AMA - Practice startups and early retirement

[TanMan]

So what are the procedures you do on a daily? I think you mentioned some previously so those are bolded and underlined, but I just want to make sure. Here's a list, please feel free to add the ones you do that's not there, and explain why you don't do the rest. I already know why you don't do sedation from your previous post.

1. 3rd molar extraction (full and partially bony)?
2. Crown and bridge
3. Crowns
4. Fillings
5. Cerec (onlay, inlay)?
6. Simple Extractions (D7140) How do you know when to bill for (D7210)?
7. Veneers?
8. SRP in Hygiene?
9. Molar endo
10. Invisalign or 6-month braces?
11. Peds?

Most common: Crown/bridge, endo(molar + retreat, unless the prognosis is poor or large post placed previously), fillings, Hygiene does SRP's, extractions but no full/partial bony, easy 3rd's. Surgical extraction is billed if I have to touch the alveolar bone or do major curettage of any periapical pathology.

Rarely: LANAP/Pinhole gum surgery, fillings/ssc for kids, implant restorations

I rarely do veneers and dentures, trying to transition out of them. No ortho/6MB, no cerec onlay/inlays (full coverage only)

That's pretty much it.

Edit: I realized that you wanted a reason why I don't do the rest...
1. Partial/full bony - higher liability, more time consuming, more post-op discomfort.
2. CEREC onlay/inlay - higher failure rate, I'm more conservative, if I can fill it, I think its better. If the tooth structure is far gone, I'd rather do a full coverage on it. CEREC inlays are a scam imo.
3. Veneers - unrealistic expectations of patients, usually picky. Don't want to deal with it.
4. Why would I do my own SRP? My time is worth more in ops.
5. Invisalign / 6MB - I have orthodontists referring a lot of patients to me. I wouldn't burn down my bridges just to earn some extra bucks on something I hate doing. I get a lot of cash patients from the orthodontists who don't mind paying 1k for SRP if they need it or 600 for 4bi's. Instant money right there.
6. Peds - Don't do it for the sanity. Have to deal with the parents, the patients, crying, whining, etc... I don't want to be fake and keep pretending I'm enjoying the interaction. Rarely, some adults act worse than kids, and I just have to tell them that if you don't feel comfortable proceeding, you should get sedated. I just don't do sedation here.
7. Dentures - I lose money, chair time, and unrealistic expectations. I'll do interim partials while waiting for implants to osseointegrate for restoration if they care to have a tooth there or if its the anteriors
8. Full mouth reconstruction - When I tally the amount of time and workup needed for these cases, I make a lot less than RCT/bu/crown combo on an hourly basis. Also liability and the ones that usually got to this stage are hostile towards the dentist and/or no money. I don't want to hedge case acceptance on these types of cases and the issues afterwards. People think if they are spending 30k+ on their teeth, that it should last a lifetime even if they don't brush their teeth. Their cars are worth 30k+ and they dont expect it to last a lifetime, why should any restorative work.

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[Sanducan]

Most common: Crown/bridge, endo(molar + retreat, unless the prognosis is poor or large post placed previously), fillings, Hygiene does SRP's, extractions but no full/partial bony, easy 3rd's. Surgical extraction is billed if I have to touch the alveolar bone or do major curettage of any periapical pathology.

Rarely: LANAP/Pinhole gum surgery, fillings/ssc for kids, implant restorations

I rarely do veneers and dentures, trying to transition out of them. No ortho/6MB, no cerec onlay/inlays (full coverage only)

That's pretty much it.

Edit: I realized that you wanted a reason why I don't do the rest...
1. Partial/full bony - higher liability, more time consuming, more post-op discomfort.
2. CEREC onlay/inlay - higher failure rate, I'm more conservative, if I can fill it, I think its better. If the tooth structure is far gone, I'd rather do a full coverage on it. CEREC inlays are a scam imo.
3. Veneers - unrealistic expectations of patients, usually picky. Don't want to deal with it.
4. Why would I do my own SRP? My time is worth more in ops.
5. Invisalign / 6MB - I have orthodontists referring a lot of patients to me. I wouldn't burn down my bridges just to earn some extra bucks on something I hate doing. I get a lot of cash patients from the orthodontists who don't mind paying 1k for SRP if they need it or 600 for 4bi's. Instant money right there.
6. Peds - Don't do it for the sanity. Have to deal with the parents, the patients, crying, whining, etc... I don't want to be fake and keep pretending I'm enjoying the interaction. Rarely, some adults act worse than kids, and I just have to tell them that if you don't feel comfortable proceeding, you should get sedated. I just don't do sedation here.
7. Dentures - I lose money, chair time, and unrealistic expectations. I'll do interim partials while waiting for implants to osseointegrate for restoration if they care to have a tooth there or if its the anteriors
8. Full mouth reconstruction - When I tally the amount of time and workup needed for these cases, I make a lot less than RCT/bu/crown combo on an hourly basis. Also liability and the ones that usually got to this stage are hostile towards the dentist and/or no money. I don't want to hedge case acceptance on these types of cases and the issues afterwards. People think if they are spending 30k+ on their teeth, that it should last a lifetime even if they don't brush their teeth. Their cars are worth 30k+ and they dont expect it to last a lifetime, why should any restorative work.

Thanks!

In regards to 7210 vs 7140, you're saying if you have #3 that is perio affected and is somewhat mobile, you use a forcep to extract and code as 7140? However, if the tooth isn't mobile and you have to use a perio and straight elevator to loosen, that's automatically a 7210?

It seems as if a lot of dentists up code in private practice, some on purpose some by mistake. Just want to make sure I'm doing the right thing.

