Becoming a Super GP
Tracking the trend of offering more specialty services in general practice
According to the American Dental Association’s Health Policy Institute, the average net income for a general practitioner (GP) in private practice was $180,950 in 2013, down significantly from its peak of $215,876 in 2005.1,2 Despite the slow recovery occurring in the general economy, the average net income for GPs has not seen a corresponding rebound since the end of the Great Recession in 2009.2 Today more than one third of GPs report being “not busy enough” (see Table 1).
Many dentists are kept up at night weighing strategies to recapture that lost income and encourage practice growth. There is not one answer that suits all practices, but there is a growing trend that deserves consideration—becoming a Super GP.
What is a Super GP? In essence, it is a general practitioner who makes the decision to expand his or her scope of practice to include a variety of specialty services. For the purposes of this article, Inside Dentistry is defining a Super GP as a practitioner who is placing implants, performing endodontic procedures, offering orthodontic services, and providing cosmetic dentistry.
“There’s no question that the trend of general dentists performing more specialty procedures is way up,” says Roger P. Levin, DDS, chairman and chief executive officer of the Levin Group, Inc. “In the last 5 years, 75% of general practices have declined in production. It makes perfect sense that GPs started to look for other services they can provide.”
The beginning of the changes that became the Super GP trend can be traced back to 2008, when the recession really hit. Levin Group Data Center™ research shows that the number of GPs offering specialty services has continued to rise ever since, with no signs of stopping. Today more than half of GPs offer some type of orthodontic service and perform endodontics regularly, and well over one third are surgically placing implants (see Table 2).
Although attaining Super GP status can have tremendous financial and personal benefits, it is not for everyone. Many of those interviewed stressed that offering new specialty services is not a proposition to be taken lightly. The investment needed to do it right can be great, and the stakes are sometimes high. At least for now, the Super GP as a practice model is an interesting opportunity, and with careful consideration and proper planning, it could be the answer some practitioners seek.
The Advantages
“Dentists are increasingly looking for new and better ways to serve their patients and grow their practice at the same time,” explains Louis Malcmacher, DDS, MAGD, president of the American Academy of Facial Esthetics (AAFE) and a private practitioner in Bay Village, Ohio, where he practices under the Super GP model. “There is no question that the most successful dentists I see when I lecture at dental meetings are those who love to learn new skills and are on their way to becoming Super GPs.”
Success has many definitions in dentistry, but some of the most common markers—high production, improved dentist satisfaction, and elevated patient care—are among the characteristics of the typical Super GP practice.
Increased Production
In an economy in which every appointment matters, adding specialty services is one way to boost production.
Michael R. Sesemann, DDS, a private practitioner in Omaha, Nebraska, who fits our Super GP definition, began his practice with a strong background in endodontics and periodontics from his training at the University of Nebraska Medical Center College of Dentistry. Over the years, he subsequently added implant prosthodontics, comprehensive esthetics, periodontal surgery, endodontic surgery, occlusal treatments, Invisalign, implant placement, and injectable esthetic treatments like Botox and fillers to his practice’s offerings.
“All of those additions were well received by our patients and they stabilized our production, much like how a diversified portfolio reduces risk in investing,” Sesemann explains. “Being able to offer a lot of different services allows us to ensure our own security.”
Levin has found that a general practice can expect on average a 12% to 15% increase in production by adding one or more specialty services. He stresses that it is not the whole answer, however. Offering additional services can be for naught if the practice is not also efficient and well run.
Malcmacher cites a recent AAFE member study that illustrates the stabilizing effect of adding specialty services. “AAFE members who are Super GPs and incorporated Botox, fillers, trigger point therapy, bruxism monitoring, and dental sleep medicine into their practices averaged a monthly production increase of $26,500,” he says.
Many dental manufacturers are well aware of this trend and what it means for production. Michael Augins, president of Sirona Dental, Inc. and executive vice president of Sirona Dental Systems, Inc., says his company is focusing on a model called ROI (Restorative, Orthodontics, and Implants). Although not yet complete, preliminary research around Sirona’s ROI model is promising.
“When our customers add orthodontics and implants, they get a 50% growth in revenue production, but generally close to double their profits,” Augins says. “This is because they have all their overhead already—they’re just really adding the education and technology. They don’t have to add a new room or a new office, and they already have the patients in their practice.”
