Andrew Burdette 00:00:00  The grower Group Practice Podcast is part of the practice of the Practice Network, a network of podcasts to help you grow, manage and promote your business and yourself. To hear the other podcasts like The Practice of the Practice Podcast, go to practice at the Practice Network. You are listening to the grower Group Practice Podcast, a podcast focused on helping people start, grow, and scale a group practice. Each week you'll hear topics that are relevant to group practice owners. I'm Andrew Burdette, a practice owner, and I love to hear from people. Their stories and real life experiences. Let's get started. Hello and welcome back to another episode of the grower Group Practice Podcast. This episode, I'm here with Elizabeth Carr, who's the founder of Caitlin Psychotherapy. Welcome to the show.

Dr. Elizabeth Carr 00:00:56  Thank you. Andrew, it's good to be here.

Andrew Burdette 00:00:58  Yeah. Good to see you. So I. You and I met, at two different of Joe's conferences, both of which were a good time in very different ways. So it's good to see you a couple of weeks ago with the one up in Traverse City.

Andrew Burdette 00:01:09  And it sounds like they're going to do another one next year, which I'm definitely excited to get back to you. I know it was a lot of fun. Well, cool. usually I invite guests to give a little backstory about how they got to this point in their career. So if you want to share with the audience how you got to be a building owner of a three story building and have a thriving practice up in Maryland, I'm sure listeners would like to hear it.

Dr. Elizabeth Carr 00:01:32  So I was a Navy psychologist. I resigned my commission after six years on active duty because I had a one year old at home, and we were in the middle of the Iraq War. and I started private practice, assuming, like I think many of us do, that I would just be a solo practitioner for the rest of my career. one person joined, and really just as kind of an opportunity for me to have somebody else using the space when I wasn't seeing clients, I didn't think of it in terms of starting a group practice at all.

Dr. Elizabeth Carr 00:02:02  And I think that's probably not uncommon, that you sort of backdoor your way in, and then you wake up one day and you realize, oh, I'm a group practice owner and hadn't really planned on it, so I guess I better figure out how the heck to do it.

Andrew Burdette 00:02:13  Yeah, I relate to that. I was one of the community members in next level practice, and everybody pointed out that my solo practice really was a vehicle, and there's people that don't want to be a vehicle owner. They just want to ride along as a passenger in someone else's vehicle being a business. And that really reframed thinking about group and kind of got started similarly with just hiring a friend of mine from grad school, and we ironed some things out and created a system. And here we are. You know, I guess years later at this point and have a whole thing going.

Dr. Elizabeth Carr 00:02:44  And I think it's so much more efficient, too, because we're all reinventing the wheel. When we're solo practitioners, we each have to figure out what the EHR is going to be and pay for it and get our own internet and get everything.

Dr. Elizabeth Carr 00:02:57  And when you can come together as a group, you can make the overhead lower and and have centralized processes and people really appreciate that.

Andrew Burdette 00:03:06  Yeah. And also is somebody that like so we're an insurance based practice I realize you're, you're not and there's pros and cons of that and there's plenty of other episodes to discuss those. But just the idea of like, you know, pricing out like a biller or pricing out resources or, you know, shared resources, like, could we move into a bigger space or, you know, buy a nicer coffee machine for the office or whatever it is, and being able to spread those things around to more than one person, is also a really cool thing to be able to do as a business owner.

Dr. Elizabeth Carr 00:03:35  Particularly, you know, when you think about the dreaded social media presence that most of us feel like we need to do. and many of us don't want to do it. And I think the people in my practice are really glad that it's an active effort on our part that they have very, very little, if anything, to do with, but they can benefit from it.

Andrew Burdette 00:03:56  Yeah I have. We have the accounts created. We haven't yet moved into actually really utilizing those accounts for my practice. But I'm also thankful someone else is going to handle that when we get there because I have no interest. I would absolutely get rid of my personal pages if it wasn't necessary for 1 or 2 Facebook groups professionally to be a part of on a regular basis.

Dr. Elizabeth Carr 00:04:17  Yeah, yeah yeah, yeah. So we oh, go ahead.

Andrew Burdette 00:04:21  No. Go ahead.

Dr. Elizabeth Carr 00:04:22  I was just going to say this year we hired a college student from one of the local universities who's a communications and PR major, and she's now very closely working with me on these social media efforts. And that's been fantastic. She's it's a paid position for her, but she's also getting credit for it, and she's very good at using Canva and things like that. And I think this is one of the things that we don't think about very often. We think, oh, can I have an intern or not? but we always think is it's a counseling intern or a psychology intern, but to work with someone who's majoring in marketing or communications, I think can be such a win win, because it gives you an opportunity to work closely with somebody to help them in their career, put something on their resume, and have a cost effective way to flesh out that that effort.

Andrew Burdette 00:05:08  Yeah, that portfolio piece for people that do this kind of work is a big deal. And being able to do that outside of something that's especially in a non-traditional kind of way for what many student opportunities are offered or are definitely not working in our field to support it. And I'm for listeners out there. I'm slowly consolidating all my office space into one building, which means I could actually have an intern here and have a space to have them on site, and I'm excited for that for 2026. New adventure for lots of different things.

Dr. Elizabeth Carr 00:05:38  Yeah. And you know, one of the we post on the usual Facebook and Instagram things like that, but we also post on Next Door. Next door, we'll send you an email saying your last post had 723 views. And I'll forward those emails to the student and say, put this on your resume, because the metrics that she can brag about, you know, eventually.

Andrew Burdette 00:05:56  Yeah. And also, you know, with that data point, you can track how much traction things get over time.

Andrew Burdette 00:06:01  So if it started out with a K, this about 50 different impressions or views, whichever site and their their jargon relates to those interactions. and just watch it grow over time like as in people more and more doing it. And then that also says too, that you're savvy enough to understand how each of those algorithms works to end up getting ranked and the way that they end up ranked.