 

[Steins;Gate]

I have orthodontists referring a lot of patients to me

How are you able to have orthodontists to refer lots of patients to you? Is it through establishing a strong local reputation as well as referring a lot of ortho cases to them?

What is a collections rate that your office tries to adhere to? 95%? 98%, etc.?

Will you ever have any travelling specialists do some cases in your office on a weekly/monthly basis? What are your thoughts on this versus just referring out the specialty cases you do not want to perform (I guess if you already have strong relationships with specialists, you don't want to burn any bridges)?

 

[TanMan]

Thanks!

In regards to 7210 vs 7140, you're saying if you have #3 that is perio affected and is somewhat mobile, you use a forcep to extract and code as 7140? However, if the tooth isn't mobile and you have to use a perio and straight elevator to loosen, that's automatically a 7210?

It seems as if a lot of dentists up code in private practice, some on purpose some by mistake. Just want to make sure I'm doing the right thing.

If I have to use a bur to trough/section or curette a huge periapical radiolucency, I'll charge a 7210; otherwise, I'll do a 7140.

Edit: It's better to overquote than underquote. If a case is iffy on whether its going to be surgical or simple, quote the surgical. If you don't have to do it through a surgical approach, you can tell the patient that you didn't have to drill into the alveolar bone, section the tooth, etc... and they'll be paying less (and bill out the simple). Patients will be a lot more appreciative v. if you quote a simple, then you end up having to do a surgical. Your patients will think you're just nickle and diming them. Usually, it can be iffy on VRF cases.

How are you able to have orthodontists to refer lots of patients to you? Is it through establishing a strong local reputation as well as referring a lot of ortho cases to them?

What is a collections rate that your office tries to adhere to? 95%? 98%, etc.?

Will you ever have any travelling specialists do some cases in your office on a weekly/monthly basis? What are your thoughts on this versus just referring out the specialty cases you do not want to perform (I guess if you already have strong relationships with specialists, you don't want to burn any bridges)?

I aim for 95+. Orthodontists send a lot of cases to me because I send them a lot of patients too and the local reputation/advertising engine/volume drive.

I am resistant to having traveling specialists for the reason that I'm going to have to do their post-ops which I don't want to deal with. I get a lot of referrals from ortho, so I wouldn't mess with their territory. I'll also need more staff to cover those specialists since I already work my current staff pretty hard. Is it worth it? Not to me.

 

[Steins;Gate]

Thanks TanMan. How do you handle your many columns on hygiene? How many patients does each of your hygienists book an hour? How much time do you spend per recall?

 

[TanMan]

Thanks TanMan. How do you handle your many columns on hygiene? How many patients does each of your hygienists book an hour? How much time do you spend per recall?

The rule is... just keep going. Please as many people as possible by making sure they feel like they are always being attended to. I'll always ask my DA to have the appointment up so I can have full awareness of who's been waiting, who hasn't been waiting for long, families (periodics v. initial exam), etc... I move a LOT. I will get warned by DA's of patients who are probably going to use up a lot of my time (they go last). Usually the hygienists will have 1-3 patients per hour (depends on workload, are they kids, recalls, initials, etc...).

Recall can be quick. If the patient is asymptomatic, no issues, no problems, and I don't see anything on the radiographs, few minutes at most. If they have problems, 5-10 mins. How do I do it quickly? During some downtimes of certain procedures, I'm reading radiographs, looking at probings, asking the hygiene DA's of patient status'(s), etc... if I see anything on the radiographs or need a retake, I'll tell the DA to do it before I get in the room or if I need other things such as a tooth sleuth, EPT, endo ice, etc...

In certain procedures, you have 10-60 seconds of downtime between certain steps.

 

[Steins;Gate]

The rule is... just keep going. Please as many people as possible by making sure they feel like they are always being attended to. I'll always ask my DA to have the appointment up so I can have full awareness of who's been waiting, who hasn't been waiting for long, families (periodics v. initial exam), etc... I move a LOT. I will get warned by DA's of patients who are probably going to use up a lot of my time (they go last). Usually the hygienists will have 1-3 patients per hour (depends on workload, are they kids, recalls, initials, etc...).

Recall can be quick. If the patient is asymptomatic, no issues, no problems, and I don't see anything on the radiographs, few minutes at most. If they have problems, 5-10 mins. How do I do it quickly? During some downtimes of certain procedures, I'm reading radiographs, looking at probings, asking the hygiene DA's of patient status'(s), etc... if I see anything on the radiographs or need a retake, I'll tell the DA to do it before I get in the room or if I need other things such as a tooth sleuth, EPT, endo ice, etc...

In certain procedures, you have 10-60 seconds of downtime between certain steps.

Do you stand for certain procedures? Or is it mostly sitting during procedures with a lot of moving from op to op?

 

[TanMan]

Do you stand for certain procedures? Or is it mostly sitting during procedures with a lot of moving from op to op?

I stand for almost all procedures.

 

[Steins;Gate]

I stand for almost all procedures.

Do your assistants stand as well? And do you use microscopes? I'm just curious about maintaining ergonomics and reducing sitting time especially in a high patient flow office like yours.

 

[TanMan]

Do your assistants stand as well? And do you use microscopes? I'm just curious about maintaining ergonomics and reducing sitting time especially in a high patient flow office like yours.

They have to stand. No microscopes, loupes + headlights only.

 

[I-hate-alginate]

I know you see a lot of patients everyday in a limited amount of time so my question is, on a scale of 1-10, 1 being "how did I graduate dental school" and 10 being "Im the best dentist to ever walk on this planet", how do you rate your work in terms of quality?... Another question if you dont mind, Since you stand all day pretty much, I believe you would feel exhausted by the end of work, so when you go back home, do you have the energy to do any other activities or just go to sleep early and get ready for your next day at work? I know those questions are a bit personal but I just want to see the lifestyle for dentists who own their own business.

