Don't Try to Scale Your Practice Until You See This In Your Numbers

Hire another associate, open a second location, drop insurance — or maybe change nothing at all? The truth is, just because your practice can grow doesn't mean it should.

In this episode, the DPH coaches will help you figure out what kind of practice actually fits the life you want. You'll hear the mistake that almost buried one of them, the steps you should take before scaling, and the honest questions that reveal whether a bigger practice is right for you.

Topics discussed:

(00:00) Introduction

(02:26) How to make your own decision

(06:45) The mistake that can break your practice

(09:52) A framework for deciding whether to scale

(11:40) The client who was happier staying small

(13:12) What type of leader you are (and why it matters)

(15:38) One thing to do whether you scale or not

(18:30) How to know when you're ready

This episode was produced by Podcast Boutique https://www.podcastboutique.com

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Transcript

Scaling Is Optional

Paul Etchison 1:09

Now, I know on this podcast we always talk about scaling, but here's the truth. Not every dentist needs to scale. And not every dentist should necessarily stay small and stay solo. That's the hard part. At some point in your practice journey, if your practice is doing well, you start to have these questions. Should I add an associate? Should I expand? Maybe I should open another location. Maybe it's time to drop insurance. Or maybe I shouldn't change anything and I should just keep doing what I'm doing. But the problem is that when you start having these questions, everybody you ask is going to have an opinion. The dentist that has 10 practices, well, they think that scaling is the answer. And the solo dentist who's just working three days a week, they think stink small is the answer. And then there's that person on Facebook who just thinks you made a big mistake going into dentistry at all. But you know what? None of these opinions matter if you yourself haven't figured out what you actually want. You know, just because you can grow doesn't necessarily mean that you should. And today we are talking about how you can better figure out what type of practice is best for you, how you can approach these questions, and what you should do when your practice is ready for the next step. Now you're listening to the Dental Practice Heroes podcast, where we help dentists build practices that fit their goals, create more freedom, and run on stronger systems, whether they want to stay solo, scale up, or just simplify. I'm your host, Dr. Paul Edison. I'm a practicing dentist, a two-time author, a dental business coach, and I'm the owner of a multi-doctor practice in the south suburbs of Chicago. And I can tell you, the longer I do this, the more I realize that growth only works when it's built around a life that you actually want, not the life that somebody else told you to chase. Now, today I am joined by my awesome DPH coaches, Dr. Steven Markowitz and Dr. Henry Ernst. We all have different stories, which is really cool. And it's going to give you some different perspectives. So this conversation that we're going to have in this episode, it's not about a right answer because there isn't a right answer. It's about it looking at the different paths, the different possibilities, all the different trade-offs, and deciding what's really right and what makes sense for you because we're all different and there's no right answer. All of the options are good, but you've got to figure out which one is right for you. All right, let's dive in. So,

Steve’s Growth Mindset And Trade-Offs

Paul Etchison 3:33

Steve, I'm gonna pass to you first, man. I mean, you're somebody who has gone from one practice to two to three to six, and you just kept going and going. And I mean, it was an addiction for you. Like your family couldn't pull you away from it. They were like, Dad, pay attention to me. And you were just like, I'm so invested in the business. I must own more. So tell us more, making some uh assumptions here, but it's yeah, no, it's okay.

Steve Markowitz 3:56

I I I'm uh I'm self-loathing, so this works out perfectly. This is such a hard conversation because it's so personal. And you're gonna listen to podcasts or read on Facebook, and and everyone's gonna show their how awesome their their way of doing it is the right way. And I I think it's all bullshit. So I think for all three of us, we all have our own journey and we're gonna share our perspective. But when you're deciding what you want to do for you, listening to me is probably the dumbest thing because this is what worked for me, and and I came from the mindset of if I'm not growing, I'm dying. And I didn't want to die, so I just kept growing. And that doesn't mean that that that was the right thing to do. In many ways, it may have been the wrong thing, but it's the reason why I kept growing, adding doctors, adding locations, all of the things that we're doing was if I I felt like if I was going backwards, that was wrong, or I was doing a disservice to my purpose, to who I am. And that's just what how it worked for me. At the same time, if someone were to say, I love being a single doctor, and I love my team of three, five, seven people, and this is how I want to keep it. Don't change it. Just because I I said I think that you can grow more, or you have patient demand that's saying that people want to see you. Like that, what a great thing, but that doesn't mean you need to say yes to every single thing that's coming at your way. So when you think about asking, answering this question, do not take it lightly. Just because you can does not mean you should. So sit with it, understand what you actually want out of life, what you actually want to be doing in that this time next year, at this time in three years from now, and say, like, does that involve adding a doctor, adding locations, adding chairs, adding team members? If the answer is yes, let's come up with a plan to do it. If the answer is no, let's come up with a plan to do that too.

