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The use of associates in private practice
68 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
endogenous epinephrine in amounts greater than those introduced with the local anesthetic solution. SUM M ARY
Under a simulated office procedure, it appears that the sedated hypertensive pa tient supplied with a vasoconstrictor plus local anesthetic fares better in terms of blood pressure changes than those high blood pressure patients not given sedation nor epinephrine. It would be highly fruitful to redo this
study employing the same and other seda tive, local anesthetic and vasoconstrictor agents at different dosages, different routes o f administration and different time intervals to establish the most suit able pre-extraction regime. It should be emphasized that this investigation repre sents an attempt to study cardiovascular changes under conditions which prevail in the average dental practitioner’s office. In other words, this study attempts to de termine not what to do but rather to re late what the average practitioner has been doing.
Th e use o f a sso c ia te s in p riv a te p ractice
G len n A . T h om a s, D .D .S ., W ich ita , K a n .
There are many practitioners in the field o f dentistry who need to have one or more associates in their offices. For those who consider the services o f an associate, and for the many young dentists who are weighing whether or not to become associates instead o f setting up their own offices, this paper will attempt to evalu ate the pros and cons from the stand point o f each. Before this evaluation is begun, how ever, the advantages and disadvantages to the new graduate, or the new man in the community, o f starting his own prac tice will be considered. Th e advantages can be outlined as follows:
2. Building his own practice from the start. There are men who are too proud and independent ever to want help in starting their practice because the feeling o f achievement is an important part of their personality. 3. Freedom to follow the technics o f his own choice. T h e new graduate is so thoroughly involved with the technics he has learned in school that usually for at least two years after graduation he pre fers the use of these technics rather than learning and using other and better ones. 4. Freedom to establish his own office procedures. Even though this can be a distinct disadvantage, many men have 1. Being his own boss. There are their own dreams o f how they choose to many men who cannot follow the lead operate their own offices, and are not too ership and ideals o f another. Such a man Presented as part of a Forum on Dental Practice at is better o ff being his own boss, and will the ninety-eighth annual session, American Dental be far happier from the start. A sso cia tio n , M ia m i, Fla., N o v e m b e r 7, 1957.
T H O M A S . . . V O L U M E 58, J A N U A R Y 1959 • 69
self-assurance. There are people who receptive to other men’s methods. These firmly believe that a lesson learned the men should be privileged to evaluate “ hard way” is never forgotten. Although their own methods by trial and error. 5. Self-satisfaction in being independ that usually is true in most instances, it can certainly play havoc with self-assur ent. This is self-explanatory, and was ance. From a psychological standpoint, touched on briefly earlier. N ow for a brief exploration o f some self-assurance is a most important asset of the disadvantages o f a young man’ s to a dentist, as it is one o f the motivating factors that make him strive to do better starting his own practice: dentistry and to achieve greater success 1. Lack of capital, probably the most financially. By being able to profit from universally experienced disadvantage. the experience o f an established practi There are many dentists who remember tioner, a young dentist could actually only too well what a problem lack of gain several years in his ability to cope sufficient capital presented when they with certain problems. Correct judgment were graduated and ready to open their also can mean the difference in correct own offices. In this day o f government or incorrect treatment, possible loss of aid in education, small business loans and so forth, this is not as difficult a a good patient or even, perhaps, a mal practice suit. problem as it was only a few years ago. 2. Inexperience in organizing a prac tice. This is not too great an obstacle, as ASSO CIATIO N FROM V IE W P O IN T the average man possesses reasonable OF PROSPECTIVE ASSOCIATE ability to plan and organize. It must be A d v a n ta g es • T h e advantages o f associ remembered, however, that many do not possess this ability, and help from some ation with a well-established dentist from the standpoint of the prospective associ one else could prove an invaluable asset. ate, for example, a fairly recent graduate, 3. Difficulty in securing immediate might be: advice when needed. Dentists know from 1. N o investment or capital outlay. past experience that, on rare occasions, Th e importance of this feature has been immediate advice can prove very helpful discussed earlier in this paper. and is, indeed, w elco m e. 2. Invaluable dentist-patient relations 4. Low er income because o f insuffi cient clientele. This, of course, most den ' instruction. It is well known how impor tant dentist-patient relations are, for tists have been through and, somehow, chairside manner can prove to be most the young man always seems to weather the storm. Used to a lower scale o f liv valuable in building a professional prac tice. Some men never are able to develop ing, he apparently does not worry too this finesse and their practices usually are much except about outstanding debts. 5. Inability to afford auxiliary per not to be admired. M any things about sonnel. It is useless to develop this dentist-patient relations can be learned problem, because the necessity and ad from the established dentist. 3. Rapid growth o f prestige. Patients vantages o f having adequate auxiliary often say o f an associate, “ W ell, if Dr. X personnel are known. T o o often a dentist thinks Dr. J is good enough to be in his will try to carry on as long as possible without at least one assistant, falsely be office, he is good enough to do my work.” Strangely, patients think a dentist has lieving that he is saving money. By the many ways o f finding out about the type time he realizes he is practicing false economy, he has lost a great deal o f pro o f dentistry his associate can do before he is brought into the office. This belief is duction time and prestige. erroneous, as the only methods at hand 6 . Lack o f experience, judgment and