 

[TanMan]

I know you see a lot of patients everyday in a limited amount of time so my question is, on a scale of 1-10, 1 being "how did I graduate dental school" and 10 being "Im the best dentist to ever walk on this planet", how do you rate your work in terms of quality?... Another question if you dont mind, Since you stand all day pretty much, I believe you would feel exhausted by the end of work, so when you go back home, do you have the energy to do any other activities or just go to sleep early and get ready for your next day at work? I know those questions are a bit personal but I just want to see the lifestyle for dentists who own their own business.

I'd say 7.5-8.5. Not the best, not the worst. There's always room for improvement. I am tired, but I actually sleep kinda late (2-3am-ish). Physically tired, mentally alert if that makes any sense.

 

[Sanducan]

Wow, you're working tremendously hard! Not even sitting down to do procedures, never heard that one before for a GP.

Since the entire goal is to retire early, if I were you, I would open multiple practices, insert management layers i.e. Practice managers and area managers, then ride off into the sunset. Have you ever considered this?

 

[TanMan]

Wow, you're working tremendously hard! Not even sitting down to do procedures, never heard that one before for a GP.

Since the entire goal is to retire early, if I were you, I would open multiple practices, insert management layers i.e. Practice managers and area managers, then ride off into the sunset. Have you ever considered this?

I looked into it. You'll end up with a top-heavy organization with larger administrative overhead and costs. More headache for marginally more money. As I mentioned before, I don't need hundreds of millions of dollars, I'll be happy with 5-10.

 

[I-hate-alginate]

If time goes back to the year you graduated dental school, would you do anything differently?

 

[TanMan]

If time goes back to the year you graduated dental school, would you do anything differently?

Be more ambitious, don't be so short sighted and focus on the endgoal (retirement). Also, make sure you're with a man/woman/partner that will support your ambitions, if you choose to be with someone.

 

[TanMan]

Wow, you're working tremendously hard! Not even sitting down to do procedures, never heard that one before for a GP.

Since the entire goal is to retire early, if I were you, I would open multiple practices, insert management layers i.e. Practice managers and area managers, then ride off into the sunset. Have you ever considered this?

Also... wanted to add: since you're still in dental school, try working standing up for everything (endo, fills, etc...), you'll notice its better for your lower back, more visibility, and faster procedures. I started standing in my 3rd yr. I see it like jacking up a car and you don't have to do what a lot of dentists seem to do when their sitting down - putting the patient in trendelenburg (not a very comfortable position for you or the patient!)

 

[I-hate-alginate]

Be more ambitious, don't be so short sighted and focus on the endgoal (retirement). Also, make sure you're with a man/woman/partner that will support your ambitions, if you choose to be with someone.

Can you list few things that you believe held you back/wasted time that you recommend us to not do?... let's say that we want to retire at young age too... 10-15 years after graduating DS.

 

[TanMan]

Can you list few things that you believe held you back/wasted time that you recommend us to not do?... let's say that we want to retire at young age too... 10-15 years after graduating DS.

Trying to pay off student loans faster, rather than saving the money to start an office. Incompatible partner who doesn't share same goals. Thinking that 200k+ as an associate is good money (almost fell for the trap of being happy with that getting out of dschool). If you get too complacent, you'll be happy where you're at for the time being, then it'll be many years that pass then realize that you need to kick it in high gear and open your own office even if it risks the comfort of being an associate. There's a saying... some people are corporate for life, its a joke that we throw around saying if you're in corporate for 4+ years, chances are, you're there for life.

 

[I-hate-alginate]

Trying to pay off student loans faster, rather than saving the money to start an office. Incompatible partner who doesn't share same goals. Thinking that 200k+ as an associate is good money (almost fell for the trap of being happy with that getting out of dschool). If you get too complacent, you'll be happy where you're at for the time being, then it'll be many years that pass then realize that you need to kick it in high gear and open your own office even if it risks the comfort of being an associate. There's a saying... some people are corporate for life, its a joke that we throw around saying if you're in corporate for 4+ years, chances are, you're there for life.

Some people are corporate for life indeed! Thank you for the tips! Here is second part to this question... few questions. What are the things that we MUST start doing in dental school (D4) to achieve our goal (retiring early)? And what are the things that we must do as soon as we graduate? Also, how do you figure out when it is the right time to start a practice... when you have enough experience, enough money to start one, etc?.... and last question for the night, if you graduated school with the objective of retiring early, would you be able to retire now or would you still have to work for few more years to reach your goal?

 

[TanMan]

Some people are corporate for life indeed! Thank you for the tips! Here is second part to this question... few questions. What are the things that we MUST start doing in dental school (D4) to achieve our goal (retiring early)? And what are the things that we must do as soon as we graduate? Also, how do you figure out when it is the right time to start a practice... when you have enough experience, enough money to start one, etc?.... and last question for the night, if you graduated school with the objective of retiring early, would you be able to retire now or would you still have to work for few more years to reach your goal?

1. Clinical proficiency, know of the area that you may want to practice in the future, secure a job immediately anywhere for the most amount of money.
2. Right time is when you have enough money. If you have common business sense, enough money, and the drive, you will succeed.
3. Probably a year or two earlier than what I expected (I project 2020, but maybe shave a year or two off that)

 

[I-hate-alginate]

1. Clinical proficiency, know of the area that you may want to practice in the future, secure a job immediately anywhere for the most amount of money.
2. Right time is when you have enough money. If you have common business sense, enough money, and the drive, you will succeed.
3. Probably a year or two earlier than what I expected (I project 2020, but maybe shave a year or two off that)

The question every pre dent, dental student, and most dentists want the answer for is how do you get the common business sense.... we clearly lack it... lack it in abundance?

