Michael Durbin, DDS — More Than One Path In: What Ownership Looks Like for This Generation

Dr. Michael Durbin bought his first practice in 1990 with about $15,000 in student debt, from a faculty mentor. A resident today can finish owing more than $500,000, and many of the practices they’d want are already owned by OSOs and DSOs. The sitting president of the American Association of Orthodontists joins host Dr. Michael Jerkins with an unusually complete view of that shift: he has been an owner, an associate, and a corporate doctor, worked alongside pediatric and general dentists, and eventually sold his practice to his son and stayed on as an associate.

From there, it gets practical. Mentorship doesn’t come standard, so ask for it by name before you sign. Startups are back on the table precisely because acquisitions often aren’t. A practice running two days a week is a practice worth filling, not a gap to plug with associate work elsewhere, and that’s the one thing he’d do differently. The new loan caps are the open question, and the person most exposed is the resident with dental school debt and no cosigner. AI, meanwhile, is already in the building: diagnosis, treatment planning, and the front desk. The AAO’s rule is “human in command,” meaning the software suggests, and the doctor decides. And the part nobody puts in the sales pitch is that a tool can move work rather than remove it.

Would he buy a practice again at today’s valuations? Is corporate consolidation still climbing? Why should nine states requiring an in-person exam matter to a doctor practicing in the other forty-one, and what exactly is “vocation insurance”? Tune in for an honest look at what ownership asks of you now, from someone who has tried nearly every version of it.

Here are 5 takeaways from our conversation with Dr. Durbin:

1. Student debt is reshaping the path to practice ownership

Dr. Durbin contrasts his roughly $15,000 in student debt when he bought a practice in 1990 with the much higher debt many orthodontic residents face today. That financial pressure can lead new graduates to choose employment first and postpone ownership.

2. Doctor ownership remains viable, even as corporate practice grows

Dr. Durbin sees signs that the rapid pace of practice acquisitions may be leveling off, in part because financing has become more expensive. He expects corporate settings to remain part of orthodontics, while privately owned practices and small groups continue to have a place.

3. Advocacy gives doctors influence they cannot achieve alone

The AAO’s efforts—including advocacy for in-person exams before treatment and its work with the FDA—show how professional organizations can help shape rules and guidance. Dr. Durbin describes membership as “vocation insurance” because collective advocacy can support both the profession and patient care.

4. AI can support care, but the doctor remains responsible

AI is already used in areas such as diagnosis and treatment planning. Dr. Durbin emphasizes the principle of “human in command”: doctors must evaluate AI-generated suggestions and make the final clinical decisions. He also cautions that new tools can shift work into evenings rather than simply reducing workload.

5. Mentorship and deliberate investment matter early in a career

New graduates should ask directly about mentorship when considering a role, Dr. Durbin says. Looking back, he also believes he could have invested more time in building his own practice instead of filling every available day with outside work.

Transcript:

Dr. Michael Durbin:

Do we become totally corporate, or is there still a place for solo-owned or even small group practices, you know, one- or two-doctor practices? I think what we’re seeing already is a plateau.

Dr. Michael Jerkins:

Today on The Podcast for Doctors (By Doctors), we’re joined by Dr. Michael Durbin, the sitting president of the American Association of Orthodontists and a practice owner. Dr. Durbin trained at Loyola and the University of Illinois Chicago College of Dentistry, and he’s spent the last three-plus decades doing two things at once: treating patients in Des Plaines and shaping the profession from the inside.

He joined the AAO Board of Trustees in 2017. He’s chaired its interoperability task force, served on the OSO/DSO task force, and led the AAO’s donated orthodontic services program, now known as Gifted Smiles, which provides free orthodontic care to kids who would otherwise go without.

He’s also a past president of the Illinois Society of Orthodontists, a diplomate of the American Board of Orthodontics, and closer to home, a longtime member of the Des Plaines and Prospect Heights Lions Club, a former Cub Scout Cubmaster, and an assistant baseball coach. He’s very busy.

Dr. Durbin, welcome to the podcast. Happy to have you, and we’re going to dive right in. I’m very excited to talk about what you’ve been up to over these three-plus decades in orthodontia.

I’m curious. You bought your practice in Des Plaines in 1990, and you’re still there 36 years later. What did buying a practice at 27 look like then versus what a resident walks into today when they’re considering this choice?

MD:

Thank you. Thanks for having me. Glad to be here.

Well, I should add one caveat to that. I’m no longer the owner, as I sold my practice to my son two years ago. So now I’m an associate again, working for him.

Yeah, quite different back then because the debt load was really nonexistent. I was buying a smaller practice from a faculty mentor, and so I felt like I was ready to go into that practice right from day one, right out of school.

