Ep. 58: All About Associate Doctors, Part 1
Are you looking to bring on an associate? Do you already have an associate but it’s not working out quite as well as you’d hoped? This week, Jeff is joined by Sabri Blumberg for our series on successfully bringing on associate doctors. They’ll discuss where things can go wrong, when you’re truly ready to add an associate, having enough production to support them, structuring the working relationship, onboarding them successfully, and much more.
Topics:
:52 – Where associate relationships can go wrong
7:16 – Determining if you’re ready to add an associate
19:46 – Getting enough production to support an associate.
Links:
Learn more about MGE - https://www.mgeonline.com
Want to get out of PPO plans? https://www.mgeonline.com/fees-and-plans-analysis
The Art of Scheduling Productively Course - https://ddssuccess.com/p/art-of-scheduling-productively
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Questions From This Episode
What's the single biggest reason associate relationships go wrong, according to Sabri?
Owner doctors stop treating the associate like an employee once they've hired them. The normal supervision, correction, and clear expectations applied to any other staff member quietly disappear, on the assumption that a doctor should simply already know what's needed, leaving the associate to guess at overhead realities, sales philosophy, and diagnostic approach on their own.
Before hiring an associate, what should a practice check first?
Whether the doctor genuinely needs one at all, versus simply feeling maxed out due to fixable inefficiency. A doctor working long hours but only producing $50,000 a month out of four operatories with one full-time hygienist likely has a scheduling problem, a case-acceptance problem, or heavy PPO participation dragging down the numbers, not an actual capacity ceiling. Hiring an associate on top of those problems just adds overhead to an already inefficient practice.
What three things determine whether a practice can actually support an associate?
Hygiene capacity, new patient volume, and physical facility space. Enough hygiene to keep generating a steady stream of sales opportunities, enough new patient flow to support an additional provider, roughly 20 new patients per doctor as a benchmark, and enough operatory space for that associate to actually work, ideally without needing to split shifts.
What's the ideal doctor-to-hygienist ratio, and why does it matter?
One doctor to one or 1.5 hygienists. Since most of a practice's real sales opportunity should come out of the hygiene chair, not enough hygiene capacity limits how much new treatment ever reaches the doctor to present. Too many hygienists per doctor creates the opposite problem, doctors constantly gloving and degloving between exams with no real time to do proper dentistry.
What's a smart way to bring on a new associate if you only really need them two days a week?
Have that associate split their time between hygiene and doctoring rather than doctoring full time right away, especially useful given how hard hygienists are to find. Two days doing hygiene and two days doctoring keeps the practice's overall doctor-to-hygienist ratio balanced immediately, and as the associate's own patient volume builds, the practice can bring on dedicated hygienists to free them up for full-time doctoring.
Episode Transcript
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Jeff: Is it time for you to get an associate doctor? Are you sure you actually need one? And if you were to bring one on, what are your real expectations, and what should you be asking yourself before you even start the hiring process? How should you set the practice up to make sure the relationship actually succeeds? These are just a few of the questions we're covering this week and next week, a two part series here on Dental Business Rx. Whether you're looking for an associate right now, might be at some point in the future, or already have one, this episode is for you.
Jeff: I'm Jeff Blumberg, your host, joined again this week by Sabri Blumberg, our Deputy Chief Operating Officer here at MGE. Some of you have heard Sabri on prior episodes, her last appearance was two weeks ago, when we covered the twelve steps for dropping managed care and PPO plans. For anyone hearing her for the first time, Sabri oversees all of our technical delivery for clients at MGE, she genuinely knows this material inside and out.
Jeff: Sabri, you're all hooked up?
Sabri: I am, thank you.
Jeff: Welcome back. It's been exactly two weeks. The reason we're covering this together is that it's something we've been advising clients on since the nineties, and it comes up constantly. As we were putting this together, we ended up structuring it around three things: the questions we get asked most, what we actually tell clients, and how these relationships tend to go wrong. Before we get into the main structure, since clients come to us with associates who are already struggling, where do you see it go wrong most often?
