Private Dental Practice vs. DSO Dominance

Dentistry, Lifestyle

Spoiler alert! This post is ALL about dental talk. You see, for the past several months – since I was notified that the company I work for (for the last seven years of my life mind you) was now under the ownership of a large dental support organization (DSO) – I have been deliberating whether it is time for me to pursue an ownership or partnership arrangement of my own. I have written about this very subject here; however, that was under the (much more ideal) circumstances of being employed by two pediatric dentists and not some massive private equity company that buys up dental offices for investment purposes. While the name of the new owners is irrelevant, their portfolio currently consists of over 250 dental offices across the country and they are continuously growing aggressively.

This business model is not new. In fact, I am sure you have seen many of your local, private-practice physicians selling to private equity companies. As a pediatric dentist that works closely with anesthesiology doctors, I witnessed first-hand when they started to be taken over. Once a large investment firm enters the picture, and really gets its claws into an asset class, you have to believe they are going to streamline the shit out of it in order to drain every last dime of profit out of a business they acquire. In the case of the anesthesiologists I work with; all of a sudden they were forced to work with an expanded lineup of surgeons, taking on more call schedules, learning new systems, performing post-op surveys, and more.

For someone that is close to retiring, some of these DSO offers may not be so bad. I imagine they give a very hefty upfront payout, and after mandating the doctor(s) stay on for ‘x’ amount of years (to ensure minimal attrition occurs), I am sure there is a golden parachute that many people receive on the tail end of the acquisition as well. My bosses both have to stay on four more years, but after which, they can and likely will retire from dentistry forever. Me? on the other hand. As a mere employee, with absolutely no equity stake, I get squat from the buyout and have yet to see how they plan to ‘trim the fat’ (so to speak) within our company. They’re a big company that tries to entice you with a matching 401k plan you can enroll in, some solid health insurance plans you can participate in, and some perks that smaller run organizations may not be able to afford to provide their employees with – but, its the changes in the day to day operations that scare me.

For example, I heard the words ‘production goal’ uttered from my office managers mouth for the first time in seven years last week. She also asked my lead assistant ‘why we ordered so many nitrous oxide tanks’ for our office? Something that has neither changed/increased, nor been scrutinized or questioned, up until this point. The way I see it, they are still in a transitionary period where they do not want to rock the boat (i.e. don’t spook the staff, keep changes to a minimum, etc.) – but certainly, the tides are changing.

While I am grateful that the transition has at least kept me gainfully employed; in the last couple months I have updated my CV, set up a LinkedIn and Indeed profile, arranged lunches with some pediatric dentists around the valley, reached out to dental supply reps and expressed interest in any partnership/ownership opportunities they may be aware of. Out of the five dentists that I reached out to, two recently sold some or all of their practice to a DSO, one is content and is not interested in any arrangement, but two are willing to discuss my coming onboard with some equity stake on the table.

“Success comes from taking the Initiative and following up…Persisting…

What simple action could you take today to produce a new momentum toward Success in your life?

– Tony Robbins

For the last seven years, I have worked for someone else because it has afforded me a comfortable working environment, good pay, a flexible work schedule, and no interference in how I chose to practice clinically. And, I am not a risk-taker. Or, I have been too afraid of failure. Unfortunately, I have come to realize all the time I have worked, was to build up someone else’s brand and valuation.

One of the pediatric dentists I met with recommended a book called “The Millionaire Master Plan” by Roger James Hamilton. He spoke highly of the book, and claimed it would expand my way of thinking and put me quite a few years ahead in terms of wisdom and self-awareness. I am a few chapters in, and so far a good portion of it has been dedicated to helping someone recognize their ‘genius’, their strengths and weaknesses, and talks about expanding on those traits to build your wealth.

For the sake of completeness, I should say that I have also toured a couple of empty, grey-shell office spaces as well. The problem here is that, dental build-outs can be quite costly, plus you have no cash flow for the first several months/years, plus you’re competing against the deep-pocketed DSO’s with their endless marketing dollars and – it really steepens the curve when it comes to opening up a start-up. I also have investigative work to do (with the help of an attorney), to review my existing contract and gauge the enforceability of my non-compete and other restrictive covenant clauses.

My way of thinking is changing. I am now seeking opportunities I would normally be too nervous to pursue. I hope to write again soon to share the results of some of these meetings, and with any luck, announce that I may have new endeavors underway. Thank you for taking the time to read all of this, and sorry to limit it primarily to the dental folk out there. Enjoy your day!

Anxiety and Panic Attacks

Lifestyle

Just to offer you some context, it is exactly 2:26 AM as I sit to write this post. That said, I cannot guarantee any actual coherency or substance in what follows. Writing has always offered me some degree of catharsis and, hopefully, a cure for my current bout of insomnia.

A few weeks ago, I was working in the surgery center when – mid-procedure, my heart started rapidly beating, I had a slight uncomfortable tightness in my chest, and I found I had to take a couple of deep breathes to essentially restore myself to a baseline where I felt normal again. The dentistry was going fine, nothing stress-inducing had happened and it was all very routine-Monday sort of work that I was doing.

I want to say, either the next day or the day after (shame on me for not keeping better records), a similar episode occurred while I was in the office working on a patient for dental treatment. Basically an identical presentation to what happened earlier, a brief couple of minutes where I had a slight aching in my chest, a shortness of breathe and what felt like I was getting tachycardic or having some palpations of my heart muscle – not exactly sure.