Dr. Elizabeth Carr 00:06:23  And honestly, I think that I'm not that savvy, but I don't think many of us are posting on next door. It's something that we don't think about. But you can and you can do it for free. And you get a lot of eyes because there's less competition. So I highly recommend. Think about that as one of your social media platforms.

Andrew Burdette 00:06:39  Cool off to bookmark that and keep that in mind. I will say, I guess my experience generationally with Nextdoor is I'm in that Gen X camp and kind of more on the millennial end of things. So I think some of next door, based on where we are locally and the interactions I see are are definitely older generations, maybe spend more time on that platform than they might on Facebook.

Andrew Burdette 00:07:01  So for listeners out there, if you're thinking about is it worth my time or not? If you're catering to Gen Z people, maybe not. But if you're catering to like, you know, say people over 35 or 40, it's probably a good platform to look into.

Dr. Elizabeth Carr 00:07:13  Yeah, I thought next door was just people trying to give away their leftover moving boxes and half dead plants. But there's more to it than that. Yeah.

Andrew Burdette 00:07:21  Cool. you want to pivot over to talking about lifestyle planning and lifestyle practice stuff, and then, other people may know this as exit planning, and they're very interrelated. So do you want to, I guess first tell listeners what exit planning is as far as a business strategy and what that really means.

Dr. Elizabeth Carr 00:07:38  Sure. So exit planning is this idea that every business eventually is going to end, it's going to be sold, it's going to be shut down, it's going to whatever. And so and we're not going to live forever. So there's always this question about what's going to happen, especially if you've built something of substance and you want to be concerned about your legacy and about continuity of employment for your staff.

Dr. Elizabeth Carr 00:08:00  So exit planning and even I think an offshoot of that is just sort of emergency coverage planning. because what if you what if you're in a bad car accident and you're out of commission for four months, is the thing going to come to a grinding halt? Do people are things in place for someone to cover in a pinch? And so just like when you have children and you think about, well, who's going to be the godparents, who are going to be the people that say that they'll take care of your child? If there's ever a need, there's a similar need for that, with your business, even if you don't hope to sell it. Obviously, the main reason people do exit planning is because they're hoping to sell their business. But, even if you're not hoping to sell it, you should still have a plan for how to land the plane. I think the good news is that when you're doing exit planning with exit planners, they will tell you that your business is more valuable, the less effort it takes from you to run day to day.

Dr. Elizabeth Carr 00:08:57  And so if you have a million hats, then somebody's buying the business. They need to also have a million hats, or they have to hire a million different people to wear each hat. So the more you can start to flesh out mid-level management, the more you can put systems in place so things move smoothly. The more valuable the business is. Now. Coincidentally, what you find when you do that is that the business is more fun to own. And so for many people, I think if they start that path because they think I'm burning out, I got to get out of here. Let me make the business worthy of selling in the next five years. They may find that five years later they don't feel that way anymore, and they're happy to keep it, because now it's a joy. And that certainly I wasn't really burnt out, but I also kind of, at a certain point had two hats. I think if you're seeing 20, 25 people a week and the business is growing, one day you wake up and you realize, I have two full time jobs and you can't instantly discontinue with all your patients.

Dr. Elizabeth Carr 00:09:52  But you also can't just stop running the business. So it takes a little while through attrition and transfer to to right the ship on that and get things back into balance. Because most people, I think, don't see it coming until it's a little too late.

Andrew Burdette 00:10:04  It's my experience is has been some of those things. I've kind of had an awareness that they're on the horizon. And then depending on what happens between having that awareness and then actually arriving at that point on the horizon depends on whether or not you're really prepared for that handoff or not.

Dr. Elizabeth Carr 00:10:23  And if you do this continuity planning, kind of like what I call emergency coverage planning, but I think it's properly called continuity planning. you have to start thinking of identifying who would be good at what. Sometimes I think we're good at a lot of different things that might be really good at seeing patients and also good at marketing and also good at this, that or the other. And and there might not be anybody in your staff that's good at all of those things, but you might think, well, someday I'm going to hand off social media to this one person, and I'm going to hand off dealing with the bookkeeper with this other person.

Dr. Elizabeth Carr 00:10:54  based on leaning on everyone's strengths. And when you do continuity planning, it starts to really force you to start thinking about things that otherwise just seem so far off that we just don't make it a priority.

Andrew Burdette 00:11:05  For listeners out there, I'm just going to invite you to maybe think about it this way. So in January, I took my first full hands off, like full unplug a week away from the business and had to have enough stuff in place to be able to walk away and not be worried about my business. And I literally on a Thursday, handed everything off, hopped the plane. I think Saturday or Sunday I flew to New Mexico and came back a week later and literally left everything at home. so that this continuity planning we're talking about is having at least enough in place to leave for a week. And then, on a broader scale, do you have enough of a playbook written down that somebody could come in, pick up the social media stuff if needed? Somebody can make sure all your employees are getting paid and payrolls run in a timely way.

Andrew Burdette 00:11:48  All the all the nuts and bolts in a functional way, and how the nuts and bolts go to better go together in the way that they do. so even if you're not at a point where conceptualizing, like taking six months off is a thing. Think about if you just wanted to take one week off, how much would you have to communicate to then take that one week off that's not already written down?

Dr. Elizabeth Carr 00:12:08  And also what can be paused? You know, for a long time I was the one that called back every single prospective patient. I felt like I was really good at it. I didn't want to let it go. I was afraid nobody else could do it as well as I could do it. You know, there's the probably the narcissism that's a little bit active in a lot of us as leaders. and eventually, when I did hand it off, I found that the person I gave it to did a perfectly wonderful job. And it really didn't have to always be me, and I didn't want to take it back.

