The Modern Day DSO: Creating a Culture for Clinical Excellence

In Culture by Dental Entrepreneur

I vividly remember the feeling spring semester in my fourth year of dental school. Finishing up my requirements was the only thing on my mind — that last denture adjustment, the final crown seat, only a few more patients to transfer, and I was ready to graduate. Suddenly, I realized I was graduating in four weeks and I still didn’t have a job. I had a fantastic educational experience that prepared me for board exams, but unlike the majority of my classmates, I wasn’t planning to stay in-state to practice and was unaware of the upcoming challenges I’d face while searching for a job.

Little did I know that accompanying my graduation would be the financial collapse and Great Recession of 2007, leaving me to find a job in the worst job market in over 80 years. I was also moving to a new city where I had no contacts in the dental profession, which was a huge disadvantage since the ADA was reporting that over 80 percent of dentists in 2005 were in a solo practice. I started my search from scratch, looking at job boards or anything I could find online. My search was directed toward solo practices, as the stories I heard regarding “corporate groups” were mostly negative.

It was not long before I learned there were very few jobs in private practices and even fewer available to a new graduate. Although my resume was filled with leadership activities, including serving as class president, involvement in ASDA, various community service activities, several weeks of externship experience and being in the top tier of my class, I quickly learned none of that mattered, as I didn’t have experience practicing dentistry in the real world.

With no luck in private practice interviews, I began to interview with more corporate-style practices or, as I now know them, Dental Service Organizations (DSOs). My two biggest goals as a new graduate were to (1) find mentorship, and (2) practice a wide variety of clinical procedures with autonomy and focus on quality dentistry. The only job offers I received were from group practices, which seemed to be more willing to hire new graduates. Several of these groups said they saw a high volume of Medicaid pediatric patients, and the others said the dentists only performed restorative dentistry, while the specialists did all the endodontic and surgical procedures. I realized these types of groups were not the right fit, as they didn’t align with the goals mentioned above.

I finally found a group that said it offered both mentorship and clinical variety, but was told the office would be busy and I would be required to work every Saturday. Six-day workweeks with short lunch breaks did not sound like my dream job, but I knew I would learn a lot. I weighed my options, and because I felt comfortable working in a fast-paced environment, I decided to join this group.

From my first day, I didn’t receive the training I wanted and needed as a new graduate. Although another doctor was available in the office to assist me, I primarily had to lean on other assistants to learn how to do even the simplest tasks, such as how to use specific instruments. I did not feel the “mentor” doctor had an interest in helping me grow as a clinician, and I later learned this mentor was assigned as such only because he was the longest tenured doctor in the group. Coincidently, I felt that his tenure added to the disconnect in mentorship, as it was difficult for him to relate to the struggles and nerves of a new graduate.

My first year was as hectic as I was warned. I worked 52-straight Saturdays, some six-day weeks, and rarely got more than a 15-minute break for lunch. There was also very little staff interaction, since all the employees were required to speak Spanish, and I was often the only doctor in the office speaking English. Initially, I didn’t mind this, as I always loved being busy. I thrived on getting clinical experience and was able to increase my efficiency without compromising quality or ethical standards. However, as a natural extrovert, it was challenging for me to spend so much time without conversing throughout the day. I never established and grew an ongoing relationship with the patients, and often the patients rotated among the dentists without receiving continuous care. Over time, the workload I once enjoyed became too much, leaving me feeling burned out within one year of graduating.

After leaving that position in 2008, it was back to the same job hunt, but in an even worse economy. Despite having a year of experience, I spent several weeks interviewing only to hear that the available positions were part-time. I was still determined to find a job at a private practice, and after another round of seemingly endless interviews went by, I finally landed an associate role working alongside an owner dentist. The owner was someone who had been practicing for years, knew everyone in the community and promised the mentorship I was so eagerly craving. The position also boasted a higher-percentage compensation, a four-day work week, an hour for lunch and staff that spoke English. It was a dream come true! But within my first week, I realized the role I was seeking was not what I wanted.

I walked into an established office that was in operation for almost 10 years. The ownerdoctor, who I thought would be my mentor, spent the majority of the day in his office while I sat in an empty operatory watching TV. Since I was his first associate, he had no idea how to welcome or integrate me into the office. His patients who had seen him for over a decade naturally requested to see him. My schedule was always empty except for the occasional one occlusal filling which blocked off an hour of my schedule.