MJ:

Amazing.

MD:

I think today makes it a little bit trickier, depending on the size of practice that you might buy coming right out of school. I think the other thing, too, is that was really the mode of operation at that point. You either bought a practice right when you got out, or you were an associate for several years with the eventual thought of buying that practice.

So in the back of your mind, you’re always thinking you’re going to buy a practice, whether it was right away or a few years later. I think today the landscape is a little bit different than that.

MJ:

In your mind, what are the biggest factors that have shaped that landscape change over the past few decades?

MD:

The biggest thing, obviously, is the student debt. You know, I mentioned that I had some student debt. I think I had about $15,000 of debt. The average orthodontic resident now graduates with over $500,000 of debt. So that obviously can have an impact on choices of how to practice and where to practice that were completely different from when I first got out of school 30 years ago.

MJ:

As a physician, I didn’t know that dental specialists had to pay for their residency until I was in residency. I was working with some of my oral surgery residency friends who were getting paid. They were at the academic center and explaining to me about it, especially orthodontists. I had several friends who were in dental school when I was in medical school, and I talked to them about it. At that time, as a resident, I could not believe how expensive orthodontic residency was.

Do you see much of a change on the horizon in the cost to train an orthodontist?

MD:

Well, that’s a good question. When I was going to school, the tuition was $3,600 a year. I went to a public university. Quite a bit of the cost of education was supported by the state. Now we’re seeing that money go away, and you’re under double digits in terms of the percentage of state support that a school will receive in order to educate future physicians and dentists, for that matter.

So I’m not sure that we’re going to see huge changes to that long term. The changes that were put into the One Big Beautiful Bill, with the loan caps and such, were based on the idea that by lowering the availability of money, the schools would then be forced to lower tuition. I am just not convinced that that’s going to happen, but we’ll have to wait to see.

MJ:

I agree. And notably, that $50,000 cap is not indexed to anything. Orthodontic residents still have to pay for gas, places to live, milk, and groceries, which are going to, of course, go up with inflation.

So at least what I suspect we’ll see is that doctors in training across the board will unfortunately have to rely on the private market, just because, again, a lot of what we had to borrow for, I included. I borrowed around $250,000 for med school, which is still a lot. A lot of that was just for cost of living. It’s obviously gone up over time.

So it’ll be very interesting to see what things we can do to try to make it more affordable for people to continue down not just the dental specialist track, but other tracks in healthcare.

MD:

Yeah, I think the other part of this is that I’m not sure even HHS and other agencies that are putting forth some of these ideas understand what you pointed out. Number one, in many specialties, you are actually paying tuition, but also understanding how much school we have to go through to hang that piece of paper on our wall, allowing us to do what we do.

I think once they start to see that and understand that, maybe some changes will take place.

But I think that was the part that was disappointing for us: just not understanding that while $50,000 in a year might seem like a lot of money, it really isn’t when the cost of attendance for a lot of these programs is well over $100,000. And then certainly, $200,000 as a cap with up to eight years or more of post-college education becomes really difficult.

MJ:

Absolutely. We talked about how you’ve been doing two things at once over the last 30 years: seeing patients, but also trying to advocate for and change the profession from the inside.

Now that you’re president, what is one thing that you want to be true about orthodontics at the end of your term that isn’t true today?

MD:

I think there are a couple of things. First of all, I would preface it by saying I’ve been on the board for over nine years now. I kind of chuckle when people say, “Well, what are you going to get done this year?” And I’m thinking, “Well, if I didn’t get it done in these last nine years, how am I going to get it done in this one year?”

But I think a couple of things. One is that I’d like to see us continue our advocacy for an in-person examination before orthodontic treatment is started. We now have nine states in the U.S. that require that in-person exam. Obviously, we’re not going to get to all 50 by the end of my term in June, but I would certainly like to see that number grow during that time.

I think the second thing is that, as we’ve seen the growth in the OSO and DSO market, I would love to see support from the OSOs and DSOs for their doctors to not only become members of the AAO, but also to continue that membership.

When you look at the practices that were bought by these OSOs and DSOs, they were buying really successful practices with excellent clinicians and businesspeople running them. When you look at that population, the majority, if not most or all, of those doctors were members of the AAO.

I’d like to believe that they felt their membership in the AAO had something to do with their professional and personal success. So right now, we’re not always seeing that, with OSOs and DSOs perhaps subsidizing or paying for the dues for their doctors. But I would certainly like to see that happen. It certainly won’t happen by the end of my term, but I’d like to see some movement toward that as we move forward.