Dr. Elizabeth Carr 00:12:34  So if she was going to go on vacation for a week, then this question becomes, do I go back to doing it? Or what's plan B? And one of the things that I realized also is that also things can go on pause. You want to go on vacation for a week or two. You could just not post anything on social media or make a few ahead of time and time them to be posted while you're gone. but it's also okay if your admin people are answering the phones and maybe you only have one admin person and they're on vacation for that week between Christmas and New Year's to have your voice mail say. Our admin team is getting a long needed break and we support that. Mental health starts at home and please leave a message. We'll call you back as soon as we can on this date.

Andrew Burdette 00:13:15  Yeah. So is someone that in the past year has, as a community, we've gone through a hurricane to where we literally couldn't access anything because all of our infrastructure was knocked out, too.

Andrew Burdette 00:13:27  nobody had a mental health crisis that was so urgent that we couldn't handle it, that we couldn't pick up backup, and we got back on track. And so even at that level, it's doable. And then, just like you said, the auto responder thing, like it was like I caught a couple emails in the middle of that, I was like, hey, glad you're taking a break. Actually. Like, you know, with the autoresponder thing. So remember, you're human and it's important to communicate that to your clients as well because they respect having a human therapist much more than they do the alternatives. Yeah. So we've talked about just the general concept of contingency planning and kind of having everything kind of written out. are there certain phases of group practice development that kind of coincide with certain pieces of this? like for example, I'm going from that four and last size to the size where I'm kind of midsize. So there's a whole lot more centralization that I'm in the process of implementing right now.

Andrew Burdette 00:14:24  and part of not having done the stuff you're talking about previously is everybody kind of function independently. We just kind of pulled some resources together. But collectively we were all kind of our own solo people under a moniker. And it's a little different now as we're centralizing things. So as you grew into the size you are, how did you kind of handle these different growth phases and implement what was needed to have things handed off?

Dr. Elizabeth Carr 00:14:47  I think the kind of people who have joined my practice very consistently have been the kind of people who don't want to run their own group practice. They don't want to have to shop around for hours. They don't want to deal with it when the air conditioner stops working or the internet is down. They don't want to think about marketing or running a social media campaign. They don't want any of that. and so I in terms of wanting to have really strong, retention of quality staff, I know that is true about them. And so I lean into that. I think that if that's the kind of staff that your practice is recruiting for, and you know that, then you may be smart if you can afford it, to have an admin person do things for them that they don't want to do.

Dr. Elizabeth Carr 00:15:32  Right. Like, booking that first appointment and sending them all the paperwork and making sure they submitted the paperwork and things like that. I think a lot of times when we start group practice, because we're not thinking about really starting a group practice, we are really like a collection of solo practitioners. And I hear so often group practice owners complaining that their staff keep leaving to start their own practice. And I can't help but wonder if that's because we're recruiting people who have ambitious to have their own group practice, and there's nothing wrong with that. But if you want continuity and you want stability and you want people like we've had people that have stayed ten, 15 years with our practice, and if you want that, then you really need to think about who is the kind of person that's going to want to stay that long and then very intentionally recruit for that.

Andrew Burdette 00:16:18  This is all stuff, by the way. You can put in your job posting and things like that. Like, for example, mine says if you're if you'd like to start a solo practice in the next 12 to 18 months, let's talk about that instead of you working here.

Dr. Elizabeth Carr 00:16:30  Right, right, right. Yeah. And sometimes I'll sort of test the waters, and people will always come into the office and say, this place is so beautiful, I love it. And I say, yes, you know, I'm a closet wannabe interior decorator. It's like a passion of mine, and I have an outlet of this office. Does that seem like something that appeals to you? And if the person were to go on and on about how they'd love to decorate their own office someday, then I think, well, that's just a little hint that they may not be around too long. you know, and it's just one of many, many questions, but it's the kind of thing that helps you get at that. And how would it be for you if you were just about to start an appointment with a patient, and someone came to you and told you that the internet wasn't working in the building, and, you know, there's four other clinicians that need to do telemedicine, and now you're pulled in two directions.

Dr. Elizabeth Carr 00:17:13  You have a business problem, but you also have your own patient waiting to be seen. How would you handle that? And those kind of questions, I think really get to this idea of, is the person, the kind of person that really likes the shelter and protection of a group practice, that they're not in charge of.

Andrew Burdette 00:17:31  Some other things too. And this shows up pretty frequently in our area because it's pretty saturated is a lot of people think, think. Just having a private practice name and a license is enough to be in business as a solo practitioner, for example. And so a lot of the group practices around here will get applicants that are wanting additional caseload and are not looking to shut down their solo practice. And it's like, those are not your people to hire because they're there just for the moment and once things right, once their ship gets written, you know, relevel or whatever, they're they're off on their own. Again.

Dr. Elizabeth Carr 00:18:07  It's hard to fill a practice, especially if you're entirely fee for service and you're not taking insurance, because of course, insurance is going to channel people towards you.

Dr. Elizabeth Carr 00:18:14  But if you're not doing that, it can be hard to be full. And sometimes I agree with you that there are people who have a small private practice, and they want to join a group practice just to fill their schedule. They often want to be entirely virtual, and they're just trying to flesh out their calendar if they're trying to be entirely virtual in particular. I think you're absolutely right when they get full in their own practice, they're going to leave you. And why wouldn't they? if they come to you? Because they are entirely virtual in their own practice, and they want a little bit of a sense of community and brick and mortar space, but they don't want to set that up themselves. they might be okay, although they might be better off if they have their own referrals just subletting someplace. And when they figure that out again, they're going to leave. so the question always has to be if somebody has their own thing, why are you applying here when you have your own place? Talk about that.