As I would walk in to do hygiene checks, I was routinely greeted with a surprised look on patients’ faces, with the repeated exclamation, “Wait … who are you? Where is my doctor?!” He didn’t train his staff to let patients know who I am, put my information on the door or the website, or even take an active role to ensure my schedule was busy. These tasks were all left up to the office manager, who I soon realized was my real boss. Anytime I had a concern, my directions were to go to her, and she would “take care of it.”

This routine continued for several months until the private practice I worked in was acquired. Through this acquisition, I was able to connect with the founder of DECA Dental, Dr. Sulman Ahmed. Through working alongside him and our third business partner, Dr. Rodney Alles, we collaborated based on our collective experiences as associates to form the foundation of our presentday DSO – led by dentists for dentists. Our focus was to enable any dentist to transition into practice with proper clinical training and mentorship without the burdens of operating a business. The three of us spent full days treating patients and countless nights developing and refining the systems for a model that could be replicated.

We spent several years working through the numerous challenges of running a business, enduring substantial personal and professional debt required to grow, continuously hiring, and training and managing teams, all while keeping patient care as the top priority. Through our personal experiences working in both private practice and DSO practices, we genuinely gained an appreciation for the various ways of practicing dentistry. These experiences were instrumental in helping shape the culture of clinical excellence in our organization today.

I tell this story transparently to express that I fully understand the stigma out there about DSOs. I hear these stigmas all the time, and my first instinct is to be defensive and say it’s untrue, but I know that’s not the case. I am not here to tell you that all DSOs are perfect. There are opportunities for all aspects of the profession to improve. I learned that the negative experiences, stories and overall stigma I heard about DSOs were not exclusive to groups and may be found just as frequently in private practice. Working on both sides, I gained awareness and a great appreciation of what it takes to be successful, not only as a clinician but also as a business owner. I have a tremendous amount of respect for successful dentists on both sides of the spectrum.

The Journal of Dental Education estimates that by 2025, “large, DSO-managed group practices will be the setting in which the majority of oral health care is delivered.” Each group practice or DSO has its advantages and limitations, as they differ in business structure, culture and patient-care model, but all share the common goal of removing business-centric and administrative responsibilities of the practice from the dentist, allowing them to focus on practicing dentistry. There is a growing need for a DSO in dentistry, and if done the right way, they will continue to evolve appropriately.
Below are some advantages a DSO can provide to a dentist:

  • Job Opportunities: According to a survey conducted by the American Dental Education Association in 2017, the average debt per graduating dentist is $287,331. For students attending private or out-of-state schools, the debt may be far more substantial. The ADA Health Policy Institute reports that 7.4 percent of all practicing U.S. dentists are affiliated with DSOs. But for dentists ages 21–34, that number rises to 16.3 percent. DSOs offer jobs for new graduates, providing a smooth transition to “real world” dentistry and immediate access to a variety of procedures and a patientcentric environment. This opportunity allows them to improve their confidence, clinical skills, and efficiency without the additional responsibility of the non-clinical areas of the office.

    The ADA also reports that dentists are waiting longer to retire. In 2005, dentists’ average age of retirement was 66.1 and increased to 68.8 in 2015. At this rate, the age for a retiring dentist would be 70 in 2025, which equates to fewer opportunities in private practices when owner-dentists are not selling. On the other hand, many dentists want to work later in life to continue their passion for providing quality care to patients without having to handle the day-to-day responsibilities of being a boss and running a practice. Thus, the aging dentist may turn to a DSO for stable income and lifestyle benefits.

  • Mentorship: Mentorship is key to our success and the foundation of our clinical culture. A new doctor or team member should never feel unprepared or unsupported when beginning their job. Mentorship must be prevalent in each practice. Every doctor joining our group receives an assigned mentor who has undergone rigorous leadership training to join our clinical advisory board. These mentors follow a streamlined training and orientation process in which new doctors rotate among select offices on a set schedule to shadow and take part in live clinical procedures.

    There is also a hands-on orientation and clinical-simulation session in which all concepts presented during training can be reviewed in detail, allowing the clinician to ask questions along the way in a familiar setting, similar to dental school. As a group, we have clinicians leading clinicians to provide the continuous support our dentists need to succeed.