Admittedly, this has not been the best year. Most recently, certain members within my household contracted COVID; and so there were health issues amongst family to be worried about. Still a very fresh and extremely agonizing is the financial loss I incurred with my poor Celsius investment. And to pour salt on the wound, the practice I work for recently sold to a large corporate entity – leaving me with a suffocating uncertainty of whether or not to stay employed with the new group or finally take a leap (along with the many headaches and financial investment) of practice ownership.

I already do not manage stress well. My entire life I have lived very phobic of everything; social situations, new endeavors, taking on risk, basically changes of any size or shape. Just today in fact, something as simple as watching my boys play in a tennis tournament this afternoon – I can literally feel my cortisol levels spiking when the game gets close. To the point where I have to walk away, stare into the sky and observe the clouds through the trees, all the while playing calming music in my AirPods. Let me tell you, it makes for a miserable existence.

Doctor Googling the way that we do, tells me a rapid heart rate and chest tightness are commonly associated with Atrial Fibrillation (abnormality in the heart rhythm), panic disorder (panic attack), anxiety, and/or stress. Fortunately, I also saw my actual physician today; who recommended we do 1) an EKG (which I did right there and then – and thankfully, everything looked good according to him) and 2) a CT calcium score (which I plan to schedule soon). An electrocardiogram (ECG or EKG) assesses the heart rate and rhythm; but could be used as a tool to diagnose a possible arrhythmia (irregular heartbeat), blocked arteries, heart damage, failure or even a heart attack. While I did not experience any dizziness or faintness, the chest pain, rapid heartbeat and breathing warranted me getting this done. Apparently, the cardiac CT calcium score (aka coronary calcium scan) will help identify the amount of calcified plaque in my coronary arteries. As he put it, the EKG might be a past indicator of heart healthiness, but this Calcium Scoring may be more of a future indicator of sorts.

Once we have (hopefully) ruled out maybe this being a physical ailment with my heart; the next item on the agenda is to address the psychological element of it. My physician (as I am sure all do) encouraged me to exercise more regularly, incorporate yoga and if need-be, try therapy. No quick Xanax fix I guess.

Throughout my life, the times I have felt my best (both physically and mentally) are always when I exercise regularly. Unfortunately, it is easy to fall into a rut and lose momentum. I really am going to make it a priority now to squeeze in 3 or 4 days a week of a solid exercise regimen, and maybe – just maybe – I can get these panic attacks (?) to subside or disappear altogether.

The boys after their USTA Junior Circuit Tournament

Every post I write, I am always curious to know what others experiences are in this realm. I find my stress and anxiety (and now, panic disorders?) sometimes make it hard to get up in the morning. Other days I feel great, enthusiastic even, and embrace what the world has in store for me. Hopefully a healthy regimen of working out, eating right, yoga and (if need be) therapy get me feeling better. Thank you for taking the time to read this post!

Conquering Change

Dentistry, Lifestyle

Recently, I was made aware that the office I have gainfully been employed at for the past seven years was going to be sold to a larger, private-equity company. One of two owners called me to break the news about the transition, and nonchalantly tried to reassure me that not much should change about the terms of my employment other then who signs my paycheck.

I have never been one to embrace change well. I would almost go so far as to say I fear it.

I see day-to-day change take place in front of me constantly, and I struggle to accept even that. My kids getting older is a prime example. Google Photos reminds me of this day ‘7 years ago’ and I am an emotional wreck. Why do they have to grow up so freaking fast?

Listen, I know, it is a part of life and we cannot control it. Without a doubt, my best days are when I manage to block out the seemingly infinite “what if’s” scenarios that float around in my head. When I somehow silence all that noise that occupies my mental space, my days are much more peaceful and happier.

Years ago, I read a book called “Who Moved My Cheese” by (Patrick) Spencer Johnson. From what I remember, it was a quick enough read with a very simple message. Life moves on, and so should we. “The quicker you let go of old cheese, the sooner you find new cheese.” The author devotes the book to trying to embrace change in work and throughout our lives.

I have worked for enough large DSO’s (Dental Support Organization’s) to know they are not run the same as smaller, privately-owned offices. In an attempt to streamline operations and cut costs (and maximize profits), something’s gotta give – it may impact the quality of dental materials, the staff, the schedule – it could touch on every aspect of the practice.

As a mere associate, I am not privy to the terms of the sale and transition of ownership. Only time will tell what changes will come. The way I see it, at best, my office stays as-is and nothing changes. At worst – the autonomy I have enjoyed in picking out my own materials and setting my own schedule starts to disappear. What would be utterly devastating is if my beloved staff get spooked and decide to quit.

This is the second office now that has been sold out from underneath me. Because I have been just an employee, as the practice changes hands – even though I worked hard to build it up, because I have no equity stake – I reap none of the benefits of its successes throughout this sale taking place. The two original owners (not much older then I am currently) have now paved a pathway for retirement for themselves; and I am but a commodity being sold along with the chairs and other equipment.

On the flip side, I have been compensated well over the years and had I invested more wisely (thanks a lot Celsius Network), I might also in my own right have been on a path towards financial independence. Plus, over the last seven years I have not been burdened by administrative hassles of running this practice – and when the A/C fails, addressing staffing issues, dealing with payroll matters – none of that has really weighed on my shoulders.

“Change happens when the pain of holding on becomes greater than the fear of letting go.”

― Spencer Johnson, Who Moved My Cheese?

How my staff will respond to the new owners, how my pay will be affected, how my patient schedule may change – all of these are unknowns that occupy my mental bandwidth these days. Mixed in with regrets about not building up equity all these years and reaping zero ownership benefits. And do not get me started on the massive financial setback I have incurred with the atrocious investing missteps on the Celsius ordeal.