Sabri: Plenty of small things go wrong, sure, but the main one is that owner doctors stop viewing the associate as an employee once they've hired them. So the normal things you'd do to make sure any employee succeeds, correction, supervision, clear conversations about expectations, just don't happen. The associate is left to figure out on their own what's needed and wanted, and very often what they land on isn't actually right, because they have no real visibility into the practice's overhead, its sales philosophy, its diagnostic approach, any of it. It creates real problems.
Jeff: I think it's this idea that, well, they're a doctor, so they should just know.
Sabri: Right, and it's true, they're more educated than a hygienist or an assistant, they have a doctorate. But if they're an associate, they're still an employee of the practice, they still have to follow that practice's policies. Think about how we bring in an experienced front desk hire, a scheduler, a receptionist, an insurance coordinator. Even with real prior experience elsewhere, we don't assume they automatically know how our specific practice runs, we train them, or at minimum verify what they know, and provide some level of supervision. If you don't apply that same standard to an associate doctor, you're going to run into trouble.
Jeff: I usually see it play out a bit differently, though probably a related pattern. A genuinely great associate comes in, the owner likes them, the associate is looking for more of an opportunity, maybe a future partnership, a place to finally settle down. The owner doctor alludes to it, sure, you could become a partner if things work out, without ever spelling out the actual metrics or benchmarks required. The associate starts producing well, and six or eight months in, they're ready to talk partnership, but the owner was never actually thinking that far ahead. It's a bit like a couple who never discussed having kids, and six months in one of them says, actually, I do want kids, and the other says, I never wanted kids, that's simply a mismatch nobody caught early.
Sabri: That happens constantly, and it really comes back to your point and mine both, clear expectations laid out from the very beginning. I genuinely like that you always insist partnership expectations, buy-in amount, how it's calculated, the timeline, all get put in writing in the contract from day one.
Jeff: It just makes sense, that way nobody's coming to you six months later if the contract says a year, it's already agreed to in writing, you're both starting from the same page.
Sabri: Exactly, and going back to the employee piece, the same clarity needs to apply there too. How much do I want you producing? How do I want that production achieved? How should your schedule be structured? How do I want you communicating with my patients? What's the minimum standard I expect? All of that spelled out clearly.
Jeff: So that's some of where it goes wrong, we could genuinely do a whole separate episode just on that. But let's get into how to actually keep it from going wrong. We came up with six points worth addressing if the idea of getting an associate has crossed your mind, whether you're adding a second one or evaluating a relationship you already have.
Jeff: Point one, when someone asks us whether they should get an associate, the first thing we look for is whether they actually need one.
Sabri: It starts with why they want one in the first place. Do they want more time off, or do they genuinely believe they're maxed out and can't produce any more on their own, which is the more common reason we hear.
Jeff: It's interesting, because if you look at maxed for time off specifically, you could have someone working six days a week doing fifty thousand a month, which on paper looks maxed.
Sabri: But they're not actually maxed. That's exactly where we start, looking at production against how many operatories they actually have, and whether that number is genuinely reasonable given the type of dentistry they're doing.
Jeff: Let's use a concrete example. Say I'm working Monday through Friday, doing paperwork Saturday, genuinely stressed, doing fifty thousand a month out of a four-operatory practice with one full-time hygienist. I'm thinking, I need an associate to handle my emergencies, all of it.
Sabri: That's actually a really common example, more common than you'd think, and it's a great one to walk through. Realistically, even doing straightforward bread-and-butter dentistry, that practice shouldn't be maxed until it's producing eighty to a hundred thousand a month out of four chairs, and honestly it could do considerably more than that. That range is really the floor for what I'd consider genuinely maxed at that size. So why is this doctor only doing fifty?
Sabri: That usually comes down to scheduling problems, using chair time inefficiently, say they've got one hygienist, one assistant, and they're scheduling vertically instead of properly double-booking. Or it could be they're only selling pieces of a treatment plan at a time, doing quadrant dentistry at best, or worse, only ever selling the next single procedure.