MJ:

It makes total sense. I heard it once at a medical society meeting addressing membership, trying to appeal to folks who maybe don’t understand the value of advocacy. They used the term “vocation insurance.”

You get life insurance, you get disability insurance, and this is vocation insurance to make sure that we, as physicians or orthodontists or dentists, have someone advocating and speaking on our behalf, which is very important when our opinions and work affect communities.

So I’m curious, if we go back to the nine states, I don’t know much about this, so I’d love to dig in more. How long did it take for that to go from zero to nine states? And where do you reasonably see growth in the states that would require an in-person exam?

MD:

Well, it’s actually occurred relatively quickly. It’s really been in only the last couple of years.

First of all, we look at states where we have a good relationship with the state dental association. While we supply some funding and such to support these efforts, we can’t do it by ourselves. We also need support from that state dental society.

We looked at smaller, medium-sized, and larger states, and we were able to get that provision passed in all three. That gave other states a model to look at and say, “Yes, that’s something we can do.”

As we move forward and identify states that might be opportunities for us, I think the first step is looking at our relationship with the state dental society, but also asking where we can make a difference.

The way the legislature works matters because, again, this is a state law that’s passed. Some state legislatures only meet every other year. Sometimes they only meet for half a year. So our advocacy team is always looking at that and asking, “Where’s our opportunity? Where can we make a difference in the quickest and easiest way?”

MJ:

Makes total sense. Staying on the advocacy topic, if we could, and we’ve already talked about private practice, but I’d like to talk about both of those topics. Are there any policy changes, from your perspective, that would do the most to support private practice sustainability right now?

MD:

Yeah, it’s a great question because this is something that I’ve really learned in even just the last couple of years of being on the board.

I always had a really good understanding of how the Dental Practice Act in Illinois worked and what it allowed an assistant to do, or what it allowed a hygienist to do, whether under direct or general supervision of the dentist.

What surprised me was the difference across the country in what is allowed. In Illinois, much of the training that we do for our staff can be done on-site, as on-the-job training, so to speak. Theoretically, you could hire someone on Tuesday, and on Wednesday they could be working on a patient. Now, obviously, that’s up to the dentist to make sure they’re well-trained before they do that.

In some states, like New York, you are required to go to a program. In New Jersey, I believe it’s the same way. You actually have to attend a dental assisting program approved either by the state, DANB, or CODA. Your assistant has to attend that before they can ever work on a patient.

The problem with that is, first of all, there aren’t many of these programs. Secondly, the assistant or potential assistant has to pay to attend, and sometimes that can be costly. They just might not have the funds to do that.

So what I’d like to see, and where I think advocacy from the AAO can really make a difference, is working with those state boards and legislatures to say, “Hey, here are some ways we may be able to increase access for our members to hire additional assistants to help them in their practices.”

I think if we can make some headway there, that will make a huge difference. We also have to understand that every state is different, and that makes it a little more complicated.

MJ:

Definitely. You have your work cut out for you, but that makes total sense.

When we think about healthcare, a big topic across a lot of aspects of healthcare, of course, is AI. I’m curious, from your perspective, where does AI change orthodontic practice, if at all? If it does, where do you see that change happening initially? How does that change the day-to-day work of an orthodontist, in your opinion?

MD:

Well, first of all, it already has, right? In terms of diagnosis, treatment planning, and even the front desk, AI is already being used in orthodontics.

Recently, the AAO published a white paper on the responsible use of AI in clinical practice. We had a group of really dedicated and skilled volunteers who worked through all the important points of AI and where it might impact a patient, including things like informed consent. Should the patient be informed that AI was used in that process?

I think that’s where we’re going to see awareness that there could be regulation moving forward, not necessarily legislation right away.

In terms of who’s been affected the most or what staff position is affected the most, it’s the doctor, because they’re the ones who are going to have to navigate this new landscape. In addition, a lot of the tools are designed for the doctor to use, so it’s going to be up to them to decide how they’ll incorporate that not just into their practice, but into their personal life as well.

We see this already, even with clear aligner systems, where doctors are going home and spending another hour or two at night working through treatment plans, working through ClinCheck or whatever that may be. While this makes their day more efficient, their night has become more difficult or more involved than it used to be.

MJ:

That’s the interesting dynamic across medicine and dentistry. A couple of things are happening. One is that the technology might increase efficiency in one area, as you said, but actually increase demand for the doctor’s time in another area that’s not necessarily being addressed.

The second thing, of course, is how much evidence we need to meet the bar for saying something is okay to use in clinical practice. Historically, outside of AI, other technologies had a pretty high bar to reach to show that they were effective and safe for use in clinical care.

