What We Wish We Knew – Expanding From 0 To 1, To 2, To 3+ Clinics With Nathan Shields And Adam Robin Of PT Owners Club Coaching Program

The challenges of opening a second or third clinic in your PT practice aren’t the same challenges that you face when opening the first clinic. As you scale, the need for more robust systems and processes increases. In this episode, Nathan Shields and Adam Robin discuss what they wish they had done differently in their ownership journey, especially as it relates to expanding beyond the first clinic. Going into an expansion, a Physical Therapy Clinic owner may have an “I don’t know what I don’t know” mindset. Let this episode (and a trusted coach) guide into some of the things that you haven’t foreseen. The opportunities and the growth are great, and pitfalls should be expected along the way. But there are ways to see around corners – let this podcast be one of those ways.

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I got my partner in crime, Adam Robin , with me. It’s good to see you in the new year. We are back together. We had an episode where we talked about how to plan out for the next year and our strategic planning session. We broke that down. Everyone can look at that. Go back a few episodes and check that out. I brought up this idea to Adam that maybe we talk about what he’s learned from opening his clinics. At this current stage, Adam, you’ve opened your third clinic.

Just opened number three.

You’ve gotten to this point and there are lessons learned at each stage, and there are vital things to know at each stage that maybe you knew before or now you know. I thought maybe it’d be cool to talk about what you’ve learned along the way. I’ll share my insights as well as I open multiple clinics too. Let’s start from 0 to 1 and work our way up. I know opening in the third clinic is fresh in your mind, but I don’t want to work my way backward, and I don’t want to get too confused. You opened up a clinic a number of years ago. You bought into a clinic. Going into that experience, and I can share my experience because I didn’t buy into one, I made it from scratch. Talk to me a little bit about what you learned going into that first clinic that you wish you knew now.

I opened number one with a partner. I learned a lot about partnerships. I probably learned the same lesson that everybody who’s ever had a partner has learned, a bad partner has learned. I learned that not all partnerships are created equal. There’s a right way and a wrong way to do that. It’s a lot more of an intense relationship than you might think.

Talk about that a little bit before what you learned about the clinic itself. Some people are looking into opening up clinics with partners, or they have partners now. Plenty of them have gone sideways. I’ve been fortunate enough to have partners that were great relationships I consider Will Humphreys one of my best friends and business partners. What did you learn about partnerships that you wish you had known at the time?

It was less about partnerships and more about people. I was out of school for two years when I opened my clinic. I was a little whipper snapper. I didn’t know what I was doing. I had a lot of grit and determination and I was going to get it done. You can’t force your way through to success. It’s a dance. It’s an art. You have to be patient, listen and do a lot of those things.

You can't force your way through to success. It's a dance. You have to be patient.
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The main thing that I learned about my first partnership was that getting alignment with that person on day one is super key. Specifically about like, “What’s the company going to look like? What is your role going to be in the company? What are your expectations? What are my expectations? What does a win look like? What’s the exit plan? What’s the buyout going to look like when there is a buyout? How are we going to value the company?” Getting out ahead of those types of things.

Talking about sharing each other’s visions for what they want to see. What does that look like? I like getting pretty granular. We set up a partnership and I want to get as specific as you can reasonably with roles. We’ve talked about it. We did our own impact filters Dan Sullivan’s impact filter that we got online to say, “This is what needs to be true for me to be happy or successful with this venture,” share that with each other and talk about it. What does that vision look like? What am I doing that brings fulfillment? What are you bringing doing that brings fulfillment? And then talking about roles and responsibilities, like you said, “Who’s going to be in charge of what, because if you’re both in charge of everything, then it gets muddy quickly. I thought you were going to do that. You thought I was going to do that.”?

There are a bunch of expectations that are unmet by both parties and everybody’s got a mess.