Jeff: Let's unpack that, since there's a lot packed into what you just said. Starting with the scheduling piece, we actually did two episodes on scheduling a few weeks back. So, four chairs, one hygienist, working constantly, tired, but only one dental assistant, meaning I'm not really using all four chairs, and scheduling vertically instead of double-booking properly.
Sabri: Right, and if you're not using your chair time efficiently, and not properly utilizing what a hygienist or assistant can actually handle, there's only one direction your schedule can go from there, out. So now the doctor isn't producing what they're actually capable of, but their schedule is already booked three months in advance. The solution isn't to hire an associate and just keep paying more to sustain that same inefficiency, it's fixing the schedule, fixing how chairs are being used, or sometimes simply adding another assistant, which is a lot cheaper than hiring an associate.
Jeff: Now the second piece, quadrant dentistry. This is something people genuinely don't think about enough. Patient comes in needing four crowns, but the practice isn't great at selling, so they only get the patient to accept the one or two crowns insurance covers this year, then the next one or two the following year.
Sabri: I've seen that exact pattern. Or they're doing one crown per visit instead of knocking all four out together. There's this idea that patients don't want everything done at once, but most patients actually just want to be done, they don't want to keep coming back if they don't have to.
Jeff: Right, if I understood why I needed the treatment in the first place, I'd rather get it over with in one visit.
Sabri: Exactly, and once you've already prepped one crown, prepping four instead of one is almost exponential in terms of efficiency, you're not numbing the patient four separate times, not seating them four separate times, and worse than the numbing time, you're not having to resell the remaining treatment in a whole separate conversation each visit.
Jeff: So we've covered scheduling and full treatment plans. Now let's paint a third scenario, tying into what we covered last episode. Same four chairs, fifty thousand a month, working five and a half to six days a week, physically present constantly, not seeing family, exhausted.
Sabri: One likely culprit there is heavy PPO participation, massive write-offs. In most cases I see, that doctor already has more patients than they could ever reasonably fit on the schedule if they actually reached out and brought their full patient base under active care. There's genuinely no reason to keep participating in all those plans, they'll lose a small percentage going out-of-network, sure, but they're effectively already losing those same patients today simply because they can't reasonably see them.
Jeff: And if they bring on an associate at that point, since it's usually some combination of bad scheduling, weak sales, and heavy managed care participation all at once.
Sabri: Right, since hiring an associate isn't just hiring an associate, you're often also hiring another assistant, sometimes more front desk staff too. You want to be sure you can genuinely carry that added overhead. Why take that on when your biggest existing expense is already your PPO write-offs? You'd just be perpetuating the same problem, and now you're giving away a large percentage of a reduced fee to both the insurance plan and the associate. Your numbers might look great on paper, production wise, but there's no actual money left.
Jeff: Interesting side note we came across while prepping this episode, and yes, we do actually prep these, we've seen some practices, more commonly in the EU, though it happens in the US too, split into two effective offices, assigning the associate specifically to handle the PPO or government-insurance patients while the owner sees the private, out-of-network patients. Sometimes the math works, sometimes it really doesn't.
Sabri: We've had EU clients where that split is actually a legal requirement, at least half their patient base has to accept government insurance in that particular country, so the associate handles that half specifically.
Jeff: Whereas in the US, that's not a legal requirement, but the underlying problem still shows up, seeing too many patients to actually be productive. Give a dentist twenty patients a day, the traditional high-volume insurance model, trying to make up for write-offs through sheer volume, and volume alone doesn't solve a profitability problem, it makes it worse. You need more staff to handle that many patients, you don't have time to actually sell treatment or educate patients on what they need, it destroys profitability.
Sabri: So sometimes, to get the numbers where they need to be, we actually slow the whole practice down first, get them genuinely treating the patients they have well, rather than rushing volume. And there's a real difference here between a product-based business and a service-based one. If I run a store and lower prices to move more product off the shelf, I still just need someone at the register, doesn't stress me out personally as the owner. In a dental practice, the doctor is the one doing the actual production, so pushing volume just burns the doctor out directly.
