Drs. Carmen Ramos and Michelle N. Zmick answer questions about their experiences...

2006 Student Event: Ride the Wave to Success
Starting as an Independent Contractor

Drs. Carmen Ramos and Michelle N. Zmick answer questions about their experiences.
Photo Dr. Ramos is in practice in Manhattan Beach, California. She completed her periodontal residency at VA West Los Angeles—CA in 1996.

What was your ideal plan after graduation?

My ideal plan was to buy an existing practice and take that momentum and run with it.

What realities did you encounter?

The reality was, there were no practices for sale in the areas I was willing to commute (there was one 80 miles away!) and the time and months were ticking by and I had to find work! So I was forced to find jobs that would tide me over until I did find a practice to buy.

What appealed to you about becoming an independent contractor?

Being an independent contractor was nice because it gave me the flexibility to tell the offices when I wanted to work, and how long. I took on four offices where I would work one day a week.

What variables influenced your decision of becoming an independent contractor?

The variables that influenced me in becoming an independent contractor were the opportunities available to me. There were more opportunities to find work via the independent contractor route than being an associate or buying a practice.

How did you go about searching for an independent contractor position?

Word of mouth

Did location factor into this situation?

Not really. I was driving to one office a day per week; I figured it was not that difficult if the commute was far.

Please explain your financial compensation arrangement, using real or fictitious figures.

The financial compensation was not written. It was a verbal agreement that I got 50% of production. They would give me a computerized print out sheet of the day and the total production, and I got 50% of that.

What are the pros and cons of this type of practice?

Pros: You have a job (better than nothing). The pay is okay. You learn a lot interacting with the GP very closely. You have no management headaches to deal with, no staff turnover and no drama to deal with. If you are in a quality office, you can do a lot of procedures that you may not otherwise get to see as often if you were in a private practice and you don’t have to deal with marketing the practice.

Cons: You don’t have as much control as to how you want things run in the office. You don’t have certain tax breaks you would otherwise have if you had your own practice. You are at the mercy of what assistant they give you and you need to train them and if there is staff turnover, you start all over again. Depending on the office, your schedule is the last on their minds and may suffer in terms of trying to fill in a broken appointment etc, (i.e., you may drive all the way to the office to find out that you will only see 2 new patients and 3 Post-op checks).

The biggest thing I am feeling now that I didn’t feel before is, the procedures you are doing are getting more advanced and complicated, such as implants, sinus lifts, bone augmentation and the liability is very high, and yet you will only get 50% of that. I felt that these procedures although easy and not too time consuming, still have a high liability price tag on them in terms of failure, complications, etc. All of that liability is all on you after the procedure is done with no compensation whatsoever and knowing you do so much and they do nothing but provide for overhead and they get 50% sometimes makes it feel unfair. Also, your costs on continuing education seminars, licenses, etc. is part of the overhead that you will carry. This is not taken into consideration when the compensation is discussed. You are not building any equity or value. If you are sick, you don’t get paid, if you retire, you have built nothing to sell or lease.

Do you feel that the independent contractor practice is frowned upon in the profession? If so, why?

Yes. It is frowned upon because it does not create value to what we do in terms of preserving periodontics as a specialty. It just becomes a side procedure that is treated like “Oh! by the way, you just so happen to be in the same office, and you can perform this for the patient”. It also takes away from the cohesive effort of the periodontal community where you are located to come together and present a united front on how we want the GPs and the patients to perceive us as specialists and why we do what we do and charge they way that we do.

What resources (i.e. people, publications, groups) did you find the most helpful?

My alumni.

How did this experience affect your plan and decisions about your career and future?

I used it to learn as much as I could. I have observed several offices and matured as a clinician and as a business person and as a personnel manager on how I would want my own office run.

As an independent contractor, did you serve one or more offices? If more than one, how many? Were all of them general practitioner offices? If not, at what other types of offices did you perform periodontal procedures?

