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A Voice in the Arena: ‘Do Not Go to That Office!’ by Dr. Chad Foster

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Categories: Practice Management, HR and Accounting;
A Voice in the Arena: ‘Do Not Go to That Office!’   

by Chad Foster, DDS, MS, editorial director

One of many fond memories of my residency at the University of Southern California is of the quality of people on the faculty. Residents quickly came to realize how different the orthodontic instructors’ treatment philosophies were, from Tweed to Damon and everything around and between. An important lesson was learned: There’s plenty of room for healthy disagreement between colleagues, but one should be restrained when criticizing the work of a colleague—especially when communicating with a patient. It was a lesson well learned, and to this day is one I still greatly respect.

I practice in Arizona, statistically one of (if not the) corporate-dental epicenters in the United States. I spent my first five years out of residency bouncing around corporate/chain practices and at each new office, I was effectively obligated to accept a huge number of transfer patients already in treatment. I was the recipient of all kinds of cases—some were very well controlled and the previous doctor “behind the wheel” was intentional with some kind of plan. (That doesn’t mean I always agreed fully with the plan, but at least someone was behind the wheel.)

In others, there was no clear direction, or treatment was puzzlingly long, with little progress made in regard to the main issues. Whether I was the second or fifth orthodontist taking over that case, my priority was just to safely land the plane in a compromised but hopefully acceptable destination—not likely the ideal one. That was the best many patients could hope for within the circumstances of that practice. In Arizona, given the dominance of corporate clinics, this is the reality for a huge number of patients in orthodontic treatment.

I don’t expect this statement to be met with universal agreement, but I believe it’s much more difficult to control the quality of the outcome when multiple orthodontists are involved throughout the course of a single treatment. (That’s not to say it’s not possible for two or three very conscientious orthodontists to collaborate in a well-executed treatment—but it is definitely more difficult, absolutely not the norm and, practically speaking, very rare.) This is not the only variable that affects treatment outcome, but it’s difficult to argue about the significance of this one.

For most corporate (or even doctor-owned) practices with a large number of offices, employee orthodontist staffing is a challenging variable to deal with. Unless they’re uniquely structured (again, that would be the rare exception and definitely not the norm), most of these practices can’t maintain consistency in the doctor behind the wheel of the active patients.

So, the question is: Does that matter? What happens when the orthodontic position is commoditized and reduced to a carousel where there’s a new person behind the wheel every year or two?


The carousel effect
Actually, a few important things happen that directly affect treatment outcomes.

Most often, the employee orthodontists in this type of practice understand they likely won’t be there for the long haul. I can speak from experience that the orthodontist’s mentality is completely different in that scenario than if they believed they’d be there for the next 10 years. I’m not arguing that it should or shouldn’t be that way—that’s just the straight-up reality. Mentally, the ownership and accountability of the cases are different, and the effect this has on treatment in these offices is real.

Additionally, when there’s turnover, the new orthodontist—even if he or she is a talented and caring clinician—will most often be overwhelmed by the adoption of hundreds of new active cases. Very simple cases on autopilot can be managed well, but more challenging cases or ones that were questionably handled to begin with can go south in a hurry or, more often, just get stalled in a treatment going nowhere.

Nowadays, some of my hardest cases are patients who came from corporate/chain offices seeking to be treated elsewhere. Doing your best to unwind these types of cases and trying to land the plane safely with patients who are already upset and burned out is most often not a fun experience. These aren’t rare occurrences in my office in Phoenix; in any given month, I can count on three to five of these patients making their way into the consult room.


The one exception
During the first few years of owning my practice, I would never offer a critique of the state of the treatment, or the office a patient was transferring from. I first encouraged such patients to seek a resolution with their original office and continue treatment there if possible. Only if they declined that option would I offer my opinion of where the treatment could reasonably expect to go in our office, with little or no comment on what had occurred previously.

That’s still how I handle transfer patients today … with one exception. If I recognize the name of the corporate/chain clinic as one that’s notorious for its carousel approach, I will tell the patient, “I think you’re doing the right thing considering transferring your orthodontic care, whether it’s with our office or any other competent orthodontic practice in our area. The one you’re at now has earned a reputation for not having consistency behind the wheel.”

I do something similar for new patients seeking second opinions before starting treatment. If they inform my treatment coordinator that one of the offices in their consideration is a notorious carousel clinic, I’ll use the same wording to warn them about that specific practice and encourage them to limit their search to practices that don’t have a history of orthodontist turnover and where they have strong reason to trust they’ll have the same orthodontist from beginning to end of treatment.

If I do make such statements regarding these more notorious corporate/chain clinics, I always further explain that the doctors working at that practice are very likely highly skilled orthodontists with good intentions, but the structure of the clinic does not allow for consistent, high-quality orthodontic care. The problem is not the doctors, who very well could be top-level clinicians—it’s the carousel.

That message resonates with some patients immediately; for others, it doesn’t. Even if the patient doesn’t ultimately follow my advice, I still know I’ve been as honest as possible with them and have tried to steer them in the best direction.


New corporate model … same old challenges
To be clear, this is not a competitive tactic to try to secure the start. I’m fortunate to have an office that does better than I ever thought it would, even in the ultracompetitive Phoenix market. I don’t lose sleep over the prospect of losing a patient to another excellent orthodontist in my area (and there are many).

But I have grown tired of the same faces and stories coming into my office from the carousel clinics. I picture my wife bringing one of my children (Calvin, Sadie and, soon, PJ) into one of those offices if life were different and I weren’t an orthodontist. I’d hope one of the other, decent offices she visited would care enough to ask her to think twice about opting for treatment with a practice that’s notorious for having no one behind the wheel.

I can hear the argument now that this-or-that corporate/group model is different, or less affected by the challenges discussed. Those of us in Arizona and other competitive markets have already seen the evolution and iteration of a variety of corporate/chain clinics. It’s not our first rodeo—we have boots in the mud, and there is good history of what the best of intentions mixed with private equity most often begets. Again, not that it can’t be done, but it’s definitely more difficult, absolutely not the norm and practically speaking very rare.

At the very best, all that can be said of the newer corporate models is that the jury is still out. The best of intentions for those in ownership of those groups means absolutely nothing at this early point. Only when the original owner-doctor terms out or opts out of their agreement will we see the rubber meet the road, and for most that’s still years from now.

This message should not be taken as license to slam the other doctor in your town who extracts more than you do, uses a different Class II corrector or otherwise has a philosophy on treatment you don’t agree with. But if there is an office with a carousel of doctors and you’ve seen an unpleasant history of their work through your doors, I think we have a professional obligation to unsuspecting patients and potential patients to at least educate them on basic factors that influence the quality of their treatment—specifically, a consistent and committed doctor behind the wheel.

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