Paul Etchison 5:56

What it reminds me of is like this whole idea, like, if you want to be that, if you want to stay solo, cool. But like, you see on like Facebook, sometimes we'll see somebody who's a GP and they're doing specialty procedures, and then you'll get the comments that say, Jack of all trades, man, master of none, you shouldn't be doing this. And for me, that's a way of just poo-pooing on everybody else for something that you personally don't feel like you want to take on the challenge to learn how to do, which I think people that are staying solo could be, but is staying solo the easiest thing? I mean, to me, my life was pretty simple when I was solo. I was busy. Did you feel that way? I feel I was busy, like I was busy, like a lot of time spent being busy, but it it wasn't that complicated.

Steve Markowitz 6:40

It's hard to see that. Like at least what as I reflect at this point in my journey, I've always filled my house with shit, no matter what how big the house was. And I've always had problems, and that's typically how people work, and that's okay. So I know when I when when I was a tenth of the size, I still was working as many hours as I am now. I thought I had all the problems and and that a dentist could ever face. And I would be surprised if at any practice owner who has a successful thriving practice who is questioning whether or not they should take on more isn't feeling like they're working hard right now.

Paul Etchison 7:22

Yeah, you're right. And I've had this conversation with my wife where I've said, Man, I wish I could just go back to when things were simple when we were when it was just me and things are so much easier. And she was like, You were stressed out all no one's back then, too. She's like, You're exactly the same. She's like, you're full of shit. It was you're the same person, Henry.

SPEAKER_00 7:39

So I think I'm gonna make a comment is both of you guys are super rock stars, like some of the smartest dudes in dentistry, but both you guys are super, super humble, which is why I love hanging out with you guys. So a little, a little brag on you guys there, but I think what's important, well, I think what's important here is we've all made mistakes, right?

Systems Before Speed

SPEAKER_00 7:56

And I have made big mistakes, right? I kept growing to grow, to grow, to grow because it was just a rapid ascension. It was almost too quick. But here's the mistake that I made looking back, right? Don't let your production overwhelm the systems. No matter what you decide to do before you do anything, make sure you've got solid systems, a solid foundation. Because I made the mistake of, okay, we got all this production. We got all this capacity, we're full. Okay, let's add this many chairs. Let's I mean, my practice started as a startup, and within four years and 10 months, we went to just shy of $6 million and 18 chairs. I mean, imagine the rap, like the craziness that happened there. And I just kept going. And at one point, I was just ready to just put my head down and say, oh my God, I can't do this anymore. And I was really stressed. And it didn't hit, it didn't make it very efficient till I got systems in place. So the first thing I would tell any listener is number one, get your systems dialed in, leadership team, team leads, organize meetings, right? Don't because you could be masking holes in systems. Maybe one doctor practice could have holes in systems, and it's just not, it's not evident. Till you grow more, then they come out, right? They come out and you see them, and I was definitely right there. So get your systems in line. Steve made some great points. Have a reflection. Like, what do you want? It pissed me off when I had a practice where if I left, if I wanted to go on vacation, the practice was useless. Because in North Carolina, hygienists can't even see patients if the doctor's not here. So I said to myself, no matter what, I want a business. That's stupid. Yeah, it is stupid. I want to be able to leave for two weeks and have the practice still run. That's what my initial goal was in growing. But like I said, don't make my critical mistake of have systems first before you do anything. Reflect on what do you want. It's okay to be the single dentist. Who cares? What like you'll be happy. The key is being happy.