Dr. Elizabeth Carr 00:19:08  yeah. And I do find that people oftentimes group practice owners will say those folks that have their own practice and are doing work at your practice kind of as a side hustle, are not the best team members in terms of growing your practice. And I can't I don't disagree with that.

Andrew Burdette 00:19:26  The I would just say the percentage of time someone wants to spend working in your practice is probably reflective of the level of commitment to the culture that they're going to bring as well. Up.

Dr. Elizabeth Carr 00:19:35  Right? Right.

Andrew Burdette 00:19:36  It's not 100% true, but just as a general rule of thumb, I think that's a good guideline.

Dr. Elizabeth Carr 00:19:41  I think, on the other hand, sometimes people bring to the practice something that you the practice needs. No one else is doing. It's not even a full time need, but it's really helpful. For example, we have someone who has a full time day job in the school system, and she sees families and teenagers in the evening virtually. Well, we didn't have anyone else that was doing family, teenager family work at all, really, and particularly not in the evenings.

Dr. Elizabeth Carr 00:20:10  And so that was really helpful. And it was worth it to bring someone on who was going to be very, very part time because we wanted to fill that niche need. So I think sometimes you can do it, but you just have to be very intentional about why are you bringing on someone very part time.

Andrew Burdette 00:20:26  Yeah. I have I have one person that whose passion population is helping people transition out of incarceration. And she's also with her ability to work at that level. Has a unique skill set for dealing with so many other just very different kinds of things. And so she's been around for two and a half years and has gone through several different full time jobs trying to have the right relationship to that specialized population. And it's been a really great fit for both of us.

Dr. Elizabeth Carr 00:20:54  Yeah, I think people who, in my experience, people who have a full time job at an organization like a school system, who want to do a little part time private practice because they want to try it on, tend to work out, better than people who have their own private practice and are just trying to fill their caseload.

Dr. Elizabeth Carr 00:21:16  Yeah. And sometimes they will eventually transition to being with you full time because they're just testing the waters.

Andrew Burdette 00:21:23  Yeah. yeah. Hiring is hiring. Such a fascinating process. It's been really interesting. It's one of the for me as a group owner, has definitely been one of the areas I think I've grown the most of just having to come up with better ways to kind of flush out who the best people are and then do they have some skill sets and are there some? Lately it's been more like, do you have some of the life skill set things in the background that are a little harder to suss out? Like how do you prioritize things? Do you really need an explicit checklist for everything? Because maybe working in private practice isn't a good setting for that. some of these more complicated and more nuanced hiring things has been interesting to learn and grow through.

Dr. Elizabeth Carr 00:22:00  Yeah, yeah, yeah. And for example, I think a lot of people aspire to have people who do medication management, but for most of us, we don't have the kind of infrastructure gives a lot of support to a prescriber.

Dr. Elizabeth Carr 00:22:12  So if that prescriber doesn't have good attention to detail, if they maybe have a little bit of poorly managed ADHD, it's going to be a problem for the practice because they will, things will slip through the cracks that cannot slip through the cracks. and I think that's something that we don't see necessarily coming, because what they're doing in medication management is quite different than what we're doing in therapy.

Andrew Burdette 00:22:35  Not getting into like some of the paperwork, logistics of things. Just one of the big things. A fellow owner down here had said who's got, I think, still two prescribers in his practice. he just he was comparing the level of just administrative and scheduling support. He's like, basically one prescriber almost needs their own full time admin because they're going to have a case load of 500 versus 30 to 50. And so you basically need the same level of admin support. You might need for ten therapists to support one prescriber, just from the sheer volume of clients that they have, as well as the liability of having that many more people in your practice to.

Dr. Elizabeth Carr 00:23:10  All of that, and not just because they have so many more clients, which means that to fill their 40 hours a week or 20 hours a week, you have to screen so many more patients and onboard so many more patients. but then also their half hour follow up appointments. You have more patient appointments to just deal with and charges to deal with and process all of that.

Andrew Burdette 00:23:32  Yeah. So this person's feedback as a group owner was like, I'm glad I've done it. I wouldn't repeat it was kind of where he decided he's at with things.

Dr. Elizabeth Carr 00:23:41  And also it's it's it can be challenging to be in charge as a therapist for a service line that you don't understand intimately.

Andrew Burdette 00:23:52  Yeah. As someone that's hired a wide range of people, whether they're clinicians, whether they're prescribers, and then all the different layers of admin and other things that go in there. Is there like a minimum size that somebody should be considering exit planning? I mean, is there like, for example, like if you're a solo practitioner, the pretty much all your revenue is going to come from your individual services as the solo person.

Andrew Burdette 00:24:16  So that's not really a sellable, marketable thing, because unless you're going to get bought out and go work for whoever buys you, there isn't really.

Dr. Elizabeth Carr 00:24:23  Anything of value to sell. Really.

Andrew Burdette 00:24:25  Right. So do you have a is there like a minimum Some size to where there's value that makes worth considering.

Dr. Elizabeth Carr 00:24:32  Exit plan. The way I would now looking back, not to say that I did it this way, but now with the benefit of 2020 hindsight, I would say it's really more about fleshing it out with more detail as you grow and get bigger. what do I mean by that? Well, I think that, if you have a cat and you're a single person, you need to think about, if I died in a plane crash, what would happen to my cat? But that's different than if you have a dog. And that's different than if you have a child. And that's different than if you have five children, right? and so I think practice is the same way that probably it's not a bad idea to have some basic continuity planning when you think about, the ethics classes that we take to, which is how would clients get their chart if you died and you're a solo practitioner, right? We're all supposed to be doing that.

