Ep. 105: The Right & Wrong Way to Bring in a Specialist
More and more GPs recently have been bringing in part-time specialists so they can offer more services in-house. The benefits are obvious, but where can it go wrong and what considerations should you have before deciding to bring someone on? And how do you do it right? This week, we’re joined by special guest Sabri Blumberg to answer those questions and more!
Links:
Ask Sabri a question – sabrib@mgeonline.com
Learn more about MGE - https://mgeonline.com
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Questions From This Episode
What's the first thing Sabri checks when a client wants to add a specialist like an oral surgeon?
She wants real, verified referral data over at least six months, not a general impression of how much is being referred out, since people's sense of their own referral volume often doesn't match reality. That consistent data also determines how many days a month would actually be worth scheduling the specialist for.
What percentage does Sabri say practices typically pay a specialist associate, and how has that changed?
The commonly cited figure is 50 percent, and that's still accurate in areas where a given specialty is hard to find. But over the last five years, Sabri has seen practices in areas with plenty of available specialists paying closer to 35 to 40 percent, so she recommends actually researching the local market rather than assuming the higher number applies.
Why does Sabri recommend treating high-ticket specialty cases, like large implant cases, as financially separate from the core practice?
Big production numbers from cases with large lab fees, implant cases or clear aligners, for example, can look impressive without the team immediately registering that a large share, sometimes 30-plus percent, is already gone to lab costs. She recommends keeping these cases' finances entirely separate from the core practice, more like a second practice sharing the same location, so the main practice still has to be profitable on its own.
Why does Sabri say orthodontics and pediatric dentistry are much harder to add to a general practice than oral surgery or periodontics?
Both specialties run on a speed-and-volume model that requires real chair capacity most general practices aren't built for, and orthodontic cases involve a multi-year patient commitment that becomes a genuine problem if the relationship with that specialist falls apart partway through. Pediatric dentistry adds the further issue of mixing distressed children with adult patients in longer restorative appointments, something she says creates real friction for everyone in the practice.
Why does Sabri say endodontics is rarely a good fit to add in-house?
Root canal cases are genuinely urgent and unpredictable in timing, unlike an implant consult that a patient can simply reschedule for next month, so there's rarely enough concentrated, consistent volume to justify bringing an endodontist on. She says she's only seen it considered once or twice in thirty years, and usually only in very large practices with an unusually high referral volume.
Episode Transcript
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Jeff: If you're a general dentist, have you ever thought about adding a specialist to your practice, maybe a day or two a week or a month? Here at MGE, we get this question from clients as they become busier, and the reason most of them consider it usually isn't about money, it's centered more on customer service and convenience. They're referring out a lot of work, periodontics, implants, oral surgery, whatever it might be, and they figure it would be more convenient for patients to have it all done under one roof, theirs. Occasionally you'll hear a concern about losing a patient entirely once they're referred elsewhere, and there's some financial upside too, but convenience is usually the main driver.
We don't really take a position on this one way or the other. While most of our clients are GPs, we also have a large number of specialty clients, oral surgeons, periodontists, orthodontists, endodontists, and a handful limited to prosthodontics. So when a GP client is considering this, it's a personal decision, and when we're asked, we're advising purely from a business perspective, how is this actually going to work.
In a similar but not identical vein, you could also think about a general dentist bringing in an associate who performs procedures the owner doctor simply can't do themselves, implants, All-on-4s, that kind of thing. It's one thing to be capable of molar endo and just not want to do it anymore, it's a different thing entirely to bring in someone providing a service you were never trained in. With all of that in mind, there's definitely a right and wrong way to approach this. What do we actually look at when a client asks about adding a specialist or an associate who covers procedures they don't provide, and what do we recommend based on their situation? That's what we're covering this week. My name is Jeff Blumberg, and I'm your host, joined this week by Sabri Blumberg, our Deputy Chief Operating Officer. Many of you know Sabri, she's been on a number of episodes, she's in charge of all technical delivery here at MGE, and she's worked with thousands of clients, and I mean that literally, not as an exaggeration. I wanted her on this one specifically because she's usually the one fielding these exact questions and giving the advice.
Welcome to the show again, Sabri.
Sabri: Thanks, good to be back.
Jeff: Let's start with the basics. How often are you actually asked about adding a specialist?
Sabri: Probably about once a quarter, every three months or so.