Paul Etchison 9:55

Well, you know what's interesting is like you mentioned the systems, because I think a lot of people, like you just nail a few verbiages with case acceptance, or you just nail the patient experience in your practice. And all of a sudden, this practice can really grow, outgrow your systems very quickly, and you're just like hanging on for dear life, but you don't realize it in the moment because you're just like, oh, this is great. But like the thing being is uh even if you're going to stay solo and you're not going to scale up, I still think everybody could benefit from following the path of if I were to scale up, what would I do? Would I systematize my practice? Because that's the thing, is like when I think back, like you mentioned, Steve, like I was just thinking about that when Henry was talking, is that I was probably just as many problems working just as hard when I was a solo dentist. And I'm like, yeah. And the reason I was was because I just didn't have the systems at that point in my practice. I didn't have the leadership team. I didn't have all that stuff. So it made things a lot more stressful. But then as you systematize, you free yourself up. And it's for me, it just always seemed natural to grab more to bring on more stuff.

The Leadership Reality Of Adding Associates

Steve Markowitz 10:59

Is there a framework that a doctor should go through as they're trying to decide? They have this demand for their practice, and they're trying to decide I'm happy with how things are, but should I serve more patients because the demand is there? Is there a framework that you guys think of of like, how do I decide? Because it's such a big decision. And once you decide, it's really hard to undo that.

Paul Etchison 11:25

Oh, yeah. Totally. It's impossible. See, I always thought like for me, it was like I would look at the people in my community and I would look at the blessing that was my hands. And I said, should I share these magical hands with more people? And the the community responded over overwhelmingly, yes, Dr. Edchison, we want your gifted hands.

Steve Markowitz 12:51

The community needs those hands.

SPEAKER_00 12:53

While you were saying that, I only wish we had a visual effect of like a big broad light coming down, like you were Moses or something.

Paul Etchison 12:59

Yeah.

SPEAKER_00 13:01

Yes. I'm here to say, I would guide you. I think an answer to your question also is what is your personal mentality like? Because once you add associates, once you grow, your practice is never the same. And you have to accept being a leader, right? A true leader, right? Whereas I'm not poo-pooing it, but if you're a one doctor practice, you got five chairs, six employees, like it is still stressful. But you're responsible for once you have once you have multiple doctors, you could be having patient issues that you have never even seen that you have to be the one to fix it, because you're the guy with the name on the door, right? So you have to be accepted, you like accept that responsibility. You know, the old Spider-Man, you know, great power comes great responsibility. So accept that. And if that's going to stress you out, then maybe you don't have the mentality, right? Because that's really important.

Steve Markowitz 13:53

There was a guy a couple of years ago that I started coaching with, and he had a five, a five out practice. He didn't know his numbers. He thought he hurt, I think he heard us on a podcast or something, or one of his friends recommended that they talk to us. And he didn't know his numbers. He was making more money. He didn't actually care. Like he actually didn't care. He thought that because his friend told him to, he should. And then as we were sort of going through it, and like I was actually creating problems for him by sharing the information that worked for me that actually didn't even make him feel good. It was actually and like as I reflect on it, it was probably not a good relationship. I should not have been sharing all those things. He didn't actually care if he made an extra $20,000, or if he knew his production per hour, or if he knew his case acceptance, he was a single doctor practice, it was working, he had a lot of patient demand, and he thought, because he saw on Facebook and as he was talking to his friends, he should grow, he should scale. And in our conversations over the I don't know, I think I worked with him for probably six or eight months, the answer was no. And he was thankful that he had the knowledge. But I think what was more helpful for him in our relationship was the clarity that what he actually was doing was the right thing for him. And I thought that was great. Did I help grow Azebida? Did I help create more process? I don't know. I think I probably heard it because of my my coaching for you. But what came out of it was a ton of clarity for him. And what I think about as we were talking is there's this tripod of what type of person or leader are you? Are you a relationship-based leader? Are you a results-based leader? Are you a process-based leader? And as you go through this, if you truly want to scale, you should know where you are. If you don't truly care about results, which meaning this the success of the business, scaling it may not be the right answer for you. If you like the way that you do things and having someone else do it differently, or having someone having the same process as you makes you crazy, scaling might not be the right answer for you. If you truly just sit far on that relationship bucket and like want to know your patients and be their doctor and serve the community and this and the 12 or 2,000 patients that you see, and that's good and that's great for you. Sit there, enjoy it, be proud. And at the same time, if you want more and you're like, I want to be able to take a two-week vacation, have the business still still see patients. I want to be able to do all these things to help more doctors, help more patients. Well, then you need to understand that that now may not be your skill set right now, but you better learn how to do it. You better learn how to how to create processes that people will follow. You better care deeply about results. And you need that to be able to scale. And that's a question that I think is really important to answer as you go through this.

