What Should I Do After Dental School?
Twenty or thirty years ago most recent graduates bought an existing practice or started their own practice. Out of the 42 graduates from my dental school class not a single one of them bought an existing practice or did a start up right out of school. Recent graduates are feeling the squeeze of the rapid increase in the cost of tuition over the last 10 years all while dental insurance payouts are decreasing. Most grads these days leave dental school with $300K+ in student loans. To add another $300-700K for a practice and another $200-300K for a modest house would put you well over $1 million in debt . . . before drilling on a single tooth!
Lets explore some options!
Dental Service Organizations and Corporate Dentistry
Most recent graduates from my class and around the country are working for a DSO (Dental Service Organization) or a traditional corporate dental group such as Heartland, Aspen, Pacific, etc. Most young dentists will work for a DSO for a 1-2 year contract. I have noticed that DSO's generally cater to two types of dentists: Recent grads with lots of debt, and older practitioners who want to remove the stress that comes from managing their own practice. For most, corporate dentisstry is a stepping stone to get their feet wet and gives them a chance to gain the confidence they need to move toeward ownership. There are various reasons people leave these jobs rather quickly. In talking with some of my colleagues, some of these reasons include:
1) High volume of patients needed to sustain a decent income and pay off debt
2) Realizing you can make more percentage by owning all while seeing fewer patients per day
3) Wanting to have control of your own schedule, supplies, equipment, etc.
4) Not making enough or not a good fit for company
5) Feeling like after a year or two you have enough of a grasp on all facets of dentistry that you can go out on your own
While many consider all DSO's to be corporate dentistry, I like to differentiate between smaller DSO's and large corporate dental groups. The main difference is that smaller DSO's usually have less of a geographic footprint and are local to once city or region. Usually these consist of 5-20 offices or so while corporate groups have dozens of offices.
Pros - more negotiating room, more intimate and personable interactions with owners,
Cons - lack of benefits, hard to take time off,
Large Corporate Dental Groups
Pros - more established systems and training, better employment benefits such as 401k, more CE opportunity in the form of funds or company-wide training meetings,
Cons - less flexibility, not as intimate of a group,
From my experience, I have found that smaller DSO employment benefits are not as good as those of corporate denistry. Corporate dentistry generally offers better CE opportunities whether they offer cash amount each year or CE offered during company-wide training meetings. In the end both smaller DSO's and larger chains are very similar. Both usually offer you a guaranteed minimum salary each month. These are nice to bank on and sounds great as a 4th year student with a burden of debt, but but this is not free money! You end up paying back the difference from subsequent months so its only benefit is to smooth out a bad month. It allows you to take a hit over a couple of months instead of all one month if you were to take a vacation or get sick one month. Usually you get the money subtracted the next month to cover the difference of what you produced/collected and the guaranteed minimum they gave you. If you choose DSO's or a corporate gig plan on seeing tons of patients and working like a dog. The most appealing thing about DSO and corporate groups is that this is the least risky choice financially. You have a guarantee and have nothing invested financially into the practice. You can go home at the end of the day and not think about the practice. There have been headaches with some employees and patients but for the most part when I am home . . . I am home! To me that is invaluable. However, understand and be okay knowing that a good percentage of your hard work goes to giving a larger piece of the pie to the owner doctor.
MY THOUGHTS ABOUT AEGD'S AND GPR'S
I would say 6 or 7 of my classmates did an AEGD or GPR right after school. Many of these classmates did it for various reasons; but, to me there are only 3 reasons to do one of these programs:
1) you aren't confident with your skill set or speed to do it on your own without an instructor looking over your back
2) you want to gain more experience in an area like hospital/sedation dentistry or implants
3) you didn't get in to your specialty and want something productive for a resume/application for applying the next year
Just like associateships, these programs are hit or miss on the benefit you receive from investing your time into these programs. Some of these are set up for free/cheap labor and some are set up to truly teach you and help you gain knowledge and improve your skill set. If interested, I would lean more towards programs associated with dental schools or universities rather than private institutions. The key in choosing these is to talk to the dentists currently in these programs during your visit to see how much benefit they see from the program!
Owning or Buy-In
On a rotation in dental school I worked along side a recent graduate who did a start up right out of school. He was working a couple of days a week in the CHC I was doing a rotation at to get some stable income because his start up could only support one or two days a week. He was spending tens of thousands of dollars on marketing and advertising and you could sense the stress as he came to work every day. He would talk with the other Dr.'s and student dentists about his start-up and it sounded like a nightmare! He was constantly ordering new supplies, trying to find a company to empty his sharps container, talking about employee problems all while loosing money quickly, I could tell the learning curve was steep and I decided then that I didn't want to immediately climb that mountain!
Owning or buying-in is becoming less and less common immediately after school. However some people jut have what it takes! If you have a "go-get-em" personality and can stick with it when things get tough then this is may be a great option. However, I feel that these people are the exception and most young dentists like myself would benefit from working somewhere first to gain some more knowledge, comfort, and experience before your money is on the line and before it's your name on the door.