Jeff: And which specialist comes up most often?
Sabri: Oral surgery is the most common by far. Periodontics is second.
Jeff: How does that conversation usually go?
Sabri: It's usually them asking me, and as you mentioned, it's framed around convenience, having everything done under one roof for the patient. There's also a concern about losing a patient entirely once they're referred out, sometimes insurance changes or something else gets in the way and the patient never comes back to complete treatment with the specialist. And sometimes it's simply that they feel like they're referring out a lot and want to keep some of that income in the practice.
Jeff: So say I come to you and say, Sabri, I think I want to add an oral surgeon to my practice, what do you think?
Sabri: The first thing I'd ask is why. What are you actually trying to accomplish with it, is this about service, or is it about income?
Jeff: Let's say it's because I feel like I'm referring out a lot, I don't place implants myself, and I'm sending out a good number of wisdom teeth extractions too.
Sabri: That's interesting, because what people think they're referring out and what they're actually referring out don't always match. I don't know exactly why, but certain procedures tend to come in clusters, you'll suddenly see a run of implant referrals, or feel like you're sending out a lot of third molar extractions all at once, almost like these things happen in threes. So the first thing we do is get the actual numbers.
Jeff: Real numbers, not just a feeling.
Sabri: Exactly, "a lot" isn't a number, and one month isn't enough to work with either. You need to look back at least six months.
Jeff: That's interesting, I was going to ask about sample size. Six months feels sustained enough to actually trust.
Sabri: Right, and it also tells you how many days a month you'd actually want to schedule the specialist for.
Jeff: So say I tell you I've referred out four implant patients a week consistently for six months.
Sabri: That would likely be enough to justify about two days of oral surgery a month.
Jeff: Okay, so then I'd need to actually find an oral surgeon. What would I typically pay them?
Sabri: It depends heavily on your area. Like with anything, the scarcer something is, the more you'll pay for it. If you're in an area with plenty of oral surgeons available to work part-time as an associate, you might pay 35 to 40 percent. If you're somewhere it's genuinely hard to find one, you're looking at closer to 50 percent.
Jeff: Fifty percent is the number I've always heard thrown around.
Sabri: It's the number I always heard too, but it's not really accurate anymore. Over the last five years, I've seen people paying specialists 35 to 40 percent in areas where that specialty is readily available. You don't necessarily have to pay 50, but you do need to actually research your specific market.
Jeff: Now if someone's seriously considering this, say I'm bringing in an oral surgeon two days a month for implants, and we're negotiating a 45 or 50 percent split, part of that negotiation is going to involve who's providing the assistant.
Sabri: That's right, and who's paying for the implants and other materials.
Jeff: What about something like a cone beam?
Sabri: If it's only eight cases a month, I'd outsource that to an imaging service rather than buy one. There are imaging companies that will literally bring a mobile unit to your parking lot and scan the patient right there. You don't need to buy your own cone beam for a handful of cases a month.
Jeff: So have the day the imaging truck is scheduled line up with the oral surgeon's day.
Sabri: Exactly, let it start making money before you invest in anything major.
Jeff: That's always made me a little nervous when I've heard this discussed, spending $80,000 or $90,000 on a cone beam, even though you can find them cheaper, for only eight cases a month. I know in the long run plenty of offices that do implants just offer the cone beam scan for free since it pays for itself eventually, but this is a procedure that literally doesn't happen in my practice unless this specific specialist is there. So investing heavily in equipment upfront, unless I'm planning to learn implants myself, seems risky.
Sabri: It can be, which is exactly why I want to see whether the arrangement actually works first, before putting more money into it. If it turns out to be profitable and genuinely fits the practice, then start investing to make it more convenient, add the equipment, build it out properly. But you don't start by spending money and setting everything up perfectly before you even know if it's going to be profitable. What if, after the first month, you and the oral surgeon just don't get along? That's a real problem, and now you're stuck holding a cone beam payment with nobody to use it.
Jeff: Fair, though I suppose at least I'd have a cone beam.
Sabri: Small silver lining.
Jeff: So say I'm paying the specialist 50 percent and we've worked out who's covering the assistant and materials. Here's an odd question, since we don't take a formal position on this and we do have plenty of specialist clients, but both our kids had impacted wisdom teeth removed under sedation. Would I want to bring that kind of capability into my own practice too?
