QUESTION:
What challenges did you face in transitioning from a resident to a practicing orthodontist?

Clarice Law

I will never forget the experiences of my first two years out of residency. My transition from resident to practicing orthodontist was incredibly difficult, with challenges I hadn’t yet experienced that invariably stretched me in ways I hadn’t been stretched before.

Throughout college, dental school, and residency, my biggest challenges shaped me in the arena of intellect and fortitude. But those two transitional years had a profound impact in stretching my ethical standards and my social and leadership skills. I’m certain that many of these themes have touched the lives of all who have successfully passed through this transition.

The practice of orthodontics in residency was fairly idealized in my experience. We aimed for perfection as our treatment goal and didn’t mind if it took up to five years to achieve it. In my idealistic state, I felt that anything less than perfection was unethical. I quickly learned that this wasn’t always appropriate in private practice.

One of my earliest challenges was learning how to balance the pursuit of perfection with the need to consider patient cooperation, treatment time, treatment cost, chair time, and the clinical capabilities of my staff. Basically, I had to learn to be realistic. I learned to release some perfectionism without sacrificing the best interests of the patient.

My ethical standards were also challenged because of my practice environments. Although the majority of my days were spent as an associate in an established orthodontic practice, I spent two additional days a week in two different general dental practices as a contract orthodontist.

I found that my balance of financial versus treatment objectives was different than those of my employers. I often felt the pressure to increase productivity in ways that would compromise the care of the patients. I had to learn how to communicate with people who were experts in running general dental practices, but really didn’t understand orthodontic practice management. I learned to negotiate methods of cutting expenses and raising productivity that wouldn’t compromise the care of our patients.

Taking over patients from other clinicians proved to be challenging as well. Although I have a high degree of respect for the orthodontists I followed, as expected, there were cases where I differed in my treatment approach. It was a challenge to complete treatment with these patients in a timely manner, often times with a detrimental effect on financial compensation.

Finally, it was an ethical challenge to be willing to admit a lack of experience. I was fortunate enough to be trained in an environment where creativity was encouraged. I found that although this was very appropriate from an educational standpoint, it could also potentially compromise the interests of a paying patient. During my practice transition period, I had to learn how to be aware of my limitations due to lack of experience. I had to be willing to refer patients out or to admit that the treatment might not go according to plan. I had to learn how to admit to mistakes and correct them.

Another challenge during practice transition was social. Entering the workforce revealed a set of social skills that hadn’t been tested throughout the course of my education. The first challenge was finding a job. I had no intention of buying into a practice at that time, so I had to tap into rather obscure resources to identify practice opportunities. This was incredibly frustrating. I continue to hear horror stories of graduates trying to secure employment. The standard methods of seeking employment in the business world don’t appear to be available to us in the orthodontic community.

Once employed, I found that there was a new challenge of learning how to network with local practitioners and to cultivate relationships that would lead to referrals. I also learned the importance of appropriate chairside manner. As a resident, this wasn’t as important, since the patients generally didn’t value doctor-patient relationship as highly. However, in practice, I realized that appropriate behavior and office ambience often made the difference between whether a patient would commit to my practice or to the one down the street, where the orthodontist had been practicing for 20 more years than me.

Finally, the two years of transitioning into a practicing orthodontist tested my leadership skills. As a resident, I carried very little authority over others. However, as a practicing orthodontist, I found myself responsible for a staff of up to eight people. I found that I had to learn how to confidently and quickly make clinical decisions that would impact the work of my assistants, all the while trying to pick up clinical speed and adjust to the pace of private practice. I had to learn how to resolve disputes and to mediate conflict. I had to learn how to motivate the staff toward maximal efficiency while promoting a positive environment for the patients. These were not things I learned in residency. But the most difficult thing, as a junior associate, was trying to develop my own leadership style without undermining the authority of my senior associate.

I am no longer in private practice, having become a full-time academician one year ago. However, I am incredibly thankful for my two-year transition period. The lessons I learned during that period have made an indelible mark on my character and have made a difference in the way I relate to students. And here’s the payoff. Every year, I get to look forward to sending a batch of fresh graduates out into the world to experience their own set of new challenges.  

Jonathon Lee

The transition from a resident to a practicing full-time pediatric dentist and orthodontist has been exciting and fulfilling. I am grateful for having the opportunity to join my father in clinical practice. The ease of transition is multi-factorial.

First, I understood the joys and complexity of the dental profession because I am a third generation dentist. While growing up, I learned a lot by observing my grandfather and father at work.

Second, I was fortunate to attend the University of Pacific’s School of Dentistry where I received a humanistic, comprehensive and clinical dental education. I was able to practice and master with confidence all the clinical specialties of dentistry. We also received excellent courses in ethics, practice and risk management, as well as jurisprudence. Actually, going to dental school was fun!

Third, I was fortunate to have been accepted into Dr. Patrick Turley’s combined Pediatric Dentistry/Orthodontics Residency program at UCLA. There, I was able to strengthen and to refine my knowledge and skills of Pediatric Dentistry and Orthodontics. Like UOP, UCLA’s Combined Pediatric Dentistry and Orthodontic Residency Program is very comprehensive and clinical. At UCLA, we were fortunate to have a close relationship with the Medical Center.