Paul Etchison 16:44

It reminds me of the whole like that parable with the businessman, he's talking to the fisherman, and he's like, Man, you're really good at this. You should get a boat, and then you could run a fleet. And he's like, To do what? He's like, Well, so you can, you know, spend time on the beach and do the things you like with the people you love. He's like, All right, I'm already doing that. I mean, everybody knows that, and it's besides a lot more eloquently when you read it the correct way. But if you're doing what you're doing, I mean, so say you want to stay solo. I mean, I I can tell you a lot of people that want to stay solo that even like they want to take time off, even if they can just get zeroed in on some kind of production goal for the year and then figure out a way to make that and still take eight weeks off. They feel really good about it because they're not stuck in that limbo zone of, I don't know, am I doing the right thing? I mean, you can stay solo your whole life. And if you're trying to deal with the patient demand, just pull out of networks, raise your fees, things like that. Like there's so many ways to do either, and none is none of them is the right way. But yeah, I would say for me, I'm right there with you, Steve. I always wanted to like, I want to have the practice run without me. I want to have it be making money without me. What are your thoughts, Henry? Like on all this.

SPEAKER_00 17:53

I mean, I'm gonna give you an analogy that came into my mind is exercising, right? Sometimes we just don't want, we don't feel like it. We're not in the mood or whatever. And then, you know, somehow or another, you just get there and you just do it. After you're done with the workout, you never, ever, ever regret like, damn it, I just I shouldn't have gone to the gym. You always are feeling better afterwards. It's always a positive thing. So this same thing goes with the mantra of just act as if, right? Establish the systems, establish a leadership team, even if you're not gonna intend to grow, even if you want to be that small practice, because you're never gonna regret it. It's always gonna be a positive thing. And that could be a good barometer to see am I like I've created this leadership team. Oh man, this is simple. I've got people helping me. I've got people, and now I can really leverage this and be a true visionary and scale. And maybe like it's not for you. And I think that's the first thing that you should do regardless before all this inflection, and do I want to do it? That has to be done regardless.

Steve Markowitz 18:51

You guys have done expansions to your office, Henry. I think you've done like 11 of them.

Paul Etchison 18:55

Umry did a one

Proof Of Concept Metrics For Expansion

Paul Etchison 18:59

op expansion 11 times. 18 times.

Steve Markowitz 19:03

When you look back at it, do you wish that you went bigger the first time and just built it out? Or how would someone in you both had five op practices? How would someone approach it if they're like, yes, I want more? What's the first step in that? Good question.

Paul Etchison 19:19

You know, I would say if you want more, it's like it's always been following a process of demand for me. It's always about blocking out for new patients, deciding how many you're gonna get, figure out how to get it, just being very intentional with the schedule that allows you to reach those capacity points where you have to go for more. But I think if I was supposed to look back and I would say things I would have done differently, I would have had the leadership team functioning on a high level much earlier than I did. I mean, when I figured that out, I was 35 employees. I would have had that going when I was just eight employees. You know, I even if it was just me and one person, me and one person on my leadership team. So like I think you gotta look forward to because that's the thing, is my growth outpaced my system.

SPEAKER_00 20:04

How did you do that? I can't even imagine having that many employees and not having like a solid leadership team in place.

Paul Etchison 20:10

You get angry and you gotta take it out on someone. So you don't want to do it to your team, you do it to your family. You pretty much do it to your kids.

