Win some, lose some

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Confessions of a goody-goody

My sister ironically went to a Catholic private high school and as we walked through the Abbey, she motioned to the confessionals and said, "you see those porta-potties over there? Those are confessionals. You should try one sometime." For the next half hour I couldn't talk--well, none of us could. Being doubled over does that to you. But for the life of me, I never did understand exactly why she said that. I mean, little did anyone know she was about to lose her virginity before I did...a few weeks before I did...and she's five years younger. And it didn't get any more innocent from there.

It's not like I risk being brought to shame, put on the stand, burned at the stake, or otherwise whisked away into the witness protection program. But I do have a few skeletons in my closet. Like the fact that I still like the New Kids on the Block, for instance. Or the fact that the only person I've ever been fully intimate with is the man I'm married to. Or the fact that I *never* smoked pot, or did any other illegal drug. Hell, I don't even like the effects of the legal ones. I've been known to be fond of a clove cigarette, but even that is a thing of my past, having quit in school, somewhere around Tri 6. Heh! Cat's out of the bag. It's not like anybody knew at the time. I'm a hopeless conspiracy theorist, by the way.

Sometimes I crave ice cream...and at times, a clove. But, Good Girl Extraordinaire that I am, I never give in to any of it. I'm still into country music, though, even if it's on the inside. I download a shit-ton of mp3s off the internet--gigabytes a month. Screw iTunes; I'd have to mortgage several houses. I'm addicted to Dillard's. Commercials make me want to throw the TV through the patio door. So do questions about whether or not I take insurance. Satellite dishes freak me out. So do big, wide rings around the moon, heights (especially at night), bright slow-blinking strobe lights accidentally left on the daytime settings in nighttime fog, and the Northern Lights.

Nothing to write home about. (Well, except maybe the NKOTB part.) Guess I won't need to confessional after all. My sister, on the other hand...

A cleanse that doesn't suck

So anyway, we're on this 3-week cleanse. It's not the Master Cleanse, that suicidal endeavor of which variations populate the internet like dandelions. No, I actually do get to eat, and even function. I don't have to lock myself in the bathroom or stock magazines next to a toilet. I even have the energy to get out of bed and go to the office! (It's the little things.)

The Cleanse is interesting. After having our own personal Mardi Gras of sorts, what with bison, corn-based spaghetti noodles, tomato sauce with four cheeses, nightcapped with a bowl of ice cream and chocolate syrup, we took The Plunge. Three weeks of anti-inflammatory, uber-organic, hypo-allergenic diet, the middle week of which is also vegan. Oh and let's leave town for our monthly neuro class in Dallas right in the middle of that intense second week. Life just wasn't interesting enough before. (Bonus: Room Service is going to see our Vitamix blender and chocolate hemp milk and large cannisters of cleansing protein supplement/antioxidant powder and go...who TF are these people??)

Surprisingly enough, I'm not ready to kill someone for the bread crumbs in their toaster or the milk in Murphy's bowl. Nor am I craving those chocolate syrupy goodies immediately following dinner. The toughest part is actually planning the meals and figuring out where to obtain such a tall order. What I thought would be the toughest part, dealing with the cravings for various foods at various times, is a piece of (gluten-free vegan) cake. There are no cravings. None.

With the cravings disappeared half my appetite, too. I have no idea why. Then again, a salad isn't exactly ice cream. My dinner plate has maybe 2/3 the food it did before, and I don't really need dessert. The only meal that hasn't changed is breakfast. Hey, I've got a good thing going with a fruit and veggie smoothie with rice and pea protein powder; if it ain't broke don't fix it.

At the beginning, I said, "you watch--I'm going to feel so good on this diet that I'll have to stay on it forever." See, my usual curse is that the universe plays with me in said strange ways. It had my fate by the balls and it knows it. Naturally, all I was trying to do was head it off at the pass by actually voicing it. Joke's on me, because that's exactly what happened.

See, I tried to fit into my skinny jeans and at first, I had it in the bag. There I was laying on the bedroom floor with my skinny jeans zipped up (zipped up!) and then I had to go and do sort of a lay-up to get up. At that point, it was all over, but hey--I also knew that when I went to pull up those jeans they wouldn't just stop halfway up my thighs like they did two weeks ago. There is Hope. We've made Progress.