 

[TanMan]

The question every pre dent, dental student, and most dentists want the answer for is how do you get the common business sense.... we clearly lack it?

I think this is where it gets a little tricky... I don't think people lack it, but may not necessarily be able to reason through it. There's always questions that need to be answered and I think we need to know what to ask about our business situation before we can tackle it ourselves. I think we've gone through many examples in this thread on what to consider and how to think about business situations. There's more than one solution to many problems, and the ones I propose work for the way I work and my mindset. Now, some people disagree with me, but that's because their belief systems and/or practice philosophy is different.

I don't think people lack it, dentists just need to try to understand consumer behavior. From there, most of your business from the supply side should run smoothly IF you can deliver to your patient's expectations.

 

[Legacy382]

How do I favorite this thread? lol

 

[TanMan]

With hindsight 20/20, would you still have chosen dentistry as a career? I ask because folks in finance seem to follow your route quite a bit: amassing colossal wealth in 20s and 30s for early retirement by 40s.

Also, isn't starting and building your own office from literally ground up considered riskier than buying an existing office? You seem to imply that starting/building your own is superior over anything else when it comes to practice ownership. True? And how come?

Given the same circumstances, I would go the same route of dentistry still unless I had lots of money to start. Finance is tough, not everyone makes it.

Starting your office is a lot riskier if you go out and don't control your startup expenses. I think that building your own is definitely superior unless you can find that supercheap bargain office that doesn't have any underlying internal issues which usually, the office does have problems. Even if you have that bargain office that has no problems, you're essentially buying something that someone else built, their operations may not necessarily be built to the way you want nor in the most efficient way. Also, people tend to borrow obscene sums of money to purchase a practice which can sometimes be 1MM+. If their office was only producing 1-2/yr, it can take a while to pay the debt service off, whereas if you start your own office, you don't have to have that incredible markup.

Now, you may say... the practice already has patients! I'll be generating money from the start. Yes, you'll be generating money, but more of that money is going to be used to pay off the office you just bought. The primary good I see out of buying an office is that you have patients already, but there are a lot of downsides such as:
1. Staff already used to the way the other doctor was running it. More resistant to change. Sometimes its hard to fire someone depending on the state you are located. Also, too much turnover can decrease your morale
2. What kind of patients did they have? If the previous dentist did all the treatment already, all you're buying then is the leftovers (recalls) and the turnkey part of the operation for a relatively ridiculous amount of money. What guarantee do you have that those patients will stay with you? If a lot of them left, then you're just buying equipment for a very marked up price (worse than new)
3. Resources required to turn around or grow the office more. Depends on the rooms, number of patients, capacity, workflow, staff, scheduling, etc... One of the worst things is you buy an office that can't grow anymore unless they are making a LOT of money already. Your work input is essentially like buying a bond but you have to work to make money out of it.

There's more, but I need to go. I'll see if I can add to the list.

 

[distressstudent]

I would love to build my practice like yours one day.
I think you and I have very similar philosophy when it comes to work. Whether or not I have the skills/tenacity to execute on that plan is still questionable haha.

Are you on bogglehead or /r/FIRE etc? I am be interested in reading your posts there too if you are.

 

[Sanducan]

Given the same circumstances, I would go the same route of dentistry still unless I had lots of money to start. Finance is tough, not everyone makes it.

Starting your office is a lot riskier if you go out and don't control your startup expenses. I think that building your own is definitely superior unless you can find that supercheap bargain office that doesn't have any underlying internal issues which usually, the office does have problems. Even if you have that bargain office that has no problems, you're essentially buying something that someone else built, their operations may not necessarily be built to the way you want nor in the most efficient way. Also, people tend to borrow obscene sums of money to purchase a practice which can sometimes be 1MM+. If their office was only producing 1-2/yr, it can take a while to pay the debt service off, whereas if you start your own office, you don't have to have that incredible markup.

Now, you may say... the practice already has patients! I'll be generating money from the start. Yes, you'll be generating money, but more of that money is going to be used to pay off the office you just bought. The primary good I see out of buying an office is that you have patients already, but there are a lot of downsides such as:
1. Staff already used to the way the other doctor was running it. More resistant to change. Sometimes its hard to fire someone depending on the state you are located. Also, too much turnover can decrease your morale
2. What kind of patients did they have? If the previous dentist did all the treatment already, all you're buying then is the leftovers (recalls) and the turnkey part of the operation for a relatively ridiculous amount of money. What guarantee do you have that those patients will stay with you? If a lot of them left, then you're just buying equipment for a very marked up price (worse than new)
3. Resources required to turn around or grow the office more. Depends on the rooms, number of patients, capacity, workflow, staff, scheduling, etc... One of the worst things is you buy an office that can't grow anymore unless they are making a LOT of money already. Your work input is essentially like buying a bond but you have to work to make money out of it.

There's more, but I need to go. I'll see if I can add to the list.

Tanman, I definitely respect your opinion on a lot of points, but I disagree with a couple things you mentioned. I know you're a startup guy and somewhat bias to towards that practice model, but hear me out.

1. Staff can definitely be resistant to change, but at the same time it’s your practice, and staff members will get in line if you're a strong leader that can get people to buy into your vision. There aren't a lot of states where you can't fire someone from a dental practice, a matter of fact I've never heard of such a state. I do agree though that too much turnover can affect the practice in a negative way, but that can be managed.