It leads to disappointment and frustration. Getting clear about who’s responsible for what, when and where, and talking about deadlines. There’s a big part of it on the financial side like distributions if you’re going into it and sharing equally on the financial aspect of it. 50/50 financially, that’s fine. There needs to be other contingencies like, “What if you come at a deadlock? Who’s going to break that tie?” Deciding on someone that you both agree with that would break a meaningful tie that you have regarding the future of the business and agree to that, getting it in writing, putting your signatures to it. If we’re going to do some technical work that’s expected out of us, we get appropriately compensated for that.

I’m not a big believer in sweat equity. It happens. We’re putting some work into it for something greater down the line. I don’t want someone coming back on the backend saying, “Remember all that work that I did for the past two years? It’s time to pay up.” No. Let’s talk about that at the front end. If you’re going to do something for free, we’re going to agree that you’re doing it for free or we’re both agreeing that you’re doing this work now so that we can get an equal distribution later on.

If it’s not worthy of an equal distribution later on, then let’s pay you by the hour for that technical work that you did or let’s get that in writing. Get that figured out. I don’t want someone coming back at me saying, “You owe me because I did this. I put in more time than you.” Watching each other’s time clocking in and clocking out. There can be a lot of issues and frustration with all of that’s where a lot of partnerships start falling apart. It probably starts because of that lack of communication then they gradually do less and less communicating to the point where there are plenty of partnerships out there that don’t talk to each other, but there are still partners.

The bottom line is I didn’t have any experience doing anything. I had nothing so much to learn about just working. I’m super grateful for the experience because it was a challenge I learned from. Me and my old partner are still friends and we still communicate with each other. I think we both agree that it was a great learning experience.

Some of the other things, partnership or not all the legality stuff, I had no clue existed. Establishing the LLCs and getting the articles of organization in place and using a trusted lawyer, spending the money on a lawyer, spending the money on an accountant to get your financials set up appropriately from the get-go and building out a budget and proforma, I would go back now and tell myself to do some of that stuff.

Leverage whoever you can teach you how to open up a business and make sure you set it up right and all that stuff, getting a trusted commercial real estate broker who can help you understand leases and what you’re responsible for, and talk you through it as if you were a fifth grader say, “Teach me the vocabulary, the word verbiage and you name it so I can understand this lease that I’m signing my life to with a personal guarantee that I didn’t know existed until after the fact.” Those are all things that you need to take the time and spend the money on to invest in a business.

It’s a scary venture going to number one. There’s a ton to learn. I think that I can probably group all of that together to say, “The biggest lesson that I learned with number one is you’re not going to be able to control everything. You’re going to have to let go of things like collections.” You might not get paid for every visit. That’s a hard thing to freaking learn. You might not get a referral. You might not phone might not ring. You might not be able to find a PT. Your partner might not do their job. You might fail. There are a lot of things you’re going to have to learn to be okay with not controlling everything.

You're not going to be able to control everything. You have to let go of things.
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Some of that’s like a learning tax when you open up a clinic. I would highly recommend you outsource your credentialing. At the very beginning, I’d highly recommend you find a quality biller instead of learning it on the ropes. That’s tough to do for a new owner. It could be a real distraction. The most important thing when you open that first clinic is to get patients in the door. You don’t want to be worrying about collections or credentialing. You should be out marketing. When you have some extra time, do some more marketing, build some relationships, get out there and work hard to get patients.

It’s all about quantity at the very beginning. Getting that sped up helps out a ton when you can offload the third parties initially. This is a kudos to you. I know you got some coaching with me pretty early on in your ownership. I know we’re going to recommend coaching. Do you think you got coaching early enough, or should you have gotten coaching earlier than you did?

I don’t think that it’s ever too soon. As soon as you’re 30 days out from opening or so and you’re looking to put together some marketing material and some things like that, it’s probably appropriate for you to start considering working with a coach or some type of mentor. It’s a lot to learn. The thing that a coach like you provided me was direction and clarity on, “Take this one step. This is the right step, it’s going to be fine. Take that step and you can trust it’s going to be fine, then I can take a step.”