Living the dream--no, for real - Part 3: Living the dream

Slight insomniac attack. The symphony continues...

OK, now that you've made your decisions, set up your space, and you're ready to start, now what?

Like I said before, do NOT lock yourself in your office with a calculator! Do not drive yourself around in circles in financial panic. This is a tough time, yes indeedy, but it is not impossible. Keep a clear head, be prepared to work hard, and you'll survive it.

Also worth repeating: money and time go quick. Watch both like a hawk, spend both wisely. Have a plan and stick to it. Write it down if need be.

Back to regularly-scheduled programming--getting the patients.

With any luck, you've set up shop in an area where the prevailing overall personality/vibe matches yours; you've got to be compatible with the people. You've got to be comfortable where you live. If you're not, and you're miserable where you're at, don't waste another minute; consider a move.

With any luck, you feel good about your office space and how it turned out. The reality often materializes slightly different from the vision; that's OK. Hopefully, it set well with you.

Time to open your doors. During this time, try to resist any temptation to take another job. Other jobs will only take away time and energy that you'll need to invest into your own practice, and trust me, a new practice is like a newborn baby--they take a LOT of energy and resources. Now, if you're sinking or you've got a family, then be responsible and do what you need to to provide adequately, but seriously--try to slash your cost of living so that you can survive these next few LEAN-@$$ months.

Building the practice is slow at first. The best thing is, like I mentioned before, to start with your neighbors, then just up the street, and then slowly work a wider radius. It's all about headspace. When people ask what you do, stick with conditions/specialties you have some experience and confidence treating. (You'll have to fake some of the confidence for a while; that's OK. You'll have to call more experienced colleagues like old professors for help/guidance fairly often at first. That's OK, too.) But seriously--go in with the intention of helping. Be enthusiasic. Don't be slimy or sales-y. Dress nice but casual, like clinic attire without the tie. Project the persona you're comfortable with. Match your community; if you're in a down-home small town atmosphere, you won't want to go in wearing a 3-piece suit with flambuoyant accent colors. Headspace, headspace, headspace. If your intentions are good, you'll reap good karma. In fact, you'll be a refreshing switch from the weirdo fringe DCs or the cattle call MDs, and people may just flock to you - in small droves first, sort of a trickle, but then steadier and steadier.

Keep your bubble small; live, shop, work, and play within just a few square miles. This way, the same people pare more likely to see you and become familiar with you over time. Eat at the same restaurants (tip well, leave your card!), volunteer for local events, shop at the same grocery stores (strike up conversations with people in line with you or cashiers at checkout), visit gyms and yoga studios, offering to do some free demos, health talks, or even basic treatments. Limit it to something like 2 hours per week per venue, call it community service, tell people that giving back is a big deal for you and in your practice, and you'd be surprised. Choose a nearby bank and make friends with the tellers and managers. Joke with them, be friendly, have a good time. Attend their customer appreciation events. Locate massage therapists, doulas, midwives, other DCs, open-minded MDs/DOs, compounding pharmacists, conventional pharmacists, yoga instructors, colon hydrotherapists, psychologists, RNs, health food stores, martial arts studios, personal trainers, etc etc and build meaningful relationships with them. Avoid coming on too strong about your practice. Be a likeable personal first, be a good neighbor, emphasize your commitment to your community. That said, a word of caution: make sure that what you say is true. People are smarter than we often give them credit for, and their BS-o-meter will go sky-high if they don't think you're for real. So be for real--mean what you say and follow through.

Other healthcare practitioners will often invite you to events, whether it's a support group for a condition like migraines, a group for a cause like breast cancer, parental groups for kids with ADD/ADHD, etc. We got invited to a large, local cross-disciplinary Functional Medicine group. Do not be afraid to meet the other DCs in your area. Chances are, they practice differently than you do or that y'all excel in different areas. Maybe you take different insurance plans. Even if you're exactly the same, your personalities and practice management are different, so you'll attract different people. It's good to 86 the weirdness that often puts up a wall between neighboring DCs. You're not competition for each other any more than you're competing with the liquor store next door for the customer's disposable dollar. Mmmm-kay?

