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...