What happens is when you’re that brand new owner and you’ve got a lot of grit and determination with not a lot of direction, you’re running around crazy. You’re not sure what the priority is. It’s all overwhelming. It’s like billing, collections, hiring, firing, taxes, and payroll, the printer’s not working. Patience and you’re like, “My head is about to explode.” It’s a super stressful time when you don’t have a lot of clear direction, especially for someone like me who is young and out of school. I was only two years out of school. I didn’t have a whole lot of experience. I was a clinical director for five years before I opened a clinic. I was doing home health.

You didn’t know your KPIs.

I didn’t know KPIs. I didn’t know what’s a unit. There are a lot of things to figure out.

We had a few members of the coaching program that are brand spanking new. I’m a little bit jealous of those guys. They’re not going to have to learn the crap that we had to learn because when you’re in the painting, you can’t see the painting. The coach can say, “Don’t worry about that right now. Focus over here. This is what you need to do.”

I’m going to call out Zach Randolph. He’s one of them killing it. The guy doesn’t know and realize what he’s doing.

He is a brand new owner and crushing numbers.

He has been open for two months. He’s got 140 visits on the schedule. He comes to the call and he’s like, “Everybody comes to work and they’re doing what they’re supposed to do. I don’t need to worry about systems. When you told me to ask everybody to start writing things down, they started writing their own things down and they started doing their thing.” I’m like, “Exactly. That’s amazing. You’ve got people on your team writing down their job descriptions. That’s why it’s working.” He doesn’t have that experience of going through all that pain and agony. It’s happening naturally for him, which I’m I’m excited for him.

That’s a good transition point because after you get established and you start seeing some patients, then this is my opinion, but most owners, get distracted with patient care. They fill up their schedules, get full-time and stop thinking about the business and they start thinking more about the patients. I don’t blame them. That’s what they opened the clinic for and that’s what they studied for decades from elementary school all the way through to getting your PT license was to be a full-time physical therapist, treating patients the way you wanted to treat them. Once you become an owner, that goal becomes a distraction. The mindset, if it hasn’t shifted before getting, becoming full-time patient care, it’s a hard transition to make after you’ve gotten full-time patient care as an owner.

There are things that you need to save time during your week to work on in regard to the business. Otherwise, your business suffers or becomes very static, stagnant, doesn’t grow, you’re not able to provide the vision. You don’t have the time to develop the culture that you want to see in your team. You could be hiring people left and right, but the culture is going the way of the wind. Whoever’s the biggest mouth or biggest presence in the clinic, that becomes the culture of the clinic if you’re not intentional about it and you’re distracted with patient care. That’s one thing that I didn’t understand until ten years to ownership that I needed to set aside that time to work on my business.

I love watching you talk about it because it brings me back to that experience and not all owners, but a good majority of owners figure out how to hustle up some new patients. For the most part, most people can figure out how to hustle up some new patients to at least fill their schedule. There is so much fear around, “How many new patients do I need to get in this building to keep the bank account going?” They’re constantly obsessed with the new patients and the referrals coming in for 1, 2, 3 or 10 years, visits and new patients. That’s all they know.

They know more new patients equals good, less new patients equals bad. Asking them to say like, “Let’s not worry about that right now. Let’s make that priority number 2 or 3. It’s a hard thing. This is the only way I know how to make this work, is to worry about new patients and to see more patients.” It’s like, “Get them in right now. Cancel my appointment. I’ll be there, cancel my lunch, put them on my lunch break. I’ll get them in right now.” That’s a hard thing to break.

Especially if you have visions and aspirations for growth. If you’re the one-man PT clinic and that’s what you want to do you want to treat one-on-one for an hour, and especially if you’re like cash pay, out of network or whatever and that’s your dream, great. I don’t think we’re talking to those people. We’re talking to people who want to do more than themselves and want to become more than themselves. What we’re transitioning into right here is that time is necessary not only to work on your current business and that’s clinic number one and make sure it’s humming. It’s absolutely necessary to get your clinic humming to even consider number two.

Working on your business and making sure that’s humming. When I say humming, write out policies and procedures. I opened up clinic number two without these things. It went fine because I had an awesome partner in Will Humphreys and he took it upon himself to run that clinic as if it was his own. He could tell you that he was not fully supported by me at that time because I didn’t have any policies, systems and procedures in place. I gave him the software that he needed, but that’s probably about it. We talked every few weeks maybe.