At one time I was going to four different offices. I had my own office where I was the owner and was there two days a week.

Did you have your own insurance or were you insured at the different offices you were visiting?

I had my own insurance.

Looking back on the choices you made, is there anything you would have done differently?

Yes, I would have pursued getting my own office sooner and I would have been more hands on with the contract I had with the offices.

What is the most valuable advice you can offer individuals transitioning into an independent contractor arrangement?

My advice is to talk to an independent contractor like you are doing now, and get tips on how to negotiate your contract with the offices. Have the offices pay you per day whether or not you have patients and then get 50% and/or whichever is higher. This way if your day blows out, you still get paid. Use this route only as a transition into getting your own practice.

What do you like most about being a periodontist?

Everything! Photo

Interview with Michelle N. Zmick, D.D.S.

Dr. Zmick is in practice in Grayslake, Illinois. She completed her periodontal residency at University of Illinois - Chicago in 1981.

What was your ideal plan after graduation?

My dream was to join an established periodontal practice as an associate. My long-term goals were less clear, but I always envisioned myself working with other dental professionals.

What realities did you encounter?

Upon completion of my periodontal postgraduate program, I did not find any opportunities to join an established group. My then-husband was a prosthodontist, so I began my own practice by sharing office space with him. I also taught periodontics at the University of Illinois part-time as I began to develop my private practice. My three children were born during my first five years in practice, so as my family grew I reduced my teaching time.

When my children were young I worked about three days a week. Working alongside my husband was not easy. As our marriage deteriorated and our divorce became imminent, I realized I would need to make other professional arrangements. As most of my patients were referred by my husband, I would have had a very small nucleus of patients if I were to relocate my existing practice. I would need an immediate income to be able to support my sons and myself. Independent contracting seemed to be the best answer to fulfill my immediate needs.

What appealed to you about becoming an independent contractor?

I was raising small children as a single mother at the time I became an independent contractor. This arrangement would allow me to work part-time, generate an immediate and substantial income, and minimize time spent on administrative duties and practice promotion. I loved patient care but did not enjoy the business end of running a practice.

What variables influenced your decision of becoming an independent contractor?

How did you go about searching for an independent contractor position?

I found my first office by answering an ad in our local dental society journal. I found most of my positions through a local dental practice management consultant. Others were found through word of mouth.

Did location factor into this situation?

Yes. I never considered relocating to another area. I wanted to be reasonably close to my existing home and minimize driving time so I could be available for my children.

Please explain your financial compensation arrangement, using real or fictitious figures.

I am paid 50% of my production (not collection), less 50% of the cost of implant fixtures. I keep an inventory of implants, and the offices reimburse me 50% of the cost of the implants as I use them.

For example:

3 implants x $2000 = $6000
osseous surgery = $2000
total production = $8000
my implant costs = $900
total compensation = $8900 x 50% = $4450

My frequency of pay varies per office from daily to monthly. I supply all surgical instruments, which I carry with me from office to office. All general instruments (exams, suture removal, curettes) as well as all disposable supplies (suture, blades, bone grafting materials, etc.) are provided by the general dental office. My staff (chairside assistants, front desk staff) is provided by the general dental office.

Did you have any reservations about becoming an independent contractor?

No.

What are the pros and cons of this type of practice?

The benefits are numerous. I have tremendous freedom of time; I can work as many or as few hours or days a week as I want and I can take vacation time without worrying about satisfying staff and overhead expenses. I have essentially no fixed overhead. It is practically a stress-free way of practicing. I am a high income source for the dentist, so the offices are generally very accommodating to my needs regarding staff, supplies, scheduling, etc. I also enjoy the variety of personal contacts amongst the various offices. It is easy to incorporate new procedures into my practice, as the dentists are generally very receptive to methods of increasing production. Communication with the dentists is very easy, as I am regarded as an ally rather than a competitor for patients’ fees. It is easy to discuss cases when we are working side-by side. It is mutually beneficial that I am as productive as possible and that my professional needs are met.