Dr. Elizabeth Carr 00:25:19  And so that's probably the smallest version of that. And as the practice grows, then there's more and more to think about. And you don't have to wait until you have 15 people and then do it. You can just start to layer it on that continuity planning along the way as you see things that need to happen. So for example, when I started giving away more and more things to the admin person and our admin office managers, fantastic. It got to the point where she took it over for so long that she was doing things I don't know how to do anymore, and I used to think these therapists are wonderful, but it's really only the office manager. She was hit by a truck. We'd really be in trouble. things would grind to a halt in the way that if one therapist was out of commission, we would be fine, right. And so I think part of that question was, if she were out of commission, what would we do about payroll? What would we do about X, Y, and Z? and having some built in redundancy if possible, is a good idea.

Dr. Elizabeth Carr 00:26:19  There was a certain point where we got busy enough that she really didn't have time to do all the office manager activities and bookkeeping, and we outsourced bookkeeping. And one of the things I was really glad about that was that once we outsourced it, it was a it was a company, not a person. And so I didn't have to worry anymore about what if this one person had a problem. And and so I think that kind of question is what would be catastrophic for the practice. And that's where you need to be thinking about continuity planning.

Andrew Burdette 00:26:55  As a therapist, I can tell you from experience that having the right EHR is an absolute lifeline. I recommend using therapy notes. They make billing, scheduling, note taking, telehealth, and e-prescribing incredibly easy. Best of all, they offer live telephone support that's available seven days a week. You don't have to take my word for it. Do your own research and see for yourself. Therapy notes is the number one highest rated EHR system available today, with 4.9 out of five stars on Trustpilot.

Andrew Burdette 00:27:23  Com and on Google, All you have to do is click the link below. Our promo code Joe on their website. And receive a special two month trial. Absolutely free. If you're coming from another EHR, therapy notes will import your demographic data quick and easy at no cost, so you can get started right away. Trust me. Don't waste any more of your time and try therapy notes. If you just ask that question as broadly as you did. It gets really overwhelming really fast. And I guess to maybe tag on to some of what you said. One of the things I've learned is I've grown and have thought about what the next growth phase looks like, is trying to make sure some of this is built into the foundation as I go into that next phase. So, for example, like, you know, centralizing all our referral inquiries into one system and having an electronic way to track things as well as a human to kind of manage things And have a playbook of how that might work. similar kind of things about if this happens, then who do you talk to or outsourcing this? I'm, I'm opting to go with an individual at the moment for bookkeeping and payroll, so we'll see how that goes.

Andrew Burdette 00:28:38  But there are also somebody connected to my CPA and they work at a group as well. So there's some kind of indirect redundancy with that. But unlike when I first kind of jumped into group practice, I've been more intentional about going into this next phase to have enough time to document things as we get started. So it's not this overwhelming burden when you go from 4 to 10 people, and now you've got that much bigger of a scale of things to kind of track down.

Dr. Elizabeth Carr 00:29:03  Yeah. And, you know, documenting things and memorializing things and putting them pen to paper is really, really helpful. When you think about the process of onboarding a new therapist, there's certain things you do every single time, right? And we think, okay, we're going to contact the IT people. Also another outsourced company, to set up their email address. The IT people will call them and make sure that their email is going to their cell phone and their laptop. I'm going to tell them I need a temporary headshot.

Dr. Elizabeth Carr 00:29:29  I'm going to reach out to our photographer to set up the formal headshot and blah blah, blah blah blah, right? And our list of onboarding for a new clinician is probably 25 things that used to feel like eight things that I all had all in my head. Right. And and it finally seemed to me that what we should do is like what the Navy does. When you check into a new command, they give you this thing. It's kind of like a scavenger hunt checklist. And you walk all over a campus going to this department and that department, doing what you're supposed to do to check in. And I thought, well, we could do the same thing. Let's just make a checklist that, that we can see on a shared drive. And, and the new hire and myself and the office manager can all say we make sure we, you know, we don't drop the ball on anything.

Andrew Burdette 00:30:11  Yeah. And for listeners out there and one of the talk I gave a couple of years ago and Elizabeth and I first met was about systems.

Andrew Burdette 00:30:18  And we are at this point with my new hire, finishing out, building out a coordinated onboarding system and a platform called asana, which is project management. And what project management is, is it merges that checklist thing that sits on a Google Drive with the ability to have conversation and more than one person coordinate the checklist. And so reasons why you might want to consider a project management software is it allows the whole team of people to work on a group project effectively, and know what the status is as you go through larger processes.

Dr. Elizabeth Carr 00:30:49  Absolutely. And I think, Andrew, you know, one of the things that's a real advantage to you is your systems oriented person is systems thinker, and your brain works that way. And so you're already way ahead of the game considering the size of your practice. I suspect that you have more systems in place than practices twice your size in general.

Andrew Burdette 00:31:06  Yeah, and some of my friends that have practices that. So a couple of my friends started practices about the same time I did so a little over three years ago.

Andrew Burdette 00:31:13  And several of them are up in the like 25 clinician range now. And so they're my good friends. We collaborate on all kinds of different things, and some of the feedback recently has been, I could spend a little less time on the systems development thing and maybe a little more time, like pushing the referral marketing thing. So that's kind of my growth challenge this year is to to trust. I'm overfilling the systems a bit and maybe stunting my development because I'm too systems oriented. So listeners out, it's a trade off. And I do like.

Dr. Elizabeth Carr 00:31:43  You enjoy doing too. I think that's part of it.

Andrew Burdette 00:31:45  Yeah. I'm like, I really would love to be, you know, ten hours a week doing just the systems programming and stringing stuff together because I really enjoy that. and it's also one of those as someone that's still seeing, you know, probably 12 to 15 clients a week, depending on the week, and then trying to run things and also doing stuff like this podcast and a number of other things.

Andrew Burdette 00:32:05  I'm a little overbooked. And so my ability to play with the systems is not what it what it once was.