Lately though, when I am not caught in a moment of self-doubt and insecurity, I am convinced that – however horrendous these last several months may have been – I am more open to taking on the challenges of practice ownership, I am a wiser/more cautious investor, and I am, for the most part, optimistic about what the future has in store for me. I am even finding ways to enjoy my kids getting older and the fun activities I can do with them now versus seven years ago.

Hope you handle change better than I do. Every day I feel I have to convince myself there is light at the end of the tunnel. Thank you for taking the time to read my post today! Please feel free to share with me your own stories of taking on change in your life!

Weather the Storm

investing, Lifestyle

If this blog affords me anything, it is the opportunity to write about the things that occupy my attention. Day after day, since 2022 started, I wearily watch as the stock market plummets and any profits and gains from the last several years get wiped out within a matter of months. Like the gray, rainy weather in Seattle that leads some to experience seasonal affective disorder (SAD); so to can the chronic red and sharp declines in the stock market lead to gloom and mental anguish.

By definition, a correction is a market decline that is more than 10%, but less than 20% off of a recent market high. A bear market is usually defined as a decline of 20% or greater. The S&P 500 index is the overall representation of the market’s performance. There are plenty of other terms (i.e. market dip, crash, etc.) that are pertinent but could just as easily be Investopedia‘d.

Again, graphs like the one above present the performance of the overall S&P 500 Index. If you are like me, and your portfolio is a composite of index funds, stocks and bonds, and other asset classes – you may fare significantly better, catastrophically worse, or somewhere in-between.

Individual stocks are prone to much more volatility. A character on an HBO show rides his Peloton, suffers a heart-attack and dies – causing the stock to sink nearly 12% the next trading day. A large group of traders on the r/WallStreetBets Reddit forum helped drive GameStop’s stock surging up over 400% once upon a time. A misinterpreted tweet by Elon Musk stating to ‘use Signal’ confused investors and sent the wrong stock up soaring over 6300%.

More recently it is the Ukraine and Russia conflict and the question of an impending war? The Federal Reserve and possibility of several interest rate hikes? Certainly economy-related concerns but also lots of other miscellaneous events and outside influences can spook investors and cause the fear that lead to sharp market declines and panic selling.

Probably a totally irrational skepticism on my part – but I think the news media has manipulation tactics and selectively seeds content, stock analysts have their own obvious biases and agenda, and of course corrupt politicians have access to insider information that allow them the ability to execute privileged and personally advantageous trades. It is hard to find trustworthy sources to believe. Just my opinion.

In a past blog, I briefly introduced a bit about my investing approach. Certainly trying times like these test our conviction. Lots of different investment philosophies exist – each with their own strengths and weaknesses. I subscribe to a philosophy known as Dollar-Cost Averaging (DCA). You can read about it a bit more here, but essentially you put same amount of money in the same stock (or index fund, etc.) on a regular basis over time, regardless of the share price.

“Our favorite holding period is forever.”
– Warren Buffett

In terms of personal investing, the February-March 2020 bear market was the only one I have actually had to endure. Before that, I was dirt broke and too busy suffering through dental school and multiple residency programs. Even though I know many others are experiencing these same tribulations right now, there is a unexplainable loneliness and depression that sets in when you see these steep market declines. I used Vanguard’s financial advisor services for a short while, and while I ultimately decided to stop and take things into my own hands, I did appreciate that I was not constantly worrying about how the markets were doing.

I dare not try and predict where the bottom of this latest market crash will be. However, I find some solace in knowing, if we stay the course and weather this storm, the market will do what it historically has – deliver some dependable returns.

In a future post, I will go over a few other investment strategies I do to minimize risk, including: invest in syndication real estate deals, invest in REITs and rental properties, and more recently – dare I say it – cryptocurrencies. Diversification is the name of the game!?

As always, thank you for taking the time to read through this post. Hope that some of this information can be useful to you, and please feel free to share in your own experiences!

The Tennis Takeover

Lifestyle

About a year before the world knew of COVID-19, my wife and I enrolled our two young boys in a local community tennis program. They had briefly tried their hands (or feet, rather) at soccer before that; but their scrawny physiques could not handle the endurance needed to continuously run the length of the soccer field. As their enthusiasm in soccer seemed to wane a bit, we made the decision to give something else a try.

Introducing tennis to them during COVID-19 was quite a blessing. It was naturally socially-distanced, much less of a contact sport then soccer was, and it was just enough of an outdoor social activity in a time when home-schooling was mandated and kids really stopped seeing their friends regularly.

The city’s park and recreation tennis class we had them in was short lived. The teacher was an older gentleman that showed up late, used most of the class time to ask the kids what they ate for lunch, and spent a disproportionately little amount of time letting them hold a racquet, instructing them about the rules and scoring of the game, and teaching them proper form.

It did however, allow us to be out on tennis courts. And that was huge. Because just being outdoors gave us an opportunity to see other coaches on neighboring courts teaching young kids. Now, most of the tennis greats of the world were holding racquets and started playing the game by ages 3 or 4. My kids were about 10 and 6. Oops. Oh well, better late then never?

“Do not squander time, for that’s the stuff life is made of.”

Benjamin Franklin

As I saw coaches that I thought had impressive teaching styles, I would approach them and inquire about lessons for my own kids. At one point, my boys had lessons from three different instructors and were spending about 1 to 2 hours out on the courts every day of the week. One day, my oldest son told me that the way one coach wanted him to serve was a different technique then another coach; and asked me who he should listen to?