But in the last two to twelve months, there’s been so much evolution that things are moving so fast. It’s hard to get the kind of data we’re used to having in healthcare to make sure these interventions are actually useful.

And it’s especially hard when you’re running a practice, right? You’re getting people trying to sell you technology all the time. I don’t know how you tease out in the moment what’s not only safe and effective, but also what’s going to produce an ROI.

I don’t even know if I had a question there. Apologies. But how do you address that, or how do you advise practice owners to evaluate what technology they’re actually bringing into the practice?

MD:

I kind of liked where you were going with the AI side for a moment, and I just want to build on that for a second.

When we’re looking at the bar for where AI becomes effective, I think it’s a little different than medicine. In medicine, say, with cancer treatment, you can put a lot of data together and potentially find an oncology protocol that works better. Then you have data to help prove that.

Orthodontics is a little bit different. I think AI is still a tool, and the first core principle of our AI white paper is “human in command.” So while AI may make suggestions on how to treat, it’s ultimately the doctor who’s going to make that decision and say, “This is what’s best for my patient.”

I would say a lot of doctors don’t even know they’re using AI. If you look at Invisalign, which is the largest clear aligner company, they probably have the largest dataset of patient records of anybody in the world. They’re able to use that to help their technicians develop treatment plans for doctors that address the needs of each patient.

But it still has to be the doctor who looks at that proposed treatment and says, “Yes, that is what is best for my patient.” They have to determine whether those tooth movements are possible in the first place, whether they’re effective, and whether they’ll be in the best interest of the patient.

To your point, I think we’re still learning some of that, but in some cases, AI is already fully ingrained in practice. Again, the doctor has to be in charge.

When they invented power tools, that didn’t get rid of the carpenter. The carpenter was still using them. They just made their life easier and more efficient. I see AI doing the same thing.

MJ:

We have pretty effective autopilots, but we didn’t stop training pilots and start having self-driving planes. At least, I haven’t been on one that I know of.

I’d love to pivot back to your career and your experience as a practice owner because I think it’s very helpful for us as doctors. We don’t always get a lot of transparent passing of knowledge, especially when it comes to finances.

I’d be very interested to hear about your early days when you bought your practice. Could you talk about any big money mistakes you might have made in the first four or five years of ownership?

MD:

Yeah, so the practice I bought was basically a two- to two-and-a-half-day-a-week practice. I knew that wasn’t going to be enough for me, getting out of school. You kind of feel like, “Okay, I’ve got to go start making a little money,” right? I had some debt, but I was also 25 or 26 years old by that time. So it was kind of like, “Okay, I’ve got to start working here.”

I made the decision to associate with another doctor and work in some captive situations with a couple of friends of mine who were general dentists and doing orthodontics for them.

I think the mistake I made was that I probably should have spent another day in my own practice, even though I might not have been super busy that day, investing in myself. Ultimately, that would have provided a better return on investment than what I was getting just working for someone else.

Early on, I was thinking, “Okay, I’ve got to fill my week,” rather than leaving a day open to build my own practice. Frankly, I was working five or six days a week throughout my entire career, which sounds crazy, right? But I felt that was what was best for my family.

Now, if I could pivot for just a second, I’ve practiced in almost every kind of situation you can imagine. I owned my own practice early on. I was working as an associate for another orthodontist, and I was working as the captive orthodontist for a couple of dental practices my friends owned.

I then bought into a practice where I had two partners who were pediatric dentists. I had my own practice two to two-and-a-half days a week, and I also worked with the pediatric dentists two to two-and-a-half days a week. I should say two to three days, because that’s how I ended up working five to six days a week.

We ultimately sold that practice to a DSO, so I became an employee of a DSO. Then, as I mentioned, I sold my practice to my son. Now I’m an associate for him.

I’ve pretty much done the whole gamut when it comes to practice ownership and employment. Each situation has its advantages and disadvantages.

MD:

I was able to use that experience to my advantage. But again, as I said, it probably took me away from building that smaller practice at the beginning.

I’m not saying that practicing with two pediatric dentists wasn’t amazing. It was an amazing change in my life. But at the same time, I probably should have spent a little more time building my own practice on that off day early on.

MJ:

That makes sense. That’s an amazing range of experience to have across all those different practice environments.

What’s interesting is that we work with orthodontists in all of those scenarios, and they all have slightly different needs. We also work with a lot of residents and people coming out of residency who are either saying, “Hey, I’m not quite ready to be a practice owner yet. I’m going to be an employee, build up my clinical skills, pay down some debt, and then maybe revisit this in a few years.”

Then we have others who have an opportunity in front of them for whatever reason and can become owners.

