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.

 

 

 

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.

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?

Meh.

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….

Meh.

Disclaimer:

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.

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 1^st and 15^th of every month…but is currently the 20^th of February, and I still haven’t seen that 15^th 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.

 

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!

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.

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 naïve 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.