U.S. News & World Report once again ranked the orthodontic profession among the top 5 Best Jobs, recognizing great jobs as ones that challenge us, are a good match for our talents and skills, pay well, aren’t too stressful, offer room to advance and provide a satisfying work-life balance. The ability to remedy dental health problems while building meaningful relationships with our patients certainly affords us a gratifying career. Whether a new graduate, an orthodontist who has reached retirement, or someone in the middle of their career, we hope this to be true. Over the course of 2017 each of our six NESO eNews publications features a State of the Profession as depicted by a NESO Alumni in each decade of life (30’s – 80’s). We’ve asked our Alumni to share some of their personal background and experience to shed light on how the profession has evolved, offer explanation of the changes that have occurred, outline how the responsibilities of an orthodontist vary over the course of one’s career and offer a projection of where our top-ranked profession is headed.
Our previous eNews publications have featured Dr. Ron Cortese (80’s) of Rochester, NY, Dr. Richard Reed (70’s) of Burlington, VT, Dr. Ron Bellohusen (60’s) of Elmira, NY. and Dr. Carolyn Melita (50’s) of Belmont, MA. In this month’s publication we feature Dr. Kirsten Romani (40’s) of Chepachet, Rhode Island.
Dr. Kirsten Romani, DMD, received her undergraduate degree from Middlebury College prior to attending dental school at the University of Connecticut School of Dental Medicine. She completed her orthodontic residency at Tufts University School of Dental Medicine and today owns and operates a very successful two-office practice in Rhode Island. Dr. Romani is a Diplomate of the American Board of Orthodontics and is recognized as a top 1% Invisalign Elite Provider. Outside of the office she enjoys spending time with her family, being a “soccer mom” to her three growing children, gardening and collecting early American antiques.
State of the Profession Through The Loupes of Dr. Kirsten Romani, :
My journey to becoming an orthodontist began in 8th grade when I spent Career Day shadowing my own orthodontist, Dr. Leonard Friedman, in Mountain Lakes, NJ. I remember thinking that orthodontics would be a wonderful job, combining art and science to build beautiful smiles for patients. I continued on a direct path to an undergraduate joint degree in Biology and Chemistry from Middlebury College in Vermont in 1990, and progressed immediately on to dental school at the University of Connecticut School of Dental Medicine where I earned my DMD in 1994. Next came two years of orthodontic residency at Tufts School of Dental Medicine where I received my Certificate in Orthodontics in 1996 under Chairman Dr. Everett Shapiro and Program Director Dr. Russi Gheewalla. Dr. Shapiro was an icon in the field of orthodontics and I feel privileged to have known him before he retired in 1998 following 38 years as the Chair of the Department.
The Tufts Orthodontic Department prided itself on wire bending skills. We were trained with Standard Edgewise brackets (zero prescription) and told if you were a good orthodontist, you would be able to straighten teeth with a wire coat hanger! Nickel titanium wires were in short supply; it was a stainless steel world for our wire progression. The Tweed Course was taught on wax typodonts, allowing us to see a case through from start to finish during an intense week of training with first, second, and third order bends. Extractions and headgear were routine, and Single Bull Loop and double T Loop wires abounded. The respect for Dr. Anthony Giannelly, Orthodontic Chairman at Boston University at that time, was widespread among the Tufts faculty and the bidimensional use of .018 anterior slot size and .022 posterior slot size was predominant. I was one of three female residents, with five male residents in our class of eight. There were only two part-time female faculty members at that time. Dr. Lisa Giarusso, from Worcester, Massachusetts was a relatively recent graduate herself and she was inspiring. She told me “When you graduate from Tufts Ortho with our fundamental wire bending and tooth movement skills you will be able to handle any case. It’s like knowing how to drive a stick shift, when residents at other programs are being taught how to drive a fully automatic vehicle using prescription brackets and straightwires. However, that’s probably how you will practice when you get out into the real world.”