We talked about educational debt obviously being a major change. The other piece is that construction costs are different than they were previously. Are you seeing people who want to get into ownership right out of residency starting their own practices or acquiring existing ones? What are you seeing?

MD:

First of all, I think the overwhelming majority of people coming right out of school are going to work in a corporate setting at some point, simply because, as you said, they’ve got student debt they want to pay down.

I think what’s interesting is that I’m seeing more people go the startup route. I didn’t see that when I was coming out of school.

Part of this is that, given the growth of OSOs and DSOs, a lot of practices have been bought. Those practices were taken off the market, probably never to come back. So there aren’t as many practices available for new graduates to purchase.

I know there are residents out there who want to buy a practice. I also know there are still orthodontists who would like to sell their practices privately rather than selling to corporate. I think we have to find a way to bring those two groups together.

I know the ADA tried to introduce a program a few years ago to do this. It wasn’t as successful as they wanted it to be, not because it wasn’t a good idea, but I think if we can find a way to connect these new graduates with doctors who want to sell, we’ll see more people acquiring practices.

The other part of it is that some new graduates, and even graduates who’ve been out for a few years, are looking at practices that were purchased by corporate groups and seeing those areas as potential opportunities for startups, depending on how the transition has gone.

Again, these offices that were purchased were great practices. The people who owned them worked really hard to build them up and achieve the valuations they did.

I’m not sure that putting in a new doctor will always automatically translate into the same success. So sometimes that can be an opportunity in certain areas.

MJ:

That makes a lot of sense. I think another path we see is people who want to buy into a practice, kind of like what you described in your own experience. They want to get started, but they don’t want to be the sole owner. They do want some skin in the game and a way to build wealth and have a little more ownership over their day and how they practice.

I think a buy-in is a way for people to get their foot in the door. Later down the road, we sometimes see it become a way for them to eventually take over the practice.

Personally, I’m biased because I really like the idea of doctors staying in charge and owning their practices. I think it’s a model that allows patients to have a little more choice. There’s also good data across multiple specialties showing that doctor-owned practices can decrease healthcare costs.

So I agree. I would love to find ways to connect doctors who want to sell to other doctors. They’re out there. We just have to figure out how to bring them together and make those transactions happen.

MD:

Yeah, at the AAO, we do have a career center where people can post job listings. They can also post that they’re looking for a job. Again, it’s about timing, too, right? It’s like, “Okay, I need to buy something now.” Well, it might not be right now. Maybe it’s six months from now or a year from now.

That’s generally how I guide new graduates coming out. You might not find it right away, but that doesn’t mean you won’t.

I think the other real key, and you mentioned going into a practice and working with another doctor, is mentorship. The new graduates I talk to over and over mention mentorship. They want mentorship. Frankly, depending on your situation, you may or may not get that mentorship. If you’re working with another doctor, you certainly will.

Working with my pediatric dentistry colleagues was great. I learned so much from them. Being able to walk over to them in our private office and say, “Hey, what about this or what about that?” was so valuable for me. I think that’s something new graduates are craving.

Frankly, I tell them that when you’re looking at an opportunity or a situation, if mentorship is something you’re looking for, make sure you bring that up in the discussion.

MJ:

I love that. I know I keep bringing in my own clinical experience, which is different as a physician, but I think it’s very similar on the medical side. When you finish residency or fellowship, you’re in the thick of it with your colleagues, learning from people all the time. You get into private practice, or even academic or employed practice, and it’s a little bit like parallel play. It’s not always very collaborative.

I love multidisciplinary clinics. Personally, it was great for me to join the practice of people who trained me, where I could still sit next to them, learn from them, and see patients. I think that was very valuable.

We see this on the general dentistry side, too. A lot of dental students still don’t feel quite ready for general dentistry when they graduate, so they go into residency. I think that speaks to the desire for more mentorship and training, as you mentioned, so they can feel comfortable seeing patients on their own.

MD:

Absolutely.

MJ:

There’s some data the AAO put out that I thought was interesting. It’s the AAO’s Economics of Orthodontic Survey report. It showed that ownership among orthodontists was at 91% in 2014. In 2022, it was 71%. At that point, 28% of those under 35 were employed at an OSO or DSO.

Where do you think that number will land in 2035 in terms of the percentage of orthodontists who own practices? Do you think it continues to slide, or does it stabilize?

MD:

I’m going to step back for just a second and talk a little bit about what our data looks like, too, because of the way we ask the question. We list a number of practice modalities and ask you to pick one. I’m not sure that really paints a picture of what the true landscape looks like.

I’ll use my son as an example. He purchased my practice, and he owns it and works there three days a week. But he also works in a corporate setting two days a week. When he takes that survey, he checks the box for solo practitioner, owner of his practice. Well, really, he’s an owner, and he also works in a corporate setting.