Steve Markowitz 20:17

That's love right there. Yes.

Paul Etchison 20:18

Yeah. I mean, you and emotionally, you know, like it that doesn't leave bruises. That's the kind of treatment I was giving to my family. I was emotionally abusing them on so many levels. No, I mean I was just a miserable SOB. I sucked. I I mean it was it was I was just always stressed. I probably am going to die 25 years earlier than I would have if I hadn't went through that process. But it it allowed me to learn, and now I get to share it with other people. There you go.

Steve Markowitz 20:42

Were there metrics you were looking at besides the misery meter, which you were very helpful, clearly.

SPEAKER_00 20:47

I mean, I would say I'm just like Paul. Like mine was all proof of concept. Like we started at five chairs, and within four months, it was so obvious that we were getting booked out months in advance. Doctors, he was way over, you know, it's hard to get doctor time. Okay, we need to grow. So within five months, we went to nine chairs. Nine chairs, it's like buckets, right? You have five buckets, five chairs, they got all get filled up and they're filled up indefinitely. You got to add more. Then we had the nine shares. Those buckets got filled up. We were booked out, you know. I would say hygiene was booked out about uh two or three months, even with assisted hygiene, so multiple columns. It was hard to find appointments for me, another doctor. Right? Then same thing. Every time it was proof of concept, it was like there's more demand, there's more buckets to fill. Let's let's build them. So yeah, that's true.

Paul Etchison 21:37

I I like that, Henry, because it's like it. I think about the same thing is like you see some doctors and they say, I want to expand, I want to go from I want to get like 10, 12 ops, but then you look back and they can't generate more than 15 new patients a month. Yeah, like there's no proof of concept there.

SPEAKER_00 21:52

Yep. Yeah. I mean, 30 new patients is a barometer a lot of people talk about per provider. Then, but then you also have to look at as you're scaling, like, do I have the adequate admin team? I can't have all these treatment plans coming up and not enough people to be able to actually present these. So the whole thing, as you scale, you have to look at everything as you're going along. But mine was just proof of concept. And every time we added chairs, providers, it always just the production would, you know, the profitability would go like this, production will go boom, and then take another little, you know, hit here. And every time it was guaranteed, and I did it four times, not 18.

Steve Markowitz 22:29

Oh, sorry. I I do love that proof of concept because the the metrics that I look at are active patient countries.

Paul Etchison 22:35

I was just gonna ask Steve, like what about you? Like you've you've done multiple practices.

Steve Markowitz 22:38

Active patient count, number of new patients, reappointment percentage. So when we start to see that active patient count north of 550 to 600 per chair, we are feeling it. So we need at that point to increase our capacity. And if it's a newer practice that may not be able to, it's not open five days a week, well, we need to open it, open the hours. But if the if we're open five days a week, our only way to do it is we need to expand our our footprint.

SPEAKER_00 23:08

Can you define to the listeners what you're considering active patient?

Steve Markowitz 23:11

Has been seen in the office for it within any capacity in the past 18 months.

Paul Etchison 23:15

I have never heard that 550 per chair. And this is why you're the numbers guy, Steve.

Steve Markowitz 23:19

Have you ever heard that, Henry? So it's only because of my experience of like when I hit that, I was like, oh boy, this feels uncomfortable. We need to do something. So I don't know if that's the real thing.

Paul Etchison 23:29

550 per chair. So five five ops, that's 2750. Holy cow, five ops. Okay, but but see, that seems like a lot for one doctor, no?

SPEAKER_00 23:38

I think you need to go into the DPH budget of sound effects and hit a da-da. Because I have never heard that. I have never heard that. I've just I learned something new today.

Steve Markowitz 23:49

Hold on, let me keep going here on my metrics. On the last episode, Henry so eloquently took called me the numbers nerd. So I'm gonna just keep y'all. So if we have our number of active patients and we know we and now we're continuing to see new patients, and our reappointment percentage is above 90%. Where are these people going? We have no option other than to expand capacity. No option.