“Here’s the key to the building.”

“Threw the keys in there and closed the door behind me. Good luck.” He ran it like that. I’m very fortunate that he did. Going back and tell myself what I could have and should have done better policies and procedures in place that are running the front office, that run how we treat patients, how we bill, how we schedule and having billing collections dialed in. Ideally, that first clinic is running at 80% to 85% capacity before you even consider that second. When we say capacity, I’ve shared it a number of times on the podcast, but I’ll share it again that is 10% of your square footage should be your max capacity this is true for most demographics. They outrun this by a mile in downtown New York City.

The 10% of your square footage is your max visit capacity per week. If you have a 2000-square-foot office, 200 visits per week is about your max capacity. Are you seeing about that in Mississippi? That’s 100% capacity. You want to be running with those numbers. You’d want to be like 160 or 170 on the regular before you even consider a second clinic because then you know that it’s running. It’s financially stable, healthy, and running because the last thing you want to do is open a second clinic and then get distracted by that second clinic such that the clinic number one starts to Peter and falter. It becomes financially strapped. Now you’ve got two struggling clinics, one that’s brand new and one that’s older but struggling and you don’t want to be in that situation.

The way that I’ve described it in the past was when you open a second clinic, all your problems, double plus commute.  All your life’s challenges, double plus commute. It’s a huge undertaking. I believe in coaching. I’ve always surrounded myself with smart people, people who are smarter than me. I was fortunate enough to gear up as well as I felt like I could to get into number two. I had policies and procedures. I had my stats.

When you open a second clinic, all your problems double plus commute.
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All of the stats throughout the entire company systems. I had my clinical director role built out. All my training was built out. That person was seated and performing in her position. I had a recruiting machine running. I had all of those things. The front desk position was dialed in. Everything was dialed in. Basically, built up the operational capacity as if I had two clinics, but I was only running one. I had my VAs in the background running. Once I had all that support and safety, then I decided to jump into number two. It was still hard.

What did you not foresee in clinic number two?

Everybody’s journey’s a little different. Our first clinic is amazing. We’re seeing 450 or 500 visits a week there. We’re rocking. The confidence is supreme at that clinic,  “I’m going into this new clinic thinking I’m about to go in there and dominate.”

“We’re going to do another 500 visits a week”.

“Within three months, I should be making $150,000 more a year.” I had all of these expectations. What happened was that didn’t happen. I had a turnover at the front office and a couple of therapists. I found myself pinging back and forth a little bit, not quite sitting on the high horse like I had thought I was going to. That was the big lesson that I learned. It always takes more than you think.

You’re talking about the operations, but the construction alone, the TI and build-out, at the drop of a hat, you got to be over at that office space because some subcontractor is waiting for you to make a decision on the blank. You have to be there and figure it out. ASAP. Otherwise, they’re going to be standing around waiting for you or take off and not be back for a week. It’s going to drain your bank account because it’s cashflow heavy. It needs cash for that TI. You could leverage a line of credit, get a construction loan, you name it, that kind of stuff. It’s going to take some cash and you better have some reserves in place before you open that second clinic. There’s plenty of that. Maybe, it doesn’t get appreciated prior to going into that second clinic.

It doesn’t get appreciated. They’re like, “I’m going to pop up another clinic.” All your problems are going to double bus commute, It’s a lot more than you think. The other thing that I would like to bring up is that your team is going to be stretched a lot more than you think. Your administrative team, even your clinical director that you think’s got it all under control. When you’re not there nearly as much, things are a little bit more stretched for that person. The marketing person is a little bit more divided. My administration person is trying to train the new front desk person virtually. Everybody’s stretched and dealing with new challenges. like the tension and the big transition amongst the team is a lot harder.

Your second clinic now is a success. You might not be at 500 visits, but it’s successful. What would you have done differently or what would you tell your previous self?