I think we’re changing that and looking at how that works moving forward.

But the essence of your question is what happens in the future. Do we become totally corporate, or is there still a place for solo-owned or even small-group practices, with one- or two-doctor practices?

I think what we’re already seeing is a plateau. Part of the reason, I think, is that a lot of the practices purchased by OSOs and DSOs were bought when interest rates were really low. Now, as they’re paying that money back, interest rates are much higher, so acquisitions have really slowed down in that space.

You’re also seeing many more joint ventures instead of 100% buyouts of offices. They’re doing 50-50 arrangements or things like that.

When OSOs and DSOs were originally buying fractions of practices, a lot of times it involved a retiring doctor. Well, that doesn’t work great for them because they need someone to keep working at that office.

I think the landscape is changing significantly and quickly. That doesn’t mean corporate ownership is going away. I certainly don’t see that happening, but I also don’t see privately owned practices going away.

I don’t know what that number is going to be, but I do think we’re seeing a bit of a plateau. I don’t think we’re going to see the growth we saw over the past few years.

MJ:

Yeah, that makes total sense. We’ve even seen and helped dentists buy back their practices from DSOs. Like you mentioned, they were purchased at a time when money was cheap, and now money isn’t cheap.

These large private equity groups are having a hard time selling their assets when they’re working with that five- to seven-year timeline for a liquidity event involving those practices. It’s a very different time than 2020 or 2021, obviously.

The same thing is happening in orthodontics and medicine, quite frankly. People have offloaded these practices they bought and are realizing, “Well, it’s too expensive now.” So that’s a great opportunity for doctors to get their practices back and regain some control, which I’m obviously biased toward.

MD:

Given the margins in orthodontics, it’s not unreasonable that private equity would be very interested in that kind of office.

But I think one thing people sometimes forget, as I mentioned before, is that it costs a lot of money and takes a long time to get the education that allows us to do what we do. There are only about 425 new orthodontists graduating each year, which is a really small number for the entire country.

For OSOs and DSOs, that creates a difficult cycle of recruiting and retaining doctors because they’re dependent on these doctors. I think that’s probably the part private equity may not have fully understood.

As you said, they have five- to seven-year windows. That’s what they want to do, but it’s been a little more difficult to sell some of these practices, or the accumulation of these practices, on the second or even third go-around.

MJ:

That makes total sense. I wanted to touch back on the residency piece. You mentioned the number of trainees coming out each year.

I’m curious about where you see the federal loan caps we mentioned having an impact. For listeners who may not know, we’re talking about $50,000 a year, along with a lifetime cap. This especially affects people in healthcare, particularly those in dental specialty pathways who have to pay for residency.

How do you see the federal loan caps affecting residency slots?

MD:

It’s tough to say how they’ll affect the number of slots because I was just talking at UIC, where I went to school, and they had 500 applicants for nine spots. There is still a lot of demand.

In talking to other program directors and department chairs, they’re still seeing tons of people applying. I’m not hearing that they’re thinking, “Okay, we need to reduce the number of spots because there aren’t enough applicants.”

We’re still early. The law just went into effect in July, so we really don’t know what the long-term impact will be.

But we do worry that it will limit who can apply. You already have a lot of debt from dental school, so do you say, “You know what? I think I’m just going to go ahead and practice as a general dentist instead of applying to specialty programs”? Or will only wealthy people be able to apply to these programs? We certainly don’t want to see that.

We also don’t know what impact this could have on where people choose to practice or how they practice. Will they go to rural areas or areas just outside major metro areas? Those have traditionally been places where you could build a very successful practice. Will people still go to those areas, or will we end up with an access problem that’s much larger than what we have now?

It’s also important to understand that more than 50% of new orthodontic residents graduating are female. If they’re married, they also have to think about employment opportunities for their spouses and where those opportunities might be.

So it’s not as open as it used to be, when you could go to an area that wasn’t necessarily close to a metro area, a beach, or a mountain, as we always like to say. At the same time, those areas could offer a great lifestyle, a really successful practice, and an enjoyable life.

MJ:

That makes a lot of sense. Part of the concern I hear when talking to people at dental schools is the ability for students to get approved for private loans. As you said, residency programs aren’t quite feeling that yet because those students are grandfathered in and still have access to Grad PLUS right now.

The concern is that students may not be approved for private loans. According to our internal analysis, about 15% of first-year dental and medical students who needed a private student loan for this coming year had either a credit score below 660 or a thin credit history with no established score.

That’s a problem for private lenders. And as you know, just like I do, not every student has access to a cosigner who can take on potentially hundreds of thousands of dollars in debt.