2. If you're going to buy a practice, I would think knowing what kind of patients the practice has would be a big part of your due diligence. I certainly wouldn't buy a practice that has mostly implant patients if I'm a new grad, that would be suicide. I would look for a practice that has an old doc that's looking to retire in a few years that has been referring out Molar endo, ortho, extractions, doing patch work for the most part, and would be willing to stay on for at least one year. Then I would be able to go in the practice and offer all those services in house, which would be an instant profit boost. As for left overs, I would expand office hours and increase the marketing budget in order to get more new patients, all those new patients would be mine, and I would also take advantage of emergency patients. There will always be a risk of losing patients after a transition, but there are no guarantees that patients will come flooding into a start-up either, it's all about marketing correctly. If the selling doc welcomes you to his patients as a new partner and ensure them that he's going to stay on, attrition should be minimum at best.

 

[TanMan]

Tanman, I definitely respect your opinion on a lot of points, but I disagree with a couple things you mentioned. I know you're a startup guy and somewhat bias to towards that practice model, but hear me out.

1. Staff can definitely be resistant to change, but at the same time it’s your practice, and staff members will get in line if you're a strong leader that can get people to buy into your vision. There aren't a lot of states where you can't fire someone from a dental practice, a matter of fact I've never heard of such a state. I do agree though that too much turnover can affect the practice in a negative way, but that can be managed.

2. If you're going to buy a practice, I would think knowing what kind of patients the practice has would be a big part of your due diligence. I certainly wouldn't buy a practice that has mostly implant patients if I'm a new grad, that would be suicide. I would look for a practice that has an old doc that's looking to retire in a few years that has been referring out Molar endo, ortho, extractions, doing patch work for the most part, and would be willing to stay on for at least one year. Then I would be able to go in the practice and offer all those services in house, which would be an instant profit boost. As for left overs, I would expand office hours and increase the marketing budget in order to get more new patients, all those new patients would be mine, and I would also take advantage of emergency patients. There will always be a risk of losing patients after a transition, but there are no guarantees that patients will come flooding into a start-up either, it's all about marketing correctly. If the selling doc welcomes you to his patients as a new partner and ensure them that he's going to stay on, attrition should be minimum at best.

I'll provide some counterarguments here:
1. It might be your practice, but you want to make sure you have happy staff that will sell your treatment plans for you. They might get in line, but if they aren't happy, they won't sell for you. That first sentence that you said... my friend the same exact thing (everyone thinks they are a strong leader and that they can get people to do whatever they want - the problem is why do you want to make it harder on yourself to change people who already see you as the outsider. I ask people this and they are usually taken aback: Are you really a strong leader or ignorant of your strengths and weaknesses. I don't mean this as an offense, but it's important to take a good look at your personal strengths and weaknesses. You'll be surprised that a lot of people who characterize themselves as a strong leader when they really have no clue what they are doing). I don't hire DA's with too much experience. They think they know more than you or stuck in their ways.

Now, you might think its easy to fire people. In theory, it is, but lets say you have to fire the oldest one (even if its not involving their age), or the one with kids, or the one that's married, etc... Wrongful termination and unemployment can be a headache to deal with. Yes, you can document, etc... but why would I want to deal with that if I don't have to. Now, with a new office, I don't have to be worried about that as much as my office doesn't have to deal with those issues as much since I make it clear that they have to work every weekend and every evening. That tends to deter anyone from claiming that I'm discriminating based on their protected group. I don't want to deal with a wrongful termination claim, nor do I want to pay unemployment.

2. That's everyone's dream... look for an old dentist that's willing to stay on for at least a year. I'm not going to shoot it down since it does sound like a logical plan and I could nitpick each one (if you want), but it's just a slower plan for growth. I'll also say that its idealistic since I have colleagues who went through the same steps you just mentioned, only to get stuck in mediocrity. If we put both a startup practice v. an existing practice, all those ideas that you mentioned can be incorporated into a new office, without having to pay for an existing office. From an equation standpoint, I'd see it as whether the recall income > monthly payment; if they are relatively equal, then you're literally just working to pay the other guy.

@TanMan
Could it be argued that buying an existing practice, even if very successful, ultimately short changes the buyer because they did not gain the experience necessary to make the practice successful in the first place? Isn't that experience/knowledge a massive reason for success?

Somewhat, either way, you'll be learning on the fly if you have no previous management experience. You just have more at stake when you buy a practice because you have a lot more payments to make.

 

[distressstudent]

first of all, thanks for sharing your experience. invaluable indeed.

however, pretty sure if the marketing gambit at the beginning of your career went south along with lackluster performance from the super risky investment ventures, the titlte of the thread would have been "STAY AWAY FROM DENTISTRY!!! TRUST ME IT'S NOT WORTH THE DEBT" or something like that. also think the geography/demographics (Texas/low-middle income area with "underserved" ppo pop.) in addition to relatively low student loan debt load played a huge role in your success, which suggest it may be unlikely to be reproducible by the vast majority of recent grads.

starting a new practice right after school with 300k+ debt with barely any patient flow? yeah, that's a disaster. besides, i'm not even gonna go to the ethical issue of not accepting medicaid/medicare patients and turning away "picky" patients

He didn't start a new practice right after school. He learned the ropes through corporate dentistry, and even practiced through the corporate office until they fired him.