Avoid direct-mail advertising; instead, seek out niche advertising. If you'd like senior citizens, there are plenty of seniors guides and whatnot out there that you can advertise in. If you like the more well-to-do crowd, you can advertise in free holistic practitioner magazines in the bins at the front of health food stores like Whole Foods. Figure out what demographic you want to attract and go there.

You might also try networking groups like BNI. BNI is a paid version of a networking group, but there might be a free group or two out there that someone has put together for fun. If not, you can form your own! That could be another segue into meeting people that doesn't involve the automatic salespitch of your business; simply mention that you're trying to get some business owners together in a weekly/bi-weekly networking group at no cost. Maybe you can trade off whose house you meet at to save money by not having to rent out a restaurant and you all bring refreshments potluck-style.

With BNI, you can attend each group twice before they insist that you join. Bring some cash for a meal/weekly dues. As you meet people, don't forget to show interest in THEIR business. See how you can work together. Think of who you know might be looking for their services that you can refer to them.

One intern I knew got through clinic successfully recruiting all of her patients easily. I asked her how, and she said she just engaged in fun stuff she liked to do, without going there just for the patients. She did things like yoga, martial arts, working out at the gym, etc.

You'll be amazed at how life threads together to weave a tapestry. People are brought together and connections are made with a simple spark. We attended a seminar in our city, and met a fellow DC a few miles away and a compounding pharmacist who happens to be just up the street and knows everyone, including like-minded MDs/DOs. Also, one of the first people we met was a neighbor just down the hall in our building. She introduced us to a colon hydrotherapist, a Functional Medicine group, and a well-read holistic magazine at Whole Foods, and made sure we knew who the pharmacist was. This person also facilitates network/support group, body-mind-soul oriented, for those battling or winning against cancer (or who know someone who is, or maybe they don't but they're interested anyway), and she invited us to speak right away at the following month's group meeting. Wherever you go, bring cards! Offer to display other peoples' cards in your office, although be choosy. When someone has treated you well or whatever, ask them for a whack of their cards so that you can display them in a card holder that holds 6-12 cards. You never know who will see them, and you never know who will come see you!

One of the coolest things we did was, not only did we decide to treat on the first visit (many DCs think it devalues our work; I say phooey, and my experience as well as the stories I hear from the public back me up), but we decided to give that first adjustment away. Yes, you heard me: FREE. We are so confident in what we do and that the patient will feel that much of a before-and-after difference that we put our money where our mouth is (literally) and adjust them at no charge. Our reasoning for this was that in our society, there are lots of barriers to chiropractic: cost, overall prejudice, bad press, flaky/weird/substandard DCs, etc, and we wanted to eradicate one of the biggest barriers of all: the financial burden. Most people simply don't like the idea of paying someone they don't know a couple hundred bucks before they even get adjusted (because many DCs don't adjust until the 2nd, 3rd, or sometimes 4th visit!) , especially in a slumped-over, anxiety-ridden, unstable economy. Take that barrier away, and people know they feel better, and then they come back ON THEIR OWN...and they gladly pay you, and we charge about $15 more than the average DC. They also accept our recommendations for rescheduling timeframes, adjunct massage therapy treatments, lab testing, and supplements, without question. Why? They TRUST us. We've earned that trust.

Address money with your patients. You both know it's on their minds, so meet it head-on. Tell them you know firsthand what it's like to be cash-strapped. Be straight up with them. You're not the cheapest, but you're not the most expensive, either. And over time, you're the most cost-effective, the most bang for the buck, because you get people better faster and you DON'T keep them coming back needlessly. The whole subluxation-based practice thing? I hate to say this, but it doesn't work. This concept is part of the reason DCs see 6-percent-and-falling of the population. I know firsthand that the high-volume, year-o'-care, 3x/wk plans do not sit well with patients. So please don't go there.