Do you see there being a solution to that, especially when it eventually starts affecting residency programs?

MD:

Yeah, I’m hoping that because this just went into effect in July, we’ll see some changes moving forward. How quickly that will happen, I’m not sure.

As you pointed out, one of the issues with going the private loan route isn’t just the terms, but also the interest rate. Federal loan terms are much more favorable in a lot of ways, including what happens if the borrower passes away or other circumstances like that. Will those same protections exist in the private market? Who knows?

I know my dad cosigned for me for dental school. I’m not sure he would have cosigned for hundreds of thousands of dollars, so that’s certainly something we’ll be watching carefully.

Our advocacy team is always looking for opportunities, and we’re hoping we’ll be able to see some changes.

We do have a piece of legislation called the RAISE Act that would allow residents to defer their interest while they’re in residency. That would lower their loan burden when they graduate because it’s easy to accumulate another $50,000 to $100,000 in debt just from interest during a two- or three-year program.

That’s certainly something we’d like to see. But we also know that in Washington, it’s really difficult to get legislation passed, so we’ll see what happens with that.

MJ:

That idea would be huge. As I mentioned, when I had a quarter-million dollars in student debt, I would sometimes be in noon report, potentially zoning out, and calculating how much interest was accumulating on my student debt during that 50-minute session. It wasn’t a very happy way to pass the time.

If that interest weren’t accumulating because of the advocacy work you’re doing, that would be a huge win for residents.

What’s interesting is that the ADA’s Health Policy Institute had similar data on practice ownership for dentists zero to 10 years out of dental school, which was around 8%. That’s obviously lower than it was a decade ago.

But what’s interesting about their data is that it also showed that as dentists advance through their careers, the proportion who own practices goes back to nearly the same level as it was 10 years ago.

That goes back to what we discussed earlier. People need to pay off their debt, and they want mentorship and clinical experience.

Do you see that continuing on the orthodontic side, where the eventual goal for most orthodontists is to become an owner to some degree?

MD: Agree. I think so, and I think there are a few reasons. Certainly, debt is one reason people go into corporate. Sometimes people go into corporate for work-life balance because they feel like if they work for a corporate practice, the company will take care of all the issues that come with running an office.

The reality is that, in the back office, that might be true. But when you’re working with patients and an assistant doesn’t show up, you’re the one who’s working short. You’re still the one who has to deal with that issue, just like an owner would. As time goes on, people start to realize that, yes, there’s support there, but they’re still doing a lot of the day-to-day work. If a piece of equipment isn’t working, you don’t just stop for the day and quit. You try to keep going. I think that trend will continue.

The other part, which we don’t talk about a lot, is that there are significant tax advantages to owning a business. You don’t get those same tax advantages as an employee. The analogy I like to use is that plumbers and electricians all make money, but the person who owns the plumbing or electrical contracting company makes more because they own a business.

I think the tax advantages and the ways you can build wealth through business ownership, which you don’t have as an employee, become more obvious as you get further out of school. You might not even understand those benefits when you’re coming out of school. I think that creates an opportunity for people in the future.

MJ: Great point. We see early-career orthodontists who get into practice ownership having questions about growth, whether that’s adding a second location or investing in a new piece of technology. Where do you see most owners in that growth phase struggling with cash flow the most?

MD: I think what’s interesting is that, at the same time you’re going through that professionally, you’re also going through a lot personally. You’re buying a house, having kids, trying to save money for college, and trying to save for retirement. When you look at your finances as a whole, things get a little trickier.

I think separating your personal finances from your professional finances and understanding that the professional debt you’re taking on is an investment in your future can make those decisions easier. It’s hard to say, “Am I going to spend $100,000 on this piece of equipment, and what impact will that have on my personal life?”

If you’re working with the right people, they can guide you through that and show you that it might not have as much of a negative impact on your personal savings as you think. Your personal savings are important, too, but you can use debt to your advantage when making professional investments and developing your practice.

MJ: Wise words from someone with a lot of experience. I love that. We’re about to get into our rapid-fire true-or-false round, but first, I want to give you a chance to answer something I think is very important. If you could give an elevator pitch on why membership in the AAO and advocacy are important to young orthodontists, what would you say?

MD: First of all, if you look at our new brand up in the corner there, it says, “Empowering Your Today, Defending Our Tomorrow.” As you mentioned earlier, advocacy is vocational insurance. When you join the AAO, you’re getting that insurance, and there’s never been a more important time to have it because there’s never been more outside pressure on practice owners.

We’ve always had to deal with things like insurance, but other factors are becoming even more prominent. Without the AAO working on your behalf, it becomes really difficult.

