Back to Cover Page

Dental Schools – Solo No More?

If younger dentists increasingly favor the group corporate-practice model, what should schools nationwide do about it?

By Joshua Coe

MANY AMERICANS’ Norman Rockwell sensibility about their family dentist — that of a small-town solo practitioner who treats multiple generations and encounters his patients at the grocery store during the week and in church on Sunday — is becoming as much a thing of the past as, well, Norman Rockwell’s work itself.

In “The Erosion of the Solo Private Practice Model,” a paper published in the Journal of the Massachusetts Dental Society in 2014, Dr. Romesh Nalliah — an instructor at the Harvard School of Dental Medicine at the time — and five coauthors attempted to address both the causes and effects of this increasingly evident trend. Among their diagnoses: Millennials’ varied life-and-career aspirations, as compared to their parents and grandparents, and the burden of greater student debt that makes a group corporate practice more enticing. “Clearly, there is a shift away from solo practices,” the authors observed, later adding that “educational institutions should situate themselves strategically to support decision makers and curricular leaders as they prepare students for evolving practice models.”

Dr. Nalliah, now the director of Pre-Doctoral Clinical Education at the University of Michigan School of Dentistry in Ann Arbor, recently sat down with Incisal Edge to assess the state of solo versus group dentistry — and what the country’s dental schools ought to (or even can) do about the shift he began examining four years ago.

Are dental schools across the country — both prominent and otherwise — being affected by the shift toward the group-practice model, or is it more accurate to say that they’re the cause of it?

Honestly, it might be multiple factors. There is some evidence that Millennials enjoy group work and like to work in group environments. But I think that for a long time dental education has been moving toward learning groups. I can remember that back in the 1990s we were already starting to learn in small “communication teams.” Students are also graduating with more debt than ever before, and there’s some evidence that they’re moving away from less-lucrative options for careers. This means there are fewer people going into academia, research and public health, and more going into private practice.

How big a role does greater student debt play in leading graduates toward the corporate model?

Within the private-practice model, it means buying a practice becomes very challenging, because students are graduating with two, three, four hundred thousand dollars in debt. The group-practice model becomes appealing because there’s no ownership fee, but you still get to practice dentistry. Another thing the research on Millennials suggests is that they don’t want to be locked into a deal for their whole life, which used to be the dream for a dentist: Work at a practice, buy into a practice and then own a practice for the rest of your life. That’s unappealing to Millennials, I think.

How have schools like Michigan incorporated the shift toward the group model into their dental-school curriculum?

A lot of dental schools have group models to facilitate patient care when individual students are out on rotations. We’ve had this [at the University of Michigan] for decades now. Harvard too.

Coming at the question from the other end, what benefits does the group-practice model offer patients over the traditional solo model?

You know, I’ve written some papers about how good a group practice can be, but I must tell you: My dog is sick and old, and to have a vet with a solo private practice is really refreshing. She knows my name, she knows my new baby’s name, she knows my wife’s name. There is something very special about a solo practice.

But with a group practice, there’s more purchasing power — you can buy the newest technology. There’s also broadened hours of operation. If there are 10 or 20 dentists [in a single practice], you can basically work till 9 P.M. every night. Someone just has to stay there once a month, and suddenly your practice is open from 7 A.M. to 9 P.M. five days a week. So there are tremendous things you can offer your patients in a group practice; they’re just different from the great things a solo practice can offer.

In 2016, you wrote an opinion piece for the Journal of the Michigan Dental Association in which you argue that corporate group practices lower prices for patients, too. What’s the primary reason for that?

Smaller solo practices cannot possibly negotiate with larger insurers, and the trend we’ve seen in medicine is that hospitals have collaborated and formed business partnerships or mergers, thereby increasing the number of physicians they have and giving them more strength when they’re negotiating with the insurer. Dentists are just absolutely incapable of doing that — except larger corporate [group practices], because they get better reimbursement rates and potentially offer much lower prices to patients.

Are there other benefits that work to tilt the scale in the direction of the corporate model?

They can probably negotiate better deals. When they purchase dental chairs, for instance, they’re going to be buying 30 chairs, not one or two, so they can get a better deal per chair — simple economies of scale. So they can certainly reduce their costs.

The difference is they might have higher costs if they have a layer of administration that solo practices won’t have. But those in dental administration can then look at patient satisfaction, quality improvement, error rate and things like this that dentists would have to do in the evening.

Will the solo-practice model erode completely, do you think, or will it merely change?

I don’t think the solo practice will die, because as I said, I love going to my vet. If we look at [other areas of] medicine, they’re five to 10 years ahead of us in terms of pressures like student debt. Somewhere around 30 percent [of physicians] are still in solo practice, and the rest are in the group model. Dentistry is currently closer to 60 percent in solo practice, so while there seems to be a movement toward that 30 percent, I don’t think it will ever die completely. People value the fact that they can see the same dentist, even if that means waiting a week.