70 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
are to contact the school from which the prospective associate was graduated, or by ascertaining his standing in the com munity where he might have previously practiced. Actually, the most effective way is to employ an associate on a trial basis and observe the care with which he works and the apparent foundation he has gained in school. 4. Great practice builder. In an asso ciation with an established dentist in a busy practice, the associate w ill have many good patients referred to him. M any o f these people will like him well enough to follow him to his own practice when his employment with the other den tist ends. Inasmuch as an indefinite asso ciation seldom exists, this must be con sidered as an important point. 5. Desirable patient clientele. This can work also in the opposite way, and the wise associate can see quickly when this is happening. There are some den tists who prefer to keep all the desirable patients for themselves, giving those of questionable desirability to the associate. This is a poor practice, and unfair to the young man, as it is certainly unwise to clutter up his office with this type of cli entele. On the other hand, this can be good experience for the associate as it helps him early in his career to learn to evaluate patients properly. Patient eval uation, both as to their dental intelligence and financial standing, is a must to build a high-type clientele. 6 . Valuable help from the more ex perienced man. This must be considered another asset. It is always possible that the more experienced practitioner can stimulate the young man to attend den tal meetings and also encourage him to start postgraduate work early. It has been the author’s experience that about the last thing a recent graduate thinks o f is postgraduate work. H e is tired of school and study, and thinks only of starting his career. H e has to practice two or three years and observe the operations o f the more experienced man before he realizes
that there is more to dentistry than he learned in school. Usually only then will his hunger for more knowledge stimulate him to further study. It is just about this time that he is beginning to see daylight in his financial structure, so he feels he cannot afford the time and tuition for ex tra study. It can be that the more experi enced man can stimulate a thirst for knowledge much sooner than normally it would be stimulated. 7. Greater monetary return in the earlier stages of practice. Being married and even having a family is no longer a rarity on graduation; in fact it is al most the rule rather than the exception. Such a situation, as well as possible in debtedness for schooling, home, furniture and so forth, is so important that many times it is the m otivating factor in the young dentist’s decision to associate with an established dentist. 8 . Learning to work with auxiliary personnel. M any dental schools do not teach the student the use o f auxiliary help. I f the personnel he works with are properly trained, they can aid him greatly in learning the office routine, dentistpatient relations and, above all, how in valuable their aid is. H e will learn not only their use at the chair, but many things about the secretarial department which will enable him to establish and conduct his own office and practice on a sound basis. In spite o f the many lectur ers discussing this subject, and the books and articles written on it, it is positively shocking to know how few dentists em ploy auxiliary personnel for their greatest personal benefit or even realize when more than one girl is needed in the office. 9. Determining appropriate dental fees. Because o f lack o f knowledge o f the fees in the community, and certainly be cause of lack o f experience and self-confi dence, the new practitioner usually undervalues his services. M any times, er roneously, he thinks lower fees might stimulate a quicker influx o f patients. I f it does stimulate such an influx, it is usu
T H O M A S . . . V O L U M E 58, J A N U A R Y 1959 • 71
ally the type o f patient that is not amen able to an ultimate high-type dental practice. Association with an established practitioner who has a good fee sched ule certainly can be a stimulating factor in helping upgrade the fees o f the young man. In fact, in many practices where there is an association, a contract is drawn which states that the associate must render a fee for the service exactly, as nearly as can be determined, the same as the senior man in the office. 10. Healthy competition. A very defi nite advantage, valuable to both parties, is a healthy competitive situation. It is only human nature, and not peculiar to dentists, that if a practitioner believes another dentist whom he knows w ill see the work he has done, he w ill attempt to do better. This type o f stimulation is healthy for the men and office involved, and helps upgrade the profession. D isad van ta ges • There are a few disad vantages that are impossible to overlook in considering becoming an associate. 1. N o t being his own boss. It is true that most men can adapt themselves readily to new surroundings but there are those who resent guidance even when given with the greatest of finesse. Such men would never be adaptable to an as sociation and it would be wise not even to make the attempt. 2. Patients’ insistence on the services o f the senior member. This insistence is not at all uncommon and sometimes may have to be complied with but, if handled properly, arrangements usually can be made with the mutual good will of all parties concerned. I f the junior member is doing the same high-type dentistry as the senior member, the latter and his staff very nicely can promote to the pa tient the services o f the other man and, in most instances, the patient will feel he is getting services as good as from the senior dentist. 3. Lack o f a feeling o f freedom. Th at the associate may not feel free to pursue
