Am I Ready for an Associate?
Knowing that you are ready for an associate chiropractor is based on more than the number of patients you see. It’s based upon your capacity. Depending upon the technique that the doctor utilizes, some practices can see 300 visits a week or more with a single chiropractor and have no problem with capacity. Other practices, that use more time-dependent techniques, might reach 125 visits a week and feel like their practice is bursting at the seams.
You’ll know that you are ready for an associate when it starts getting difficult for you to get patients on your schedule due to a lack of space. When you begin to hear patients complaining about having to wait longer to see you during their regular office visits or that they are having difficulty even getting on your schedule at all, you may have hit the “glass ceiling” for solo practitioner patient volume for your practice. If your patients are used to same or next day appointments and you have to book them three and four days out, it may be time for you to consider an associate.
Step Away from the Table
If as the owner of your practice, you find yourself anchored to the adjusting table to care for patients without being able to devote the time you need to grow and market your practice, or manage and train your staff, you may have reached maximum volume. If you are interested in taking a more entrepreneurial role in your practice, having an associate can buy you more time to devote to working on your practice rather than only being able to work in your practice.
An associate can also make it easier for you to achieve the work-life balance that is necessary to sustain a successful chiropractic career for the long term. Working 60 hours a week without having time to devote to your family life and outside interests is a recipe for practitioner burnout. Chiropractic can be physical work. If you are coming home at the end of the day with sore arms and dragging energy, you may be at your personal physical capacity.
The phase of your chiropractic career can also influence if you are ready for an associate. If you’ve been a solo-practitioner for 30 or more years and you’ve never felt that you needed an associate, bringing on an associate can be an important first step toward exiting your practice. Selling your practice to an associate who has worked there for several years can make selling the practice much less challenging. You’ve already established a relationship together, the patients know the associate, and if you are going to have to hold a note to finance the practice, you’d rather not be in the position of doing so with someone whose work habits and ethic are
unknown.
Where Is the Best Place to Find an Associate?
A great place to find an associate is right in your local community. In most communities there are doctors who are excellent chiropractors but not the best entrepreneurs. They are world class diagnosticians and give a great chiropractic adjustment. On the other hand, they are poor at running their own business. Merging this type of practice into your practice can be a win-win scenario for all parties. You’ll have more time to devote to the business of the practice while the associate doctor can focus on patient care.
If there is a chiropractic college near your community, make time to visit the campus to get to know the students and who the faculty recommend as potential associates. Most colleges have career fairs that will distribute your associateship information and pre-screen applicants for you. Even if the campus is not local to you, many students are open to relocating when given the opportunity. Some states provide the opportunity for chiropractic students to perform an externship in your practice before they graduate. Having several externs can give you the opportunity to see who rises to the top to receive an offer of an associate position.
Other Great Places to Find an Associate
Place notices in the student listing boards of the chiropractic colleges that surround your practice. Take note of colleges that are north, south, east or west of your location. Most colleges will allow you to post a job listing on their website for free or for a nominal free. It’s a good idea to peruse these websites on a regular basis, whether you are actively looking for an associate or not. This gives you a handle on what type of an associate pipeline will be available to your practice when you are ready.
Social media, in particular LinkedIn and Facebook are good sources for potential associates. Most associates looking for a position have a listing on all of the major platforms. Let your contacts know that you are in the market for an associate by posting on all of the major social media channels. All of the state chiropractic associations have websites that will allow you to place a job listing and many of them have printed journals that invite listings by members at a discounted fee or for free. Many state boards will make the list of recently licensed chiropractors available to you.
Your current patients can also be a source for potential associate referrals. They may have friends or relatives that they know who have a connection to a student who is looking for a job when they graduate. Make your network of patients work for you by asking them to help spread the word.
The Associate Paradox
There are two common personality types for associates: the technician and the entrepreneur. The technician is great at following the owner doctor’s direction. They will do a good job at maintaining your current level of patient volume. They, unlike the entrepreneur, do not have the ability to market the practice, generate new patients, lead a practice team and manage the business. There are several personality profiling tools available to help both associates and owners determine how well they will work together and they should be included in the hiring process once you have narrowed the field down to the final candidates.
The risk/reward that accompanies these two personalities is that the potential for employment longevity is greater for the technician than the entrepreneur associate. The associate who is entrepreneurial is more likely to see your practice as a stepping stone to owning their own practice in the future. As an associate, entering into an employment position, along with your own desires for the job, it is important to understand how the owner doctor sees your role in the practice. Have an open conversation about where you both see yourselves a year from now, three years, and five years from now.
It is common that a technician will be given a role of focusing on patient care and documentation. A technician will adjust, adjust, adjust, and adjust patients. An owner who is interested in an entrepreneurial associate will include him or her in running the practice as a business. This could include managing staff meetings and other aspects that will help the associate become prepared to run that practice or eventually a practice of their own. Finding the right match between personalities and the role the associate will play in the practice and agreeing upon both parties’ expectations is the key to a successful outcome.