During my residency in the mid ‘90’s, Orthodontic Centers of America (OCA) was a new force in the market. Orthodontist and Entrepreneur Dr. Gaspar Lazarra had built this management company aimed at providing a full range of services to multiple satellite orthodontic offices with the goal of increasing operational efficiency and profits above which he thought individual private practices could achieve. What started in Florida primarily in general dental offices was now spreading nationwide, with efforts to open up in freestanding locations affiliated with shopping centers. Many of the faculty at Tufts were appalled at this new development of “mall orthodontics,” and Chicken Little was very concerned the sky was falling on our beloved profession. OCA underwent a corporate restructuring in 1994 that placed Lazarra in the position of Chief Executive Officer, and soon thereafter the Initial Public Offering (IPO) sold 26% of the company to the public with stock sales netting $18 million dollars. Between 1994 and 1996, the exact period of my orthodontic residency, the number of OCA centers more than tripled. Increasing from 75 to 247 locations, OCA spread out to cover 28 states. By 1997, two more stock offerings of 34% followed by 12% had been offered to the public, netting an additional combined total of $157 million dollars. Some of the orthodontists who were concerned about the new competition of OCA were paying particularly close attention, and quietly adding OCA stock to their financial portfolios.
The Tufts Orthodontic faculty shared with us their own personal love for the traditional private practice model, and cautioned us about falling victim to the temptation to join the new and aggressive corporate alternatives. Advertising was considered tacky by the senior doctors in their sixties and seventies. They came from a time when quality doctors simply hung up a shingle with their name on it, and general dentists readily referred their patients to a specialist for orthodontic care. Some doctors were willing to place a modest ad in the yellow pages, but even that was considered questionable by some if the ad was too big. Yet OCA was implementing a very aggressive advertising campaign aimed directly at the public with television, radio, billboards, and print advertising encouraging the consumer to bypass a referral and come right in for braces. Promises of little money down and low monthly payments extended over the entire length of treatment; these concepts seemed radical and shocked many doctors who lamented about the outrageous changes taking place in marketing and payment options. Ultimately, Orthodontic Centers of America did not withstand the test of time, but they certainly influenced the orthodontic industry.
After graduation, my husband Dan and I moved to Rhode Island where he was already employed by The Rhode Island Historical Society as their Director of Education. I joined the group practice known as Orthodontic Associates, Inc., becoming an associate of father and son owners Dr. Raymond George, Sr. and Dr. Raymond George, Jr. At that time the Georges operated four offices located in Providence and East Providence, Rhode Island, and South Attleboro and Seekonk, Massachusetts. In the coming years, the practice would grow to include three more locations in Rhode Island and restructure into a new corporate entity named Orthodontic Partners, Ltd. I became an equity partner in 1998 with 25% ownership of the practice. We worked hard to deliver quality care in a private practice setting, while striving to accomplish improved efficiency by utilizing size to our best advantage. One of the greatest challenges during the early-to-mid 2000’s was straddling the practice’s traditional private practice foundation and the bigger, more demanding corporate model that our seven office, five doctor practice had grown to become. Staff size and overhead were both greater than they should have been, and management was challenging.
God has blessed us with three beautiful children. Balancing work with three healthy pregnancies and maternity leaves between 2000 – 2004 was well timed for the group practice setting, which provided ample doctor coverage by my partner and our associates. Dan willingly stepped into the role of stay-at-home Dad, allowing me to continue practicing orthodontics full time with 4 clinical days and 1 administrative day to “catch up” or work on marketing.
In 2008, I was given the opportunity by my partner, Ray George, Jr. to buy out the two office locations where I spent all of my time practicing. In 2009, Romani Orthodontics, LLC was born and my life as a solo practitioner began. Dan was officially brought into the practice as the Business Manager, and was instrumental in developing our new branding and marketing, as well as taking over the job of accounts payable at the office. I promptly endeavored to become Board Certified and accomplished ABO status in 2010. Although I had technically become an ABO member through the Gateway program in 2005, it did not feel deserved until I underwent the process of submitting my own cases for review by the Board of Examiners. The process was well worth it, for it forced me to evaluate my clinical skills in a new light and to identify the areas that needed more attention and improvement. Without this humbling experience, I do not think I would have the same perspective about the quality of care I deliver.