Seriously, just be straight up with patients and be patient-centered. If you are, people will see that, and they'll appreciate it. If you truly, sincerely want to help, they'll sense that from you. If you tell it like it is and you're nice the whole way through, you'll build trust quickly. If they want to go, let them go, and let them know they're always welcome back. You won't please everyone, and some people are simply set on being negative. Those people won't be happy no matter what you did, so don't take it personally. Others are subconsciously attached to their issue. This sabotages any progress you try to make. Usually they're not consciously aware of this. And truth be told, not every treatment failure is the patient's fault. It's the doc's fault almost as often. Sometimes it's no one's fault; it's just a personality or preference mismatch. That's OK, there's someone/something out there for everyone and for everyone that goes, there will be many more that come and stay! :)

Living the dream--no, for real - Part 2: Managing your money

OK, that got a little long. My apologies!

Where were we? Oh yeah--money, and trying to save it.

My husband and I lucked out. I'd been a licensed massage therapist in private home-based practice for about 3 years prior to starting chiropractic school, so, anticipating this point in our lives from that far back, I worked like a dog through undergrad (and the first couple trimesters of chiro school as well) to save up a really decent amount of money. Add to that our decent money-management skills and, well, we were among the lucky ones who graduated with a bank balance in the black.

While we were in school, we assumed that opening our own practice from scratch was NOT the route we were going to take. We figured it would be too nerve-wracking, so even though we knew we wanted to have our own practice soon, we operated from the mindset that it'd be best to work with/for someone else for a while first. This way, we could hone our adjusting skills, make beginner mistakes under a name other than ours, figure out how an office runs in real life, learn how to really recruit and relate to patients, and start saving the necessary funding.

Ha. My how things change. We met our mentor who taught us everything I mentioned before, and before we knew it, we were pouring over commercial properties for lease instead of job openings. Life often takes unexpected turns; be ready for anything.

While we were waiting for our licenses, we started designing our own paperwork. We went to seminars - neuro, Functional Medicine, pediatrics, and adjusting. Those classes gave us the much-needed confidence we new docs often seriously lack. We prepared--hard, often staying at the office until sometime between 10pm and midnight, having arrived between 10 and 11am and worked straight through lunch.

The biggest thing to remember is, SAVE YOUR MONEY. I'm talking mainly to the newly self-employed here. Also, if you can, try to avoid taking another job. If you have to take a part-time job, do Saturdays at Whole Foods for decent pay, decent benefits, and a discount on good groceries, or work with another doc (not too close to your office, but not too far either), whether adjusting or just doing exams. You'll keep your hands warm and you'll be forced to interact with people.

The WORST thing you can do is hole up in your office, scared to move, alone with a calculator, locked into a number-crunching frenzy, freaking out over finances and overhead, going further into the red, all the while meeting no one and driving yourself to insanity. I know what it's like to be nervous - been there. Just when you feel like hiding in your office, you need to force yourself to leave your office. Put the calculator away. And meet people. Start with your neighbors. This way, you can introduce yourself not as a nervous peddler of services, but a neighbor. Go in with the intent of making a friend, someone who can hold your FedEx packages for you or whose phone you can use when your power goes out. Be a good neighbor first and foremost.

Figure out exactly what you will need on Day One. We actually sat down and made a list of conditions we can help with (i.e. figuring out our first target markets) and then we brainstormed for all the supplies/equipment we would absolutely need to help with those conditions. We didn't think too big on this one - sure, we might have an interest in working with people with brain injuries, paralysis, stroke, seizures, etc, but we're not prepared to do that yet, so we shouldn't market to them yet. This also means we won't need that equipment yet. Carpal tunnel and food allergies, on the other hand, we were confident we could help. When you visualize your practice while still in school, you think in terms of theory, because none of it is real. Well, now it IS real, for the first time. You may have had a grand vision of 10 years in the future, running full boar and treating everything under the sun, but chances are, you're not there yet, so you have to step back and ask yourself, what can I do TODAY? What are you confident about? What do you have internship experience with? Start there. Then, put it to the test; if such a patient walked into your office RIGHT NOW, what would you do with them? Visualize that, from start to finish--the handshake, the paperwork, the history-taking, the lab work (how would you order the lab test?), the exam, the report of findings, the treatment plan, the treatment itself, the schpeel for follow-up treatments, offering to reschedule, the whole nine yards. This is infinitely easier if you have a mentor that you can shadow a few times. My husband had one for spinal adjusting; I didn't have one for Functional Medicine. I had a lot of work to do when it came to managing cases and my entire side of the practice. In fact, I'm still tweaking it. Time management is the biggest issue for any new doc; learn to manage it well, and early, so that patients don't develop an expectation that you're always going to spend a long time with them. You might be able to spend an hour and a half with them now, but this won't be the case for very long.