Going by that logic, no one should ever start a new practice. My impression is that the cost of his new practice costed him a lot less than what his colleagues are paying (i.e: look at the post about breakaway seminars). So really, this business venture of his isn't as risky as you're making it sound. The riskiest thing he did was dumping so much money into marketing/advertisement; that's the only thing that is outside the norm. Even then it is really easy to cutback on marketing if it isn't working out. Lastly, it isn't an investment venture. It's his business venture as an owner. Which mean he has a much greater control of his costs and fees and that much less likely he will go under. If he had to participate in HMO/medicaid to stay afloat, he would have done it.

I can't speak on the ethics issue. I know many dentists that practice like this. Oh well.

But student debt shouldn't hinder anyone from starting a practice if they are ready. Why? Because income-driven program exist. Even if you don't plan on relying on the forgiveness , these income-driven program will insure that you will never default. In my humble opinion, it is much riskier to enroll into a 400k dental school than to start a private practice.

 

[TanMan]

first of all, thanks for sharing your experience. invaluable indeed.

however, pretty sure if the marketing gambit at the beginning of your career went south along with lackluster performance from the super risky investment ventures, the titlte of the thread would have been "STAY AWAY FROM DENTISTRY!!! TRUST ME IT'S NOT WORTH THE DEBT" or something like that. also think the geography/demographics (Texas/low-middle income area with "underserved" ppo pop.) in addition to relatively low student loan debt load played a huge role in your success, which suggest it may be unlikely to be reproducible by the vast majority of recent grads.

starting a new practice right after school with 300k+ debt with barely any patient flow? yeah, that's a disaster. besides, i'm not even gonna go to the ethical issue of not accepting medicaid/medicare patients and turning away "picky" patients

Well, you can't force me or any dentist for that matter to work on any patient that they don't want to work on. Thank goodness there's other people willing to take them. Do you think I have an obligation to take medicaid/medicare patients and picky patients?

From a financial perspective, no, unless I have no patients on my schedule. I'd have to be hitting rock bottom to accept them because I'd be losing money running the office unless I made it into a mill.

From a professional perspective, I still don't have to accept them. If I'm not comfortable accepting them, why should I?

The irony here is that the ppo population is the underserved in my region. I sense a lot of sarcasm in your post and it makes me wonder if you've hit the realities of practicing as a dentist or still under the idealism of the academic world. I remember a very similar response from the "high and mighty classmates" of dental school and they seem to gravitate towards pediatric dentistry.

I think that this is reproducible, regardless of your skepticism and doubt. It would be harder if you had more debt or a family to sustain, but those are personal circumstances that are hindering you, not so much your professional circumstances. Debt and family are probably the biggest obstacles to opening an office; what I propose is that you can open it for cheap and succeed. Now if you want to see only medicaid/medicare/picky patients, go for it, if you think it's your obligation to do so. There's plenty of dentists that are doing that already, why should I?

 

[distressstudent]

idk your way of life sounds too much like gaming the system

super sketch

If you think serving a niche population is immoral (lol)

Then letting a insurance company /agency dictate a treatment plan is even more sketch

 

[deleted696582]

Well, you can't force me or any dentist for that matter to work on any patient that they don't want to work on. Thank goodness there's other people willing to take them. Do you think I have an obligation to take medicaid/medicare patients and picky patients?

Do you think that early retirement and accepting medicaid/medicare patients are mutually exclusive?

 

[TanMan]

Do you think that early retirement and accepting medicaid/medicare patients are mutually exclusive?

Definitely not. There are business models that operate in seeing medicaid/medicare patients. The problem with medicaid mills is usually overtreatment, massive volumes - more than what I see, and halfass dentistry (1 min prophy?, 20 SSC's+pulps all at once under restraint? - excuse the language for those easily offended). With medicare, corporate offices tend to sell you services that are often unnecessary and coincidentally not covered. I don't want to be in the situation where I have to swindle old people into getting a lot of add-ons just to make money. You just have more risks, challenges, and difficulty dealing with medicaid/medicare, especially with the efficiency of the corporate mills. There's more than one way to retire early, just want to make sure I'm still sane by the end. These are the unfortunate realities of these mills, and I would rather not have to deal with that and make money at the same time.

Maybe you can see where I'm coming from. I choose to do no evil by not participating in these shenanigans in the first place.

 

[Roy Williams]

Definitely not. There are business models that operate in seeing medicaid/medicare patients. The problem with medicaid mills is usually overtreatment, massive volumes - more than what I see, and halfass dentistry (1 min prophy?, 20 SSC's+pulps all at once under restraint? - excuse the language for those easily offended). With medicare, corporate offices tend to sell you services that are often unnecessary and coincidentally not covered. I don't want to be in the situation where I have to swindle old people into getting a lot of add-ons just to make money. You just have more risks, challenges, and difficulty dealing with medicaid/medicare, especially with the efficiency of the corporate mills. There's more than one way to retire early, just want to make sure I'm still sane by the end. These are the unfortunate realities of these mills, and I would rather not have to deal with that and make money at the same time.

Maybe you can see where I'm coming from. I choose to do no evil by not participating in these shenanigans in the first place.

I have a question, and I'm sorry if this has already been asked/answered previously. But given that you see so many patients every day, do you feel like you're able to spend enough time with each patient and give them the time they need? Or are you constantly rushing? Are you able (or even want to) form relationships with them, or do you simply see them as an opportunity to make money and pump through as many as possible?

 

[TanMan]

I have a question, and I'm sorry if this has already been asked/answered previously. But given that you see so many patients every day, do you feel like you're able to spend enough time with each patient and give them the time they need? Or are you constantly rushing? Are you able (or even want to) form relationships with them, or do you simply see them as an opportunity to make money and pump through as many as possible?