At first, I thought I was doing them a favor recruiting all these accomplished trainers. One coach had almost gone pro himself. Another taught university level men’s tennis. Still another had such infectious passion for the game; and not only taught form and technique but focused on and spoke to the mental acuity and emotional stability needed to really succeed at it.

As it turns out, the coach that once told me “it’s not good to have too many voices in their heads” is the last one standing. He hosts a clinic a couple times a week, and offers private lessons on weekends that we sometimes take advantage of. He’s the right amount of strict/stern, pushes the boys to advance their game, encourages them to always be ready, to strategize the placement of their shots, and has really done well to teach them the intricacies of the game.

My wife and I went on to the U.S. Tennis Associations (USTA.com) website late last year and inquired about tennis tournaments our boys could participate in. Since then, they’ve played in several and have faired better in some then others. Our oldest son, Ishaan (12 yo), is mentally confident going into matches and just has a tendency of making unforced errors. Our youngest, Krish (8 yo), has an impressive passion and skill, but struggles a bit with nerves and believing in his abilities.

Part of the reason we wanted them to enter tournaments is to desensitize them to being in competitions. It is one thing to leisurely play against your sibling, against kids in your class, etc.; but it is a totally different dynamic when you are in a match against a stranger, you are officially keeping score, and there are rankings and trophies on the line.

We want them to learn responsibility; to eat a good healthy breakfast, get a good night sleep, and to get their tennis bag ready the night before a competition. We want to have them figure out how to cope with losses, and learn from mistakes they make within their matches. We try to reward them, win or lose, by letting them decide what they want for dinner or picking the dessert of their choice.

Tennis has, in many ways, taken over our lives. I absolutely love that my kids ask if we can go play tennis at the park on the days when they do not have lessons with their coach (and even some days when they do). I love that they want to watch tennis highlights of Nadal and Djokovic and Federer playing. I love that they now coach and correct me on how to properly grip a backhand or toss my serve.

Honestly, it has been an expensive hobby. Tennis shoes and attire, racquets (not to mention restringing) and balls, lesson (both clinic and private) – it adds up very quickly. I can only hope this is a lifelong passion of theirs, and that they go on and teach their own children to love and be good at the game.

The truth is, I secretly want them to be champions of this sport. I want them to progress, work hard, and potentially turn this into something professional if they can. But if they lose interest, want to explore other passions, that is okay too. I do not ever want to be the parent that forces their child to fulfill my own desire for stardom and success.

Thank you for taking the time to read this post! And spending time on my blog. As with so many topics that I discuss (investing, dentistry, medical issues, etc.), this will likely be the first of many posts about this matter. If you have any questions, or suggestions, I would love to hear from you! Be well!

Sciatica Sucks

Lifestyle

I find it incredible just how much we take for granted the elemental things within our lives. When I was in my early 20’s, I had a glob of wax obstruct my ear canal for a while. My sense of hearing was diminished, until I eventually got in to see an ENT; who, quite painfully, unclogged that cruddy cerumen. I remember tearing up in the last few seconds of him teasing out what looked like a nasty, slimy brown ball of goop about the size of my pinky finger tip. My point being, losing my hearing (out of one ear) for a short while made me realize how even the most rudimentary facilities we are given in life are not always fully appreciated until we are bereft of them. Thus goes everything in life I suppose. Don’t know what you got till it’s gone.

I probably spent a few days on cloud nine elated by my newly restored sense of hearing; and then sadly lost that appreciativeness and exhilaration to carrying on with the daily grind. However, today, I did not want to talk again about gratitude, but rather, yet another health problem that has recently affected me.

One pastime I enjoy most in life is receiving massages. However, a month ago after having received one – from a massage therapist I have visited several times before – I noticed a day or two later that sitting (and then standing) was tender in my right gluteal region. At first it was relatively mild, similar to muscle soreness we might experience after a solid workout. As days passed, that soreness was no longer isolated to just my gluts but started to radiate and extend down my right leg into the calf region. The severity of the pain also increased substantially, as did the frequency of when it was occurring. Tasks like sitting on the toilet and driving to work had me tearing up.

Sciatica is a nerve pain which originates in the lower back and radiates from deep in the buttocks and can travel down the lower leg. Usually sciatic nerve pain is unilateral and will only be symptomatic on one side of the body. There are several known causes, but a herniated (or “bulging”) disc in the lumbar (lower) spine is typically the most common. As a result, the nerve becomes compressed and there is pain (sharp, burning, radiating), inflammation and often times numbness/muscle weakness associated with it.

My commute to work each morning is only about 15 to 18 minutes; and I kid you not, I almost had to pull over multiple times to just stand up and stretch. Sitting for even short periods of time became excruciating. Fortunately mine was only an intermittent and postural pain; others unfortunately may experience it on a more constant basis. I had everything from a light tingling sensation, to pins-and-needles, to a strong, sharp burning and numb atrophy feeling in my calf muscle.

By the time I would arrive to work, daily, I would be popping 800 mg of Ibuprofen. That would get me through most of my day. At home, I would apply a heat pack and do some stretches. I also made one visit to a chiropractor and had some spinal manipulation and adjustment techniques performed.

“That which does not kill us, makes us stronger.” 
— Friedrich Nietzsche

According to SPINE-health.com, this affects 10-40% of the population, typically around the age of 40 years. Also, certain types of occupations (perhaps dentistry?) who often bend their spine forward or sideways or raise their arms frequently (okay, definitely dentistry!) may be higher risk. Thankfully, most cases typically get better with nonsurgical treatments within about 4 to 6 weeks. Some have persistent (over 1 year), and even progressive symptoms, in which case sometimes surgical intervention may be indicated.