Dr. Elizabeth Carr 00:32:10  I do wonder, though, if it's possible that when you spend so much time on the front end figuring out these systems while other people who aren't doing that are racing ahead of you. if it's a little bit like the tortoise and the Hare, that once you have all of that in place, it will make it easier for you if you wanted to, to grow exponentially, because now you have the framework in place to do it where you could easily surpass everyone else, because now you have all these systems in place.

Andrew Burdette 00:32:38  I'm kind of feeling like that's about right. That's the exciting thing of this year is I'm I have all my stuff streamlined and kind of set up and built. And then this year we're kind of just going to expand laterally because, once I finish onboarding my, my current higher rate, now all I have to do is replicate that. So then I can focus on building relationships with all the primary care places in town and get the referral stream.

Andrew Burdette 00:33:00  And then I can add clinicians at whatever speed I need to to keep up with referrals. So I feel like I'm kind of in that same position versus, oh, I added ten people and I don't know what's going on because I never wrote anything down.

Dr. Elizabeth Carr 00:33:11  Right? Right. You know, it's it's like, our comms department and and our communications intern. She's putting so much into our platforms right now, but next year, we don't need to create a whole new canvas for Mother's Day. We can replay the Canva that we did for Mother's Day. We can just repost that next year for Mother's Day. And so once you've got that bank account of all those social media posts, many of them that are annual holiday shoots can be on repeat and it will get. I like to think it will get easier and easier over time.

Andrew Burdette 00:33:43  for me at least as someone that likes to plan a lot as well, I feel like I have a good understanding of how the how everything works. and the challenge right now is just getting some of these more complex things strung together, these more complex recipes written down for other people to understand them the way I do.

Andrew Burdette 00:34:00  But yeah, I mean, starting with systems or jumping in and ending up with a big practice and then figuring out systems, there's not necessarily a right or wrong way. We all kind of get to the same place differently. And I'm I'm more of a tortoise planner, I guess I've learned and I'm fine with that. It's. It's who I am, so I enjoy it.

Dr. Elizabeth Carr 00:34:19  Yeah. Well, you know, I, I talked, as you know, with the conference recently about lifestyle practice, development and, and part of my motivation for that from the very beginning was that I wanted to be with our son in the morning before he went to preschool, and I wanted to pick him up in the afternoon when they let him out of preschool. And I couldn't have resigned my commission and turned around and taken a full time contractor job at Walter Reed and done that. I would have had to get up early in the morning, been on 270, getting back at home at night in the dark, and I didn't want that.

Dr. Elizabeth Carr 00:34:48  And so I've always grown the practice sort of slowly around other lifestyle considerations and demands of my time. So it wasn't about run, run, run and then slowed down. It was more like just being in a manageable pace from the very beginning.

Andrew Burdette 00:35:05  Yeah, this here is for me is to to downsize all the things that I do and get rid of lots of plates to other people. And, I'm also appreciating that I'm giving myself a very healthy, long time frame to accomplish those things. That's not not without some goals and milestones, but I'm not looking to try and have all this done by Q3. There's just no way it's all going to happen that soon, but we'll get a good chunk of it done.

Dr. Elizabeth Carr 00:35:29  Yeah. I'll give you an example. You know, I used to train every new clinician on our EHR, and we hired someone right before I went an out of town trip. It might have even been this conference, actually. And, and we needed to do that initial training. And so our administrative assistant, who knows the EHR quite well, met with her in person to train, and she did a fantastic job.

Dr. Elizabeth Carr 00:35:53  And then I realized, why am I doing this all the time? She did a great job. She knows it just as well as I do. And and really, the things that she doesn't know, because she's not a clinician. You don't really have to train people. People that we've hired know how to write a note, a clinical note. It's really more about like the technical. How does the software work? yeah. So sometimes I think you back into realizing, oh, why am I doing this? Somebody else could do this and do just as good, if not better of a job.

Andrew Burdette 00:36:16  I'm going to invite you to consider why aren't you having it automated? So I have a I have a dummy clinician in my EHR that I pay extra for. It doesn't cost a whole lot in my platform. So Space Ghost has this whole caseload of of all kinds of people, and I record zoom videos of all the things that a clinician needs to do. And so then people go in and do that.

Andrew Burdette 00:36:36  And on a more recent hire experience, I decided to put in a little competency test. So as I go through and they take Barbara Griswold's note training on how to do insurance notes, so when they're done, they basically have two hours to complete the assignment, which is create a new client with your email address, fill the paperwork out as if you were filling it out, and then do the intake note, do three sessions and then do a discharge thing. And then let me know when you're done. And we'll go over the notes and see how you did. So yeah. for listeners out there, this is something I did with my second hire. so it's not a size thing about being able to do this. And these couple of platforms are pretty cheap to make it happen, but once I once it's done, I already have that in the bag. So the training piece of things freaks me out for doing the things I actually have to do. As the business owner in the middle of my crazy schedule.

Dr. Elizabeth Carr 00:37:22  This is my someday wish list is to have little video tutorials on how to do a bunch of things like this, right, that are just very brief and and our EHR has them too, but somehow they just don't seem that user friendly to me. but I think that again, because you're a systems person, you've made that a priority early. You get to take the benefit of it early as well.

Andrew Burdette 00:37:43  Yeah. Right now I just need to do updates. but most of what I did two years ago is still valid today, which is great. So, that allowed me to hire all three hires last year. Went through this whole training thing, and they're all thriving. So. So it works. So yes, listeners out there, you can do this on a budget. And, if you did want to check out loom, it's loom just like you're looming, you know, doing something. It's I think $100 a year and, it's great.

Dr. Elizabeth Carr 00:38:07  But if you pay an admin person for two hours for every new person you hire.