It's actually a really slow day, so I'm going to answer this right now:

Spending time with the patient can be broken into two primary parts: Clinical and social aspects of interaction. From a clinical perspective, I think I give all the patients the time that they need. What you may be referring to is the social aspect of the interaction. Surprisingly, patients are different. Some want to have a long chat with you, some are cordial, some just want to get out asap, some are very apprehensive, etc... As long as the patient is interested in a friendly, cordial relationship, I'm able to integrate enough time for what's needed socially and clinically. Friendly, but useful banter. Now, if the patient is completely apprehensive hates you already, I just make it quick. I am always rushing, but those that come to the office know that already.

I'm definitely able to form relationships with them, I remember their kids, any major life events like surgeries, pregnancies, graduations, etc.... if they are interested. If not, then I don't even go there. Making money and forming relationships are not mutually exclusive. I'm here to make as much money as possible, get along with as many people as possible and speed up my service as much as possible to give the best dental experience that I can provide. If you are not fast, you'll make people wait. People hate waiting. If you are mean or cold, they most likely won't come back to you. You can be nice, fast, and make money.

Now, if a patient demands an hour of my time exclusively, then there's a problem. I remember a patient demanded that I spend an hour only on her for an exam and my staff gave her a quote of 1500 for an hour of exclusive time just because they were being obnoxious about it. She came back a few more times after that then never came back.

 

[Roy Williams]

It's actually a really slow day, so I'm going to answer this right now:

Spending time with the patient can be broken into two primary parts: Clinical and social aspects of interaction. From a clinical perspective, I think I give all the patients the time that they need. What you may be referring to is the social aspect of the interaction. Surprisingly, patients are different. Some want to have a long chat with you, some are cordial, some just want to get out asap, some are very apprehensive, etc... As long as the patient is interested in a friendly, cordial relationship, I'm able to integrate enough time for what's needed socially and clinically. Friendly, but useful banter. Now, if the patient is completely apprehensive hates you already, I just make it quick. I am always rushing, but those that come to the office know that already.

I'm definitely able to form relationships with them, I remember their kids, any major life events like surgeries, pregnancies, graduations, etc.... if they are interested. If not, then I don't even go there. Making money and forming relationships are not mutually exclusive. I'm here to make as much money as possible, get along with as many people as possible and speed up my service as much as possible to give the best dental experience that I can provide. If you are not fast, you'll make people wait. People hate waiting. If you are mean or cold, they most likely won't come back to you. You can be nice, fast, and make money.

Now, if a patient demands an hour of my time exclusively, then there's a problem. I remember a patient demanded that I spend an hour only on her for an exam and my staff gave her a quote of 1500 for an hour of exclusive time just because they were being obnoxious about it. She came back a few more times after that then never came back.

Awesome, thanks for the response!

Follow up, do you feel like rushing adds stress that would not be there if you weren't rushing so much? If so, I'm assuming the pros (more money) outweigh the cons (more stress) in this situation. But whether they would for somebody else would be a personal decision.

 

[TanMan]

For the social part, do you have any tips for reading pts? Do you get better at knowing what to expect/what they want in a social relationship through pt volume and experience?

I rely on my staff and their mannerisms. Usually can read them within the first few sentences of the formal introduction whether you're going to be met by friendliness and hostility. If their every other sentence is "Does my insurance cover it?", then most likely they won't get any treatment. Look at their arms (crossed or relaxed), their eyes/mouth, body language, and staff input as well (before they go into the room). On the course of the conversation, you need to know what type of patient they are and what to do with them.

Edit: Yes, you get to read the patients better as time progresses.

Awesome, thanks for the response!

Follow up, do you feel like rushing adds stress that would not be there if you weren't rushing so much? If so, I'm assuming the pros (more money) outweigh the cons (more stress) in this situation. But whether they would for somebody else would be a personal decision.

Rushing adds more stress... but doing nothing is even more stressful. The fact that I have to be there means I want to maximize my time. The boredom of doing nothing can be much worse than running all over. At least when you're running, time passes by faster.

 

[Steins;Gate]

At least when you're running, time passes by faster.

How fast does time fly when you're working? Do you feel like the days just fly by and most days are enjoyable?

Do you do morning huddles with your staff about the production goal for the day/week/month, which patients will be coming in during the day, etc.?

 

[TanMan]

How fast does time fly when you're working? Do you feel like the days just fly by and most days are enjoyable?

Do you do morning huddles with your staff about the production goal for the day/week/month, which patients will be coming in during the day, etc.?

Time flies fast when I'm working. Could be the end of the day already and not even realize it based on the time (based on last patient). Days do fly by and most days are enjoyable when they are done and over with. Sometimes I dont even know what day it is unless I look it up or ask my staff.

No morning huddles. I've set monthly goal at 250/mo. They all know what to do already. We go in and we work and we get out. Sometimes they'll eat their lunch before work starts.

 

[Roy Williams]

I rely on my staff and their mannerisms. Usually can read them within the first few sentences of the formal introduction whether you're going to be met by friendliness and hostility. If their every other sentence is "Does my insurance cover it?", then most likely they won't get any treatment. Look at their arms (crossed or relaxed), their eyes/mouth, body language, and staff input as well (before they go into the room). On the course of the conversation, you need to know what type of patient they are and what to do with them.

Edit: Yes, you get to read the patients better as time progresses.



Rushing adds more stress... but doing nothing is even more stressful. The fact that I have to be there means I want to maximize my time. The boredom of doing nothing can be much worse than running all over. At least when you're running, time passes by faster.

Thanks for the response again!

If you don't mind answering this, would you mind talking a bit about your life outside of work? I imagine you try to live pretty frugally, but is there anything you splurge on? Do you have time for any hobbies or doing things you enjoy, or are you of the mindset that you are 100% committed to your work right now so that you can retire early and enjoy life then? Or is there a balance somewhere in between?