Sabri: That's genuinely up to you, it depends on your available space, your comfort level, and what you're clinically comfortable with. We don't take a position on whether you should offer sedation, that's the client's call. What I'm looking at is whether you have the physical space for it, whether it interferes with your day-to-day operations, and whether it's actually profitable. That's it.
Jeff: If I were a GP considering bringing in an oral surgeon mainly for third molar extractions, and some of those required sedation, I'd want to be referring out quite a few of those, five or ten a week or more, before I'd even consider that.
Sabri: Right, or you start simpler. Begin with just implants and the extractions that don't require IV sedation, let that generate some profit, then add a cone beam once that's proven out, and only later consider investing in the setup needed for IV sedation. You don't have to go all in immediately, you can scale this gradually as you learn how it fits your practice and as your staff gets comfortable scheduling around this new provider.
Jeff: Let's say we've got this oral surgeon in, and we're also doing some All-on-4 or All-on-6 cases, and I'm restoring all of them myself. Some of these cases run $40,000, $50,000, even $60,000 depending on your area, with a substantial lab fee attached. Part of what makes these appealing, and I'm not saying it's the primary motivation, is that big number. But if you don't structure compensation carefully, it's a bit like clear aligners in that sense.
Sabri: Exactly, any case with a large associated lab fee works similarly. If I'm already deducting the lab fee before calculating compensation, and I'm paying the specialist 50 percent, and I'm handling part of the case myself, by the time you factor in the big lab bill, that impressive-looking production number might leave very little actually left over.
Jeff: I see the same thing with clear aligners. Someone doesn't do many cases, gets excited because each one is $4,000 to $5,500, and the numbers look great on the front end. I think it's because there's no instant connection between the production number and the lab bill, it's not like you're billed for the aligners the moment you start the case. So production jumps, which is fine, since it's a legitimate service patients need, but people don't immediately register that 30-plus percent of that number is already gone to lab fees.
Sabri: Right, and that's part of why we recommend treating any high-ticket item with an unusually large lab fee as a genuinely separate, adjunctive service, almost like you're building a small secondary practice within your practice. Keep it financially separate. Think of it as the gravy, not the bread and butter.
Jeff: Walk me through that a bit more.
Sabri: Your core practice, whatever regular dentistry you do, hygiene, restorative, the normal day-to-day work, needs to be profitable and growing entirely on its own. Now you're adding a piece on top, whether that's clear aligners or bringing on a specialist or an associate who does something you don't. That new piece needs to be built and evaluated separately from your existing practice. It can't become your practice, because the overhead structure is completely different. You have to keep those numbers apart.
Jeff: So in a nutshell, I need a profitable, successful core practice doing basic dentistry first, and whatever I add on top should genuinely add to that, not become the practice itself.
Sabri: Exactly. When we talk about bringing in a specialist, the assumption is usually that it's an additional service layered onto a healthy practice. But what I also see is a practice that's barely covering its own overhead regardless of its raw numbers, you'll see practices doing great collections that are still barely breaking even, and smaller practices with the same problem. As a supposed fix, they bring in a specialist for these high-ticket cases, assuming bigger numbers automatically means more profit. It's usually the opposite.
Jeff: We've actually seen a version of this that you flagged for me a couple of years back, maybe even longer. We have clients who genuinely do a lot of high-end work, and you've always been pretty blunt about it: the high-end stuff is great, do it, it's wonderful, but your core practice still has to be successful and profitable on its own. The specialty work should be an add-on, not the nature of the practice.
Sabri: Right, and even if the owner doctor genuinely doesn't want to do bread-and-butter dentistry anymore, for whatever reason, that's fine with me. But then they need to replace themselves with a general associate who handles that core work, and that needs to be running profitably before the doctor steps fully into specialty procedures, whether that's only doing full-mouth reconstructions and implants, or only sleep apnea, or only clear aligners. You just can't throw away the foundation of the practice, it's also the most safe and secure part of it.
Jeff: And in that same vein, we've seen people run into real trouble here. If you've got genuine volume, a healthy hygiene department, all your regular procedures running well, that volume naturally surfaces implant candidates, sleep apnea candidates, clear aligner candidates. You're not having to separately market for those cases, they're already walking through your door. The moment you start actively marketing for those specific procedures, which isn't wrong in itself, you need to make sure your foundation is already solid first.