his own technics and procedures can also be a factor worth reckoning with. A l though many a young man has shown an older practitioner a technic o f real value, just how far he should pursue his own ideas is a question that must be settled, and a thorough understanding should be reached before the association actually begins. It is a well-known fact that no two dentists operate exactly alike. Each has his own pet ideas and technics, and if the associate can produce the type of dentistry the senior practitioner is pro ducing, without a waste of time and pro vided it does not necessitate extra labora tory or other auxiliary personnel, he should be allowed to use those methods from which he obtains the best results. I f he is eager to do better work and has learned to adapt himself to his new sur roundings, his interest in other technics o f proven worth soon will be stimulated. 4. Little or no choice in office design or physical equipment. Again the ready adaptability o f the associate w ill be an important factor. H e can use the avail able setup as a proving ground for time and motion studies and, when he is ready to design his own office, can correct thf things he felt were a mistake in the office where he was associated. I t is the wise young man who will “ go along” but tab ulate for future use those things that can be improved on. 5. Lack o f complete control of treat ment and fees. This is another question that should be settled before an associate practice begins. It is often wise, and good not only for the entire practice but the younger man as well, that the senior den tist keep in close touch with the type of treatment rendered and, certainly, the fee schedule of the associate. It is true that some men will resent this, and may even consider it “ meddling,” but that w ill depend to a great extent on the adaptability o f the associate and the un derstanding gained in advance. 6 . Possibility o f temperament dishar mony and personality problems consti-
72 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
tute the greatest hazard o f all the dis income for the senior member. A t this advantages to be considered. D evelop point it might be w ell to state that the ment o f this thought will be given later. Internal Revenue Department rules that 7. Risk of professional prestige. I f an an associate must be classified as an em associate unknowingly establishes him ployee and his entire gross income self with a practitioner whose standards handled exactly as though it were the of dentistry are not of the highest, his dentist’s own. This o f course puts the reputation can be badly damaged. It senior dentist into a higher tax bracket. would seem wise for the prospective as T o be considered is how productive is sociate to investigate the established prac the associate. I f he becomes extremely titioner as thoroughly as he himself ex productive, which most cannot do in less pects to be investigated. than three or four years, his productivity can offset the tax loss enough that some profit is made. Also to be considered is A SSO C IA TIO N FROM V IE W P O IN T the investment necessary in equipment OF SEN IO R D E N TIST and space, and the dentist must plan to Th e foregoing discussion has been a amortize this over the number o f years he expects to have an associate. Th e cost thorough examination o f the advantages and disadvantages from the standpoint of added personnel must be considered of the prospective associate. T h e follow also in the question o f profit, as it can ing observations w ill deal with the estab be agreed that it is entirely possible for lished dentist who is contemplating hav an associate to be an unprofitable or prof ing an associate. itable undertaking. Number one among the advantages, Added prestige is an advantage in the and probably the greatest, is that an as employment o f an associate. It is only sociate may help take a work load o ff the human nature to believe that if a dentist is so good his practice demands an asso dentist’s shoulders. I f a man has a great backlog of work to be done and a long ciate, he must be well above the average list o f waiting patients, it would seem ad as a dentist and, generally, this is true. visable to employ an associate. This as N ow to evaluate some disadvantages sociate can help dissipate this backlog from the standpoint o f gaining an asso and re-establish the existing practice on a ciate. Earlier in this paper mentioned as current basis. It should be remembered, a disadvantage to the prospective associ however, that if the associate is an affable ate was a clash o f personalities and tem individual and a skillful operator, he perament, and most assuredly this cansoon will establish his own practice to the be a great hazard to both parties con extent where he no longer can help take cerned. Wholeheartedly recommended the burden o ff the operator. are two things that m ight overcome such Another distinct advantage is that if a possibility: (1 ) a definite clause in the the dentist wishes to have time away from written agreement that the existing rela the office, the associate and hygienist can tionship can be broken by either party keep on working, thus adding continued on 30 days’ notice (an association is of income to the office in spite o f the senior no real value anyhow if one or both member’s absence. It is also comforting parties are unhappy or incom patible), to know that if one o f his own patients and (2 ) a trial period, agreeable to both has an emergency arise, proper treat parties, for a minimum o f 90 days. A fter ment can and w ill be rendered in his this length of time it usually can be de own office. This would be impossible if termined if the proposed relationship will there was not an associate. be compatible and pleasant. A questionable advantage is increased Another hazard to be reckoned with is
T H O M A S . . . V O L U M E 58, J A N U A R Y 1959 • 73
