Dr. John Q. Experience has been in practice 15 years. He has built a good practice. He has a nice facility and a well-trained staff. But he isn't feeling quite as passionate or energetic as he used to.
Dr. Experience goes to bed puzzling over the solution to his dilemma. Suddenly it hits him: "Get an associate doctor. Of course! This will be perfect!" He pictures himself supervising a bustling office where the new doctor is doing all the hustling and running from room to room.
He pictures Dr. Jane New, fresh out of school, seeing all the patients - or at least the ones Dr. Experience doesn't want to see. And of course, she will do all the lectures in the office, and she will have to stay late or come to the office on weekends to see emergencies. He can imagine all the money this is going to make. He will never do another insurance form or report - he'll assign them to Dr. New!
He pictures Dr. New out in the community meeting people and giving lectures, since Dr. Experience hasn't quite felt like there was time to do such things in a while. Patients will be calling the office because they will see how progressive and busy it is. Dr. Experience may just need two associates so that he can spend more time on hobbies and golf. Dr. Experience knows his patients love him, and they will obviously love anything his office does. Patient loyalty is like money in the bank.
Dr. Experience drifts off to a dreamlike state while he envisions leaving the office in time to have dinner with his family every day - every day except Wednesday and Friday - when he won't be working at all! And maybe he will need to take Tuesdays off just to take care of administrative matters; there will be a lot of supervision and business matters to tend to. Maybe he should just stop seeing those needy patients altogether, and get even more associates!
Wait - maybe he should open another office! Dr. Experience hits REM sleep just as he sees a chain of clinics with his name on the buildings. Being a chiropractic tycoon makes for sweet dreams. But how can he find the associate of those dreams?
Meet Dr. New
Simultaneously, Dr. New is finishing a long day at the student clinic. She will be graduating next month. She has done well in school and exceeded the minimum clinic requirements. She is clinically skilled and enthusiastic, passionate even, about helping sick people get well. She can't wait to go to work.
Dr. New's dreams are plagued by the haunting presence of school loan demons. Every time she pictures herself in practice, she wonders how she'll be able to repay the student loans. Then there are the managed care goblins. She's heard you have to be in practice for three years before you can be on a managed care panel. She wonders how she can survive for three years and still pay back the student loan demons. Dr. New does not sleep well.
Dr. New comes up with a plan. She will get a job as an associate! Yes, that's it. She can get a job with a guaranteed paycheck, she can pay toward her student loans, and all the while she will be "pulling down the big bucks" because, after all, she has worked hard in school and she had to take more parts of the National Board testing than even Dr. Experience did. She feels she's worth it.
She'll learn all that she can possibly learn, make all her rookie mistakes on "the old guy's" patients, and then build a little nest egg before moving on to set up her own office (maybe not far from Dr. Experience). Of course, she will be collecting all the forms and materials that Dr. Experience uses. She thinks she will have it coming to her after the way he will pay those slave wages while he makes all the real money. It will be part of the compensation.
This plan is perfect, she believes. She'll get a job where she will be paid a doctor's salary: she will have no risk; and the patients will be handed to her by Dr. Experience. She can just focus on being a doctor and won't have to get involved in any of that distasteful marketing activity. This is the solution - no risk and all reward. If it doesn't work out, she'll just move on.
Dr. New needs to find this job. She has plans to load up her 1984 Toyota and drive for two days to the state in which she prefers to practice. She'll get a room at a local motel, then get the phone book and start cold-calling all the chiropractors in the area to find one that needs an associate. This is her ticket to success.
| Dr. Experience | Dr. New |
| Established, ongoing business | Latest scientific and clinical information |
| Reputation | Energy |
| People know to come here for chiropractic | Passion to get to use her new skills |
| Established systems and paperwork | Need for "real world" clinical training |
| Fully equipped facility | Need for a guaranteed income |
| Years of experience | Need for training on business of practice |
| Desire for more personal time | Willingness to devote large blocks of time |
| Desire to be around fresh enthusiasm | Desire for increased income opportunity |
| Desire to expand services and hours | Geographic mobility (usually) |
| Financial stability | Excitement |
| Trained and managed staff | Possibly a long-term commitment |
| Possibly a retirement transition strategy | Desire to get in practice without starvation |
| Community contacts | Desire to learn business practice |
| Positive cash flow | Desire to gain experience for managed care |
| Desire for increased income | Possible springboard to her own practice |
| Managed care contracts (sometimes) | Desire to maximize the return from the efforts of those first few years in practice |
| Possibly cheap labor for undesirable tasks | Desire to avoid a false start or bad relationship that costs valuable time |
| Ability to influence the rest of the new doctor's career | The most to lose in momentum if relationship ends prematurely |
| Willingness to advance salary now as investment with long-term payoff | Risks investing the high-energy years of career with potentially no job security in the practice to see long-term payoff |
| The most to lose financially if relationships end prematurely |
The Contract
Dr. Experience and Dr. New somehow hear of one another and find that they seem to get along over the phone. Dr. Experience doesn't want to spend any money on having a contract drawn up, so he calls up a former classmate and gets a copy of a copy of a contract. In fact, he gets several contracts and blends them. It doesn't occur to him that the contract could have clauses that are unenforceable in his state.