On the “con” side, it is essential for an independent contractor to be flexible and patient in terms of working with staff and the various office scenarios. I am essentially a guest in someone else’s office, so I do not have the authority to make changes without agreement from the owner doctor. It is sometimes difficult to follow up patients in a long-term sense, as I am reliant upon the efficacy of the general dentist’s recall system. Probably the biggest drawback, for some, is the negative connotation in the eyes of other periodontists of being an independent contractor.

What obstacles did you encounter and how did you overcome them to be successful?

Probably the biggest obstacle was finding the right “fit” of office, regarding quality of dentistry and practice philosophy that would mesh with mine. Also there is the initial “break-in” period of training staff and dentists to accommodate a periodontist into their practices. Overall, it is a relatively stress-free way of practicing.

Do you feel that the independent contractor practice is frowned upon in the profession? If so, why?

YES, YES, YES. Being an independent contractor is definitely, without question, frowned upon by the periodontal profession. I think the biggest reasons, quite honestly, are ego, jealousy, and fear of losing referral doctors by independent contractors coming into their practices. As one who has had my own referral-based practice in the past, I have already satisfied that part of me (my ego) that wanted “my own practice.” That element is no longer an issue, and the things that are most important to me, i.e. independence, flexibility of hours, relief of administrative duties, and the ability to do quality dentistry, are being satisfied by my independent contractor status.

I have often heard from periodontists in referral-based practices that being an independent contractor is limiting with respect to the quality of periodontics one can practice. In actuality, I believe independent contracting provides me with an equivalent, if not increased, ability to perform quality procedures. I do a plethora of periodontal procedures, including implants, bone and sinus grafting, laser procedures, and intravenous sedation; i.e. more varied procedures than most practicing periodontists. I am a Diplomate of the American Board of Periodontology, so I have proven my abilities as a periodontist. The “in-house” arrangement allows for increased communication between periodontist and general dentist regarding treatment planning, as we can both view radiographs and other records together on a more regular basis. In addition, I am able to introduce new procedures into my practice very easily, as my increased production is mutually beneficial and well-accepted.

What resources (i.e. people, publications, groups) did you find the most helpful?

As I was somewhat of a pioneer in the independent contracting sector of practicing periodontists, there were not a lot of resources available to seek advice from regarding the structuring of my practice. Most of my ideas came from my own imagination, and from my prior experiences.

How did this experience affect your plan and decisions about your career and future?

My success as an independent contractor has diminished or even eliminated my desire to have my own, referral-based practice. I was actually approached by another dental specialist recently to join him in a space-sharing endeavor, and I did accept this opportunity but on a part-time basis and without any expectations for development to a full-time basis.

As an independent contractor, did you serve one or more offices? If more than one, how many? Were all of them general practitioner offices? If not, at what other types of offices did you perform periodontal procedures?

I have generally worked in eight different general dental offices, with each office having from one to three general dentists. I work anywhere from one to three days per month in each office, de pending on the busyness of each office.

Did you have your own insurance or were you insured at the different offices you were visiting?

All of my insurance, continuing education, and license costs have been my own responsibility.

Looking back on the choices you made,is there anything you would have done differently?

All in all, I have been very happy with my career choice. There have been a few offices over the years that did not work out, either because of lack of work or differing practice philosophies. It may have helped to research each office more thoroughly prior to beginning working there.

What is the most valuable advice you can offer individuals transitioning into an independent contractor arrangement?

Do the necessary research to find the right “fit” of office with regards to practice philosophy and quality of dentistry being performed. Establish your rules and agreements regarding compensation, provision of supplies, etc., before beginning work.

What do you like most about being a periodontist?

I enjoy the patient contact and the fact that I am helping people. I enjoy the clinical aspects of practicing periodontics.

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