For the new doctor, it is generally an easier transition to practice as an associate in a good, ethical office than to start up a new clinic. Going from school to the real world is difficult; there are many variables, and it can be overwhelming. Starting a practice in the 1980s was easier than it is to start a new practice in 2002. Managed care did not exist in the 1980s. Another disadvantage with managed care for established doctors is that it has routinely cut into their incomes and makes them less able to support associates.
Let's talk about a few key points for both parties to consider. A written contract is obviously important. There is an old lawyer's saying that if it is not written down, it does not exist. Be wary of the doctor who does not want to have a contract and does not want to put the specifics into writing. This contract should be reviewed by an attorney. It is particularly helpful if you have an attorney who is familiar with this type of work. In our area of the country, we do have such an attorney, and it is quite convenient, because he can design a contract in less time and, therefore, for less money than an attorney not familiar with this type of work.
Establish up front what the length of the contract will be. If the associate wants to learn with you for a couple of years and then move on to start a practice, that should be established up front. If the owner-doctor plans to have the associate eventually buy into the clinic, or if the owner-doctor has no plans for such a transition, that should also be established up front.
Pay should be another up-front issue. If discussing money is avoided and danced around, that is a red flag; if the pay scale is so complicated you need an accountant to figure out how you are going to be paid, that is a red flag; and if the pay sounds too good to be true, it probably is, and there could be ethical and legal issues involved. Conversely, if the associate doctor is willing to take a very low salary, there may be problems to watch out for. Remember, you get what you pay for: location, location, location. You should go where you will enjoy living. You do not need to be in a vacation resort; however, if you despise warm weather and the beach, then south Florida is not for you.
The techniques used, and the practice style of each doctor, are quite important. There are advantages to having doctors with similar practice styles, and there are advantages to having diverse practice styles. We feel in the long term, it is much easier on patients if the doctors have similar styles. For example, a Gonstead practitioner and activator practitioner can both do outstanding work; however, there will be confusion for the patient. Another example might be a Gonstead practitioner and a diversified practitioner. These two would more easily work together than the Activator and Gonstead practitioners.
Consider whether you feel your doctor-owner or doctor associate has any ethical challenges. If there are any signs that the other doctor is willing to sidstep ethics for money, that should be a red flag. There are plenty of ethical, outstanding doctors who have wonderful clinics.
What kind of learning environment will there be? This goes both ways. Will the owner-doctor take time to help with case management? Does the new associate bring any new information and enthusiasm to the clinic? A good learning environment makes it more fun for the doctors, and it ultimately benefits the patients.
How is the doctor-owner going to help the associate build a practice? What is the associate doctor going to bring to the table to help build it? If the owner-doctor is not willing or is not able to help the new practitioner build a practice, the doctor does not need an associate. The owner-doctors may argue that the new practitioner does not know how to manage cases, and will simply mishandle patient care. Well, the way to shorten that learning curve is to allow them to handle cases and help coach them in a positive way as they learn.
In regards to pay scale, one example is to set the new doctor up with a salary for the first year and help the associate build a practice, then transition the doctor into a performance-based salary the next year. The associate has a full year to start to build a practice. If no progress is made at the end of that year, it will be obvious that the associate needs to move on. The pay scale varies significantly from one area of the country to another, but it can work if the doctors are up front and desire a mutually beneficial relationship.
Generally, the associate doctor should be an employee of the clinic rather than an independent contractor. The IRS has specific criteria for independent contractor status, and it is difficult to meet that criteria as a full-time associate. There are tax advantages to bringing on an independent contractor rather than an employee, however, it may not be worth the risk. Such an arrangement would necessitate the services of an accountant and an attorney.
There are many financial advantages to having a group practice, including shared expenses, vacation coverage, and collective brainpower. There are also many pitfalls, including the fact that many chiropractors are quite independent in nature and have trouble "playing well with others." In summary, both parties must go into the negotiation with an open mind, an open heart, and the desire to ultimately do what is best for the patients.
Joel Johnston,DC
Oxford, Ohio
Mark King,DC
Cincinnati, Ohio
Dr. Mark King graduated from Life Chiropractic College in 1986. He is a clinician at Mt. Lookout Chiropractic Sports & Injury Center in Cincinnati; president and lead instructor of the Motion Palpation Institute; and a coach and co-founder of Cutting Edge Chiropractic Consultants.