Dr. Elizabeth Carr 00:38:11  You've paid for loom pretty quickly. Yeah. And that's, I think, the way you need to think about it.

Andrew Burdette 00:38:16  Well, the other thing is, instead of paying the admin the two hours, plus you're going to pay them two hours to like, track down their employment verification, all the paperwork, making sure they're going through that onboarding checklist. I'd rather pay the admin for just that, and then pay the staff person that's coming on to do all the training stuff on their own independently, because it also shows me how effective they are for managing themselves and time and these other things that are soft skills. So you could pay your admin for five hours and supervise that, or you could just have a self-starter thing going on and. Yeah. I still very much culturally in my practice, I want people that are really much independent and think that way, even if what they don't want to do is all the actual the actual logistics of making insurance work and these other things. Yeah.

Dr. Elizabeth Carr 00:39:00  Yeah.

Andrew Burdette 00:39:01  one thing you definitely wanted to make sure we did talk about is planning your exit as a clinician and as a, like, Minnie hat wearer.

Andrew Burdette 00:39:10  As the owner. As you grow. And for listeners out there, there are different kind of tiers of group practice size that make different things and balance your time out. So for example, under four people, you're still going to be as a as the owner, seeing primarily a full time caseload and then managing the handful of people you have with you to get out of that, you're going to have to hand things off. So you're going to start adding in like admin support and maybe eventually like on the top end of that, around 10 to 12 people that say some of this, maybe like a clinical director that sees 15 people and then kind of manages your clinicians and kind of handles that mid management level. and then from there you start seeing less and less people, and then your role really gets to be primarily owner and visionary, which really is hopefully where you if you don't know that this is where you're headed as a group owner, it's time to start making peace with that too, because that's really what you're doing.

Dr. Elizabeth Carr 00:40:03  And and if you don't want that, if you if it makes you very sad, the idea that you might at some point not see any patients. Then you got to pump the brakes sooner, because at a certain point, the practice will grow to a point where you you have to choose the practice over seeing patients. And so just see that that's what the light is at the end of the tunnel. And if you perceive that to be a train about to run you over, then just pump the brakes sooner and and cap the size of your group practice. Because most people can't see 20 hours a week of patient care and run a large practice. Some people manage to do it, but they put a lot of mid-level infrastructure. And so it really depends on how you want to structure your practice as well. And I would say for myself, I really want to know every clinician personally. And so for me, 2025 people is about my max of how many relationships I can I can sort of plates that are spinning on the on the stick at one time.

Dr. Elizabeth Carr 00:40:54  so that's how I cap it is, is that but that's I think what you have to kind of do some soul searching about is do you want to see clients or not? Ultimately, how many clients a week do you want to see and then reverse engineer it to how how big your practice. You probably should be.

Andrew Burdette 00:41:10  Yeah. And another way to think about it, and I kind of use this analogy when I'm working with consulting clients, it's like going from a studio apartment to like maybe a three bedroom house to like, you know, a quad plex or like two duplexes in one building to like an apartment building. And so as the owner of each of those different places, how much do you really want to manage in each of those is going to have their own way to manage that space and the people that are in it and needs and communication and costs and other things. And so, obviously, if I have a four bedroom house and three, three roommates, I'll cover the mortgage. You're doing pretty good.

Andrew Burdette 00:41:45  And that kind of ties back to the planning yourself out of the cost of the business operations as well.

Dr. Elizabeth Carr 00:41:50  And you know, I love this analogy because if you think about when you have a studio apartment and you're busting at the seams and you think, I need a bigger place, and let's say you buy a house that's got three bedrooms, for a while, you don't have enough furniture for the house, and it costs you a fortune. Maybe you're single still and you want to get roommates, but you don't have the roommates yet. And then you slowly get the roommates. And then at some point now, every room is filled with a roommate, and some of your roommates have a girlfriend that's staying all the time, and it feels like it's too crowded again. And now you want to get a different house and be on your own. And just like that stair stepping that happens in a personal level. It happens, I think, with practice growth too. And you're probably seeing this now because you're in a new space.

Dr. Elizabeth Carr 00:42:28  But, I always was very conservative financially. And so I would wait until I was busting at the seams before I'd get the next space, and then it would be a little loose and spacious and then busting at the seams before I get the next space. And so you'll see a stair stepping of your finances where you're doing really well, but you have to make the next move, and then you're going to take a hit for a while until you flush that out, and then you're doing really well again. But you either have to stop or you have to take another step where you're going to take a hit for a while. And it wasn't until we purchased the building and wanted to move into another floor of the building. That was a hot mess, and we needed to knock down all the walls and do a build out that I took out my very first ever loan for the practice, and it was a quarter million dollars, which just seemed, you know, breathtaking for me. but that's the scale you're working on, you know, at this point.

Dr. Elizabeth Carr 00:43:23  But it was also worth it.

Andrew Burdette 00:43:25  Yeah, I was last year kind of doing your kind of plan where we're going to like, add a room and just kind of conservatively do this. And then the hurricane flooded my office and forced us to move at the end of the rebuild and all that. So, the new space opportunities this year came from this very natural disaster disruption, which has been really stressful in and of itself. But the other cool thing that goes with it is, I guess, because all of those foundational things were really set up and set up in a way that was independent of our physical space. We've also been posting like our best month ever since December, every month since then. So it's been cool to kind of see the effort that went into things. And even though we're having this whole rearrangement of physical space, which is grown, what we have potential for and will host us for the next. You know, I don't know, probably six, eight clinicians I'm imagining. wasn't what I expected, but just kind of came and coincided and it became an opportunity to rebuild in a different kind of way.