Jeff: That makes sense. So let's say we've taken a client through this, maximized their scheduling efficiency, and if you want more detail on that specifically, we did a two part episode on scheduling a few weeks back, and we also run a seminar called the Art of Scheduling Productively a couple times a year, link on the episode page, along with a video I did with Chris on DDS Success and full scheduler training. Say we've also gotten the doctor selling full treatment plans, and if PPOs were heavy, we've had them drop a good chunk of those, and yes, they almost never lose as many patients as they expect.
Sabri: Right, and at that point, the practice picture is actually clean, and we can see what this doctor genuinely has. Often, at that point, the honest answer is they still don't need an associate yet, not until those things are actually in place.
Jeff: So once those fundamentals are cleaned up and we've established this doctor could genuinely use an associate, we haven't yet looked at how many days a week they'd actually need one for. This is really question two, attached directly to question one, would they actually be able to support one productively?
Sabri: I'm looking at three things there: do they have enough hygiene, how far out is their schedule currently booked, how many new patients are they bringing in, and the size of their facility.
Jeff: So hygiene, new patients, and facility. And they need to actually be busy enough to begin with, having a hygienist who isn't seeing many patients wouldn't really tell us anything.
Sabri: Right. On hygiene specifically, here's why it matters so much: in a properly structured practice, most of your sales should be coming from patients you're already seeing in hygiene, either completing existing treatment plans or discovering new interest, cosmetics, whatever it might be. So your hygiene chair is really where most new sales opportunity originates. If a practice only has four days of hygiene supporting one doctor, there's a real ceiling on how much sales opportunity that generates, and you'll want to expand it. We use a specific ratio for this, roughly one-to-one doctor-to-hygienist.
Jeff: I think I've mentioned that ratio in a prior episode too, one-to-one, or one-to-1.5.
Sabri: Right, so two doctors would ideally want three hygienists comfortably, two at an absolute minimum. Push much beyond that ratio, say six hygienists supporting only two doctors, and you run into real trouble, doctors constantly gloving and degloving multiple times an hour trying to fit in every exam, no real time to do the actual dentistry or a proper exam.
Jeff: Where did that specific ratio actually come from? I remember you mentioning a client years ago.
Sabri: Right, we had a client with two and a half doctors and only one hygienist working three days a week. They were technically productive, but the way they were surviving was bringing in around a hundred new patients a month.
Jeff: Which sounds great on paper, productive, tons of new patients, already two and a half doctors, why would they ever come to us?
Sabri: Because that model runs into serious profitability problems eventually, doctors are simply an expensive way to generate that volume, and they were essentially giving away half their potential business by not having the hygiene infrastructure to support it, functioning almost like a specialist practice instead of a genuinely healthy general practice.
Jeff: So hygiene ratio matters. What about new patients specifically?
Sabri: I'm generally looking for around twenty new patients per doctor. So if I'm a solo practitioner currently getting thirty new patients a month, I'd want to see that pushed toward forty as I bring on an associate, either by tightening up marketing or specifically assigning someone to handle internal referrals.
Jeff: A ten-patient jump doesn't sound too dramatic.
Sabri: It's usually achievable just by tightening existing referral programs, and that work can happen concurrently while everything else is being addressed.
Jeff: And facility space specifically?
Sabri: If I've got two hygienists and the owner doctor is using two operatories out of only four total, there's an obvious problem, where does this associate actually work? Same issue with practices running only three operatories that genuinely need an associate. If there's simply no available space, you have to get creative with hours, splitting shifts or extending your operating hours.
Jeff: Would you consider adding a chair at that point instead?
Sabri: If there's room to physically do it, absolutely, that's always cleaner than moving to a split shift, unless you genuinely know what you're doing organizationally and are essentially building two separate practices sharing one space and staff, otherwise nobody ends up truly responsible for anything since that person isn't always there.
Jeff: Could you explain split shifts a bit for anyone unfamiliar?