Most older dentists I talk to say the sooner you own your own practice the sooner you maximize your practice and you can enjoy peak earnings earlier in your career and build your practice earlier. Having said that, they all say that the first few years are building years and they can be rough! It isn;t uncommon for young dentists to make as little as $50K their first year of ownership or from a start-up, which isn't going to pay the bills. Some people make it work great, but you are working out the kinks and learning as you go. I would venture to say that if you have the personality or a dynamite location go for it, but be cautious and have a fall back or ease into your practice with another part-time gig while you grow into the practice. Owning or buying-in is less risky in rural locations with a low dentist to population ratio or if you plan to take over a practice with a strong client base and history. I would not do this right out of school if you are wanting to open shop in Southern California, the Wasatch Front in Utah, D.C., or other saturated locations like suburbs with high dentist to population ratios. For most, I think it is wise to gain some experience with a good associateship or DSO for a year or two before jumping in to ownership. I think it is good to pay back some of your loan so you have less financial risk and or save up a practice downpayment during those first years as an associate so that you can get better terms on your practice loan and be more cash flow positive right out of the gate as an owner.
TO SPECIALIZE OR NOT TO SPECIALIZE
I have learned that your likes and dislikes will change after school. I loved doing pedo in school and had some really good experiences with good kids. Now, kids are the death of me and so unpredictable! Now, that kid who you had for $500 of production decided he wasn't going to cooperate and you are sitting for an hour or two paying your staff. Some days kids are great and the next they are in tears before they even sit in the chair. I actually hated crown and bridge because of a few nightmare cases in dental school but now it is awesome. I loved endo in school and now am not as fond. It would have been easy to jump on the specialty bandwagon but unless you are just passionate about one field of dentistry I would give it some serious thought and spend all your extra time in that specialty area of dental school. Continue to shadow people of that specialty while in school so you can see what it is like outside of the school setting. Nothing says you can't be a general dentist for a couple years to see what you like or dislike before applying to specialty. Some specialty areas are actually easier to match to if you have been practicing before applying. But once you jump in, you are in; and I know a fair share of dentists who will reluctantly admit one on one that they hate the specialty they went in to.
I also didn't find one specialty that I excelled at. I liked some areas but wasn't passionate about one thing. I liked the variety and flexibility of doing all procedures. I don't like being the final stop for a patient and I think as a specialist you are exactly that. General dentists will send you their toughest cases or maybe just their toughest patients, and I didn't want that. I like having someone to punt a patient off to if I am stuck or don't know what to do. I also LOVE the thought of being able to shift and pivot your focus throughout your career. If 10 years down the road I decide I hate root canals I can start referring them out. If I get sick of whiny kids I can refer them. If I love doing implants I can take courses and do more implants. This was one of the biggest draws towards being the "jack of all trade's" general dentist.
As I considered applying to a specialty program I realized that all my reasons were all financial! It was the same when decididng whether to join the military to pay for my school. It sure would be nice to come out of school close to debt-free. It would be nice to get specialty pay and not have to worry so much about whether I could pay off my student loans quickly. It is true that specializing opens up the potential for double or triple your income but, at the end of the day, I realized I personally would have only specialized for financial reasons and that I personally would not have been as happy had I specialized. If you have a passion for one field and dislike or shy away from the other disciplines then specializing is for you, but please do not specialize only for a financial reason!
WHY I CHOSE TO WORK FOR A DSO
I chose to work for a DSO because it seemed like a safer option than buying a practice right out of school. I figured I would work for a couple of years to see what I could do production-wise and so I could focus only on the dentistry and not on running a business. I couldn't imagine trying to get comfortable with the dentistry part on your own all while trying to run a practice, deal with employees, payroll, insurance, product ordering, etc. My goal was to focus on ONLY the dentistry part for the first 6 months or until I felt more comfortable with fillings, root canals, crown/bridge, dentures on my own and finding the speed/pace that was right for each. Something you don't realize is that all these procedures are quite a bit different outside of school. No longer could I back fill or have every gadget for root canals. I had sealer, a gutta percha point, and a torch to cut and plug the top. I don't have every bur, I have 3 kinds of cements to use, and I had to learn to make do with the unfamiliar and minimal materials I was given. There is a learning curve and there are hiccups along the way. Now, just over 6 months in, I am starting to gradually focus on the other working parts to the practice including: scheduling, employees, insurance, and supplies as the dentistry has become a little more second nature.
I hope to pay down a good amount of student debt and invest for a couple of years to get a decent jump on lowering my financial risk before I look in to owning. People always say the sooner you own the better because then you build your client base that much sooner, but those people that say that also haven't been $1 million or more in debt by doing so and felt the financial burden of that. Not that I think I would be dishonest, but I think the weight of $1 million in debt in the back of my mind would make my treatment plan a little different or a bit more aggressive, and I don't like that thought. I think if I can get the debt to a more manageable amount then I will be doing a better service to the patients of future practice and I will sleep better at night, and that is important!
Do what is best for you, both financially and emotionally. If you are hard headed, don't take criticism well, or have to be in control, then an AEGD, GPR, or associateship is NOT for you. If you are unsure of your skills or are scared to do it on your own then go the AEGD or GPR route. An AEGD or GPR may be used to gain more training in a specific area as some programs focus on certain specialties or niches in dentistry. Some may be more hospital based, implant based, prosthetic based, etc. If you hate talking and being around people then be an endodontist or oral surgeon where you see most of your patients once or twice or where sedation is more heavily used.