that the new man in the office may not follow guidance and readily adapt him self to the established routine. Those dentists who have practiced a number of years have established a routine and an office policy. It is necessary that the as sociate lend himself to these policies. Most dentists know, by trial and error, what policies and technics work best for them, and to maintain harmony the as sociate must follow the practitioner’s guidance. Disagreement because o f failure to have reached a complete understanding on financial arrangements, philosophy of practice, responsibilities, and conduct of office before beginning the association can be a pitfall of no small importance. Even though many people say a contract is not worth the paper it is written on, the author cannot urge all concerned too strongly to have a very definite contract drawn up by a competent lawyer before the association is begun. It gives a cer tain psychological advantage, as well as being a legal instrument to break or ter minate an association without any finan cial liability. Th e author also strongly urges that the dentist acquiring an asso ciate have lengthy talks with the pros pect concerning his philosophy o f prac tice, responsibilities, and so forth. T o sum up this hazard quickly, let no dentist contemplate or propound an association without benefit o f a written agreement. Th e inability o f the associate to pro duce the proper quality o f dentistry can be a problem indeed, and one of an exas perating nature. Here again a 90 day probationary period can prove an inval uable move. It takes valuable chair-time periodically to watch the associate work and to inspect his finished product but it is definitely worth it. I f the practitioner should find himself in the unenviable cir cumstance where the associate needs to be worked with after office hours, the lat ter should be urged strongly to do post graduate study and work. Should the associate not be amenable to this sugges
tion, the relationship should be termi nated quickly. It is to be expected that the ability of the new graduates to work with speed is slight. Th e practitioner should be patient with these men and urge accuracy first and then the acquiring o f speed. It should be remembered that senior den tists are helping to mold and influence the entire careers o f the new graduates. It is easy to become disgusted with the inabilities of these people, but it should be remembered that patience many times pays. T h e established dentist also should reflect on his own shortcomings when he graduated from dental school. Friction caused by auxiliary personnel always is likely when a new man comes into the practice. It is just as essential to have a good understanding with all the staff members in advance as with the prospective associate himself. It should be thoroughly understood by all the staff that if any person causes friction, after a fair chance his or her resignation will be requested. Th e final hazard that will be discussed in this paper is the question o f added personnel. There are men who are nat ural personnel directors, but for those who are not, every member added to his staff increases his problems. It is incon ceivable for this essayist to fathom why the addition o f personnel, whether it be only one or more, should be a deterring factor in the growth o f a practice. It is true that the greater the number o f per sonnel, the greater the chances are for petty jealousies, dislikes, and friction of many types. It is felt that a definite office policy regarding employees, a thorough understanding in advance, regular staff meetings, and a preference given to the hiring o f more mature women can greatly alleviate and probably forestall undesirable situations completely. N ow comes the ever important ques tion: what is an equitable financial ar rangement and how is it determined. An equitable financial arrangement is one
74 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
that is o f benefit to both parties. It must provide sufficient income for the associ ate and be profitable for the established dentist. Th e associate, and especially the new graduate, should recognize that his capacity to produce dental work is lim ited and, in the early stages o f his rela tionship, his financial gain is therefore limited. It is entirely possible that in the early months of an association it will not be profitable. Naturally as he becomes more productive, his remuneration should increase. In time he should be al lowed to participate in the added income o f the office. This is only a fair return for his services, and usually will be an incentive to do better dentistry and achieve greater production. There are several financial arrange ments that might be utilized where the state dental practice laws permit. They a re: 1. A straight salary, which can be paid on a monthly or yearly basis. This is not a good arrangement, especially from the standpoint of the associate him self. 2. A straight percentage. This is based usually on the cash gross receipts, not from fees rendered. 3. A salary and a percentage. For in stance, the young dentist could be guar anteed a $100 per week salary up to a gross receipt o f $5,700 per year. As his gross receipts increase over that amount, then these receipts should be considered in determining his percentage. As his yearly gross continues to increase, so could his percentage of all over his yearly
guarantee increase. Th e author person ally favors the latter plan as it is the most equitable to both parties concerned; how ever, the choice actually depends on the individuals involved and the specific practice in question. Th e final consideration will be how long the association should be main tained. Ideally, a permanent arrange ment should be planned, but few people feel free to commit themselves to such an agreement. T h e author feels firmly that a minimum o f five years is necessary in order for both parties to gain m axi mum benefit. It must be remembered, however, that there is no advantage in having a dissatisfied associate, and he will do the practice no good if he is held by a binding time agreement against his will. Likewise, when the established den tist finds the association inharmonious and unsatisfactory, the agreement should be terminated. T h e advisability of a 30 day termination clause in the contract was mentioned earlier. COM MENT
An attempt has been made in this paper to present the subject of an association from all aspects. It is hoped that any dentist contemplating such an arrange ment will evaluate his problems, person ality and practice. I f all these aspects are thoroughly studied in advance, the chances o f a pleasant, productive and profitable relationship certainly will be enhanced. 9 0 8 C en tra l B uilding
• In contrast to the scientist usually represented by newspapers and science fiction writers, true scientists pcrceive that the facts still not known appear some how to increase geometrically in comparison with facts already discovered and evaluated by scientific research and knowledge. G ard ner M u r p h y , In the M in d s of M e n , 1953.