Sabri: Right, because if you're not getting that volume organically and you start marketing for it directly, that marketing costs real money. We've seen clients who weren't doing the higher-end work themselves, hired a specialist, sometimes not even a credentialed specialist, just a GP who trained specifically in that procedure, which is fine clinically if they're genuinely comfortable and qualified, I'm not a clinician myself. But their core general dentistry wasn't profitable, and instead of fixing that, they took what little profit existed and poured it into heavy marketing for these big cases, paying the specialist a significant cut, and went broke in the process. At that point you're essentially building a practice for someone else, who doesn't even carry your overhead, since they're just taking a percentage.
Jeff: I know exactly the scenario you mean. No successful basic general practice, so instead you market aggressively for All-on-4 cases, bring in a GP trained to do them, since an oral surgeon typically won't restore the full case themselves, only a GP or prosthodontist would. And part of the problem with adding any associate is you have to keep them genuinely busy. So say that associate could also do bone grafts, and a patient needs one, you hand it over even though you could technically do it yourself, because that associate is sitting there and you don't want them idle.
Sabri: Right, so now you're giving away treatment you could have done yourself, and you're essentially selling cases for that associate with your own marketing dollars.
Jeff: And basically giving someone else a great living while you're struggling.
Sabri: Exactly, it's not a smart way to run things. Bottom line: your practice has to be healthy and profitable on its own terms, and you can't let that change regardless of whether you're personally specializing in one area or bringing in someone else to do it.
Jeff: So if we were to turn this into a rule of thumb, say I want to bring in an oral surgeon for implants and extractions I don't feel comfortable doing myself. Step one, you'd have me check the actual last six months of genuine referrals, not just my sense of how much I'm referring out, and it has to be consistent. Then run the math based on what I'd actually be paying the specialist to see if it's worthwhile. If it is, bring them in for however many days the volume supports. But when it comes to actively marketing for more of that work?
Sabri: You can, as long as you don't touch your existing business systems, the marketing budget for your regular practice stays exactly as it is, growing and profitable on its own. Treat it almost like two separate practices. Any marketing spend for the specialty work needs to come out of the profit that specialty work is actually generating. You can't have one side funding the other, it's like buying a second practice and having the first one pay for it, eventually you'll go broke.
Jeff: Let's play that forward. My GP practice does $200,000 a month doing solid, basic dentistry. I bring in an oral surgeon for implants and extractions, referring about four implants a week, we work out a 50 percent split after supplies and everything else. The oral surgeon ends up producing $20,000 to $30,000 a month, I'm keeping $10,000 to $15,000 of that, they're getting the rest, depending on how we structured it. It's working well, and then I think, it'd be great to get more of these implant cases. You'd want me to fund that marketing push entirely out of the profit I'm making from the oral surgery side, without touching a dollar of what I'm already spending on my core practice.
Sabri: Exactly right. Think of it as two separate practices that happen to share a location, but each one has to cash flow on its own. You can't merge them together, because that's when you start seeing problems, one practice effectively subsidizing the other, or staff and doctors pushing cases toward whichever service makes the month's numbers look better, without accounting for the real overhead sitting behind that revenue. With that 40 or 50 percent you're keeping from the specialty work, if you're also paying bonuses out of it without accounting properly, the math stops working.
Jeff: That covers oral surgery and periodontics, the two most common. What about prosthodontics?
Sabri: A prosthodontist is essentially a highly trained restorative dentist, so it behaves similarly to bringing in a well-trained general associate from a business standpoint. Not identical clinically, obviously, but those three, oral surgery, perio, and prosthodontics, get handled the same way from a pure business perspective.
Jeff: Have clients ever asked about adding an orthodontist?
Sabri: Yes, and my answer really depends. Orthodontics, and pediatric dentistry too, operate under a completely different organizational model than what we've been discussing. Those are built around speed and volume. That's the first real problem, do you actually have the physical space for it? An orthodontist might need to be bending wires on four, five, or six patients simultaneously in a single afternoon.
Jeff: Which means real chair capacity.
Sabri: Exactly. And sometimes clients will say, well, I don't work Wednesdays, so that space is free. Fine, but if that space is sitting open and you're not using it, are you actually busy enough as it is, and are you planning to expand? You might want that open Wednesday for a general associate instead, something that actually fits the model you've already built. So ortho and perio-adjacent specialties like this are genuinely harder to add from a pure workflow standpoint. There's also the commitment issue, say it's a two or three-year ortho case, and two months in, you and the orthodontist just don't get along.