Unfortunately, and I don’t mean to sound negative, nonmembers benefit from our advocacy efforts as well. We try to explain that to what I’ll call future members. You can’t do this by yourself. The work the AAO does on your behalf behind the scenes can’t be done by an individual.

For example, I just got an email from the FDA a couple of weeks ago saying that it had changed its guidance on clear aligner therapy based on recommendations from the AAO. Those recommendations came out of face-to-face meetings with the FDA. That would never happen for an individual, unless maybe your brother-in-law worked there. An individual wouldn’t have that kind of access or be able to make that kind of change.

As we discussed when talking about the state level, making changes to the Dental Practice Act can help keep your patients safe while also helping you become more efficient. That won’t happen unless the AAO is strong and our advocacy efforts are strong.

Market share is really important when you’re talking to a legislator because they want to know who you’re speaking for. We’re speaking for 85% of orthodontists in the country. That means something different than saying we’re speaking for 45% or 30%.

When you invest in the AAO, you’re investing in your future, too. I kind of chuckle because it’s old guys like me doing this work, but I’m really doing it for my son and people his age and those coming after them.

MJ: I love the specific example with the FDA, too. That really brings the point home. Some might call nonmembers freeloaders on all the hard work that AAO members do. The same goes for organizations like the AMA for physicians or the ADA for the broader dental community.

I appreciate the work you do for your profession, but ultimately, it’s for patients, which is the purpose of all this work. Thank you for that.

I’m going to move into the rapid-fire round. Essentially, I’ll give you a statement, and you’ll tell me whether you think it’s true or false. It’s generally not that rapid because we start going down rabbit holes, but I’ll try. All right, let’s start with number one.

True or false: You’d buy a practice again today at 2026 valuations?

MD: Absolutely. I think there’s still so much opportunity, and there’s still demand for our services and for specialty services. I’m very bullish on our future.

MJ: All right. True or false: In 10 years, most orthodontists will be employees?

MD: True, but with the caveat that many of them, probably most of them, will be employees of their own S corporation. So they won’t necessarily be employees of a corporate practice. They might be employees of their own S corporation.

MJ: I love the nuance there. That’s great. It makes sense.

This one’s a little harder. True or false: Orthodontics is the best specialty in dentistry?

MD: Absolutely, right? I mean, I’m obviously very biased. My son didn’t follow in my footsteps, so I guess I had an impact on him.

MJ: That makes sense. Well, this one’s an easy one, too. Speaking of bias, true or false: Chicago is the best food city in America?

MD: Absolutely. Across the board, from fine dining all the way down to the best Italian beef and pizza. There’s an amazing array of ethnic cuisines and options at every price point. You can spend a paycheck on dinner, or you can spend $10 and get a great beef sandwich.

MJ: That’s amazing. Now you’ve made me want to go back. I’ve been to Chicago a lot and have eaten plenty of food there, so I agree. It’s a great food city.

Of course, at Panacea, we’re very excited to work with the AAO to support practice owners as they buy, acquire, and grow practices. It’s been a pleasure working with you all.

We always ask the same question at the very end, so I’m going to ask you what might be the hardest question: What’s one thing you’ve recently changed your mind about?

MD: I thought I was going to be able to walk into this job as president and still maintain a normal life. I was completely wrong about that.

Thankfully, my son owns the practice now and can run it, because I didn’t realize I was going to be forced into retirement when I took on this position, which I love. As I mentioned, I was on the board for nine years, so we see what’s coming. But I don’t think we fully understand on a day-to-day basis what the impact is going to be.

I was just away for the weekend for my daughter’s wedding. We were staying somewhere outside the normal service area for internet and cell service. The minute I got into an area with cell service, my phone started exploding with questions and messages.

So that’s what I’ve changed my mind about: I thought I could step into this job without it having too much of an impact on my personal life.

MJ: Well, I appreciate the sacrifice you’re making for the profession. This has been great. Thank you so much for your time. I know you’re very busy. Where can our listeners find out more about your work and the AAO?

MD: Absolutely. They can go to www.aolinfo.org. That’s our website. For our members, I would encourage you to read The Wire every week. That’s where information comes from the AAO to keep you up to date on what’s happening in orthodontics and what’s impacting your practice.

MJ: Dr. Durbin, this has been great. Thank you so much for your time and for sharing so much information about what you’re doing for the profession. We appreciate it. Thank you.

MD: Thank you. Thank you for having me.

MJ: You can catch The Podcast for Doctors (By Doctors) on Apple, Spotify, YouTube, and all major platforms. If you enjoyed this episode, please rate and subscribe. Next time you see a doctor, maybe prescribe this podcast. See you next time.

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