Scientists in F a ct and F ic tio n
endogenous epinephrine in amounts greater than those introduced with the local anesthetic solution. SUM M ARY
Under a simulated office procedure, it appears that the sedated hypertensive pa tient supplied with a vasoconstrictor plus local anesthetic fares better in terms of blood pressure changes than those high blood pressure patients not given sedation nor epinephrine. It would be highly fruitful to redo this
study employing the same and other seda tive, local anesthetic and vasoconstrictor agents at different dosages, different routes o f administration and different time intervals to establish the most suit able pre-extraction regime. It should be emphasized that this investigation repre sents an attempt to study cardiovascular changes under conditions which prevail in the average dental practitioner’s office. In other words, this study attempts to de termine not what to do but rather to re late what the average practitioner has been doing.
Th e use o f a sso c ia te s in p riv a te p ractice
G len n A . T h om a s, D .D .S ., W ich ita , K a n .
There are many practitioners in the field o f dentistry who need to have one or more associates in their offices. For those who consider the services o f an associate, and for the many young dentists who are weighing whether or not to become associates instead o f setting up their own offices, this paper will attempt to evalu ate the pros and cons from the stand point o f each. Before this evaluation is begun, how ever, the advantages and disadvantages to the new graduate, or the new man in the community, o f starting his own prac tice will be considered. Th e advantages can be outlined as follows:
2. Building his own practice from the start. There are men who are too proud and independent ever to want help in starting their practice because the feeling o f achievement is an important part of their personality. 3. Freedom to follow the technics o f his own choice. T h e new graduate is so thoroughly involved with the technics he has learned in school that usually for at least two years after graduation he pre fers the use of these technics rather than learning and using other and better ones. 4. Freedom to establish his own office procedures. Even though this can be a distinct disadvantage, many men have 1. Being his own boss. There are their own dreams o f how they choose to many men who cannot follow the lead operate their own offices, and are not too ership and ideals o f another. Such a man Presented as part of a Forum on Dental Practice at is better o ff being his own boss, and will the ninety-eighth annual session, American Dental be far happier from the start. A sso cia tio n , M ia m i, Fla., N o v e m b e r 7, 1957.
T H O M A S . . . V O L U M E 58, J A N U A R Y 1959 • 69
self-assurance. There are people who receptive to other men’s methods. These firmly believe that a lesson learned the men should be privileged to evaluate “ hard way” is never forgotten. Although their own methods by trial and error. 5. Self-satisfaction in being independ that usually is true in most instances, it can certainly play havoc with self-assur ent. This is self-explanatory, and was ance. From a psychological standpoint, touched on briefly earlier. N ow for a brief exploration o f some self-assurance is a most important asset of the disadvantages o f a young man’ s to a dentist, as it is one o f the motivating factors that make him strive to do better starting his own practice: dentistry and to achieve greater success 1. Lack of capital, probably the most financially. By being able to profit from universally experienced disadvantage. the experience o f an established practi There are many dentists who remember tioner, a young dentist could actually only too well what a problem lack of gain several years in his ability to cope sufficient capital presented when they with certain problems. Correct judgment were graduated and ready to open their also can mean the difference in correct own offices. In this day o f government or incorrect treatment, possible loss of aid in education, small business loans and so forth, this is not as difficult a a good patient or even, perhaps, a mal practice suit. problem as it was only a few years ago. 2. Inexperience in organizing a prac tice. This is not too great an obstacle, as ASSO CIATIO N FROM V IE W P O IN T the average man possesses reasonable OF PROSPECTIVE ASSOCIATE ability to plan and organize. It must be A d v a n ta g es • T h e advantages o f associ remembered, however, that many do not possess this ability, and help from some ation with a well-established dentist from the standpoint of the prospective associ one else could prove an invaluable asset. ate, for example, a fairly recent graduate, 3. Difficulty in securing immediate might be: advice when needed. Dentists know from 1. N o investment or capital outlay. past experience that, on rare occasions, Th e importance of this feature has been immediate advice can prove very helpful discussed earlier in this paper. and is, indeed, w elco m e. 2. Invaluable dentist-patient relations 4. Low er income because o f insuffi cient clientele. This, of course, most den ' instruction. It is well known how impor tant dentist-patient relations are, for tists have been through and, somehow, chairside manner can prove to be most the young man always seems to weather the storm. Used to a lower scale o f liv valuable in building a professional prac tice. Some men never are able to develop ing, he apparently does not worry too this finesse and their practices usually are much except about outstanding debts. 5. Inability to afford auxiliary per not to be admired. M any things about sonnel. It is useless to develop this dentist-patient relations can be learned problem, because the necessity and ad from the established dentist. 3. Rapid growth o f prestige. Patients vantages o f having adequate auxiliary often say o f an associate, “ W ell, if Dr. X personnel are known. T o o often a dentist thinks Dr. J is good enough to be in his will try to carry on as long as possible without at least one assistant, falsely be office, he is good enough to do my work.” Strangely, patients think a dentist has lieving that he is saving money. By the many ways o f finding out about the type time he realizes he is practicing false economy, he has lost a great deal o f pro o f dentistry his associate can do before he is brought into the office. This belief is duction time and prestige. erroneous, as the only methods at hand 6 . Lack o f experience, judgment and