Practicing at a Higher Level
The variety of services a Super GP performs facilitates a comprehensive approach to more cases, allowing clinicians to practice at a higher, and often more satisfying, level.
Taking an implant case from presentation and planning through surgery and restoration, for example, allows complete control over, and responsibility for, its final outcome. “Our office was getting patients who came from specialists with implants that were at difficult angles to restore,” Malcmacher explains. “That motivated us to learn to surgically place implants decades ago so we could control the whole case from start to finish.”
Although Amanda Seay, DDS, a private practitioner in Mount Pleasant, South Carolina, is not a Super GP, she sees how a GP could bring a unique perspective to specialty services that could have huge clinical benefits. Seay has contemplated offering limited orthodontics with aligners in her practice for the convenience of her patients and for the benefit of being able to monitor teeth movement before and during the restorative phases of treatment. And although she does not place implants, she says, “I think the major advantage of a restoring dentist knowing tooth length, shape, contours, contacts, embrasure spaces, and emergence profiles of the final design as well as restorative material options cannot be denied.”
Practicing at a higher level can boost a practice’s reputation as well. Malcmacher explains, “We have seen AAFE dentist members become the best Botox injectors in their geographic locations, with physicians referring patients to them for esthetic and TMJ/orofacial pain and headache treatment. One AAFE general dentist member gets referrals from the Mayo Clinic.”
A Super GP who is practicing at the top of his or her game has days that are challenging and full of variety, a characteristic that is appealing for many. Sesemann says, “In providing such diverse services, every day is fresh and exciting because it is not the same, day in and day out. Even though my team has been in practice for a number of years, we still find our work stimulating and satisfying, and part of that is due to the variety of things we do.”
Patient Care and Satisfaction
The Super GP represents a truly patient-first model of practice, according to Filippo Impieri, vice president of marketing, North America for KaVo Kerr Group, Dental Technologies. “The primary motivation for GPs adding treatments such as endo, ortho, or implants is to offer better, more comprehensive care to their patients,” he says. “In fact, stories of improved patient experience and retention are what we hear most.”
Malcmacher has seen this positive effect on his patients. “For the last 40 years, we have always provided as many services as we possibly could to patients,” he explains. “We were able to provide better treatment because we knew exactly what the proper treatment sequence should be and what dental materials we used so they were compatible with other materials. Patients were thrilled to be able to receive all of their care in one place instead of getting bounced around from office to office.”
Patients’ lives are hectic today, Sesemann says, and they like the convenience of treatment by one office, as long as it is clinically appropriate. They also appreciate having everything done by the team of people they have come to know and trust.
Going to one location for fewer appointments to get a range of services completed leads to a more satisfactory patient experience, Augins says. “Dentists who provide a broader range of services to their patients create this kind of one-stop-shop effect that makes them attractive to new patients. We found in our ROI modeling that it increases overall patient satisfaction.”
The Disadvantages
Super GPs should have a passionate drive to learn everything they can about their craft, Sesemann says. “With that inspiration and motivation, it then becomes a commitment to put two important resources towards that objective—time and money. That is not easy to do, because it is initially in direct competition with personal time off and salary compensation.”
In addition to the expenditure of time and money, which alone are big enough disadvantages to deter some, there are other potential downsides to becoming a Super GP. These stem generally from proceeding with the practice model without proper planning and communication.
Stretching Yourself Too Thin
Providing a wider range of services can have a negative effect on practice production if clinicians attempt to add too many new procedures or services at once. Understanding your personal limits—and those of your team—will go a long way to avoiding this first disadvantage.
“It is important to be aware of possible distraction from what made the practice successful, or putting it another way, a lack of focus,” Impieri says. “We encourage clinicians to evaluate the ‘do-it-yourself’ approach versus creating partnerships where specialists come into the GP’s practice.”
Levin confirms that if a practitioner offers services before they can be performed competently and effectively, the workflow in the practice could really suffer. “Adding specialty services can create a more chaotic practice, because now you have GPs trying to master more and more procedures and complete them throughout the day,” he says. “The more variation in procedures you have, typically the less efficient you are in your process.”
Seay explains that she decided to focus chiefly on restorative care for a variety of reasons. She doesn’t offer certain services, such as endodontics and oral surgery, because she just doesn’t enjoy them that much. After spending years refining her restorative skills and learning to be a better business owner, Seay says that mastering another discipline was something she just wasn’t ready to take on.