As I write this, I am relieved to say my sciatic nerve pain is the best it has felt in over a month. It exists still, but not at an unbearable level like a month ago. Time, medication, proper stretches, heat therapy and the hands of a good chiropractor seem to have helped me make nearly a full recovery. Who knew something so simple like a drive to work or sitting on the toilet could be so painfully agonizing. Sciatica sucks!

Okay, so I have some PTSD about getting massages now. That is a blog post in and of itself. If you are just starting to have sciatic nerve pain, I am happy to share with you some of the Youtube videos and bookmarked websites I have on stretches that were effective with managing my pain. Please feel free to contact me directly or leave comments below! Thank you for taking the time to read this post, I appreciate it!

Craving the Controller

Lifestyle, Uncategorized

Throughout my life I have witnessed the evolution of video game systems. In 1985, I was six when Nintendo released their very first game console (in the United States). My parents gifted it to us a couple years later, but once it arrived into our house, my brother and I were hooked. We would play Super Mario Brothers, Duck Hunt, Zelda, Contra, Tetris, etc. so much that the unit would overheat; and of course we would simply take the game cartridge out of the console, and with great fervor, would blow on it until we were blue in the face. Then we would immediately pop it back in to the console and hope that our near cyanotic episode was enough to buy us a couple more hours of play. We knew cheat codes (“up, up, down, down, left, right, left, right, B, A and Start”), glitches in certain games, hidden levels, you name it.

Over the years, we weren’t ‘lucky’ enough to own every platform that was introduced onto the market. In fact, we owned the original NES (Nintendo Entertainment System), the Super NES, and a first generation XBOX. That’s it. Never an Atari, never a Sega Genesis, nor any of the Sony PlayStation series. I know what you’re thinking – what a rough and deprived childhood I must have had, right? Tell me about it.

In elementary school, I can still recall sleep-overs at friends houses staying up all night rescuing the princess from Bowser in Super Mario Bros. or button-smashing away to defeat (Mike Tyson’s) Punch-Out(!!). I would invite junior-high friends over right after school to come play Street Fighter II or Teenage Mutant Ninja Turtles on the Super Ninetendo system. But I actually hit a peak of ‘addiction’ later in life, right before registering for dental school, when three friends and I would get together every week or so and play the game Halo. No joke, we would play basically from early evening until the sun started to crack through the shutters. Then I would somehow make it home, and dream about Valhalla (a map in Halo), and snipers (a weapon in Halo), and trying to annihilate my friends at the game. We loved the online multi-player option for Halo, but we’d still meet regularly for the camaraderie and joy of witnessing someone’s face when you just finish rocket launching them from behind.

Life ended up interfering with our Halo group. I eventually started dental school, one friend moved away to Phoenix, another left to serve in the military and it all just unfortunately fizzled out.

A few years ago, I got excited to gift my two boys a Nintendo Switch. My wife initially opposed the idea. She was nervous (and rightfully so) that our boys would become addicted to video games. According to this article, 6 to 15 percent of all gamers exhibit signs that might be characterized as addiction. Emotional signs such as a feeling of restlessness or irritability when unable to play, preoccupation with thoughts of previous online activity or anticipation of the next online session, lying to friends/family about the amount of time spent playing and also staying isolated from others in order to spend more time gaming. Some physical symptoms might present as fatigue, migraines from eye strain or intense concentration, Carpal tunnel syndrome, and exhibiting poor personal hygiene.

Video games today are undoubtedly better than the 8-bit, pixelated consoles I used to play on. The graphics are insanely good, the online multiplayer setup gives them a social setting to feel accepted in, and all-round the games are designed to be more addictive then ever before. What’s worse, many games now are streamed – requiring minimal computing power and little more than a solid internet connection. Gaming companies have also become increasingly cunning in that they offer games for free and instead, now charge for things within the game. If not offered free of charge, have moved towards a monthly subscription-based model versus when I was a kid and my parents would have a one-time charge to buy the cartridge. Also, games now-a-days rarely have “levels” to beat, and therefore allow for continuous play and generally have no ending.

After dental school/residency, I never resumed my love of video games. I have so many precious memories, but now – older, more educated, more enlightened, more self-aware – I can’t help but consider the opportunity costs on the countless hours I spent on video games. I should have participated in sports or clubs instead of rushing home to turn on the Nintendo. How much better could I have done with my education? How much earlier could I have entered my career?

“Changing our thoughts, actions, experiences- and in the process changing our brains- is what will help us finally feel satisfied and free from the desperation of not being able to get enough.”

– Omar Manejwala

We ultimately decided to purchase the Nintendo Switch; however, that ended up not being the source of their addiction. After all, there are computers, phones, tablets, Apple TV’s, and so many other means of accessing games if they so desire. Before it was Angry Birds and Candy Crush. This generation seems to be all about Minecraft, Roblox, Fortnite, and something new seems to come out every day.

There have been studies that show an alarming correlation between video game addiction and depression, restlessness/sleeplessness, and even substance abuse. It can grow to be quite dangerous.

For a short while, I contemplated setting up parental controls, installing spy software, and cutting offer internet access to get them to stop playing so much. However, I genuinely do not believe that will inhibit addictive behavior. It is more reactive versus being proactive; and I feel like they will always find a way around the barriers I keep putting up. I would rather find solutions and methods that help decrease their cravings as well as distract them from thinking about gaming in the first place.