“I don’t know if there’s a whole lot that you could do well.”

Is there a way you could have trained your team to be prepared for the extra effort? Is there anything like that that you could say, “I should have been aware of blank or could have made your team aware of that stretching that they were going to do?”

I would say, “I feel like on paper we did all the right things because I was coached up on it.” I think the only thing that we were missing was the experience. You have to learn the lesson. You got to take your hits. Looking back and debriefing that experience, it’s like, “Now I have that experience of like, “Remember when we opened up clinic number two? Remember how that felt? That was called hard. We’re about to do it again. What are three things that we can do this time?”

Leverage your team.

“What are three things we can do this time to get out ahead? Let’s write down the big issues that we had and solve those. I can only do that now because I went through that.”

You can say, “What went well? What didn’t go well? What do we need to have in place before we open this next one?” Do you think that conversation would’ve worked with your 1st one going into the 2nd one or do you think having not had the experience, they wouldn’t have been able to figure that out?

I think they could have figured it out.

There are some things they’re not going to know because they haven’t been through it.

Including me. once you start building that middle management piece, clinical director, director of administration, you get separated at a higher level from the butcher. There are a lot of mindset challenges that you have to develop as an owner at that level because I don’t think you are ever going to completely get rid of the challenge of wanting to jump in and fix things. Learning how to sit a little bit higher in the organization is its own challenge as the owner.

Learning how to sit a little bit higher in the organization as the owner is its own challenge.
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This goes back to you having not had that experience before in going from one clinic to two clinics. Is another reason why get an experienced mentor coach consultant?

One hundred percent. If you’re about to open up another clinic, get a coach.

Learn from someone else.

If you’re going through a big transition, get a coach. You’re going to bring on a new thin. You’re jumping into this new valley of unknown territory. Get the coach and you will save yourself much time, energy and money.

You can either pay for a coach or spend probably ten times the money in tax.

Lose your health.

Also, the extra hours that you have to put into it to learn it from a coach. Save the time and money.  Sarah has the question on Facebook, “Top three pitfalls of opening multiple location.” You bring it up to me all the time that you hate opening up new locations because all of a sudden you have no money.

That’s a big one.

It’s cashflow heavy.

All you crazy PT owners and freaking psychopaths, it’s going to cost some money. You’re going to have to get comfortable. You think your margins are thin. You’re going to have to get very comfortable with like, we’re talking like single-digit margins for a while. It’s going to be tight. You’re going to be looking at your wife or your husband and saying, “We might not be able to go out to eat for a little while.” thing. Save the cash. Have way more cash than you need, but expect to spend it and prepare yourself mentally and emotionally. Develop the coping mechanisms to go through that because it’s going to put some financial strain not just on you and your business, but your family as well.

I’ve been out of the business for a few years I admit. It used to be $60,000 to 70,000 could get you an open clinic. That doesn’t include TIs and stuff that you’re going to do to change the layout of the office space. Would you still say it’s in that range for a 2,400 square foot space, 2000, 2,500 square foot space or is it closer to $70,000 to $100,000 now?

It’s a lot more than that.

This does not include construction.

You have to factor in the months of negative cashflow that you’re going to have. In your first month, it’s going to be negative $15,000 grand gone. In month two, it is going to be negative $14,000. Now you’re at $30,000.

Hopefully, the money starts coming in and months 3 to 6 if the credentialing is going well.

This is going to go into factor on location, but like all in hiring a staff, getting your clinic built out nice is going to cost you $200,000.

You’re including construction costs. If you’ve got a proven business track record, you could probably get that in a line of credit. I’m not sure if you want to use a line of credit considering the interest rates, but they are there. Maybe you can get a construction loan for the TI. I can’t speak to that experience, but that’s one pitfall. What’s the second pitfall of opening multiple locations?

The next thing that’s going to be the biggest challenge is your ability to maintain the culture across both locations.

I was thinking this exact same thing. Your physical presence was so much of the culture in clinic number one, that without you being physically present, can the culture and the systems and processes run on their own without you being physically present. That’s a real challenge. That’s why it’s important to have value-aligned employees, especially in the leadership levels who agree with you on how things get done.