  • Quality Control and Autonomy: A significant concern regarding DSOs is the lack of quality control and the focus being “all about the money.” Speaking only on behalf of our DSO, I can assure you that this is not the case. In fact, it is quite the opposite. Our group performs regular chart audits to help new and existing doctors with both diagnosing and quality control matters. Our quality efforts are actually supported and benefitted by our size.

    As for a solo practitioner, how are they able to ensure that they are upholding quality standards? Who or what are they using to compare or hold themselves accountable? At DECA Dental, we firmly believe that constructive feedback and peer reviews from clinician to clinician are excellent ways to ensure that you are doing quality dentistry. As our senior clinicians offer constructive feedback, it is clear that the choice of treatment is ultimately always in the hands of the doctor, and they have the autonomy to make their own decisions. Our board doctors are not just present during the training and onboarding process, they also take time out of their schedules to consistently visit doctors in their offices to offer guidance on diagnosis and treatment planning, as well as perform chart reviews. It is because of our size that we can maintain and hold our dentists to a higher standard of quality care.

  • Financial Stability and Benefits: As mentioned, the debt of school alone is higher than ever, and growing. Many students opt to gain more clinical exposure without worrying about the bills and overhead of running a solo practice before (if ever) tackling the day-to-day business operations and financial burdens of purchasing a practice. Our dentists, including new graduates, earn significantly more than the national average. Most DSOs also can offer a comprehensive benefits package.
  • Continuity of Care: Traditionally, solo-owned practices only offer general services and refer patients out for specialty procedures. This model is an inconvenience to the patient, as they have to go to another location, complete more paperwork and see an unknown provider. This is also a disservice to the general dentist since they refer the patient out and are unable to grow or learn from the experience. It also does not guarantee continuity of care. Our associates have complete autonomy to create their treatment plan and first right of refusal on providing treatment. In a DSO that has in-house specialists, the general dentist and specialists work in close proximity, communicating immediately to ensure that there is a smooth transition for the patient and their care.
  • Lifestyle Flexibility: The DSO model offers a flexible work schedule and a more balanced work-life balance of family and social life, along with a fulfilling work environment. The responsibilities of owning and running a practice (hiring and firing, payroll, purchase orders and dental suppliers, legal support, management help, insurance and benefits plans, compliance, etc.) take time away from other aspects of your life.
  • Patient-centric: A true DSO, and even private practice associateship, should separate clinicians and their treatment choices from the business side of dentistry. This division allows the clinician to focus on dentistry full time, while not being distracted by traditional business decisions or owner obligations. A DSO provides the backend to support to allow a dentist to practice and treat their patients, focusing only on their care.
  • Growth and Development Opportunities: The DSO environment provides opportunities for continuous growth, including continuing education, strong partnerships with dental suppliers giving access to modern dental materials, equipment, techniques and technology. Some also offer professional advancement or ownership, including ownership in the individual practice, ownership in the group of practices they work in or an equity stake in the group as a whole.
  • Culture: Every practice or group will have a unique culture, and it is essential to find what best matches your personality and aligns well with your short-term and long-term goals. We strive to deliver comprehensive patient care at an affordable price and convenient location. Our culture supports this goal, and our offices are built on the foundation of quality care, customer service, innovation and collaboration. We strive to integrate into the communities we serve by participating in community outreach programs, charitable events and dental education for schools.

    Culture is essential to the core values of a group, so we always recommend asking for referrals from dentists who work for groups or DSOs you are interested in to hear their experiences. The landscape of dentistry is changing just as it has for multiple other healthcare models in the past. Although DSOs are not a new concept for today’s dentist, they are still developing and continue to evolve into a better form year after year. One of the biggest misunderstandings about DSOs is that they are focused on profits before patients and provide no value to the doctor beyond a job and a place to practice, primarily as a first job right after dental school. Hopefully, as the modern world and healthcare industry continues to evolve, so will the mindset of the profession. The common goal is to elevate the standard of the profession and provide patients with more accessible, efficient and convenient models for dental care. DSOs achieve this — and much more.

Dr. Shalin Patel is Partner and Chief Clinical Officer at DECA Dental Group, named one of the fastest-growing companies in America by Inc. 5000. Dr. Patel oversees new doctor recruitment and has created unique and innovative systems to train hundreds of new dentists across Texas.