Go bare bones for a while. Once you've figured out what you absolutely need Day One (adjusting table, paperwork, a computer and printer, phone, desk, chair, exam equipment, lamps and other furniture, etc, get it as cheaply as possible. Amazon is good, as is Craigs List if you know what you're doing. Always do your research and beware of scams. When going to make a Craigs List exchange, bring someone with you and try to meet in as public a place as possible. Everything you don't absolutely need Day One, shelf it for a while. You can always get it later. You don't need the expensive art or big TV for the waiting room just yet. You don't need a second phone line yet, a view box yet, or big fancy rehab equipment. Wait till you've made some money first. For things we didn't need on opening day, our philosophy is, once the business has 1) demonstrated a need and 2) brought in sufficient money to fund it while meeting other upcoming bills, then we make the purchase.

Next item - you're going to suddenly feel very popular. People will crawl out of the woodwork and magically know you exist, but they're not prospective patients--they actually want YOUR money. They're salespeople. They'll try every trick in the book to sell you anything under the sun. You'll be visited by many Ghosts of Chiropractic Future--nutritional supplement companies, Acai juice MLMs (pyramid schemes), advertising guides/magazines, bulk mailers, office supply retailers, credit card machine vendors (multiple), and even some lab companies. If you're interested in their products/services, cool - give them your time, but put a cap on it, say 30 minutes. One lab rep actually had the audacity to TELL me he was going to need at least an hour and a half of my time. I denied it, allotting an hour instead, which is generous. Having learned from that experience, I now cap anyone trying to sell me anything at 30 minutes. My philosophy is, my own patients, who are paying ME, get 30 minutes of my time at a time, why should someone who wants me to pay THEM get any more than that?

When salespeople come in, don't forget to spend just as much time talking about your own business. Always have the meeting at your office, not theirs, because this sets the stage nicely for you to start off with a tour of your office, during which you explain all the services you offer. "Here's our front lobby; we don't like the word 'waiting room' because that sounds like such a cattle call", and "here's our massage therapy suite over here; massage therapy here isn't a feel-good spa experience, per se, but we can deal with the serious cases like post-car accident or sports injury - it's called medical massage and it's often covered by insurance", and "here's our treatment room here with nice lighting, i.e. no fluorescents, and we have special cushy drop tables that absorb a lot of the impact of a spinal adjustment so that you get the results without feeling all the force", and "here's our PT area where we'll do active rehab using a Wii Fit - who says you can't play video games at your doctor's office??" etc. The tour is surprisingly quick and by the end, you've just nonchalantly promoted every one of your services. The salesperson may never come see you, but they know where you are located and they know what you offer, and you never know who they'll tell, especially if they like you.

When presented with products or services, especially those involving commitments or contracts, never, ever, ever make a decision on impulse. Take time to look over the contract. Ask questions. Don't worry about being a pest or taking up their time; they came to you, remember? They have something to sell you, and they have a commission to gain from your business. It's your money and money is typically finite, so make sure you spend it wisely. Make sure you've obtained satisfactory straight-up answers to every single question. If you don't understand an answer or their reasoning or a procedure, have them clairfy or explain again. And, ALWAYS make sure to compare multiple offers. This is especially true for things like advertising mediums or credit card processing machines. Lots of money and long contracts are involved, and there's a wide variety in the quality of terms, contract, equipment, support services, etc. Go with your gut, no matter how insignificant or "overreactive" it seems.