Paul Etchison 24:19

Yeah. So that's that's kind of like my my whole play is like if we're blocking out new patients six months in advance and ours, there's nowhere to put our recall patients, the only way is to expand hygiene, to which we add hygienis, to which we can only check a finite amount of hygienist, to which we will have to then add more providers. So mine isn't so much based on math as it is functionality, depending on how many new patients you decided you wanted to get. But it's I think the numbers probably work out exactly the same.

Steve Markowitz 24:48

Paul, it is based on math. You're just choosing to not, you're choosing to ignore the math and go by your feelings.

Paul Etchison 24:53

Well, I'm sure there's math in there.

Steve Markowitz 24:55

Your feelings are right. They just also match the math.

Paul Etchison 24:58

Yes. The laws of math do not cease to exist on my practice, BL. But yeah, no, it totally. It's just a different way of arriving at it for sure. Well, I see a lot of people they say like 1200, 1300 active patients per full-time doctor. That's a weird number. You know, and I feel like it's actually more. I feel like you could you could do about 1800 easy.

Steve Markowitz 25:18

It depends on the type of dentistry you're doing. Right. But for bread and butter dentistry, that 1,500 number is is is pretty accurate.

Paul Etchison 25:26

Yeah. I think that's why like when you look forward and you look at the block schedule, it works for everybody, regardless of your level of dentistry.

Steve Markowitz 25:33

If you're diagnosing and treatment planning and doing all the things that you're supposed to do that we talked about last time.

Paul Etchison 25:38

It always works, Steven. It always 100% of the time it will work.

Steve Markowitz 25:42

100% of the time it works, 60% of the time.

Paul Etchison 25:44

Yes. Correct.

SPEAKER_00 25:46

There's the math guy.

Paul Etchison 25:52

One of the biggest takeaways from this conversation is that there is not only just one way to build the dental

Clarity, Demand, And Next Steps

Paul Etchison 25:59

practice. You can stay solo and you can be super successful. You can scale to multiple providers, you can scale to multiple locations. You can simplify, you can drop insurance, you can raise your fees, you can build something smaller and take a bunch of time off, whatever the heck you want. But the question should never ever be what is everybody else doing? The question needs to be what kind of practice is going to support the life that I want. So here's what I want you to remember from this episode. First, start with clarity before you add chairs, associates, locations. Be honest about what you want your life and practice to look like. And no matter what you choose, build the systems either way. Even if you've never scale, better systems, stronger leadership, better communication, clear processes, those are all going to make your practice easier to own and they're going to make your life less stressful and more predictable. And look for proof of concept. I mean, if you're booked way out and you're turning patients away and your hygiene department's full and the demand is real, growth, I mean, it makes a lot of sense. Scaling makes a lot of sense. But if you don't have that demand, it's just not there yet. It's probably best that you just focus on creating that demand before you start worrying about all of this expansion and scaling. Scaling, I guarantee it, it can create way more freedom, but it's got to be done right because it will expose every single weak spot in your practice if your foundation isn't ready and you haven't built those systems. Growth is not the goal by itself. The goal is to build a practice that works for your patients, for your team, for you and your family and for that life that you wanted to create. It needs to work for that. Now, if this episode made you realize that you're not really sure what the next step is in your practice, that is exactly what we help dentists work through. We've done it in our own lives and we've helped so many dentists do it in theirs. Head over to dentalpracticeheroes.com/slash strategy. Schedule a free strategy call with me. I promise it is no pressure. You will actually talk to me. I will talk through your goals and what's going on in your practice. And I'll give you some advice that comes from real experience that I've had in my life because I promise wherever issues you're having, whatever you're thinking about, whatever's going through your head and the struggles and the challenges that you're going through, I have had something similar and I can offer some wisdom to you. And if our coaching programs can help you get to the next step, I will share what that looks like and give you an opportunity to find out more about that. And if you like this podcast and you're like, dude, I want to help etch out, please help me out by leaving a five-star review. It would mean the world to me. And I so very, very much appreciate it. So thanks for taking some time out of your day to spend it with me. I appreciate you. And I want you to go into your practice this week and look around. Is it the way you want it? Is it the practice that you desired? Is it the practice that works in your life? Because if it isn't, let's start taking steps to get it to where we want it. Thanks for listening. We'll talk to you next time.