What I have found so far to be the most effective thing at helping overcome their dependency on video games and screen time as a whole is enrolling them in outside activities. Our kids take tennis classes, Kumon tutoring, and piano lessons. On weekends, we will try and do family board or card games, bake together, or go to the park. As dental school seemed to do for me, my hope is that – if we offer them better ways to occupy their time, and minimize exposure to the addictive substances – hopefully the brain rewires and overcomes dependency on things.

Everything in moderation, right? I think depriving them outright is not fair; they should be able to have some commonality and shared interests with other kids their age. But I want them to not be constantly thinking about them, or throwing tantrums when we tell them to turn it off. I want them to read books, spend time outdoors, interact with people, observe the world around them, become cultured. Recognizing and controlling obsessions and addictions is not easy for anyone; however, with some help and support from family and friends we hope to overcome these obstacles in life.

I love self-improvement, mental health and various psychology topics; I would be curious to know if anyone else has similar experiences and other good options to overcome addictive behaviors and tendencies. Please feel free to leave comments or contact me with your thoughts. Thanks for taking the time to read this post!

Hiding My Hair Loss

Lifestyle, Uncategorized

This next post has been a long time coming. On this site, I have written about my astounding student loan debt, my parenting faux pas, my time as president of an organization, and even a disconcerting medical condition that occurred to me fairly recently. Perhaps the reason I have been so reluctant to write this next post is because I have spent so much time, effort and money over the years trying to conceal this problem in the first place. Well, without further ado, here is a little tale about my struggles with hair loss.

In my early 20’s, I started noticing a few hairs on my head started to go scraggly. Even more distressing were the ones that would shed outright; usually discovered to my dismay while shampooing in the shower. Certain, close family members of mine (i.e. uncles) had an early history of hair loss; but my father retained a healthy mane well into fifties and sixties, and my mother (while thin) didn’t have any appreciable alopecic areas on her head. Please note, there can be genetic (e.g. family history, male sex hormones) and/or environmental (e.g. stress, nutritional deficiencies, thyroid conditions, etc.) causes to hair loss – I would strongly encourage everyone to seek the true etiology before starting on any particular treatments and therapies.

I just knew mine was not your normal ‘ordinary day’ hair loss. I started noticing discernable areas of my scalp in the mirror. By 23 years old, I took it upon myself to start visiting dermatologists and hair-transplant consultants to see what my options are. My form of hair loss, as best as I can tell, is the typical male pattern baldness known as androgenic alopecia. Back then (and perhaps even now?), the Norwood Scale was used to gauge the various patterns and stages of balding.

The Norwood Scale

Fortunately for much of my twenties and thirties, I fell under a Norwood stage I classification – where, especially when styled just right, there was not much noticeable change in the hairline or elsewhere. Now, in my forties, I have progressed to a stage III/IV where the hairs on my vertex/crown have more appreciably thinned and there is more generalized loss within my front and mid-scalp sections.

The dermatologist I saw in my twenties (and who has since retired) was a family friend of ours. With great reluctance, he prescribed me Propecia to help slow my hair loss. I say “reluctance” because, however rare, it may have sexual and other adverse side effects. He also made me promise that, when my wife and I decide to start a family, I stop taking the medication for several weeks (preferably months) prior to trying to conceive in case it may cause some unintended birth defects in our unborn child. Again, please consult a health care professional before starting any particular treatment; but personally I credit this medicine for retaining much of what I have left on my head today.

As I’m sure we all do in times of weakness and vulnerability, I turned to the Internet for answers. Forums like Hairlosstalk.com became my obsession, and I was constantly seeking other cocktails, potions, elixirs, “cures”, what have you to supplement and help stop (or better yet, reverse) my hair loss. Let me assure you, men’s hair loss is a multi-billion dollar (and growing) industry and there is no shortage of ‘strand-restoring’ products out there. Perhaps it was the recommendation of strangers online, or simply succumbing to the brilliant advertising and the promises of “stimulating regrowth” and “reactivating hair follicles” on the Rogaine packaging; but soon after starting Propecia – I found myself also applying 5% Minoxidil topically 2x a day.

Propecia and Minoxidil was my hair loss treatment regimen for over a decade, with relatively decent results. The scraggly hairs were no longer an issue, and hairs would still fall out in the shower, but in what seemed like more stable, ordinary amounts. I purchased expensive shampoo’s (e.g. Revita Hair Growth Stimulating Shampoo), tried vitamins (e.g. Viviscal Pro), used a micro-needling roller a few times a week, and even bought a laser helmet (e.g. Theradome EVO Laser Hair Growth Device) – but nothing really helped to any significantly appreciable degree.

About a year or so ago, I started noticing my hair receding in more substantive amounts again. I don’t know if there was elevated stress from the whole Covid-19 time period, I don’t know if maybe the tolerance or the efficacy for the medications I have been taking has started to reach its limit, it’s impossible to say. Nonetheless, it has concerned me enough that I have again started up consultations with dermatologists and hair-transplant specialists.

So far, the consensus among the three or four doctors (some dermatologists, some surgeons) I have met with (in-person or virtually) is that I am still not an ideal candidate for a hair-transplant (either FUT or FUE) procedure. While, in some strange way, that feels reassuring to hear – I am constantly paranoid about this problem progressing. My most recent research into hair loss remedies has introduced me to PRP (Platlet-Rich Plasma) Injections – which seems to be gaining popularity for this and other health conditions. Pricing and the recommendation on frequency seems to vary among providers, but I am resolved that this will be the next logical therapy in my desperate attempt to slow/stop my hair from falling out.