Avoid pitfalls such as: high credit card percentage/rental terms, MLM (pyramid) companies, service contracts on printers, supplement companies who devote more literature space to sales rewards and perks than to genuine product info, supplement/equipment/lab companies who drag their feet when it comes to producing genuine third-party peer-reviewed research to support their products/services, companies who diss their competition, PR/marketing firms (trust me, the average startup DC is not big enough for that, nor are we usually prepared to handle the kind of sudden traffic a media blitz will generate), people who don't follow up or return phone calls (or conversely, people who won't leave you alone and keep checking on you every other day), lab companies who are all-too-eager to bill the patient's insurance for you (especially if you've expressed that you'd like to bill their insurance yourself), landlords who push their contract on you without considering any of your own wishlist items, or anyone who gets defensive when asked a tough/sensitive question.

Ways to cut costs: as mentioned, shop Amazon and Craigs List. IKEA can also be good (the quality can be surprisingly good; you just have to evaluate each item for itself, as not all are created equal), but the best we've found are local stores and warehouses. There are many good used furniture warehouses, usually located in light-industrial parts of town. Find them on the internet or via word of mouth. You can save lots of money by buying used. The only things we didn't buy used were our tables; our protocol requires uncommon features/design, so we had to custom-order them. We went to our local tourist trap for our cultural office decorations. They were surprisingly inexpensive and we got some neat items that contribute spashes of color throughout the office. Shop sales (especially during holidays like Memorial Day, Presidents Day, or Independence Day), order items together to combine shipping costs, etc. You'd be surprised at how much the savings can add up.

More ways to save: forgo hiring any employees just yet. Yes, answer the phone yourself, or if you have a partner with a flexible schedule, have them come in and help you. Employees are expensive, even at minimum wage without benefits - and good luck attracting even the bottom of the barrel with that. We got a voice mail system and explained to our patients that in order to provide what we do at the reasonable cost we charge and to keep it that way, we need to keep overhead low, which means forgoing a front desk assistant for now, and in the event that they call the office and both of us docs happen to be seeing patients, to please leave a message and we'll call them back as soon as we get done. Everyone's been real cool with that. As for adjunct staff, hire massage therapists, personal trainers, PTs, etc, and make them all independent contractors. You can't dictate their schedule or how they accomplish what you want them to do, but you save on the withholding taxes and you don't have to pay them during downtime when they're not doing anything.

Last, do accept credit cards. We went back and forth on this idea, at first deciding not to because of the costs involved, but ultimately deciding to go forward with it when our mentor said: "make it easy for people to pay you. Soon you won't even notice the fees involved. You won't even care."

Up next: how to add MORE money to the pile - once you're open, how do you get those patients?

Living the dream--no, for real - Part 1: Groundwork

Seems I've been MIA in terms of the blogosphere. Sorry about that! My absence is actually due to reasons we like to hear: it's getting busier. Make no mistake, it's not like we have a waiting list practice (yet--think positive!) but it's starting to pick up. Some days are busier than others; in fact, some are downright quiet. But we've been blessed so far, and it has been a combination of 1) the universe/higher power working in our favor, bringing the right people together at the right time and convincing people to call us, 2) our sound patient management strategies, and 3) I don't know but it seems like there should be a third reason.

I was going to wait a little while before writing an entry that gives tips and tricks for getting started and being successful, but I've heard from several sources that I should probably write what I've learned so far now, because people could probably use it. I know it's probably a little premature, and I'm definitely not going to claim to be any kind of practice building/management expert, but why wait?

First, don't panic; we're all in the same boat, more or less, and we're all sort of freaking out. I remember asking several profs a mere couple weeks after graduation if it was normal to be this nervous. And it's not like the nervous tension lifted, either. In fact, with the bills piling up and our licenses processing like molasses, I barely slept through February, March, or April. I had heart palpitations. I had a sympathetic nervous system reaction every time debt relief commercials came on. In fact, by April, I was so limbic about money that I couldn't watch my favorite Disney film "Aladdin" because I was so envious of them being able to go into that cave where they're surrounded by coins and jewels and such. Sucked. And that was only about 3 months ago.

Second, unless you go straight to work in a firmly-established practice as an associate under another doc, keep in mind that two things are very precious and they're going to go very fast: money and time. Utilize both very wisely.

Now we can get down to brass tacks...

