What one $6 million orthodontic practice teaches us about systemic health
By Siegfried A. Naumann, DDS, MS
A young orthodontist recently shared a story with me that has stayed with me.
He had worked in a three-doctor practice producing nearly $6 million annually. From the outside, it appeared exceptional: strong revenue, full schedules, modern technology, and steady new patient flow. By most conventional measures, it looked successful.
Three years later, it was bankrupt.
The assets were liquidated, the team dispersed, and the patients were transferred.
On paper, nothing looked wrong. Production remained solid. New patients continued to arrive. By conventional measures, the practice appeared healthy and valuable.
Yet internally, something very different was unfolding.
The team felt chronically overextended, and turnover rose gradually until it became routine. Appointment schedules grew denser each quarter, patients felt rushed, and the doctors became increasingly removed from operational direction and long-term decision-making.
There was no dramatic collapse. Instead, pressure accumulated quietly across multiple areas until the structure could no longer hold.
That experience led me to reflect more deeply on our profession.
Orthodontics remains one of the most financially strong and professionally rewarding specialties in healthcare. In most cases, practices generate healthy income, meaningful patient relationships, and professional autonomy.
And yet, because that strength, we sometimes tolerate strain we would not otherwise accept. We may feel stretched, rushed, or disorganized, yet reassure ourselves that profitability justifies the stress. We tell ourselves that working hard and feeling pressure is simply part of running a successful practice.
I believe we can expect more.
Orthodontists are trained to think clinically. We diagnose malocclusion, design biomechanics, and anticipate tissue response with precision. But most of us were never formally trained to think systemically about the organizations we lead.
Modern orthodontic practice now requires both.
The profession does not lack structure. It lacks structural alignment.
If we want durability, not just growth, we must become system thinkers. Orthodontics deserves more than strong production. It deserves strong systems.
That shift in perspective may be one of the most important professional evolutions facing our field.
What It Means to Think in Systems
Most orthodontists manage their practices through numbers: production, collections, new patients, case acceptance, overhead. These measures are important, but they represent outcomes—not causes.
Systems thinking begins one level deeper, asking what structural relationships are generating those outcomes.
Instead of reacting to changes in production or turnover, system thinkers examine how the components of the practice interact. How does scheduling density influence assistant workload? How does workload affect morale? How does morale shape patient experience? How does patient experience influence referrals? How do referral patterns alter growth pressure, and how does growth pressure reshape scheduling?
In a system, nothing operates independently. Financial design, operational flow, clinical protocols, delegation patterns, team culture, and patient perception continuously influence one another. When one element shifts, others respond—sometimes immediately, and sometimes months later.
Understanding those relationships changes how we lead.
Core Principles of System Thinking in Orthodontics
1. Structure Drives Behavior
When assistants feel rushed daily, it is rarely a personality problem. More often, it is scheduling design, chair allocation, or delegation imbalance. When turnover increases, it is seldom coincidence. It often reflects structural strain: role ambiguity, workload compression, or unsustainable pace.
System thinkers look beyond surface symptoms to the underlying architecture that produces them. They adjust structure rather than simply reacting to frustration.
2. Delays Create Illusions of Stability
One of the most powerful principles in system dynamics is the principle of delay. In orthodontic practice, cause and effect are frequently separated by time, making the connection less obvious.
For example, a marketing push today increases starts in three months. Capacity strain appears six months later. Turnover begings to tick up nine months after that. Patient satisfaction declines gradually thereafter.
By the time symptoms become visible, the structural decision that initiated them feels distant.
This delay can create a dangerous illusion: the belief that growth is strengthening the practice when it may be quietly destabilizing it. The $6 million practice did not collapse suddenly. It unraveled through reinforcing feedback loops. Growth increased workload. Workload reduced morale. Morale increased turnover. Turnover reduced efficiency. Efficiency loss intensified scheduling pressure.
System thinkers learn to anticipate these delayed effects. They ask not only what a decision will accomplish next month, but what it may produce six or twelve months from now.
3. Growth Amplifies Existing Structure
Growth does not correct weaknesses; it magnifies them. If scheduling design is inefficient, growth increases chaos. If delegation is incomplete, growth increases doctor fatigue. If team training is inconsistent, growth increases variability.
When infrastructure is aligned, growth feels energizing. When it is not, growth feels exhausting.