Sabri: Sure. A normal dental practice week runs thirty-two to forty hours. With a split shift, you might extend to sixty hours total, say open seven in the morning to seven at night, five days a week, plus a Saturday morning. You'd divide that into two separate shifts, say seven to two and two to seven, each functioning essentially as its own practice.
Jeff: And the owner doctor obviously isn't working all sixty of those hours themselves.
Sabri: Right, that would be genuinely rough. Where split shifts tend to go wrong is with front desk personnel specifically, more so than assistants. Front desk roles carry very specific statistics they're accountable for, a scheduler owns production, a receptionist owns referrals, a treatment coordinator owns collected income. If that person isn't consistently present, or different people handle the same role on different days, nobody's genuinely accountable for those numbers anymore. It really has to function like two separate practices sharing the same physical space, individual staff, individual statistics for each shift, even though you're only paying rent once.
Jeff: I've seen this most often with clients in genuinely tight urban markets, Manhattan, for example, where space is at a premium and expanding into the next suite simply isn't an option. In a place like here in St. Petersburg, you can usually just find more space to annex instead, so it's less of an issue.
Sabri: Exactly, in those tight-space scenarios, splitting shifts is a viable option, but it's usually our last recommendation, since you're genuinely managing two separate practices at that point, and there's real groundwork required to do it well.
Jeff: So to sum up where we are, this is really a continuation of the first question, would the practice actually be able to support an associate? You're looking for a one-to-one or one-to-1.5 doctor-to-hygienist ratio, they've likely already dropped their lowest-reimbursing PPOs, they're getting around twenty new patients per provider, or if they're already at thirty solo, adding another ten isn't a major lift, and ideally they have enough operatories to fit the associate without needing to split shifts, which, while it can absolutely work, is a genuinely specialized undertaking, not a quick or simple one.
Sabri: One more thing worth mentioning here, and this is genuinely timely given the current hygienist shortage. Say you're bringing on an associate specifically to maintain that doctor-to-hygienist ratio, but you only really need them for two days a week of doctoring. You could bring that associate on and have them work two days of hygiene and two days of doctoring, functioning on a four-day week like you might be. If you're doing four doctor days and one hygienist is doing four hygiene days, and the associate does two doctor days and two hygiene days, you've got six total days of each, maintaining that one-to-one ratio immediately. As the associate's own patient volume builds up, you bring on dedicated hygienists to free them up for full-time doctoring.
Jeff: That's a genuinely comfortable way to grow into it, and I've seen you walk clients through that successfully more than once. Where I've seen it go wrong instead is the owner doctor ending up picking up hygiene shifts themselves because the associate simply doesn't want to do it.
Sabri: That happens more often than you'd think. Some associates flatly won't do hygiene, and don't get on board with the idea that it's a genuine stepping stone toward eventually practicing in a fee-for-service, private setting, rather than a heavily insurance-driven, high-volume model that may not actually be the best way to practice long term. If you want to eventually operate at a genuinely private level, sometimes this is simply part of that path. Think about everything the owner had to go through to build this practice in the first place, the risk, the stress, you don't just hand that over.
Jeff: That makes sense. Alright, I think that's a good place to end for this week, we've genuinely blown past our usual thirty minutes.
Sabri: I don't mind at all.
Jeff: This is a two part series, as I mentioned earlier, I'm getting into these two-parters lately. Next week we'll get into how you actually use this associate once you've brought them on, how you'll pay them, finding the right person, and how to onboard them successfully into the practice. We'll also briefly touch on bringing in a specialist specifically, which is a genuinely different conversation and might end up as its own episode entirely.
Sabri: I might be getting us into trouble bringing that up, but it's genuinely relevant right now.
Jeff: No, it's worth at least touching on. Sabri, thank you so much for joining us again this week.
Sabri: Happy to be here, and I'll see everyone again next week too.
Jeff: If you want to learn more about MGE, find us online at mgeonline.com or call 800-640-1140. Links mentioned in this episode are on the episode webpage at dentalbusinessrx.com, or wherever you're listening. If you want to be notified about episodes like this, don't forget to subscribe or follow wherever you listen. Have a great week, and we'll see you next week for part two.