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!

Programmer to Pediatric Dentist

Dentistry, Lifestyle

One evening my father came home from a dinner party and told me that he had an interesting conversation with a gentleman he met there that said computers were going to be the future. This was in 1997. That, sadly, is how I resolved to be a computer science major in college. Which was okay by me since I was addicted to AOL chat rooms anyhow. I had no idea what computer science entailed, no clue about programming languages, no concept of coding at all. But a degree that lets me sit at the computer all day and allows me to talk to random strangers in chat rooms? Sign. Me. Up!

To this day, I have no idea how that random stranger at the party knew the world would be dominated by Microsoft, Amazon, Netflix, Google and AOL. Okay, maybe not so much AOL. But oh how I miss that thrilling static sound of the modem connecting, and the euphoric notification that I have mail once it finally logged in. But I digress.

Come to find out, the field of computers and information technology certainly did not need another Indian person. I did not know it until I began taking classes, and quickly came to realize the fact that everyone in the department looked like me.

It’s hard for me to say if I ever really became passionate about programming. I would guess not. I learned several languages relatively well (e.g. C++, Java, Assembly, Visual Basic, etc.). I liked very much the critical thinking component of it, and thoroughly enjoyed the challenge of troubleshooting and debugging code. For four years, I went through the motions and became technically just adequate. However, that intrinsic passion hackers have? It wasn’t in me.

I could not have picked a worse time to graduate. The year 2001, the dot-com era was crashing, programmers were getting laid off everywhere you looked, and tech companies were over-working the few people they did retain. I was fortunate enough to land a job shortly after graduating for a local company that invented and promoted casino games. It was not so much hardcore programming as it was web-design and some Flash scripting; but beggars can’t be choosers. The pay was embarrassingly low, but the owner of the company owned several properties around the world he would allow employees to vacation at, plus I had an office with an amazing view overlooking the world-famous Las Vegas Strip; perks like that mixed with a low-stress work environment prompted me to stay for several years. I had designed some logos, some websites, some online Flash games; all-in-all, it was a chill and semi-creative (but not professionally challenging) position.

A couple years into that job, a college friend reached out and let me know of an opening for a programming instructor at a trade school he was working at. I had a fear of public speaking at the time, and I immediately applied for that job for no other reason but to set myself on a path to conquer that fear.

When you are afraid, do the thing you are afraid of and soon you will lose your fear of it.
-Norman Vincent Peale

Let me tell you, it was stressful. Class typically ran about 5 hours between the lecture and the hands-on component, and averaged about 20 to 30 students. Coming up with a weekly curriculum that keeps peoples attention for such a long period of time was not easy. And I was teaching to people from all walks of life; different personalities, different motivations and pursuing different types of degrees. I would have multimedia majors, engineering, and of course programming students. It also took a minute for me to accept the fact that I was now the one delivering the PowerPoints, administering the tests and grading the assignments.

Throughout the week I would teach some evening classes from 6-11 pm as well as some Saturday morning or afternoon classes. I was lucky my 8-5 gaming job offered me a little flexibility to bow out early so I could drive across town to get to job #2 on time. Looking back, I am still not sure how I managed to balance both jobs successfully. In fact, years went by complacently, but then slowly I started to feel the tides changing.

My gaming job hired a new manager, who introduced stricter (and often times unrealistic) project deadlines. Within months of his arrival, that same manager brought on the bookkeeper’s husband to be an additional I.T. ‘support’ guy; which had an unsettling “I’m training my replacement” kind-of feel to it. I put in my two-week resignation soon after. Even the teaching job had some dark truths slowly come to light; their aggressive recruiting and marketing practices brought in just any warm body willing to pay their steep tuition costs, and ultimately lead to their closure by the Department of Education in 2016. Luckily I saw the writing on the wall well before that, and realized it was time for a life change.