I would be remiss if I did not mention the psychological ramifications in all of this. While I recognize (and appreciate) that I am a lot better off than some male men in their forties, I can’t help but feel down, depressed, and distraught about my decrepit appearance. I already know my facial type is not fortunate enough to look good with a bald head, like the Bruce Willis or Dwayne Johnson’s of the world. I hate being so vain, and already struggle emphatically with aging and my fleeting youth. I spend SO much time trying to hide and disguise the problem; time I could spend with my kids, reading, exercising, just all-around bettering myself. So much expended energy worrying about how many strands I have waiting on the shower floor or in my comb. While I didn’t experience any erectile disfunction (thankfully), it is hard to pinpoint the hormonal changes that happen when you’re on medications (especially, electively) and the negative effects it may have on testosterone production and energy levels. I wish I could come to terms with it, accept and embrace it, age gracefully and focus on what really matters in life. For me (and many others suffering a similar fate), having hair is very much integrated into our identity, our self-esteem and our self-confidence; it a symbol of our youth, virility and feeling of attractiveness – and not so easy to let go of.

So, on that propounder-ing note, I thank you for reading this latest post. As with so many other topics, I wish I had better photographic documentation to incorporate in this post. Please feel free to contact me or leave any comments to discuss your own personal story and struggles.

Investing and Gambling(?)

Lifestyle, Uncategorized

Being born and raised in Las Vegas, growing up around slot machines and poker/blackjack tables, perhaps helped desensitize me a bit to the appeal of gambling. In my early twenties, I worked as a web developer and programmer for a local gaming company and it helped solidify in my head the notion that ‘the house always wins.’ As much as I love the idea of getting rich quickly, I knew that – at least in casinos, the cards were stacked against me.

After we paid off our student loans, I started to take some of that monthly income and began investing. Fortunately, I had already been reading content from The White Coat Investor for years; and his philosophy on refinancing, saving, investing – it was ingrained deeply within me. Now, there is A LOT to investing – certainly too much to cover for a mere post where the author tends to write extemporaneously i.e. here. There are countless books, websites, blogs, podcasts and forums in which to educate yourself and start the journey.

As always, I am happy to share with you the little information I have gleaned over the years. For starters, I subscribe to a FIRE (financial independence, retire early) movement; in which adopting a certain disciplined lifestyle and setting financial goals helps someone achieve freedom from the workforce. Of course raising your annual income, lowering your expenses, increase your saving/investing rate, maximize retirement accounts, reducing your tax liabilities, living below your means, etc. – it all feeds into successfully reaching this goal. Also, familiarize yourself with the 4% rule. In order to sustain a 30-year time horizon in retirement (adjusted for inflation), your nest egg should have about 25x what you expect to spend annually stored away.

Which brings me to my next point – calculate your savings rate and track your monthly/annual expenses. In addition to using our Mint account to budget and track expenditures, I also use an Excel spreadsheet to simply monitor our overall finances (monthly income, account balances, investment gains/losses, etc.). Consciously (and maybe, subconsciously?) seeing these numbers regularly not only keeps us organized and informed, but (for me at least) motivates me to improve/correct some spending habits. Generally my family stays within a 30-50% savings rate every month. Depends how early you start, but I have read a 20-25% rate (at least) is typically what you want to shoot for.

In order to start investing, I created an account (brokerage and retirement) with Vanguard. I love the story of Jack Bogle, the founder of The Vanguard Group – which was really my only deciding factor to open my accounts with them. I imagine Fidelity, TD Ameritrade, Charles Schwab, etc. have just as good (if not better) platforms set up as well. All my ‘long-term’ investing is done in Vanguard. There is some ‘uncompensated risk’ that goes along with investing in individual stocks and specific companies. Theoretically, a company can go bankrupt and you stand to lose everything. My distribution or asset allocation in my Vanguard account looks something like this: 1/3 Vanguard Total Stock Market Fund, 1/3 Vanguard Total International Stock Market Fund and 1/3 Vanguard Total Bond Market Fund. Every month, whatever I can contribute, gets split evenly amongst these three. The growth has been steady enough over the years, and there is a certain serenity in knowing my risk is drastically minimized because index funds are highly diversified. Another reason I have come to love Vanguard is because their fees and expenses to purchase and own these funds are so low compared to some other companies.

About a couple of years ago, I opened up a Robinhood account as well. All my ‘short-term’, active trading takes place there. Every month, a very small percentage of the money I set aside for investing purposes gets deposited here. Honestly, I consider this ‘play’ money – it affords me an opportunity to invest in companies I like (i.e. Apple [ticker: AAPL], Tesla [TSLA], Costco [COST], Netflix [NFLX], Berkshire Hathaway [BRK.A – which I can’t afford, and BRK.B]), and dabble in speculative stocks like GameStop (GME) if I so desire.

It has been interesting to see how my Vanguard (i.e. long-term, passive trading) compares against my Robinhood (i.e. short-term, more actively traded) account performs. The Robinhood app makes it super easy to execute trades; and within that simplicity, I think a lot of people succumb to their emotions and either 1) sell in a panic when the market or stock price is down or 2) buy in big on hyped-up meme stocks that are supposedly ‘going to the moon.’ Investing 101 teaches you either of these can be dangerous and really cut into your long-term gains. Timing the market is impossible. In my own experience, giving myself a fixed allowance every month to ‘dabble’ with has worked well; it allows me to keep myself in check and not get too carried away. If I happen to randomly pick some winners, great! However, in my mind, every single dollar I have placed into that Robinhood account is mentally money I have come to terms with completely losing. And just FYI, my Vanguard account is currently well out-performing my Robinhood gains.