Associate Agreements
There are two primary ways for associates to get paid, salary plus a bonus commission and straight salary. Let’s discuss these two different models. When determining the component of salary, first and foremost, and I encourage this in the interview process, is finding out exactly where the potential associate is financially. It’s one thing for an owner to have a base salary in mind. If the associate agrees to the amount without proper consideration to their financial needs, and the salary doesn’t meet those needs, there is going to be stress and anxiety that will not support a long lasting position.
Sometimes you have to ask some tough questions: “What do you need monthly to live?” “Have you determined a personal monthly budget, including professional loans that you have taken as an undergrad or grad school, and car, or credit cards?” “What kind of housing requirement do you have?” Think of this as more of a formula, rather than a fixed number. The base salary for an associate can vary widely based upon different states’ level of reimbursement, cost of living and the income your practice currently generates without the associate. If your ideas and your associate’s needs don’t match up, there might not be any sense in moving forward.
In most instances, the base salary will also include FICA and Social Security matching, state licensure fees, continuing education fees, professional coaching and seminars, health insurance, malpractice insurance and then any type of 401(k) or matching retirement account that you have in place. These expenses should also be taken into account when determining a bonus commission structure. In order for an associate to participate in a bonus structure, he or she must generate income at least equal to the base salary, over and above what the practice
was generating without the associate.
Bonus Structures
There are two commonly applied bonus structures. One is a percentage of collections that is on a scale that tiers up, based upon the volume of collections. As the volume of collections increases, the percentage of bonus increases up to a cap. The other bonus is based upon the total number of offices visits seen by the practice and is not based on a percentage of collections.
The office visit bonus is typically used when starting a recently graduated associate, who is not experienced in generating income. It’s an easy number for a new graduate to grasp and alleviates the owner from having to open his or her books to a junior staff member. The percentage of increased collections bonus gives the associate a greater opportunity to control his or her income by focusing on patient retention, delivery of ancillary services, active care and product sales. This structure also gets a more mature associate in tune with case management and minimizing missed appointments.
Training an Associate
Most chiropractors, when looking for an associate, seek a doctor who has a similar adjusting technique and philosophy toward case management and treatment plan recommendation. Be sure to have the potential associate adjust you to determine his or her competency as part of your interview process. It’s important for associate and owner to have a similar bedside manner. The ideal situation is one where patients are comfortable being seen by either the owner or associate for their adjustment. This removes stress from the patients and the practice team members.
In terms of training, I recommend a “shadowing process”, where the associate becomes the owner’s shadow for anywhere from up to 30 to 90 days. The associate follows the owner into the treatment room and observes the process of delivering an adjustment. Shadowing procedures should include new patient examinations, clinical and financial reports of findings.
Have the associate help out with ancillary services and active care to increase patient interaction and familiarity. Shadowing the front desk, billing department and other administrative positions provides an overall view of the function of the practice and the value of each role.
Priming the New Patient Pump
If the purpose of bringing on the associate is for the growth of the practice, then they will be expected to participate in new patient acquisition. A good attitude to have is that if you want your community to support you, you have to support the community first. Whether that’s getting involved in the Chamber of Commerce, a charity, an organization, or volunteering for a sports team—get involved.
If the associate was hired to maintain the existing practice, they will be assigned new patients by the practice for a set period of time in rotation with the owning doctor. This helps to “prime the pump” for the new associate. If a patient is not requesting to see a specific doctor, or if their referral is not from a referral source specific to the owner doctor, then there is a rotation. For example: with every three new patients that come in, two are assigned to the associate.
A popular approach, called the tandem practice, employs a rotation of roles between the owner and associate doctor. Each takes a turn performing examinations and reports of findings, while the other provider adjusts patients. This approach ensures that the associate doctor has the opportunity to learn important patient management procedures without requiring the owner of the practice to cede complete control over to a less experienced clinician.
When to Say Goodbye to an Associate
As chiropractors we don’t like saying goodbye. We think we can fix everyone. So how do you know when it’s not a right fit? Is it purely practice statistics or is there some leading indicator that lets you know that this is just not working out?
There are many indicators that an associate is not the right fit. They typically include procedural insufficiencies. It could be a lack of follow-through with documentation requirements, timeliness to the office, or timeliness with treating the patients. There is a tendency for associates to perceive themselves as being a peer with the non-licensed practice team members. This results in a sense of familiarity that makes it challenging for the associate to move into a leadership position. Owners can set their associates up for success by having the
preemptive conversation about being cautious to be perceived as a member of the practice leadership. A good attitude is always essential for all parties. Saying goodbye to an associate who was not the right fit for your practice opens the door for that person to achieve success in another practice in the future. It also makes room in your practice for the associate who is the perfect match for you, your team and your patients.
Dr. Mark Sanna is a member of the Chiropractic Summit, the ACA Governor’s Advisory Board, on the Leadership Committee of Chiropractic Future, LLC, and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching
(www.mybreakthrough.com 1-800-723-8423).