“Specialists have spent many years going to school to learn how to perform their specialty at a high standard, and I respect that,” she says. “That is not to say that a general dentist could not perform the same quality, but I would want to do some serious training and schooling before I decide to do anything else.”
Case Complications
Despite the name, Super GPs are not infallible. Problems will likely occur at some point when incorporating new services, and it is wise for practitioners to plan accordingly.
Case selection is key—just because a GP can offer a procedure doesn’t mean he or she has to. Levin says that general dentists need to become experts at recognizing which cases they can take and which they need to refer immediately. Failure to do so can be disastrous.
“There are certain implant or endodontic cases that are easier than others, and as a general dentist, you don’t always know when you get involved if that case is going to turn into a more complex case,” he explains. “It may well end up in the specialty office anyway, but the patient has gone through a lot to get there.”
Along with mastering careful case selection, general dentists must not eschew interdisciplinary care, Levin says. It is important to maintain existing relationships with specialists, even after you have achieved a high level of comfort and skill with a new procedure or offering.
Although his office does a lot of specialty procedures, Sesemann says his practice highly values its relationships with specialists in the community, especially because patients are sometimes best treated by a specialist or interdisciplinary team.
“My obligation is making sure that I direct our patients where they can obtain optimal care,” he says. “If GP dentists are placing patients on their schedule, they need to be confident they can provide the same type of care for that procedure as the patient could obtain at a specialist’s office. If that assurance cannot be given, it is better to refer the patient for treatment to one of our talented specialist colleagues.”
The Turf Wars
This leads us to the elephant in the room—the friction that exists between GPs and specialists. One argument against the Super GP is that a general practitioner cannot provide the same standard of care as a specialist. Although that may have been true decades ago, John Kois, DMD, MSD, director of the Kois Center and a prosthodontist in Seattle, Washington, says that two trends are changing the game.
“First, technological innovation has simplified many of the restorative, surgical, and orthodontic skills required to provide successful treatment outcomes,” he says. “Second, many of these newer technologies have not been incorporated into graduate specialty programs so the ‘playing field’ has been equalized because many specialists learn about them after their specialty training anyway. In fact, many young specialists do not always have more experience or expertise than seasoned general practitioners regarding these newer procedures.”
Mirroring Sesemann’s sentiment, Kois notes that patient protection requires that the same standard of excellence be applied to all procedures, regardless of whether they are provided by a general dentist or a specialist. But technology is making it so that the label of “specialist” or “GP” is not as significant as the education and training behind the title.
“In the future, the most expert or qualified clinician may not always be the person with recognized specialty training, but the one dedicated to continuous learning,” Kois says.
In addition to the question of competency, there is little doubt that some specialists will see the Super GP trend as a threat to their livelihoods, a view that Malcmacher thinks is shortsighted.
“General dentists already perform over 90% of the endodontics in the US, and endodontists are busier than ever,” he explains. “Why? Because the more general dentists are trained, the more they recognize cases that need endo and refer. The exact same scenario is happening in orthodontics now. We will see the same thing in implants as well. Dental specialists need to get on board with the Super GP concept—they will thrive more than ever.”
Making It Happen
If a clinician determines that working toward becoming a Super GP is the right move, a careful plan is the key to success. When asked what advice they would give a colleague on getting started, the Super GPs we interviewed put education at the top of the list, along with ensuring you have the proper tools to proceed and making sure your staff is up to speed.
Educate Yourself
Simply put, the first step in creating a Super GP practice is continuing education. As Levin says, “It’s the basis of everything. No dentists should be doing procedures unless they have the education behind them to do it properly.”
Sesemann emphasizes that clinicians need to be strategic and focused when choosing a course of study. “More often than not, the education needed is more curriculum-oriented in structure as opposed to a one-day course taken locally. This is usually a more expensive proposition,” he explains. “In addition, you have to account for the cost of travel and the probability of loss of production due to the closing of the office while the practitioner and/or staff are away. For those reasons, it is extremely important to make the decision of what to pursue as calculated as possible.”
The type and quality of continuing education are also critical, according to Malcmacher. “I know dentists who have taken thousands of hours of wasted CE because there is only so much you can learn in a lecture,” he explains. “You can’t learn skills-based training in a lecture. The only way to become a Super GP is through hands-on and live patient training so you can develop the diagnosis and treatment skills necessary to treat patients with Botox, fillers, ortho, and implants.”