First and foremost, we approached a mentor. This person taught us quite a bit about business and a protocol he designed, using some conventional and outside-the-box chiropractic and soft tissue techniques. He taught us practice management, how to shave costs without cutting corners, and lots of other stuff, even furnishing us with a complete set of his paperwork, both internal and public. So, I highly suggest that this be your first step, whether you're still in school or you've already graduated. It's never too late. They'll save you tons of time and money, and they can be a great seasoned sounding board for dilemmas that arise as you progress further into practice.

Second, we had to make a decision of which type of practice arrangement we wanted. The 2 main choices presented (and given the most emphasis) in school are: 1) start your own practice (typically from scratch) or 2) go work for someone else (in theory whether you're a W-2 type associate or a 1099-type independent contractor is governed by the IRS and there is supposed to be a sharp distinction but in reality there isn't).

What they don't emphasize so much is that there are several other options. 3) You can rent space under someone else in sort of a sublet situation. This "someone else" can be a DC, and it usually is, but it doesn't have to be. I know many who went to rent rooms in other DCs' practices but I also know a few who went to work in integrated practices alongside MDs, PTs, and PAs. You can also 4) start a practice from scratch with some buddies. Again, these buddies are usually DCs, but they don't have to be - same as above. In options 3 and 4 you can save lots of money by sharing the space, equipment, utilities, phone lines and internet connections, office supplies, and even employees like receptionists and massage therapists. Another option 5) is to go mobile. This is the lowest overhead of all, but it's also the trickiest. Most insurance won't pay much for housecalls, and depending on the traffic situation where you live, it may not be worth the energy or time it takes to get from Point A to Point B. Also, this doesn't work so well if your primary technique is osseous, because you may want to have x-rays first. And there's the issue of lugging exam equipment. But I do know some mobile DCs and they're having a lot of fun. They save money and they can help people who can't easily get around. They also have an ever-changing environment. They can also fill a niche that isn't often offered by most DCs. And the last option I can think of is 6) buying a practice. This was the option we were going to choose. Like every option, this has its advantages and drawbacks. It's great in that the practice is already set up, the location and name are already established, and most importantly, you have patients on Day One. Pitfalls arise when there is a personality, philosophy, or technique conflict, or a miscommunication of expectations between you and the current practice owner, or between you (the newcomer) and the practice's patients. They're used to one thing, and you may want to do another. Maybe they're used to using their insurance and you want to go cash-only. Or they're used to osseous adjusting and you like Activator. Or they're used to 15-20 min appointments and you want to be higher volume. Or maybe they just want their neck and back cracked and you want to augment their experience with nutrition. If you go this route (buying an existing practice), make sure the current practice fits well with where you want to take things.

Third, we had to decide what kind of practice we wanted. We're continually tweaking this, as we evolve with increasing education and inspiration. At first, my husband and I were both going to be doing the same thing--adjusting. We'd just let the cards fall where they may in terms of patients and which of us got which patients. Then I found a way to get back to my nutrition and cleansing roots, and I decided I liked that even better, so our pathways diverged. This worked out great because there was no longer a question of which of us would get which patients. If they have any body aches and pains or any musculoskeletal problem, they go to my husband for chiropractic adjusting. If they have any other health issue involving disrupted physiology, they see me. We're currently involved in a post-doctorate neuro program (the Real One :) ) and we may or may not decide to incorporate more neuro into the practice once we finish. Our practice is continually evolving and changing in subtle ways.

Fourth, we had to decide where we wanted to practice. Our mentor said, to paraphrase, screw the demographic studies. They're helpful, but not everything. Instead, go where you feel comfortable. First you figure out which climate you like, then which state, and finally which city/town. When deciding between multiple states, first evaluate them in terms of how much you LIKE the state. This is incredibly subjective. If you find you like 2 states exactly the same, THEN look at scope of practice laws. (Now, if you're doing something like nutrition or ordering lab tests as big parts of your practice, you may want to start by eyeballing which states have better scope of practice laws and then figuring out which of those states you like best.) Once you know which city/town you like, visit. We would take 3-day stints, book a hotel, and we acted like tourists, then we acted like residents. We drove the main freeways in rush hour traffic so we could see what an average rush hour commute was like and evaluate the rudeness factor (or lack thereof). We stopped at local neighborhood grocery stores to shop for tomorrow morning's breakfast cereal to evaluate what's available and again, how people acted. We went to the neighborhood malls, visited various office buildings, drove through residential neighborhoods, picked up local papers, watched local news, listened to local radio, and more. We drove and drove for 3 days, and we took lots of 3-day trips over the course of a year. Then we went on City-Data not for the demographics and crime rates so much, but rather the neighborhood forums to see what citizens are saying, to see how helpful they are to each other, and become familiar with local issues, events, attitudes, philosophies, shortcomings, and amenities.