The biggest mistake you could make is pick a productive therapist and make them the clinical director because they’re productive or throw them in a new clinic because they’re productive. Going back to the partnership piece, it would be like, “You’re smart. Let’s be a partner,” which is a piece of it, but there’s this whole other emotional and value alignment piece. That is probably more important, to be honest with you.

It saves a lot of headaches if you can be aligned.

You’re going to have pivots in your culture and it’s going to affect your team. There are chances that you may even experience a little turnover that you weren’t anticipating or maybe that higher that you were like, “This is going to be the person that gets me there. It didn’t quite work out,” in the middle of construction. We’re going into number three now. The most important thing at this point for me is the leadership team. What does it mean to be a director? What are our values? Not just words on the wall, but what are they? I need to know that you know when to raise your hand, when to take action, when to not take action. How to behave in the clinic? how to represent this company well? How to provide that experience. I need to get to a place where I can lean on that very heavily and not be worried about it.

That speaks to a third pitfall. I’m not transitioning to a different topic entirely, but I would say a third pitfall is a quote that you put in our Slack channel with a coaching group, but it’s, “The people who got you here are not the same people that will get you there.” If you are in clinic number one thinking, “I’ve got this front desk person, they’re going to be with me forever. I’ll move them up into middle management. We’ve got this family.” That first clinic becomes like a family. You’re going to have some people fall away. They can’t handle the added responsibility if they’re moved up into leadership.

The people who got you here are not the same people that will get you there.
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It’s hard.

Some of them can’t handle you not being present all the time and having that direct link to you when you put someone between that front desk person and when you started off, it was you and that front desk person now you put a middle manager between the two of them, and that front desk person thinks they can go around the manager and text you directly and you have to say, “Talk to your supervisor.”

They don’t get along. Maybe it’s a different vibe. You’re a visionary. They’re an integrator. You got to be like, “She’s an integrator, but that’s good. Let’s see how it’s different.” You got to handle all those things.

You’ve got to handle it, but also be ready to let go of some of those people. They’re not going to get it. This is exactly what you’re doing. You’re going from a mom and pop to an enterprise and some people can’t handle that going from mom and pop to enterprise. You’re going to lose some people along the way, unfortunately.

Sarah is a rockstar. She and I have been chatting a little bit in DMs. She’s killing it. She’s doing great. We need to get her on her story one day. We talked about money, culture and leadership.

The third is to understand you’re going to lose some people, unless you have another one that you want to add.

I think that’s a good piece. I can talk a little bit more about that losing people. I think you should always have a plan for everybody to quit. Once a quarter, build your team out or you can even delegate to this, to your leadership team. It’s like, “What if Billy quits, what are you going to do? What if Joe quits? What are you going to do?” Have it ready because it’s going to happen. You want to be able to press play on that and move forward as opposed to all the pieces coming down.

When you get to your level, you’ve created this, you’re already living in it. You have to have built and maintain systems that are running in spite of you. When you’re clinic number one, it’s all you all the time spinning all the plates. To get to a third clinic, you can’t spin all the plates anymore you need to know that you have someone else who is manning the recruiting program, marketing program, HR issues and productivity piece. You can’t do all those things anymore. Your job is to make sure people are in place trained, know what’s expected out of them and what their roles and responsibilities are to make sure all those plates are spinning and then you’re in constant communication with it.

I tell my team all the time now, “Don’t ask me what to do. Tell me what you did.” I’m building that culture of like, “I don’t want to answer any questions. I cannot answer all the questions.” It’s like, “Sarah asked for a raise the other day and what do you want to do?” I’m like, “Does she deserve the raise?” “Yeah” “Tell me that you want to give her a raise. You tell me why she should get a raise.” Developing that routine or rhythm of having things reported up as opposed to you reporting down is something that takes practice.