70 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
are to contact the school from which the prospective associate was graduated, or by ascertaining his standing in the com munity where he might have previously practiced. Actually, the most effective way is to employ an associate on a trial basis and observe the care with which he works and the apparent foundation he has gained in school. 4. Great practice builder. In an asso ciation with an established dentist in a busy practice, the associate w ill have many good patients referred to him. M any o f these people will like him well enough to follow him to his own practice when his employment with the other den tist ends. Inasmuch as an indefinite asso ciation seldom exists, this must be con sidered as an important point. 5. Desirable patient clientele. This can work also in the opposite way, and the wise associate can see quickly when this is happening. There are some den tists who prefer to keep all the desirable patients for themselves, giving those of questionable desirability to the associate. This is a poor practice, and unfair to the young man, as it is certainly unwise to clutter up his office with this type of cli entele. On the other hand, this can be good experience for the associate as it helps him early in his career to learn to evaluate patients properly. Patient eval uation, both as to their dental intelligence and financial standing, is a must to build a high-type clientele. 6 . Valuable help from the more ex perienced man. This must be considered another asset. It is always possible that the more experienced practitioner can stimulate the young man to attend den tal meetings and also encourage him to start postgraduate work early. It has been the author’s experience that about the last thing a recent graduate thinks o f is postgraduate work. H e is tired of school and study, and thinks only of starting his career. H e has to practice two or three years and observe the operations o f the more experienced man before he realizes
that there is more to dentistry than he learned in school. Usually only then will his hunger for more knowledge stimulate him to further study. It is just about this time that he is beginning to see daylight in his financial structure, so he feels he cannot afford the time and tuition for ex tra study. It can be that the more experi enced man can stimulate a thirst for knowledge much sooner than normally it would be stimulated. 7. Greater monetary return in the earlier stages of practice. Being married and even having a family is no longer a rarity on graduation; in fact it is al most the rule rather than the exception. Such a situation, as well as possible in debtedness for schooling, home, furniture and so forth, is so important that many times it is the m otivating factor in the young dentist’s decision to associate with an established dentist. 8 . Learning to work with auxiliary personnel. M any dental schools do not teach the student the use o f auxiliary help. I f the personnel he works with are properly trained, they can aid him greatly in learning the office routine, dentistpatient relations and, above all, how in valuable their aid is. H e will learn not only their use at the chair, but many things about the secretarial department which will enable him to establish and conduct his own office and practice on a sound basis. In spite o f the many lectur ers discussing this subject, and the books and articles written on it, it is positively shocking to know how few dentists em ploy auxiliary personnel for their greatest personal benefit or even realize when more than one girl is needed in the office. 9. Determining appropriate dental fees. Because o f lack o f knowledge o f the fees in the community, and certainly be cause of lack o f experience and self-confi dence, the new practitioner usually undervalues his services. M any times, er roneously, he thinks lower fees might stimulate a quicker influx o f patients. I f it does stimulate such an influx, it is usu
T H O M A S . . . V O L U M E 58, J A N U A R Y 1959 • 71
ally the type o f patient that is not amen able to an ultimate high-type dental practice. Association with an established practitioner who has a good fee sched ule certainly can be a stimulating factor in helping upgrade the fees o f the young man. In fact, in many practices where there is an association, a contract is drawn which states that the associate must render a fee for the service exactly, as nearly as can be determined, the same as the senior man in the office. 10. Healthy competition. A very defi nite advantage, valuable to both parties, is a healthy competitive situation. It is only human nature, and not peculiar to dentists, that if a practitioner believes another dentist whom he knows w ill see the work he has done, he w ill attempt to do better. This type o f stimulation is healthy for the men and office involved, and helps upgrade the profession. D isad van ta ges • There are a few disad vantages that are impossible to overlook in considering becoming an associate. 1. N o t being his own boss. It is true that most men can adapt themselves readily to new surroundings but there are those who resent guidance even when given with the greatest of finesse. Such men would never be adaptable to an as sociation and it would be wise not even to make the attempt. 2. Patients’ insistence on the services o f the senior member. This insistence is not at all uncommon and sometimes may have to be complied with but, if handled properly, arrangements usually can be made with the mutual good will of all parties concerned. I f the junior member is doing the same high-type dentistry as the senior member, the latter and his staff very nicely can promote to the pa tient the services o f the other man and, in most instances, the patient will feel he is getting services as good as from the senior dentist. 3. Lack o f a feeling o f freedom. Th at the associate may not feel free to pursue