When you're driving the streets, you don't necessarily know everything about that neighborhood, but you can start comparing neighborhoods and you start to get a feel for where you feel more comfortable. You'll start gravitating toward certain areas, and away from others. Neighborhoods and even whole cities have prevailing personalities; make sure it's a good fit for you.


Next, if you're not going to work for (or buy) an existing practice, you'll want to visit Loopnet.com. This site has a comprehensive listing of commercial property for sale AND/OR rent. The search feature is good, although the returned results are only partial; you have to pay to become a premium member to see all the listings. If you're starting your own, either by yourself or with buddies, I HIGHLY recommend you bite the bullet and pay for the premium access. It's only something like $20 for 24 hours or $50 for a month. It's easy to see what a good investment it is, especially when you consider how much you could save over the life of a several-year lease if you stumble upon a good deal.

The space we scored was perfect; it was an 1100 sq ft suite in a 2-story commercial building (in a great area, off a main thoroughfare) that has professional office/executive suites upstairs and some high-end retail shops on the first floor. Our particular suite had housed a chiropractic practice before; we were told he went under because he overextended himself financially on a side project, but we hear from various other people that his technique/practice management were slightly subpar. Nevertheless, his space was perfect for us; the front lobby and receptionist area were already in place, as was a fully enclosed treatment room, a break room, and a large rehab space. We kept the front lobby and receptionist area as is, converted the treatment room into a massage therapy studio, and we opened up the break room into a PT/rehab area of our own, and then took the wide-open space and divided it in half and enclosed it into 2 matching treatment rooms. A thousand square feet of space is overkill for one doc, but it's good for 2 or 3. If you have more than 3, consider a bigger space.

Keep in mind that no matter what any real estate brokers (primarily on behalf of the owner), property owners, or landlords tell you, commercial developers overbuilt commercial office space in many major markets. Add to that a sagging economy, and it's been that way for several years already. This means that there is more vacant space right now than they want to admit to. What this means to you is, negotiate, negotiate, negotiate. Remember that what the landlord claims is a "standard lease agreement" may be just that to him, but in reality it's a landlord's wishlist. When entering lease negotiations, do remember to bring a wish list of your own. Make sure to include some items that you'll ask for but aren't all that emotional about getting; this way you can appear to make concessions and appear agreeable so that you're more likely to get the things you really want, like contributions toward buildout, etc. Note: it really helps if your landlord is NOT a mangement company but rather a family-owned kind of situation, especially if the family is somewhat local.

I forget what all we asked for in our own wishlist, and we certainly didn't get everything on it, but the biggest plus is that we secured ourselves the first 2 months rent free. The landlords also contributed a certain (generous) amount toward our buildout (to our specs, even) and all we had to pay for were any upgrades we wanted. They also included our electricity (lights, A/C, heat) and water. We avoided that pesky extra Triple-Net (NNN) because we're on the second floor instead of the ground floor. All in all, we got a great deal.

About 90% of all small businesses fail within the first 5 years. Of those that survive, 90% of those fail within the next 5 years. Why? Insufficient funding. Usually this comes from underestimating expenses, but we DCs have the added "bonus" of being fairly cash-strapped upon graduation. Banks aren't helping much, either, having tightened the reigns when we were still in school. You either have to have private funding from another source (like family or business networks) or you go through SBA's program, jump through their (reasonable) hoops (at no cost to you) and they sort of act as support for you when you go approach the banks. You're slightly more likely to obtain a loan if you're with SBA. To quell the urban myth, there is no such thing as an SBA loan in that the SBA doesn't issue loans. They will, however, go to bat for you when you try to get a loan through a bank if you've been through their training.

More on money and overhead after these messages...