We knew there was a weakness in our systems when we had questions like that. For example’s sake, we decided clinic directors have the responsibility to decide whether or not someone gets a raise or not based on the parameters we give them, “Here’s a pay range for what you’d call a staff team, physical therapist. Based on years of experience, there’s a scale backed by research that you did with the Bureau of Statistics or indeed you name it what surrounding salaries are for front desk, PT, PTA, tech or clinic director. You can give them any pay you want in these pay ranges as long as you can justify it and you report that to us and we will give you a thumbs up or down.”

That’s all I want to do. Thumbs up or thumbs down.

“We went through the gyrations once and we might review them next year. We did all that so that you had the autonomy to figure that out yourself. Don’t come to me with a question or a problem without first having done the homework or look to see if there was a system or a process in place already for that then make your own decisions. Even then, if it’s not in the systems or policies and procedures, then come at us with a couple of solutions. Don’t give us more homework, please. My job is not to do that.”

What we’re doing is we’re getting into clinic number three. Cclinic number 2 is like you’ve got that leader in 1 and you’re developing that leader in 2. You’re still a little bit of an answer in some capacities. Once you get to three, like now I’m starting to experience what it’s like to be with three different clinics, I do two things in the company now. I lead out on one meeting and I do recruiting. I don’t have the bandwidth to hire or fire everybody, “Do you want to do lunch with Dr. Smith? I can’t make all those decisions.”

“You have a budget. Figure it out.”

“Tell me what you want to do and why.”

“Make sure the numbers are going in the right direction.

I’ll be like, “Cool.” That’s a hard thing to let go of as an owner because there are layers of like, as your company starts to grow, you start to realize that what you focus on becomes the priority the most important thing to manage is your ability to focus on what’s important. As you get to number three, it’s like you have to get more narrow because you have to shed more so that you can focus on the 1 to 2 things that are most important.

1 or 2 things that you are expert at.

That you’re the best at.

Hopefully, they bring you a lot of energy. Hopefully, those are the things you want to do. That’s the beauty of having your own company. When you’re at your place of fulfillment and freedom, you are doing the things that you truly want to do and that bring you energy. Everything else is delegated off to other people so that you can live in your sphere of influence or sphere of expertise. That’s where you truly want to go. It’s hard to do that until you get to such a size. You could have it in one clinic and if you had 1 clinic and 20 providers in that huge location. You can get to that point. Most people can’t do that. You’ll see once you get to a certain number of clinics for you to optimize your time and your energies, you have to start focusing exactly like you talked about.

You got a niche down and then, you get further into the future. In clinic 1, it’s day by day. In clinic 2, it’s quarter by quarter and year by year. In clinic 3, it’s two years by two. You’re getting further out. It takes energy to see that far ahead. You can’t have blinders on. You can’t be distracted. You got to see the stuff coming down the pipe way before everybody else does.

You got to be at the front of that.

I got to recruit now for my fifth director who I’m opening my fifth clinic with. I’m going to start looking at properties down there for 2026. You got to get way out. You can’t be worried about the little things.

It was interesting when we got to a point where we had five clinics where there were people that were getting hired and I had never met them until they were 3 to 4 months in. It’s like, “Nice to meet you. I’m the owner by the way. What happened to so-and-so?” “We had to let them go.” “That’s too bad. I liked them,” to learn about that stuff after the fact is that it’s an interesting place to be in, but you know things are going well if people are following your processes and procedures and your statistics are going the right direction, that’s exactly what you want to see.

I have gotten to where therapists are being hired without my direct involvement. I haven’t gotten quite to the firing part yet. I’m still doing all the firing. That’s one of the things I got to let go of.

You got to train someone who likes to fire people.

I feel bad for them because it’s such a hard thing to do. I still hate it.

I know this isn’t the topic for discussion, but it’s so much easier for me to let go of someone when the objective numbers say it’s time, “These are our expectations. Hopefully, on the front end, you’ve set up productivity standards even in the interview process, ‘Are you cool with seeing many visits per week and billing many units?’” They agree to that, but then they can’t follow through it with it on the backend or things slip or maybe they go against your values or a values-based firing, makes it much easier, “We talked about this. You’re falling through on our values, we have to let you go.”