his own technics and procedures can also be a factor worth reckoning with. A l though many a young man has shown an older practitioner a technic o f real value, just how far he should pursue his own ideas is a question that must be settled, and a thorough understanding should be reached before the association actually begins. It is a well-known fact that no two dentists operate exactly alike. Each has his own pet ideas and technics, and if the associate can produce the type of dentistry the senior practitioner is pro ducing, without a waste of time and pro vided it does not necessitate extra labora tory or other auxiliary personnel, he should be allowed to use those methods from which he obtains the best results. I f he is eager to do better work and has learned to adapt himself to his new sur roundings, his interest in other technics o f proven worth soon will be stimulated. 4. Little or no choice in office design or physical equipment. Again the ready adaptability o f the associate w ill be an important factor. H e can use the avail able setup as a proving ground for time and motion studies and, when he is ready to design his own office, can correct thf things he felt were a mistake in the office where he was associated. I t is the wise young man who will “ go along” but tab ulate for future use those things that can be improved on. 5. Lack o f complete control of treat ment and fees. This is another question that should be settled before an associate practice begins. It is often wise, and good not only for the entire practice but the younger man as well, that the senior den tist keep in close touch with the type of treatment rendered and, certainly, the fee schedule of the associate. It is true that some men will resent this, and may even consider it “ meddling,” but that w ill depend to a great extent on the adaptability o f the associate and the un derstanding gained in advance. 6 . Possibility o f temperament dishar mony and personality problems consti-
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tute the greatest hazard o f all the dis income for the senior member. A t this advantages to be considered. D evelop point it might be w ell to state that the ment o f this thought will be given later. Internal Revenue Department rules that 7. Risk of professional prestige. I f an an associate must be classified as an em associate unknowingly establishes him ployee and his entire gross income self with a practitioner whose standards handled exactly as though it were the of dentistry are not of the highest, his dentist’s own. This o f course puts the reputation can be badly damaged. It senior dentist into a higher tax bracket. would seem wise for the prospective as T o be considered is how productive is sociate to investigate the established prac the associate. I f he becomes extremely titioner as thoroughly as he himself ex productive, which most cannot do in less pects to be investigated. than three or four years, his productivity can offset the tax loss enough that some profit is made. Also to be considered is A SSO C IA TIO N FROM V IE W P O IN T the investment necessary in equipment OF SEN IO R D E N TIST and space, and the dentist must plan to Th e foregoing discussion has been a amortize this over the number o f years he expects to have an associate. Th e cost thorough examination o f the advantages and disadvantages from the standpoint of added personnel must be considered of the prospective associate. T h e follow also in the question o f profit, as it can ing observations w ill deal with the estab be agreed that it is entirely possible for lished dentist who is contemplating hav an associate to be an unprofitable or prof ing an associate. itable undertaking. Number one among the advantages, Added prestige is an advantage in the and probably the greatest, is that an as employment o f an associate. It is only sociate may help take a work load o ff the human nature to believe that if a dentist is so good his practice demands an asso dentist’s shoulders. I f a man has a great backlog of work to be done and a long ciate, he must be well above the average list o f waiting patients, it would seem ad as a dentist and, generally, this is true. visable to employ an associate. This as N ow to evaluate some disadvantages sociate can help dissipate this backlog from the standpoint o f gaining an asso and re-establish the existing practice on a ciate. Earlier in this paper mentioned as current basis. It should be remembered, a disadvantage to the prospective associ however, that if the associate is an affable ate was a clash o f personalities and tem individual and a skillful operator, he perament, and most assuredly this cansoon will establish his own practice to the be a great hazard to both parties con extent where he no longer can help take cerned. Wholeheartedly recommended the burden o ff the operator. are two things that m ight overcome such Another distinct advantage is that if a possibility: (1 ) a definite clause in the the dentist wishes to have time away from written agreement that the existing rela the office, the associate and hygienist can tionship can be broken by either party keep on working, thus adding continued on 30 days’ notice (an association is of income to the office in spite o f the senior no real value anyhow if one or both member’s absence. It is also comforting parties are unhappy or incom patible), to know that if one o f his own patients and (2 ) a trial period, agreeable to both has an emergency arise, proper treat parties, for a minimum o f 90 days. A fter ment can and w ill be rendered in his this length of time it usually can be de own office. This would be impossible if termined if the proposed relationship will there was not an associate. be compatible and pleasant. A questionable advantage is increased Another hazard to be reckoned with is
