the following 6 months.  In 2013, I started 3-days a week as an associate in a private practice office.  In July of 2013, I picked up 1.5 days at an FQHC facility treating primarily Medicaid kids.  Without getting into pinpoint details, I can tell you that working 4.5 days a week, I was grossing well under 6 figures.  The cause of this was primarily due the associate position and a lack of patients, poor collections policies, and just poor systems in general.   The best way to relate this is that I make the same amount salaried at the FQHC in 1.5 days a week as I do in the private office.

My wife (also a dentist) works 5 days a week in the same private practice office.  She recently cut down to 4 days because she was burning out and wasting time with a schedule full of holes.  Now her schedule is much fuller the days she works and she gets three-day weekends to detox from dentistry.  She started off making good money here, but due to poor business decisions and alterations to compensation, she has made less money each of the two years she has worked there.  Quite the opposite of what you want right?

For anyone who knows practice numbers, the office we work in collects about 2 million a year and has an A/R of 600K.  You heard me, 600K of uncollected money.  I have attempted to discuss changing office systems to improve this situation, but the owners are disinterested and resistant to change.   2 million is nothing when your overhead is in the 80% range and has two owners to split what’s left.  Yet these dudes seem content seeing 20+ patients a roller skating from hygiene check to hygiene check.  This is a great example of what I DON’T want.  When I hit 70+ years of age, I want to see 2-3 patients a day and work 1-2 days a week.  I don’t see myself ever 100% retiring.    I’m sure everyone reading this could think of a lot of great things you could do with 600K.  But poor office systems are not the point of this post – we will evaluate systems down the road as it becomes more pertinent to my situation.

So with a combined student loan debt of around 700K, we simply aren’t making enough money.  What were the options?

 1.  Both find new associate positions

                a. Pros – find a better situation, make money

                b. Cons – No guarantee of finding anything better

 2.  Go corporate

                a. Pros – Make a lot of money

    b. Cons – working for a corporation is rarely in the best interest of the patient.  Often your    boss is some coin-counter that only cares about production, not the person you are treating


3.  Buy an established practice

                a. Pros – Instant cash flow and patient pool

    b. Cons – dealing with staff that is stuck in their ways, dealing with all the legal BS of transitioning


4.  Starting from scratch

                a. Pros – you are your own boss instantly, can mold the team to your vision from the beginning

                b. Cons – zero cash flow.  Negative income for many months – FINANCIAL STRESS!!

I never pictured myself as an entrepreneur, but go figure – I’ve opted to start from scratch.  If my wife wasn’t working and bringing home the bacon, I probably wouldn’t be so ballsy.  How did we come to this decision?  Essentially we have been looking to own for the past six months.  We briefly checked out the seller’s market and even met with a doctor and got the preliminary info/talks going.  As soon as he gave me his asking price, I ran away from the deal.  Old dentists tend to overvalue their current market worth.  Their practices may have been worth more five years ago, but as they slow down and take more vacation – they produce less.  The value of a practice is always steered by its revenues.  I can’t blame them though.  The economy nose-dived in 2008, and they all have to work longer than expected and are clinging to some hope that an idiot new doctor will pay them what they are asking.  This touches upon what the topic for my next post on this subject – assembling your professional team and avoiding getting ripped off.
Basically I got tired of dealing with older docs.  They all were decent fellows, but I need to do what is best for me.  I also cringed at the thought of dealing with staff in a transition.  Some employees at the office I was looking into were probably my mom’s age.   I couldn’t picture them taking orders from me. The environment just didn’t seem amenable to my infant business/management stages of life.  I’d rather work with people I hire from the start.  Now you could argue to simply fire everyone and bring in your own team.  But that would kill a lot of practice value because patients would leave due to the dramatic changes.  People hate change.
The decision was made based off the fact that I make so little income as it is, that going a few more lean years now rather than post-kids and mortgage sounded like the right thing to do.  I was also encouraged by the fact that every bank I have spoken too has basically tripped over all the giant bags of money they are trying to get me to accept.  This wouldn’t be so easy if dentistry didn’t have a good history of success with loan repayment.
We have no children, rent a condo my parents own (decent family discount), and really no other financial obligations outside of student debt.  Now seems like as good a time as any to jump on in and go for it.
What’s another 400-500K debt anyways right?  The key is to think of a practice loan as a business investment rather than straight up debt.   Most start-ups are 100% financed by the big players and 7-10 years is the range most repayments occur.  Wouldn’t it be awesome to have my practice and student loans killed off before I hit 40?  This is possible if we are proactive NOW and get things moving.
My wife will stay at the same office (or maybe associate somewhere new) for a few years while I build the new practice base.  I will stay in the FQHC for income boost.  We may have to dip into savings and hold off on a home for few more years, but we are finally at peace with this decision – and that is one of the toughest parts about any career move – you need to want the change.
Could I have jumped into this straight out of residency?  Hell no!  Experiencing an office with poor systems has actually been more valuable to me than if I had made it big in some FFS office.  If I made a lot of money as an associate, I would be unmotivated to change and unlikely to pursue ownership for many years.  And when you don’t own – you are expendable.  You could get let go at any time.  Security as an associate is a fallacy.  So being in an office that just makes me want to fix the business end of it has taught me a great amount.  And while I have not been as busy as I would have liked – I have indeed gotten much better at dentistry over the last year.  I feel confident enough to do it on my own.
I’ve been reading business, leadership and behavioral texts for the past year and I can’t believe I just typed that sentence.  I always thought that stuff was stupid and you could figure it out on your own.  I can’t even begin to explain how much I have developed and learned in such a short time.  Controlling my own emotions seems easier; analyzing other people’s behavior is engaging and leads to mutual purpose over name-calling and back-stabbing. 
Most importantly, it helps ground yourself in you.  Read that a few times, it makes sense.
So know the end goal before you start.  Where do you want to be?  What are your professional goals?  What are your personal goals?  How do you want to be remembered?  Write it down.  I thought it a dumb exercise at first, but having these thoughts in writing will motivate you in everything you do.  It gives you a compass for your life which will help you with major decisions. 
This post has been more scatterbrained than usual.  But as my usual copout, that is how this experience has been.  This decision to make my own path simply feels right after running countless scenarios through my overstressed mind.
The introductory post is more to get your brain juices flowing.  Are you a dental student contemplating the future?  A new grad stressed about paying loans?  Another doc looking to start-up or buy?  You need to figure out where you are in life and what you feel ready to tackle.
I still argue that dentistry is a great profession.  However, I would caution anyone thinking about this career path to consider the time sacrifice.  While my income is technically higher than most of my friends, they still have the same amount of disposable income because my loans are so insanely high.  Most of my friends are married, own a home, and are starting to have kids.  I spent 5 years after college getting an education that would allow me to live a more comfortable lifestyle yet I feel behind the curve.  I know I will find the promised land eventually, but the time it takes to get there is definitely not how the field of dentistry is advertised.  Like any other profession, you have to pay your dues in the trenches before ascending.  The difference between other career paths is that you are four years older starting in the trenches.
So fellow dentites, it’s choose your own adventure time.  Spend some quiet time reflecting on exactly what you want to achieve in life and what your career goals are.
I plan to update as I continue the process.  My current goal is to be in my own office before the end of the year.
Next up – assembling your team of advisors
PS> If you can guess the acronym I have created for my post title, I will pay off all of your student debt**
** Only applicable if student debt service is less than or equal to 1.00 US