As written in the last PCSO Bulletin, the integration of medical education has helped me tremendously in my clinical practice and has benefited my patients. We were also fortunate to have been blessed with a large volunteer clinical faculty at UCLA. They taught us formal practice management courses and gave us clinical pearls of wisdom. Going to UCLA also gave me the opportunity to learn how to work efficiently within an established large institution.

A year before I graduated from my residency programs, my father and I prepared for the transition. We talked with numerous other practitioners, consultants and other professionals about handling practice transitions. Even though we were father and son, we decided to have a formal business relationship.

It helped that my father and I have open minds and that we think alike. When my father was in solo practice, he constantly kept up with the latest research and proven clinical techniques. Now together, we constantly update and improve the practice to provide the best care for our patients. We both enjoy sharing ideas with each other. Fortunately, my father does not mind letting me make major decisions as well as purchases that will improve the practice. He tells me that I have made his life a lot easier! He can now take some well-deserved time off.

The best thing about our relationship is that we are equals. He has thirty years of priceless clinical practice experience and I have the expertise and experience in technology and in computers. There is no school or book that can teach the clinical pearls and practice management that my father has perfected and still constantly improves upon.

Entering an efficient practice is a privilege, and now with the latest proven computer technology, our practice is even more efficient. It has been over a year since I joined my father in practice and it has been continuously a joy! Our patients are grateful that a father and son team provides for their care. I could not have asked for a better profession.

Rob Sheffield

This particular question is one that I could spend quite a bit of time on, but since our space is limited I will address three specific areas. I, like all of you, strive to achieve an ideal occlusion within a balanced and esthetically pleasing face. I was taught during my residency training to strive toward this goal.

My largest frustrations so far in clinical practice have been those occasions where this goal was not attainable. It could stem from lack of cooperation on the part of the patient/parents or from starting with a compromised treatment option at the outset due to the patient’s wishes i.e. choosing a non-surgical approach versus a combined orthodontic surgical option. Also, it could be due to an imperfect treatment plan.

My greatest clinical challenge so far has been recognizing these situations and accepting that I have achieved the best result possible for that particular patient in the given circumstances. I have learned quickly that not all things are within my control as a practitioner and attempt to improve upon and perfect those areas that are.

Without a doubt, my greatest challenges in private practice have been on the practice management and business side. The management of employees and all the attendant issues presents both the greatest thrills and the greatest frustrations. There were virtually no structured classes or seminars to adequately prepare me for this aspect of private practice. The knowledge I did acquire was ad hoc from our visiting faculty or through office visits outside of the residency program.

I was fortunate to associate with an orthodontist who spent time talking about these issues with me. This definitely helped when it became my time to be the employer. While each of us needs to develop our own style and philosophies as regards employee management, I believe some general instruction on various situations such as hiring, firing, reviews, salaries, and benefits would have been beneficial.

The last area I want to address relates to the insurance industry, specifically Delta Dental. As I transitioned from residency to private practice, I made sure that the practice I went to work in and eventually purchased was not part of any managed care plan or signed up for specific contracts.

During the process of purchasing the practice I found that one has to submit a fee schedule to Delta Dental to receive benefits from them. So like any new practitioner I submitted the existing fee schedule of the practice. Imagine my surprise when it came back rejected, telling me I was 28% over UCR. I would love an explanation of UCR since it doesn’t seem to cover two doctors who practice in the same office. After 17 submissions, 11 months as well as numerous calls to the fee-listing department and eventually to Delta’s vice-president of professional relations, I finally had an approved fee schedule.

The difficult part was that some of my "approved" fees were less than what we were currently charging. Why does this occur? I was told that initially when Delta first started having orthodontists submit fees the company didn’t have any data in their little database so they basically approved any fee. Over time with more fees being submitted, especially from low cost clinics, Delta began to have a nice little database to magically set the UCR. Additionally, they then changed the approval level from 100% to 80% of UCR.

Furthermore, we aren’t even guaranteed an annual increase based on the cost of living index but have to go through submitting fees each year so they can again run it through their formula to tell us what we can charge.If I withdraw my agreement with Delta, a great number of my patients would not even be able to recover their full allowable benefit based on the payout Delta gives when patients use a non-Delta dentist.

There is something truly wrong with a system that tells someone what he or she can charge for their services. I am aware that the California Association of Orthodontists (caortho.org) has a Delta Task Force that meets with Delta on a regular basis to discuss complaints such as mine. The Task Force has worked hard and accomplished limited victories against this powerful organization.

I don’t want to lose the freedom to set our own fees for services and then let the market place decide if they are acceptable or not. There is a tremendous ethical dilemma to be faced if we have patients paying two different prices for the same service. Can we honestly say we would treat these patients the same? I am not sure how I could have been prepared in residency for this particular challenge but I gather it will be with me for a long time.

Editor’s Comment:

Numerous combinations of circumstances including differences in financial, social, educational, and geographic backgrounds, as well as contrasting personalities, almost guarantees that there will be significant variation in the issues and concerns identified by recent orthodontic graduates as they embark on their new careers.

Essential to analyzing those areas that are problematic to a particular individual is the identification of ones goals and recognition of your value system. Compromise is inherent to living a functional life, but prioritizing actions in accord with your core value beliefs and consistent with your goals should help in allowing the achievement of a satisfying career as opposed to a less than completely fulfilling job.

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