Some dentists may wish to start where they already have some experience and a certain comfort level—adding endodontics or more cosmetic dentistry offerings, for example. If you want to get started quickly, Malcmacher says, start with more basic procedures and increase offerings from there.
“First learn the minimally invasive and most highly patient desired services and skills that can be integrated immediately into your office with no large capital investment or lease payment. These services will generate income immediately after live patient training, and include Botox, dermal fillers, and trigger point TMJ/orofacial pain therapy,” he says. From there, he recommends looking into services that require more investment, such as bruxism monitoring and sleep medicine and implant training.
Networking can be a big help, too, says Impieri. “I would suggest that any GP interested in advancing his or her practice take advantage of continuing education seminars as a way to understand the specialty paths available, and learn from or network with doctors who have already taken a step in diversifying their general practice.”
Get the Right Tools
As Kois mentioned, for many of the specialty services Super GPs perform, technology has an important role to play.
To get the most benefit from adding services, Levin says, make sure you have the right tools at your disposal. “If it’s going to take you two or three times as long to complete a procedure on a patient, that can be hard on a patient. If that occurs because you don’t have the up-to-date equipment or materials, that becomes problematic.”
Choosing the right tools will make procedures more predictable and help ensure that a Super GP minimizes risk and maximizes reward. As with education, the decision to invest in technology should be strategic, depending on what services a clinician wishes to offer.
“To take a Botox course, you don’t have to buy a $100,000 machine,” says Augins. “With implantology, we recommend you invest in CBCT, so the procedure is computer guided and planned. That’s a significant amount of investment, both in technology and education. But it’s well worth it—the payoffs come in the first year.”
Impieri says he sees a growing interest in implants among general practices, and 3D technology is a wise investment for those clinicians. “The increased adoption of 3D for implant planning is justified not only by the clinically rich 3D volume sets that the GP can obtain,” he says, “but also by the ability to define the entire implant plan via software and have surgical guides produced to make the implant placement process stress-free and, ultimately, to provide more consistent, better outcomes to patients.”
Combined with top-notch education, Augins concludes, technology can yield precise procedures in as few appointments as possible. The result is a better practice lifestyle and patient experience.
Educate Your Staff
When making the move to a Super GP practice model, an important and sometimes overlooked step is making sure your staff is well trained. A practitioner shouldn’t consider a service fully integrated until the whole dental team is comfortable with it.
This is where clinicians sometimes stumble, and the practice and patients can pay the price. “It’s more and more difficult for staff members to keep up with all the different procedures the practices are attempting to provide,” Levin says. “So they really do need on-going training to be able to support the doctor and the patient.”
One way to achieve this, Malcmacher suggests, is to bring appropriate dental team members to hands-on, skills-based live training whenever possible. In addition to helping support the clinician, a well-trained team can maximize case acceptance. “Most of the time, it is the team that motivates patients towards treatment, especially when it comes to esthetic services,” he explains. “CE excites the team to talk about new services—my own well-trained team always talks about Botox, fillers, and implants to patients.”
Sesemann says that without his staff’s complete encouragement and commitment, his practice would never be able to achieve everything he strives for as a practitioner. “Introducing new services, especially when they are complex treatment modalities, requires a team approach and a committed focus from all of us to make it work,” he explains.
Conclusion
Becoming a Super GP is just one option for making the most of dental practice in terms of finances and job satisfaction.
“I love what my staff and I do and recommend it to anyone who wishes to immerse him or herself in dentistry. I believe it to be at the heart of our love for our profession, patients, and practice,” Sesemann says. “However, I am sure that type of obligation is not for everyone. If someone does not feel they are capable or willing to commit resources to pursuing and obtaining the necessary education to provide diverse services, dentistry can still be a wonderful profession.”
Although it can be a daunting prospect to learn new skills, the rewards can be great for those who make a wholehearted commitment to the process. To those who are interested but still on the fence, Malmacher gives these words of encouragement: “We are oral physicians; no other health care professional on the planet knows the oral and maxillofacial areas better than dentists. It is time that dentists realize how much we really know and are capable of—every dentist can become a Super GP.”
References
1. Dental Practice. American Dental Association website. www.ada.org/en/science-research/health-policy-institute/data-center/dental-practice. Accessed August 9, 2015.
2. Munson B, Vujicic M. Dentist earnings not recovering with economic growth. American Dental Asssociation website. www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1214_1.ashx. Accessed August 9, 2015.