Dr. New doesn't have the money to have an attorney review the contract. Both parties focus on only one or two clauses, primarily the guaranteed salary and the noncompete clause. They both have very specific expectations for this relationship but, unfortunately, they have never shared them with each other.
The Outcome
Neither doctor is being realistic. They are both fantasizing; both are planning on taking advantage of each other, even if they don't admit it.
The relationship lasts about eight months and then falls apart, with both doctors feeling used and negative about the experience. Dr. Experience now knows why associates get abused: They're ungrateful. Dr. New now knows why associates don't stay very long: They are being taken advantage of.
The Costs
This episode cost Dr. Experience a lot of his time in training; he lost patients because of Dr. New's rookie mistakes; he paid for Dr. New to do work he could have done better and faster himself; he had staff trouble because his relationship was not well managed; and he spent more time in the office, rather than less. He advanced salary that brought him no return on investment.
This episode cost Dr. New her energy and enthusiasm. She now wonders if she can be as passionate in a new job. She worked hard but wasn't paid much. Her hard work was supposed to pay off when the practice grew, but she wasn't there long enough to get the rewards. She reasons that maybe it was a good thing she didn't stay, because the early experiences in her career would tend to influence her over time. Dr. Experience's practice was not as successful as she once believed, and she is left with the impression that doctors tend to exaggerate how successful their practices are.
The Reality
The reality is that neither of these doctors can be part of a successful associate relationship. They are both focused on what they can get, rather than on the value that they can add.
Dr. Experience has focused on time off; increased income; less stress; and increased reputation and ego. He hasn't evaluated his goals to see if adding an associate (after calculating the realistic costs in time and money) to his practice is compatible with those goals. He has not evaluated the pros and cons of the investment he must make.
Dr. New has made assumptions about what she is "owed" by virtue of getting her degree and license. She has not taken inventory of her needs or of the value she brought to the practice. She has not considered the costs involved to the practice that hired her. In her mind, Dr. Experience's struggle to get the practice to this point was all just "luck" during the "golden business" days.
Both doctors would have benefited from taking an inventory of what they were able to bring to an associate relationship, and what needs they were hoping to fill. I feel strongly that this inventory should always be written.
What They Bring to the Table
Below is an example of some of the assets, needs and wants that are brought to a possible associate relationship by each doctor. Some are obvious, while others force the doctors to be blatantly honest with themselves and with one another.
The list, while not complete, is an example of an honest inventory of what two doctors may bring to a practice relationship. This is one of the first steps to entering a successful associateship. The steps that I recommend when consulting with doctors are to identify:
- motivation for entering the relationship;
- goals (including length of commitment);
- "needs" versus "wants" for the relationship;
- "unacceptables" (i.e., unethical conduct);
- preparation/prerequisites (new equipment, staff, time, etc.); and
- the value each party brings to this relationship.
Why Good Associates Go Bad
Ultimately, the problem leading to associate relationship "train wrecks" is poor communication. There is a problem with quantity (not enough communication) and quality (not knowing what questions to ask). In my experience, doctors are lacking a system, a step-by-step map to follow so that all stages of communication are addressed; so that the success of the relationship can be enhanced by proper planning and setting of expectations.
The Marriage Analogy
In my consulting with doctors, taking them through a similar process as described above, I am able to detect incompatibilities and red flags. The associate relationship is a major step that almost approaches the seriousness of marriage. You will probably spend more time with your associate doctor than with your family - at least, at first. Just like in marriage, associate relationships must go through a dating stage. This is the stage most often rushed by doctors. They don't take time to really get to know the goals, dreams, personality and work ethic of the other doctors. Doctors should spend more time in this stage.
Then there is the ceremony stage: the contract signing. This is often under-researched, rushed, and poorly conceived in associate relationships. After, there is the honeymoon phase, where the other doctor can't do anything wrong and each overlooks any irritating quirks. You also go around patting yourself on the back for making such a good decision. Then reality hits.
Summary
- Dr. John Experience should evaluate if his practice justifies an associate (if it's profitable).
- Dr. Experience should evaluate his goals and expectations to see if they can reasonably be met by an associate relationship.
- Dr. Jane New should truthfully evaluate her goals and objectives, and must be willing to stay in the associate relationship long enough for Dr. Experience to see some return on his investment in salary and training.
- Both doctors should do a careful written inventory of the value they bring, their needs; wants; goals; expectations; and unacceptables.
- Both doctors should have a clear idea of what they are giving up in order to be a part of this relationship, as well as what they stand to gain.
Joseph Siragusa,DC
Charlotte, North Carolina
(704) 844-6993