Begrudged and disillusioned, I started brainstorming alternative career paths. By now I was in my mid 20’s, never worked in a real software-development setting, and was resolved to pursue a profession where I could be my own boss. I knew something in the medical field should meet that criteria, I just didn’t immediately know what to do. My younger brother was already on his path to becoming a physician and advised me that it may be too long of a road to medicine for me to start over with. My girlfriend (now wife) was a pharmacy-tech (now pharmacist) and cautioned me that there were constant patient complaints and insurance issues that comprised her day, and she would not recommend that pharmacy life for me. Thus the decision to pursue the field of dentistry was born. I could put in 4 years of professional school, graduate and jump right into private practice.

I began by just enrolling in a couple of pre-requisite classes that pretty much all health professionals would need to take. Basic biology, chemistry, organic chemistry, and biochemistry. Fortunately some pre-req’s overlapped my Computer Science bachelors degree and I did not need to put in any more time towards retaking them. Unfortunately, some recommended classes, like immunology, histology, anatomy and physiology, I had no time to squeeze in before the next application cycle for dental school. Something about returning to school, more focused and driven, gave me the determination and perseverance to excel and perform better the second time around. I got high mark’s in my classes, scored within the 90th percentile for my Dental Admissions Test (DAT), and was accepted into the UNLV School of Dental Medicine Class of 2011.

Unlike my computer science classes, I was the only Indian person in my dental school class. Not that it really mattered any, but I also felt like I did not have the same strong science foundation that most of my classmates learned while acquiring their undergraduate degrees. I quickly regretted not taking those recommended courses I mentioned earlier, and struggled with the plethora of didactic material my first couple of years. I also had a tough time early on with waxing teeth, and even had to remediate a bit over my first summer session.

Around third year, I started to find my element. Operative dentistry was going well, fabricating dentures was fun, and I had some successfully completed root canals. My confidence was building. However, in my fourth year – as graduation neared – a bit of reluctance started to kick in as I realized how slow a dental student’s schedule was compared to that of the real world, and how I had only barely skimmed the surface of the advanced procedures in dentistry like doing implants, veneers, and molar root canals.

Some soul searching, some profound apologizing to my wife that I needed an extra year to get comfortable, and a willingness to endure yet another stressful round of applications – but after jumping through those hoops, I got accepted into a year long post-graduate General Practice Residency (GPR). Meanwhile, as an attempt to get some real-world experience, I also chose to moonlight at a dental clinic on Saturdays. The office they assigned me to, interestingly enough, mostly saw children on weekends.

The more I worked around children, the more I loved it. I dreaded my week in the residency doing general dentistry, and absolutely adored my weekends with pediatrics. To the point that, I just knew, deep down, I wanted it to be a full-time gig. If asking my wife for a year long extension to my dental school training was difficult, imagine the sheer agony of having to tell her I wanted to return yet again for an additional two years of training. My brother’s advice about the medical route being too long was a moot point now, because I will have essentially dedicated seven years of my life to becoming a dentist.

I LOVE being a pediatric dentist. My personality type does well with monotony. I do a handful of procedures very well; as opposed to a general dentist needing to be competent at a large range of things. I don’t have to sell anything; I diagnose disease and present a plan to treat it. And best of all, I get to work with children; every one of them are so unique and it keeps the day exciting and entertaining.

“Find a job you enjoy doing, and you will never have to work a day in your life.”
― Mark Twain

I still do not own my own practice. I am still an employee, which, goes against one of my original goals for wanting to become a dentist. But I graduated with well over $200,000 in student loans; and opening up a dental office is pricey. My practice owners allow me a generous amount of autonomy, I am incredibly grateful to be able to work (in a lot of ways) by my own terms. Plus, my own kids are young; and instead of having the headaches of practice ownership, lease negotiations, staffing, billing, payroll, etc. – once I physically leave the office for the day and I also get to mentally check out and go spend time with my family.

Well, that was the journey. I worry about the long-term physical demands of dentistry. And just like everyone else, I get burnt out and drained from time to time. But I feel truly blessed to do what I do. I hope you are all able to find a job you can find some joy in.

Thanks for taking the time to read this lengthy post. Please, contact me with your own journey or with any questions about my own! Take care!