Most dentists thoroughly enjoy the technical aspects of their profession. We get excited about anything that makes our work better, faster, or easier. We covet these things above all else even cost. I too suffer from this affliction, when I equipped my new office in 2003 it had a $9,000 dishwasher (instrument disinfector) because it was cool and I wanted everything in my cassettes to be sparkling clean. A close friend bought a Kavo Lab Bench because he too wanted the perfect setting to do his lab work. We bought these things not out of necessity, but out of desire. We fell trap to the tension that Michael Gerber refers to in his book E-myth Mastery. The tension is the desire to fulfill the wants of the technician above the needs of the business. In fact, most of us love our private practices so much because we have each created a shrine to our inner technician without regard to the economic impact of these decisions. I believe that my friend and I were close to the end of the line of dentists who could indulge their technical desires and still make a living. Today, the marketplace is rapidly changing.
In the United States for as long as can be remembered solo private practice has been the standard form of practicing dentistry. Many dentists are perfectionists and exacting individuals, so creating a work environment that is technician centric is desirable to the dentist. Unfortunately, for the dentists who have created perfect work environments for themselves, the economics of solo private practice are becoming more challenging. The upward creep of costs associated with providing dental services is clashing against the steady and persistent force applying downward pressure on fees. These two opposing forces are quickly washing away the profit margins of dentistry. Because most private practice dentists refer to the amount of money left over at the end of the month as their income, the incomes of dentists are diminishing. A solution does exist.
Abraham Maslow, the 20th-century psychologist, described human progression as a hierarchy that allows growth to occur sequentially after obtaining achievements. Maslow describes the lowest tier of existence as that of survival. Survival is where we meet our base need. His fundamental tenant is that unless we meet our base needs, we cannot progress to a higher level of being. In using the Maslow hierarchy of needs as a tool to assess a dental practice, the base needs would be the amount of money required to pay all the bills and pay the dentist a salary that allows him or her to pay his or her families living expenses and debt. Survival in a dental office is solvency—nothing more, nothing less. Only until a dental office reaches survival can the dentist begin to live life on a higher level. The disappointing thing about our profession is that it is getting harder and harder to move past solvency. Most of us who sacrificed to become dentists did so in the hopes of having a life filled with rewarding work and one in which growth, development, and security are just rewards for the time and effort paid.
The level above survival in Maslow’s Hierarchy of Needs is Safety. To achieve safety in a dental office, you must create a positive margin. A positive margin means that you must take more in than goes out and that your family must have more coming in than goes out. In private practice, this calls for a tremendous discipline. After all, our inner technician demands better equipment, better supplies, more time, and more comfort. Also, our families who have suffered through survival with us, want better accommodations, better possessions more time away from the office. But, if our inner technician and our family win, the margin disappears, and we are back down to survival. Unfortunately, this is the reality that most new dentists face today. The battle between overhead and fees that is punishing private solo-practitioners is making establishing a margin a much bigger obstacle than in the past.
LOVE & BELONGING
The level above Safety is Love and Belonging. In the dental field, Love and Belonging occur as we enter into the reality of personally needing to do the dentistry less than the patient needs the dentistry. Dr. Pankey was famous for saying “Nothing is harder than needing the dentistry more than your patient.” This struggle has been true forever, but today dentists live here longer. Moving to “Love and Belonging” fosters the development of our relationships with our patients, our patients become more than just a source of income or a task to complete. Here our patients become our friends and neighbors who we have the privilege to help in their journey toward oral health. The same is true of our family life; no longer are we disconnected and stressed about having enough that we can be less involved in our practice and more involved in our life away from our practice. Here relationships deepen and we as dentists begin to loosen up a little. “Love and Belonging” is a phase where investment in our practice and ourselves may take on a new meaning. No longer is investment a burden but an opportunity. We might begin exploring courses on advanced dental topics or actively engage in a hobby outside of work.
Self Esteem is next on the journey toward the top of the pyramid. Achievement of respect and belonging given to those who can freely give of themselves characterizes the stage of ” Self-Esteem.” The giving of self that occurs in “Love and Belonging” ultimately leads to this achievement. It is important to point out that this level of the journey is earned, not purchased with time or money.
The apex of the pyramid is Self-Actualization. This stage is marked by an inner fulfillment, creativity, and a sense of purpose and understanding of your place in the world. A self-actualized practice is one where profits are abundant; people are freely choosing a wide variety of dental options from urgent care to whole body health. A self-actualized practice is one where the team members are engaged and engaging as they too have moved up or are moving up the pyramid alongside the doctor.