Jeff: That's a real problem if you can't do the work yourself and now you're stuck mid-case.
Sabri: Right, you're either stuck with that person, or if they go skiing and break a leg.
Jeff: I mean, they could still bend wires with a broken leg.
Sabri: Fair, a broken hand would be worse. But any specialty with that kind of long-term patient commitment attached, if you can't personally step in and finish the case, I'd never recommend bringing it into a general practice.
Jeff: That makes sense. What about pediatric dentistry?
Sabri: That one has its own wrinkle, you're now mixing in actual children. I can't picture a client running a high-end adult restorative practice suddenly wanting to add a pediatric dentist.
Jeff: We both have kids, we love kids, that's not the issue.
Sabri: Right, it's just not a good mix, a bunch of adults coming in for long, three-hour restorative appointments, with kids being run through the next chair every thirty minutes. Part of why it's a bad mix is that decent people are instinctively distressed hearing an upset child, it immediately grabs your attention. And since children are sometimes understandably upset at the dentist, you're compounding whatever stress your adult patients already feel about being there.
Jeff: So you wouldn't recommend it.
Sabri: The only scenario I've actually signed off on is a genuine big family practice already doing a lot of adult dentistry alongside a lot of children. Even then, I'd fully separate the days, adults on certain days, children on others. People push back, saying it's less convenient since families want to come in together, but running a genuinely profitable pediatric operation requires seeing a real volume of children, the hygiene model is different, the way you generate revenue is different, and how you interface with parents is completely different. You're never presenting a treatment plan directly to a child.
Jeff: If it were our own daughter, she'd say yes to whatever's most expensive without blinking.
Sabri: Exactly right, kids can't make that financial decision, you're working through the parent, which requires a very different kind of communication, and staff trained specifically to keep both children and parents calm. That pulls focus away from the time you need with adult patients to properly help them understand and accept the treatment they actually need.
Jeff: You've pretty much talked me out of ever adding pediatric dentistry if I were a GP.
Sabri: You can, if you fully separate it out, though at that point it's practically its own standalone pediatric practice sharing your address. The one time I really agreed to this was a Medicaid-focused office, which isn't typically something we work with, but this was a unique case. The doctor was in an area with no Medicaid providers at all, so he and a group of dentist friends opened one shared Medicaid office specifically for children in that area.
Jeff: I remember that, that was a genuinely cool project.
Sabri: It really was. They saw children there, but also had some adult patients, and we kept those fully separated. It worked.
Jeff: Over your career, how often have you actually told a client, yes, go ahead and add pediatric dentistry?
Sabri: Once or twice.
Jeff: And orthodontics?
Sabri: Maybe five times. Both are a very small percentage of these conversations.
Jeff: What about endodontics? I've personally only been asked about that once in my career.
Sabri: I've maybe seen it once or twice in thirty years. It doesn't tend to be a good fit, since it's so unpredictable, and there's real urgency attached to it. You can tell a patient to come back next month for an implant, you can't tell them that for a root canal.
Jeff: Right, unless for some reason all your endo referrals happened to land on the exact same day of the week.
Sabri: Even then, there are cases where a patient needs antibiotics and a painkiller first to let inflammation settle before they can even be seen by the endodontist, so there's often a built-in delay anyway. You'd genuinely need a large volume of these cases, concentrated enough to justify it, and even then, it's usually simpler to just keep referring them to a dedicated endodontist.
Jeff: That tracks, you really only see that kind of volume in the rare, very large practice. I think we've covered most of the ground here. Anything you'd add?
Sabri: Just that you really have to do your own homework as a business owner before taking this on, so it's actually profitable, and so it doesn't end up masking losses in your existing practice behind a big, impressive production number.
Jeff: That makes sense. Well, Sabri, thank you so much for joining me this week.
Sabri: You're welcome, this was fun.
Jeff: If anyone has questions after listening, would you mind if they emailed you directly?
Sabri: Not at all.
Jeff: We'll put Sabri's email on the episode webpage if you'd like to reach out about adding a specialist to your own practice. Otherwise, that's all we have for you this week. Have a great week, and we'll see you at the next episode.