The same appeal, and that ‘rush’ people get in casinos by putting it all on red (a reference to the game roulette in case it was missed) – that is a similar adrenaline high I get when putting a purchase order in on the Robinhood app. It can certainly be addictive, and really get you into some trouble. Which is partially the reason that I have not ventured into cryptocurrency trading, I do not feel I understand that investment vehicle well enough yet.

Arguably one of the most famous investors of all time, Warren Buffett, said quite a few things pertinent to my topic today. He said:

On Earning: “Never depend on single income. Make investment to create a second source.”

On Spending: “If you buy things you do not need, soon you will have to sell things you need.”

On Savings: “Do not save what is left after spending, but spend what is left after saving.”

On Taking Risk: “Never test the depth of river with both the feet.”

On Investing: “In the business world, the rearview mirror is always clearer than the windshield.”

Of course we all want to maximize our returns while minimizing our risks. However, there will be investment fees and expenses, market corrections/depressions, and asset classes that underperform just to name a few. Most investments just need TIME. The concept of compounding interest works; and for those individuals passionate enough to educate yourself, responsible enough to control your lifestyle, relentless and patient enough to withstand (and minimize) the failures along the way – I think they will earn the right to FIRE.

Thanks for taking the time to read this post! As a full disclaimer, I do not possess a business degree, have no formal financial training, do not stand to benefit any monetary gain from the companies mentioned above, and – for some – would recommend you seek assistance from a financial consultant or trained professional before beginning this endeavor. As always, feel free to ask any questions or leave any comments for me!

Figuring out Fatherhood

Dentistry, Lifestyle, Uncategorized

Colleagues in the dental field, upon discovering I do pediatrics, always squeeze in the phrase “it takes a special kind of person” somewhere into the conversation. I have also heard the words “thank God for people like you” on more than one occasion. If you have read any of my previous posts, I almost never miss an opportunity to gloat about how lucky I am to do what I do. Sure, there are stressful moments mixed into each work day – the deafening loud screamers, the biters, the pukers, and my personal favorite, the parents that tell me how to do my job. However, I would not trade my profession for any other, ever, period.

I imagine that the “special kind of person” comment implies there is a certain degree of patience and compassion for these little patients that those individuals maybe do not have a want or willingness to exert. Mind you, I do not say that judgmentally. I recognize that everyone on Earth has different skills, talents, and abilities – and what suits me may not befit someone else. I already established in my last post that I certainly do not have what it takes to be a Chippendales dancer.

Nevertheless, this notion that I may somehow possess a special amount of patience is an interesting one. At work, I am proud to say, I always try and maintain the utmost professionalism. I treat children with low-functioning autism, with attention deficit hyperactivity disorder (ADHD), and with various other medical and behavioral conditions. The truth is, throughout most of my brief appointment – whenever I have an unruly child in the chair – I think to myself how demanding and taxing it must be for the parent to take this on day in and day out. Really, kudos to them.

At home however, unfortunately, my parenting style does not always feature that same calmness and composure.

When I was younger, well before my children were born, I was driving down the street, stopped at a traffic light, with my window rolled down. At the same street corner, waiting to cross, was a father and his young boy (probably no more than around 7 or 8 years old). I caught only a brief portion of their altercation before I had to resume driving, but the dad was berating his son about his bike, either ruining it…not riding it properly, something to that effect. I remember thinking to myself, how could any material object be worth laying into your kid like that?

Little did I know back then that I would have progeny of my own one day. As recently as yesterday, I chastised my younger son for 20 minutes about being too distracted/not concentrating and doing ‘poor quality work’ on his Kumon (a math and reading tutoring program) assignments. (Ironically, he’s eight.) It is a lecture I have given to him time and time again. A few months ago, at a park, he left his tennis racket unattended somewhere and it was stolen. The drive home was filled with my reprimanding him about being more responsible with his things. I guess, so much for my ‘material objects’ memory huh?

I wish every moment could be remembered like this one above.

For the record, I am not proud of these outbursts and punitive moments of mine. All too often, I ultimately regret the vehement way in which I handled the situation. My biggest fear is the emotional scar and substantiality of the memory it creates in their mind. Although for me, disciplinary moments like these seem infrequent and tend to occur far and few between; in the mind of a child, I imagine it carries immense weight and detracts from the many jocund times we share together. And that is sad to me; because I truly do make concerted efforts to play with them, talk with them, take them places, and provide them things that I was bereft of as a kid.

The reasons for (and root cause of) my overly aggressive outbursts are probably outside of the scope of this blog post. But like so many other things in my life, in an effort to right wrongs, I try and self-reflect on shortcomings and character flaws within myself. I need to work harder at managing my expectations for my kids. While (I think that) I am trying to instill a good work ethic in both of my boys; I feel I am also setting myself up for disappointment and frustration when they aren’t delivering on things I myself believe to be important. I have to learn to exercise more patience and tolerance to the simple fact that they are children; and mistakes, and messes, and imperfections in all forms will help them learn, cope, and even correct certain behavior in the future.

When I think about the miracle of childbirth; and how even from the point of conception, we need so so so many countless processes to go right before we’re given a beautiful, healthy baby – I almost feel ashamed of myself that I let petty things like messy handwriting or a stolen tennis racket ruin a moment and a memory in time I have with my two young boys. Don’t get me wrong, disciplining and punishments have their place. I am just going to make more of a conscious effort to handle their foibles and failures with a tad bit more of tranquility. Every child is a blessing; I have to work harder to appreciate that fact not only at work but within my own home.

Really, thanks for taking the time to visit this blog and read through some of these posts. I can always use help in the parenting space, so please feel free to send any comments and questions my way!