THE DENTAL DILEMMA
Today margins have tightened, and debt loads of both dentists and practices have exploded. I fear that very few dentists that enter into the dream of solo private practice will ever be able to move past Safety. A career spent in the bottom rungs of the pyramid is tragic, not only for the dentist but for the team that works within the practice and the patients of this dentist. The dream of being in charge turns into a nightmare when not enough money is coming in. This struggle is leading to a trend toward group practice both privately held and those run by dental service organizations. Both forms of group practice can help a dentist move past the lower levels of Maslow’s Hierarchy of Needs and both can keep you firmly planted at the bottom. So what is the key? I believe that you first must acknowledge that this is not only happening but that it is accelerating. If because you are not currently affected, that one day you will not be affected, you are mistaken. It is my opinion that the answer lies in group practices, where economies of scale can influence margins, and camaraderie of professionals can lend power to the levels of “Love &Belonging” and “Esteem.” So, how can this be done?
A PROVEN SOLUTION: CORE BUSINESS
The first step is to make an assessment of your position. Do you have unused capacity (operatories that are not being used M-Friday 7 am to 7 pm?) Do you have the finances or credit to make the necessary improvements or to equip your facility to accommodate additional doctors or hygienists? Do you have the business acumen to pull off converting a solo private practice to something else? Do you have the energy to do it by yourself? If the answer is yes, the next step is to hire help. But not where you might think. Most dentists’ minds go immediately to an associate. The problem with hiring an associate first is that if your practice does not have enough patients to support an associate, you will be taking production out of your wallet and placing it into your new associate’s wallet. This transfer of income will quickly catapult you back deeper into survival. The answer lies in specialty care. Believe it or not, your current patients are spending roughly an equivalent amount of dollars to what they spend in your office in the offices of the specialists with whom you collaborate. Bringing the specialists into your practice and developing an internal multi-disciplinary team will bring in revenue and increase margins. This additional revenue stream should be the first step. This decision is consistent with Maslow-type growth. You will not be taking anything from yourself while you are still in survival. Just because this is what you should do, does not mean it is easy. I tried this while I was in private practice with a periodontist and an orthodontist. It did not go well. But just because it is hard does not mean it is impossible.
MOVING PAST YOUR CORE BUSINESS
After you have established a solid multi-disciplinary practice and your practice is growing because your patients are getting what they have always wanted, your office to just do it all, this is when you bring in more general dental help. But a word of caution, you must have margin in your practice or it will still be a disaster. Again, you need to conquer each level of the pyramid before you can move on. Not being the only general dentist in your office offers you a freedom of time that is liberating. The shackles of isolation have been a flaw of solo private practice forever. If you want to go on vacation or to attend advanced dental education, you always had to calculate the expense of the business not continuing its daily operations into the equation. For some the sacrifice was worth the cost, for others it was not. Having another dentist in the facility makes this a minor issue. If you embark on growing yourself, you will discover that as you learn more, you will be able to teach more. As you share your knowledge, you will begin to gain esteem and your outlook on life and dentistry will change. It seems strange to say that you need an associate to gain this esteem. The question might be; “did no dentist reach this level without associates?” Of course, the answer is that some dentists did achieve esteem, but they had to remove themselves from their practices to get it. They would join study clubs, dental associations, or the other organizations and give back to these outlets. Very few could afford to do this as often as they would like, most a week or two a year at most. The difference today is that those dentists had higher profit margins because of the time, today they would be hard pressed to follow the same track. In this new model where your core business is profitable, and you expand to having associates or partners, you can engage in coaching and development every day as much or as little as you like. All the while continuing to maintain your income and peace of mind.
The final stage or apex of the pyramid in the new model of dentistry is reaching your peak potential, or in other words, growth. Financial freedom and freedom of time allow you to develop into whomever you desire to become. For some, that might mean charitable work, others developing a repeatable business, and others time for hobbies and personal growth. Self-actualization looks different for every person because everyone has a different outlook on life. The point isn’t so much what this stage looks like, but rather that this stage is still achievable as a dentist. The world in which we work is changing. Change in neither positive or negative it just is change. For some, this new world will be a disaster, for others it will be better than they ever could have imagined in dental school. The cool thing is we each get to decide what to do about our future. Personally, I decided to partner with a dental service organization that supports this model. On my first day within the organization, I was in survival—all the way back to the bottom, a year and a half later I was close to self-actualization. The ramp to the top is dependent on effort, skill, and intention, not luck or secrets. I wish you success in your journey to the top.