Dr. Elizabeth Carr 00:44:19  Yeah. Yeah. Yeah. You know, it's funny how every business is going to be quite unique. we have 20 plus clinicians, and I don't have a clinical director, and and I don't feel like I need one. people all know that they can come to me if they have an ethics concern or a customer service concern. It happens from time to time. It's not that frequent. but I'm very available for that, and I enjoy that. So I don't really want to give that away. so I'm not really sure what those people are doing in other practices because it seems like we don't need it. which just speaks to how different the, the each practice is structured.

Andrew Burdette 00:45:00  I think some of that too, just is. As an owner, knowing what you do want to continue to do versus not going. Going back to that, do I still want to see clients and if so, how many? I know for me, like I'm getting rid of the website, it's going to be one of the last things because I am that tech guy, and that's an outlet that lets me be creative.

Andrew Burdette 00:45:18  Yeah. and is it can be frustrating, but because there's a creative showcase of what I can use technology to do artistically, I guess might be what I say. It's interesting enough in that sense for it more expressive than, say, getting an HR to work a certain kind of way. Right? and so the people I know that have clinical directors, they're, they're wanting to spend their time in other things that are not in that clinical oversight kind of role. So yes, they are available for ethics questions, but they don't want to be as available to everyone all the time. And so I think it's knowing who you are and how you want to manage and where you want to invest your time. And if outsourcing that kind of more clinical supervision type thing is what you want to do, and having the clinical director makes sense. If not.

Dr. Elizabeth Carr 00:46:03  Then right? Right. And I think, you know, most of the people we hire are fully licensed and and seasoned clinicians. They don't need a lot.

Dr. Elizabeth Carr 00:46:12  When we have people that are pre licensed. We put them into our EHR as if they are a client. And then we pay another clinician in-house to supervise them. So that's not on me. And I think you're right, I think some of the practices that do have these clinical, managers, the owner is still seeing a lot of patients. And so they need that in order to do that. And I think you're absolutely right. I have access to the back pages of WordPress for our, for our website, and I love doing that. I would never give that away. But you have to know what you love, right? You you make a list of what are all the things that I'm doing, what I want to keep and what do I want to give away?

Andrew Burdette 00:46:50  Yeah, for me, it was really easy. giving away insurance billing was the first thing I got rid of. And scheduling is the thing. I'm getting closer to having all of that handed off because it just it's I'm not going to be on my deathbed wishing I spent more time checking email and rescheduling.

Andrew Burdette 00:47:04  It's not going to be.

Dr. Elizabeth Carr 00:47:05  A mailing is also mathematically a no brainer, because whoever you're going to pay is going to be much more cost effective than you doing. You could see a patient, you know, for that and pay for four hours of somebody else helping with that. And so I think also some of them are just math questions. Yeah. Especially if you don't love it. And also one of the benefits is when you have a fleshed out admin team and you have an office manager. And like we also have a client care coordinator. And she sits at a reception desk now central in our building. And when the patients come and go, they see her smiling face and she's very warm and welcoming. Hi John, how are you doing? It's wonderful. And the clients love it and it makes the practice feel elevated at just a completely different level that I adore. Yeah, and it's so, so worth it.

Andrew Burdette 00:47:53  Thank you for all this. Are there any key takeaways for listeners you want to make sure that they have as we kind of wrap the show up.

Dr. Elizabeth Carr 00:47:59  As we're talking, I think the most important thing is you're growing. Your practice is to just think about systems. Think about your job objectively. Get some distance from it. be clear on what you love doing so you can prioritize being able to do it long term. You don't want to accidentally get so busy, and having given nothing away that you have to give away patient care. If you love patient care, for example, right? but also prioritize giving away the things that you would like to give away so that you can have that freedom and have the lifestyle business that you want while still holding on to the things you love most.

Andrew Burdette 00:48:34  Yeah. And I'm also going to encourage people to take some business trips away from your geographic location to clear your head, like go to these conferences, pack some extra days on the front or back end of things. Make it all a big business expense. you post from time to time, you know, pictures of you working in these really lovely places, and it's really helpful for you getting clear on what you do and don't want to keep 100%.

Dr. Elizabeth Carr 00:48:59  And it doesn't have to be expensive. You know, we have a camper, we spend a lot of time camping, and I get a lot of inspiration with the with my laptop just sitting in the camper, working on the website, things like that, I love it. Yeah.

Andrew Burdette 00:49:11  Well, cool. If listeners want to get Ahold of you, how will they reach out to you or find you?

Dr. Elizabeth Carr 00:49:15  So, we are in psychotherapy. and I'm sure you'll have it in the show notes. We're in Gaithersburg, Maryland. and come to any of Joe's events there. If Joe's having an event, I'm going to try to be there, especially the group practice boss. It was fabulous. I highly recommend it. I intend to be there next year, and I'd love to meet you if you come and you've been watching this today, please come and say hi. I'd love to. I'd love to meet you in person.

Andrew Burdette 00:49:40  Cool. Sounds great. Well, thanks so much for taking the time to chat.

Andrew Burdette 00:49:43  It's. It's lovely. Like always. I always learn something every time we, we discuss different things and, Yeah. look forward to having you back at some point in the future, and we can talk something else.

Dr. Elizabeth Carr 00:49:52  I would love it. Thank you. Andrew. Thanks for having me.

Andrew Burdette 00:50:00  Thank you so much for listening to this show today. We could not do this show without our amazing sponsor therapy notes therapy notes as the best electronic health records out there. You can go over to Therapy Notes. Com and use promo code Jo at checkout. That's going to help get you a couple months off for free. It also helps let them know that their podcast sponsorship is working. Thanks so much for hanging out with us today on the grow Group practice podcast, and we'll talk to you soon. If you love this podcast, please be sure to rate and review. This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guest are rendering legal, accounting, clinical or any other professional information.

Andrew Burdette 00:50:52  If you want professional, you should find one.