The Long Road to Start-Up City
A first-hand account of my journey from residency, through associateship and attempted buy-outs, and into the adventure that is a start-up and partnership. Please join me as I learn while I go!

Why I'm Starting a Practice From Scratch

Why I'm Starting a Practice From Scratch

7/26/2017 7:29:58 AM   |   Comments: 4   |   Views: 386

I don't know whether this will be interesting to anyone else, but it would have been interesting to me, so I figured, why not?  Let's share it.  To really tell the story, though, I find it's best to, in the words of Lewis Carroll's Alice in Wonderland, "Begin at the beginning."  And so I shall.

I am an orthodontist.  When I picked out this career, I didn't know much about how the world worked.  I had the misconception, common to lots of "good students" that wealth and success would come easily to those with good grades as long as we followed the protocol dictated by our teachers, advisors, and other authority figures.  I trusted that plan completely, and I relied on studying to get me to where I am now.  To reiterate, I am an orthodontist, but more specifically, I am an associate orthodontist, an employee.  As an "associate" orthodontist, I enjoy some cool perks.  People call me "Doctor" ... Neat!  I receive a paycheck that allows me to do, see, and enjoy many of the things I'd like to.  My work hours are reasonable, and when I leave the office, I have few concerns.

So why not leave it at that?  It's not that I don't appreciate those perks, but when I look back on all the reasons I chose dental school, I realize that I'm missing out on one of the big ones.  My dad always told me growing up that I should work for myself.  I didn't really understand what he meant at the time.  I thought he just meant that I could take as many vacation days as I wanted to.  Now I realize that it's so much more.  It means you get to choose everything from the hours you work to the paint color on the wall and the words that are used when someone answers your phone.  As a certified control freak, wouldn't you know... those things actually matter to me.

Working for yourself comes with a lot of downsides too, and don't think I haven't considered them.  I get to be the one to make all the difficult decisions.  (Should we waive the treatment fee for this unreasonable patient?  Should we invest in new computers now or try to hold off?  Do I need to fire this employee?)  I get to be the one responsible when my patients need help on the weekend.  I get to be the one to pay for the carpet cleaners when a patient spills their latte in the waiting room.  When production is down, it's my paycheck on the line.  I'm never not on call, and I can't walk away.  I'm responsible to someone.  So why???  Why would I do that??

Well... For starters, my earning potential will be tremendously higher.  It may not be that way at first, but by choosing practice ownership, I'm betting on myself.  By continuing to work as associate, I'm basically betting against myself, presuming that the risk of ownership will outweigh the rewards.  If I'm successful, then my upwards potential as an owner is infinitely greater than as an associate.  As an associate, I'm basically a factory line worker.  I can only earn as much as I can physically produce as one doctor in one place at one time.  And that has a definite limit.  As an owner, whether I choose to or not, I have the option to hire associates which increases my personal potential to earn income even when I'm not physically present.  (However, this is a post about NOT being an associate, so hopefully after reading it, no one will want to work for me.)  Besides, there are plenty of other ways besides hiring a pack of associates to increase one's earning potential as an owner-doctor.  

Next, I want to dictate how I treat my patients.  Although I work in an extremely ethical and clinically sound office, my employment comes with certain limitations.  For example, as I expect is the case in many offices, the number of treatment modalities employed is limited to several with which we and the staff are all quite comfortable.  When I see a new patient, and my first reaction is always to compose a treatment plan that employs our favorite appliances and techniques, I worry that I'm becoming less creative and limiting my capacity to improve and to offer my patients the best care that I can.  In addition to that, as a practice owner and master of my own destiny, I can choose which CE courses I want to pursue to expand my horizons.  I want to choose my products, meet with the reps who I value, try new things, fail, understand why I'm not choosing to use them, then try more new things.  And maybe some of them will be successful!