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that the new man in the office may not follow guidance and readily adapt him self to the established routine. Those dentists who have practiced a number of years have established a routine and an office policy. It is necessary that the as sociate lend himself to these policies. Most dentists know, by trial and error, what policies and technics work best for them, and to maintain harmony the as sociate must follow the practitioner’s guidance. Disagreement because o f failure to have reached a complete understanding on financial arrangements, philosophy of practice, responsibilities, and conduct of office before beginning the association can be a pitfall of no small importance. Even though many people say a contract is not worth the paper it is written on, the author cannot urge all concerned too strongly to have a very definite contract drawn up by a competent lawyer before the association is begun. It gives a cer tain psychological advantage, as well as being a legal instrument to break or ter minate an association without any finan cial liability. Th e author also strongly urges that the dentist acquiring an asso ciate have lengthy talks with the pros pect concerning his philosophy o f prac tice, responsibilities, and so forth. T o sum up this hazard quickly, let no dentist contemplate or propound an association without benefit o f a written agreement. Th e inability o f the associate to pro duce the proper quality o f dentistry can be a problem indeed, and one of an exas perating nature. Here again a 90 day probationary period can prove an inval uable move. It takes valuable chair-time periodically to watch the associate work and to inspect his finished product but it is definitely worth it. I f the practitioner should find himself in the unenviable cir cumstance where the associate needs to be worked with after office hours, the lat ter should be urged strongly to do post graduate study and work. Should the associate not be amenable to this sugges
tion, the relationship should be termi nated quickly. It is to be expected that the ability of the new graduates to work with speed is slight. Th e practitioner should be patient with these men and urge accuracy first and then the acquiring o f speed. It should be remembered that senior den tists are helping to mold and influence the entire careers o f the new graduates. It is easy to become disgusted with the inabilities of these people, but it should be remembered that patience many times pays. T h e established dentist also should reflect on his own shortcomings when he graduated from dental school. Friction caused by auxiliary personnel always is likely when a new man comes into the practice. It is just as essential to have a good understanding with all the staff members in advance as with the prospective associate himself. It should be thoroughly understood by all the staff that if any person causes friction, after a fair chance his or her resignation will be requested. Th e final hazard that will be discussed in this paper is the question o f added personnel. There are men who are nat ural personnel directors, but for those who are not, every member added to his staff increases his problems. It is incon ceivable for this essayist to fathom why the addition o f personnel, whether it be only one or more, should be a deterring factor in the growth o f a practice. It is true that the greater the number o f per sonnel, the greater the chances are for petty jealousies, dislikes, and friction of many types. It is felt that a definite office policy regarding employees, a thorough understanding in advance, regular staff meetings, and a preference given to the hiring o f more mature women can greatly alleviate and probably forestall undesirable situations completely. N ow comes the ever important ques tion: what is an equitable financial ar rangement and how is it determined. An equitable financial arrangement is one
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that is o f benefit to both parties. It must provide sufficient income for the associ ate and be profitable for the established dentist. Th e associate, and especially the new graduate, should recognize that his capacity to produce dental work is lim ited and, in the early stages o f his rela tionship, his financial gain is therefore limited. It is entirely possible that in the early months of an association it will not be profitable. Naturally as he becomes more productive, his remuneration should increase. In time he should be al lowed to participate in the added income o f the office. This is only a fair return for his services, and usually will be an incentive to do better dentistry and achieve greater production. There are several financial arrange ments that might be utilized where the state dental practice laws permit. They a re: 1. A straight salary, which can be paid on a monthly or yearly basis. This is not a good arrangement, especially from the standpoint of the associate him self. 2. A straight percentage. This is based usually on the cash gross receipts, not from fees rendered. 3. A salary and a percentage. For in stance, the young dentist could be guar anteed a $100 per week salary up to a gross receipt o f $5,700 per year. As his gross receipts increase over that amount, then these receipts should be considered in determining his percentage. As his yearly gross continues to increase, so could his percentage of all over his yearly
guarantee increase. Th e author person ally favors the latter plan as it is the most equitable to both parties concerned; how ever, the choice actually depends on the individuals involved and the specific practice in question. Th e final consideration will be how long the association should be main tained. Ideally, a permanent arrange ment should be planned, but few people feel free to commit themselves to such an agreement. T h e author feels firmly that a minimum o f five years is necessary in order for both parties to gain m axi mum benefit. It must be remembered, however, that there is no advantage in having a dissatisfied associate, and he will do the practice no good if he is held by a binding time agreement against his will. Likewise, when the established den tist finds the association inharmonious and unsatisfactory, the agreement should be terminated. T h e advisability of a 30 day termination clause in the contract was mentioned earlier. COM MENT
An attempt has been made in this paper to present the subject of an association from all aspects. It is hoped that any dentist contemplating such an arrange ment will evaluate his problems, person ality and practice. I f all these aspects are thoroughly studied in advance, the chances o f a pleasant, productive and profitable relationship certainly will be enhanced. 9 0 8 C en tra l B uilding
• In contrast to the scientist usually represented by newspapers and science fiction writers, true scientists pcrceive that the facts still not known appear some how to increase geometrically in comparison with facts already discovered and evaluated by scientific research and knowledge. G ard ner M u r p h y , In the M in d s of M e n , 1953.
Scientists in F a ct and F ic tio n