 

[Cold Front]

Sometimes they'll eat their lunch before work starts.

They will have their lunch (in the morning?) before work starts?

That's some serious conveyor-belt work life.

I'm posting this with 3 patients in the chair, and I am so happy I don't have my head in the sand all the time.

 

[TanMan]

They will have their lunch (in the morning?) before work starts?

That's some serious conveyor-belt work life.

I'm posting this with 3 patients in the chair, and I am so happy I don't have my head in the sand all the time.

We start at noon.

Edit: I hate waking up early. I'm only up right now because I had to take care of something in the morning.

 

[Roy Williams]

We start at noon.

Edit: I hate waking up early. I'm only up right now because I had to take care of something in the morning.

What's the benefit to starting late and finishing late compared to a normal work schedule? (not saying there isn't one, just genuinely curious)

 

[TanMan]

Thanks for the response again!

If you don't mind answering this, would you mind talking a bit about your life outside of work? I imagine you try to live pretty frugally, but is there anything you splurge on? Do you have time for any hobbies or doing things you enjoy, or are you of the mindset that you are 100% committed to your work right now so that you can retire early and enjoy life then? Or is there a balance somewhere in between?

I don't really do much outside of work, maybe go out and eat, go to shooting range, go cruising, etc... I splurge on guns and cars. I collect lots of firearms, but I want to start focusing more on full auto and DD's. I tend to play online games just as a distraction/relaxation, but I think most of my time is committed to work. There's definitely a balance in between. I don't think I can work 6 days a week consistently. Gets tiring and annoying.

 

[TanMan]

What's the benefit to starting late and finishing late compared to a normal work schedule? (not saying there isn't one, just genuinely curious)

Benefits:
1. I don't have to wake up early. You don't want me behind a handpiece at 8am. I like to wake up between 10-11.
2. Not bank hours. Many patients dont want to miss work or school just to see a dentist. I can see patients during their lunch breaks, and after work. Allows me to capture a larger market segment than your typical 8-5 dentist and I get more done as well.

 

[Cold Front]

We start at noon.

Edit: I hate waking up early. I'm only up right now because I had to take care of something in the morning.

How do you start at noon and block any social life off from your day by finishing work late? I'm out the door at 4p and have 5 hours to decompress and socialize after work.

Unless you are an owl at night. Most emergencies are at 8-9am for most dental offices.

 

[TanMan]

How do you start at noon and block any social life off from your day by finishing work late? I'm out the door at 4p and have 5 hours to decompress and socialize after work.

Unless you are an owl at night. Most emergencies are at 8-9am for most dental offices.

I stay up till 2-3am.

Edit: How can you NOT have a social life with my schedule... Dinner starts around that time, fun parties/nights out tend to start a lot later. If you drink a lot, most bars close at 2.... Although I don't do it often, when I do, I don't have to worry about waking up at 8am the following day.

 

[stoopidmonkeycatdog]

Off topic a bit, but what vehicles do you currently have right now?

If a dentist wanted to replicate your style (I like it so far, including the hours) would you recommend they start working on speed from the moment they get into school D1? Or just focus on learning and the speed will come with time?

 

[stoopidmonkeycatdog]

@Cold Front of I remember correctly, you branched out into multiple practices correct? Would you mind answering some of my questions? Feel free to ignore them if you don't feel comfortable doing so.

When looking to expand are you attempting to get your current practice to a pre-set production level? Which you then just copy and paste? Or are all of your practices different and you just roll with it?

How do you keep your associated around for an extended period of time without them feeling like they should continue to increase their income dramatically each year?

Do you rotate through your practices, or stay at 1?

 

[Cold Front]

@Cold Front of I remember correctly, you branched out into multiple practices correct? Would you mind answering some of my questions? Feel free to ignore them if you don't feel comfortable doing so.

When looking to expand are you attempting to get your current practice to a pre-set production level? Which you then just copy and paste? Or are all of your practices different and you just roll with it?

How do you keep your associated around for an extended period of time without them feeling like they should continue to increase their income dramatically each year?

Do you rotate through your practices, or stay at 1?

I opened 3 offices from scratch, franchised 2 of them to younger guys who are highly motivated. I'm also their landlord (I own the buildings), so they pay franchise fee (for equipment and charts) + 5 years leases (that way they are locked as tenants for longer as oppose to associates from year to year). The cash flow from rent and franchise fee per office is about $100k a year per office, so 5 year lease means $500k per office. Renewal options would be higher, so essentially I'm hands off and I just let those offices pay for the building mortgages, which should be paid off at the end of their first renewal term.

Like most offices, I had bad experience with keeping associates. They would ask for higher pay after 1 year contracts and then would slack off after they feel too comfortable or start to get ideas of starting their own practices (I don't blame them).

So I now work 4 days (M-Th)a week at my 3rd office, which is 90% pedo patients (im a GP), with a heavy hygiene program. The other 10% are the parents of the pedo patients.

I manage the buildings on Fridays. Say hello to the tenants and such. I procrastinate on weekends... watching soccer, adding features to Amazon echo, stop my parents place, and wife dates.

It took me 6-7 years to get here after d school graduation. I'm done with new ventures and all the things people say about doing more in life. I'm in my late 30s now, will max out my 401k ($73k a year; joint with my wife), and let the compounding interest take it to $6-8M in 20-25 years. At age 65, I have the chance to do more philanthropy and just use 5% of my savings between real estate, practices and retirement accounts, with zero debt. I will be happy to report back here in 20 years or so.