4. Local Fixes Can Create Broader Strain
Practices often attempt to solve problems in isolation—adding marketing when production dips, compressing schedules when capacity tightens, or hiring quickly when morale drops. While these actions may relieve immediate pressure, they can create strain elsewhere in the system.
Many orthodontists attend excellent seminars or work with skilled consultants to improve specific areas—marketing, scheduling, delegation—and often see short-term gains; however, without viewing those improvements within the broader system, delayed side effects can quietly erode the progress they hoped to sustain.
System thinkers evaluate how each intervention will influence the entire structure before implementing it.
5. Durability Emerges from Alignment
True stability occurs when systems reinforce one another. Financial discipline supports predictable staffing. Predictable staffing supports operational flow. Operational flow supports treatment efficiency. Treatment efficiency supports patient satisfaction. Patient satisfaction supports referrals. Referrals support sustainable growth.
When these elements align, orthodontics feels the way it should feel: professionally rewarding, financially strong, and enjoyable to practice.
Durability is designed.
Beginning the Shift: The Discipline of Structural Leadership
Becoming a system thinker is not a technique to add to your management toolkit; it is a leadership discipline that reshapes how you interpret what happens inside your practice. It begins the next time something feels off, when the schedule seems tighter than it should be, when the team feels strained, or when growth feels heavier than energizing.
In that moment, resist the instinct to fix the problem immediately. Instead, pause long enough to ask a different question: What structure is producing this outcome?
Not who caused it. Not how to relieve it quickly. But what structural design—what pattern of decisions, incentives, scheduling templates, delegation habits, or growth strategies—is generating what you are now experiencing?
Then trace the pressure backward until you reach the structural decision that set the pattern in motion.
If morale feels strained, what altered workload? If workload increased, what shifted scheduling density? If scheduling changed, what influenced those patterns? If growth accelerated, what reinforced it? Often, what appears to be an isolated issue reveals itself as the delayed consequence of earlier design choices.
This is the work of structural leadership.
Most orthodontists were trained to solve problems efficiently and decisively. System thinkers learn to diagnose structure patiently. They recognize that today’s pressure is frequently the downstream effect of yesterday’s architecture, and that reacting too quickly can reinforce the very pattern they are attempting to correct.
From this awareness, adopt a second discipline. Before implementing any significant change, whether expanding marketing efforts, adjusting staffing levels, redesigning scheduling templates, or modifying delegation, ask a forward-looking question: What will this decision reinforce?
Every meaningful decision strengthens a pattern within the system. It may reinforce stability, or it may amplify strain. It may increase alignment, or it may widen imbalance. The discipline lies in considering not only the immediate effect of a decision, but also the pattern it will strengthen over time.
When you begin leading this way, something subtle but powerful shifts. Problems feel less personal and more structural. Reactions slow. Conversations become more thoughtful. Growth becomes intentional rather than impulsive.
Over time, you stop managing symptoms and begin designing durability. And when durability becomes the aim, profitability and joy are no longer in tension with one another; they begin to reinforce each other.
Structural leadership is not complicated. It is deliberate. And it is available to every orthodontist willing to see the practice not merely as a collection of metrics, but as a living system shaped by design.
A Different Expectation
Orthodontics remains an extraordinary profession: intellectually stimulating, financially strong, and deeply rewarding. There is no inherent reason that profitability must coexist with chronic stress or quiet dysfunction.
We can build practices that are productive and peaceful by design. We can enjoy clinical orthodontics while leading stable organizations that serve our teams and patients well.
But doing so requires intentional design.
It requires that we move beyond managing metrics and begin designing systems.
In future articles, we will explore how these principles apply to capacity compression, turnover dynamics, growth saturation, and practical evaluation of system health.
Orthodontics deserves more than strong production. It deserves strong systems.
And when our systems are aligned, the joy of practicing orthodontics does not diminish with growth—it deepens. OP
Photo courtesy of Siegfried A. Naumann, DDS, MS.
Siegfried A. Naumann, DDS, MS, is an orthodontist and practice systems consultant based in Gig Harbor, Wash. He is a co-founder of Ortho Instinct and developer of the Practice Health Score framework, which focuses on aligning financial, operational, and clinical systems for long-term sustainability. After 16 years of private orthodontic practice, Naumann became a Sloan Fellow at the MIT Sloan School of Management and earned an MBA in Innovation and Global Leadership. He lectures on systems-based leadership in orthodontics and can be reached at [email protected].