I find that the decision is easy.

The conversation sucks.

The conversation is tough.

As you’re looking then out at number four, what do you recognize, what do you think needs to be in place for the fourth clinic to open up?

We’re going to rebuild our systems. Rebuild everything, start from the ground and build it all the way back up.

Reassess everything.

Reassess every system we have. That’s probably probably number one. We’re also going to implement a few cashpay things in the clinic and make sure our profit margins can withstand some of the changes. We’re going to add some cashpay services. We’re looking into some improved automation, particularly at the front desk and with documentation with comprehend PT.

We’re looking at making things better and more efficient throughout the company. I’m the recruiter. I’m good at it. I like it. I like the marketing and sales piece. I like the chase. I have to get rid of that. I have to figure out a way to build out a full-blown marketer recruiting program and not just that, but a sales interview process with all of our directors. I got to build that out. I don’t know what I’ll be doing after that, but that’s what I got to do.

This sounds like a lot of work. That’s what you signed up for.

You got good people around you and you start building out those trainings. Once you build 1 and 2 out, they’re all the same. You change up the template. What I found is those trainings don’t have to be perfect. They shouldn’t be. They should be guidelines. There is some objectivity to it, but as long as you can give people the vision of the product, tools to get there and their value-aligned, it comes down to plugging the right person into that seat. They’re going to make it better than you did.

Do you find more fulfillment in what you’re doing now than what you did with clinic number one at the very beginning?

Yes.

You always had that vision for yourself that you were going to be a business owner, clinic owner of multiple clinics even before you opened your first.

Even when I was in school.

I felt the same, but I had no idea what I would have to learn in order to get there. My vision was I’m going to be treating full-time and there’s going to be other physical therapists also treating full-time, not thinking about the multiple clinic aspect. What I found was as I started doing more of the business stuff, setting aside time to work on the business instead of treating, I started to find myself enjoying and loving the business side of things. That took the place of the joy that I had in treating patients. Did you see the same thing?

I do miss treating patients at times. I don’t miss the documentation. I can tell you that much.

I don’t miss treating patients.

I miss socializing, making them feel good by getting that trust, they refer you people and you make them feel good. I miss that piece, but I still do that. I do it with my team and like the people I’m recruiting. It’s the same game. It’s just pointed in a different direction. I do find myself unfortunately sitting behind a computer a little bit more than I would like to. Sometimes I’m like, “I need to get out of here or get out of this room.” There are seasons. I can tell you the thing that doesn’t change is it’s always going to be hard. You’re always going to be learning something new that is going to demand something new from you and it’s always going to be harder than you think it is. Get settle in.

It's always going to be harder than you think it is.
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It’s what you signed up for when you open up, this is what business is all about. Thanks for sharing your experience. It was cool.

I’m excited about 2024. I’m excited about what we’re doing with PTO Club. We had a group call. It’s fired up. Everybody’s winning. Everybody’s gearing up for February and going into the end of Q1. If you have any desire to grow your clinic, significantly and you need any help, tips or tricks, please let me know. Shoot me a message. I’m happy to jump on a call with you, conversate in the DMs or connect you with somebody who can help you. That’s what I do.

Adam@ptoclub.com . Nathan@ptclub.com . Don’t be afraid to reach out to us. We love talking to you about your business. Thanks for joining me.

It sounds good. Have a great evening.

You too.

Adam enjoys a commitment to recreational exercise, and nutrition, as well as his hobbies of playing golf and guitar. Adam is inspired by people who set out to accomplish great things and then develop the discipline and lifestyle to achieve them. Adam focuses on empowering and coaching his team with the primary aim of developing “The Dream Team” that provides the absolute best patient experience possible. He believes that when you can establish a strong culture of trust you can create an experience for your patients that will truly impact their lives in a positive way.

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The post What We Wish We Knew – Expanding From 0 To 1, To 2, To 3+ Clinics With Nathan Shields And Adam Robin Of PT Owners Club Coaching Program appeared first on Physical Therapy Owners Club.