The Schulman Study Group has been the greatest resource for my ongoing professional development. I became a member in 2001, and was the first female orthodontist to be elected by the SSG membership to serve a six-year term on the Board of Directors from 2007-2013. The Schulman Group started over forty years ago with business consultant Bud Schulman. Today it is comprised of 125 successful orthodontic practices in the U.S. and Canada. Membership is by invitation, and geographic exclusivity allows members to freely exchange ideas about business and marketing, as well as financial investing, practice management, staffing, etc. Clinical cases are often shared in the context of asking for advice and sharing problems, failures, and successes. Several members are nationally recognized speakers on current topics including Invisalign®, airway awareness and management, Suresmile®, and acceleration techniques. SSG’s motto is “Success Through Sharing,” which accurately captures the dynamic of our group.
In 2015-2016 I had the opportunity to work on NESO’s Annual Meeting Planning Committee for the meeting in New York City. Past President and current Delegate Dr. Jack Kacewicz was kind enough to bring me on board to work on the Office of the Future with colleagues Dr. Katie Klein and Dr. Anthea Resnick. It was a privilege to be part of Dr. Christina Carter’s annual meeting team and to observe her serving an impressive term as NESO’s President.
Women in dentistry have been evolving throughout my lifetime. When I was born in 1968, only 1.1% of dental students were female. The Survey of Dental Practice showed 48% of first year dental students in 2014 were female. The ADA’s Health Policy Institute data tells us in 2001 16% of dentists were women, and it has steadily increased to 30% in 2016. It takes time to penetrate the work force that was once exclusively dominated by men. This is also true for orthodontics. In 2017, AAO IT data tells us 31% of all active AAO members are female, and 49% of all student members are female. I write this article as the only female orthodontic specialist currently practicing in Rhode Island. We know female dentists and orthodontists practice differently from males in terms of fewer days/hours per week and lower percentage of practice ownership. Balancing a professional career with quality family time is an ongoing challenge for both genders, not just women. But females are the ones tasked with managing the logistics of pregnancy, maternity leave, and the bond of Motherhood. For a non-dental perspective of juggling this dynamic from the perspective of a successful businesswoman, I enjoyed reading the book Lean In: Women, Work, and the Will to Lead, by Sheryl Sandberg.
As I look at today’s orthodontics, 3D is here to stay using CBCT imaging, 3D scanners, 3D software and printing for in-house clear aligner therapy, invisalign®, and Suresmile®. Updated web sites, efforts aimed to improve search engine optimization, positive google and yelp reviews, social media pages, youtube videos – these things no longer set our office apart. They are now the expected norm in today’s contemporary orthodontic practice. Technology requires ongoing attention to continuously maintain and update this demanding part of our business.
Looking ahead, there are many disruptive forces to watch as they influence how orthodontics will be practiced in the future. Corporate Dentistry learned some valuable lessons from OCA’s strategies for success as well as their ultimate failure. Most of today’s orthodontic management service organizations (Smile Doctors is just one MSO example) are funded by venture capitalists, and will continue to grow, sell out, and consolidate over time. The growing number of orthodontic residency programs will produce a record number of graduates in the next few years. There has been a steady uptick of graduates since the mid-90’s as programs have expanded and new programs have opened, most recently the addition of NYU Lutheran and Georgia School of Orthodontics. This increases the supply of young orthodontists, many graduating with staggering student debt, which can readily supply orthodontic employee doctors for general dentists, pediatric dentists, and dental corporations. As the supply of orthodontists increases, so should public access to orthodontic care, with a likely influence that could reduce patient supply as well as fees in the areas of greatest penetration and competition. Smile Direct Club cuts the doctor out of the equation altogether. See BuzzFeed.com’s October 14th article by Nidhi Subbaraman for an overview. Although the AAO is fighting back, Pandora’s Telemedicine Box has been opened to unleash online options for tooth movement without doctor supervision.
Darwin’s theory of evolution teaches us it is not the biggest, smartest, or fastest that survive and evolve. It is those that are most willing and able to adapt in a rapidly changing environment. When we feel the external forces of change applying pressure to our orthodontic practices, we need to remember Darwin’s lesson and strive to adapt to the new environment not only to survive, but ultimately to evolve.