The first time consolidation stopped being an industry word and became a thing on my desk, I was doing something clerical. A cohort was about to start externships and I was renewing affiliation agreements, working down a list of offices I knew. One had changed hands. The dentist whose signature was on the old agreement was still there, still chairside on Tuesdays, but he could not sign the new one. It had to route to a regional office in another state.
The paperwork sorted itself out. What stayed with me was the site visit. The assistant who had been there longer than anyone, the one the owner used to send to a course whenever a new procedure came in, now had a title, a wage band, and a written competency tier. On paper she was doing better than she ever had. She also had no idea who to ask about the next rung.
The old ladder was built by one dentist who happened to notice you
When I built the dental assisting program at Beckfield College, the path I described to students was the one I had watched work. You graduate into a private office, and if you are good and the owner is paying attention, things start happening to you. He sends you for your radiography credential. She lets you sit in on treatment plan presentations until you can run one. Somebody notices you are the only person who understands the recall system, and the schedule quietly becomes yours.
I used to hold that up as the reason this field was worth entering. I describe it differently now, and the reason has nothing to do with consolidation. That ladder was never a ladder. It was a sequence of favors from a person under no obligation to do you any, and the people who got them were not reliably the ones who had earned them. Ask anyone who spent five years working for an owner with no interest in developing staff. There was one person's attention, and attention like that is weather.
A group can build a rung a single office cannot
That is the part the profession gets wrong about DSO growth, and I have no stake in defending it. A group with dozens of locations can do things a five-operatory practice will never afford. Onboarding becomes a curriculum rather than the new hire being handed to whoever looks least busy, and a DANB pathway becomes a budget line. Most of all, the tiers get published, with what each pays and what you must demonstrate to move, so an assistant two years out can read her own future off a document instead of guessing. I sit on the employer side now and cannot match most of that from a single site.
A posted tier is not the same as a path
Here is what I hear from preceptors and from people I have interviewed out of group practices. The tiers are published, they are accurate, and nobody's day has room to climb them. Moving up a rung means demonstrating something you do not get assigned. The office runs to a production template with no slack for an assistant to be slow at a new skill for three weeks. Advancement waits on a vacancy in the region, which is a real mechanism but not one you control.
The function the old owner performed, which was noticing, has no owner in the new structure. Standardization replaced the arbitrary part of that attention. It did not replace the attention. A regional director responsible for eleven offices cannot know that the assistant in operatory three has been taking the hardest cases all year, and the system she reports into records procedures, not judgment.
This changes what a program owes a graduate
I sequence this differently than the field does. Programs teach clinical skill and then, near the end, spend a session on resumes and interview manners. That was adequate when the first employer was a person who would fill in the rest. It is thin when the employer is a structure.
Credential literacy belongs in the curriculum, and none of it is clinical: which DANB routes exist, what the state radiography credential requires, and where expanded functions sit in Ohio against Kentucky, because a graduate here will work both sides of the river and the two answers differ. So does reading the tier language in a posting and asking about it out loud in an interview, starting with the question almost nobody asks: what did the person who had this seat last year do to move out of it. An assistant who can produce a record of what she has actually done has an argument, and a regional system that cannot see her chair will not make it for her.
What I tell a graduate now
Take the job with the structure, and do not count on the structure to develop you. Those two sentences sit badly together and I think both are true. A group will give you a published tier, funded credentialing, and a door into another location when this one stops teaching you. It will not notice you. Somebody has to, and increasingly that somebody is you, which is a lot to ask of a person in their first year out. Most of us are still teaching the ladder we grew up on, and that office changed hands.