Third, I have a burning desire to build my dream team.  I fantasize about an office... (and don't laugh at me, I know this is far-fetched)... with a staff that is loyal, feels supported, supports one another, contributes, is kind and happy, cares about our patients, and likes what they do.  In my current situation as an associate, I have a deep camaraderie and bond with my teammates, but I have always maintained that since I am not the person who pays them, and I am not the person who dictates the office policies, I don't have the tools to motivate them to develop the behaviors that I'm looking for in my employees.  I'm not in a position to reward them for great work.  The best I can do is offer my verbal thanks and let them know how much I appreciate it when they work in a way that's consistent with how I want my team to work.  I know it's not enough to shape the attitudes and behaviors of a whole team from open to close.  I want to hire people who I value for their positivity, energy, and enthusiasm rather than simply for their experience, and I want to train them to do the technical part and the interpersonal part of the job the way I believe it should be done.

Fourth, however petty this may be, I want to have more creative control over my physical surroundings.  I spend far too many waking hours in my office, and my environment has a huge impact on me.  I want it to reflect my tastes and preferences so that it's a place I look forward to inhabiting instead of one I dread and can't wait to rush out of at the end of the day.  I want my office to feel like the kind of place where I'd be happy to sit down and have a cup of coffee because presumably, my patients might feel the same way.

Next, I want to open my own office because my dad was right.  I do want to work for myself.  I do want to make my own hours.  It's not that I don't want to do work.  It's not because I'm trying to skid by, doing less work than I do now.  It's because I know what times of day I do my best work.  I know that working for nine hours with a long dragging lunch break isn't a recipe for success for me.  I know that if I work for six straight hours with a tiny snack break, I can kill it in the office and still have energy left for my life afterwards.  And the whole point of having a job is to make it possible to have a life, right?  I want to choose when I'll have a vacation and decide whether it's more important to me to make more money this month or have more free time.

Finally, this is important to me, and I'm encouraging you to do the same because it's the only way that we can make the choice to keep small business orthodontics within reach for ourselves.  Every time one of us chooses to work for a corporation or a large practice with multiple associates, we enable these big businesses to dictate how we'll practice.  I don't just mean on a day-to-day level like by telling you what brackets to use and what fees you'll charge.  I mean on a macro over-the-years kind of level.  As the ratio of small to large practices tips towards large ones, it becomes harder for the small ones to compete.  Big businesses in every industry have several advantages when it comes to human resources, supply costs, marketing, etc.  Once they get to a certain size, it's even easier for them to grow, and they can recruit new grads with the promise of a big paycheck.  That big paycheck sounds great until you realize it comes with strings attached.  When you finally want to open your own office, it will be more challenging, more expensive, and less profitable because  you'll be competing with a large practice around the corner.  And as long as we, the young orthodontists and new grads, continue to help them by working for them, this trend will continue.  (This discussion could easily go on much longer into a conversation about student loan debt and other topics, but that's for another day.)   This trend occurs in every industry, every day.  And I don't begrudge anyone the right to build their empire - that's business, and I respect them.  The difference is that we are the ones who can control it.  There are a limited number of orthodontists for hire, so we can tip the scales back in the other direction if we choose.  This trend can't continue without our consent.

One bold statement if I may.  I would prefer to encourage a young dentist to finish dental school, go into general practice, and then learn about orthodontics and start treating simple cases, maybe working with a mentor.  I would rather that happen than see all the new grads finishing dental school and paying through the nose for expensive residency programs designed to keep the graduates in debt and beholden to a large corporate office for the paycheck they'll require to pay it back.  (And you know how hard it is to get an orthodontist to say they want more GPs doing ortho... !)

One final word on large practices.  I'm not opposed to "large practices" in and of themselves.  IF that's what you want.  You do you, orthodontists.

I know it's a gamble, and I know there will be days, weeks, maybe months at a time when I ask myself why the hell I made this choice when I could have had it the easy way.  But you know what they say - nothing in life worth having comes easy.  I was too scared to do this when I graduated from residency, and now, four years later, I'm too scared not to.  I have to take this chance.  And the worst case scenario?  I'll go bankrupt, and then I'll be available to come work for you so you can grow your empire...

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