Ep 156: Behind the Scenes of a Multi-Location Practice

Click to View Transcript

Dr. John Meis (00:02.059)
Hey everybody, welcome to this episode of The Double Your Production Podcast. I'm Dr. John Meis here with my partner, Wendy Briggs. Hey, Wendy, how you doing?

Wendy Briggs (00:10.907)
Good to hear from you.

All right. This is a really special, special episode because we have an amazing guest. Dr. Milton Cook from Virginia is here to share his story and some of the wisdom that he has gathered. Some of it from mentors, some of it from books, some of it from just hard knock experience. And so we're going to hear some of those stories as well. Milton, how are doing?

Milton Cook (00:20.395)
Thanks. I am doing fine. It's pleasure to be here.

Yeah, we're absolutely delighted to have you. You want to share a little bit about your story? Where were you when we first met? And a little bit about what's happened over the last few years.

My story, I graduated Dillard School in 2003, bought a practice in a small town in Smithfield, Virginia, right out of school, just jumped into it two feet first. Kind of worked solo by myself for the next 17 years, just kind of growing it from a small town practice up to a pretty bustling little practice. I met Wendy at Virginia Dental Association meeting in 2019. I had hygienists that really were excited to listen to her and talked me into joining the Hygiene Diamonds program at the time. And kind of took me in kicking and screaming. At that point I was a solo doctor, three hygienists, you know, stereotypical little practice.

Yeah, nice.

And then we grew from there. I don't know how far you want to go from where I am now, but I maxed out the practice I had and moved on.

Hahaha

Yeah, it just... So that was 2019 and 20-ish.

Yes, January 2020 was my first official TTI meeting that we attended as a group.

Okay. The timing was perfect, Everything went to hell right after that with the COVID. Yeah, right. All right, so give everybody.

Mm-hmm. was just smooth sailing start from then on,

But you weathered that storm pretty well, right? You weathered that storm pretty well because of some of the stuff that you'd already shifted. So at that time, first start with Hygiene Diamonds, how many team members total did you have?

Right. And so.

Seven. Seven or eight. And so, and yeah, so joining TTI and Hygiene Diamonds program really just kind of elevated our practice to the next level to help really, at that point we really grew our hygiene program immensely. I mean, we literally did double overnight.

Yeah, we hear that over and over and over again. So yeah, that was amazing. And that was the first big jump, you know, and that now then drives a lot of free cash flow, right? Okay, then tell everybody kind of where you are now. So five years later.

We didn't stop there. Right. So we can do the trajectory. I officially joined TTI in a 19, early 2020, January 2020. I expanded my business through coaching and I went from one single location in 2020 to now 2025. I have five locations and just actually put an offer on a sixth. So expanded about one per year, which is a fun little journey.

Nice. And there's so many things to dig into here and I'm just.

There's lots of stories in there and it depends on where you want to start. It's been an incredible little journey.

Yeah.

Well, let's do another check in though. How many team members do you have now? We'll talk about comparisons from then to now.

Well, we just we just firmed up our Christmas party and we're right at 70.

Okay.

Okay, amazing. 10X on the team members. Right? And then what about the revenue story? Like what happened with the revenue? And then we can get into the specific questions just to give our listeners an idea of the growth that you've talked about.

Yep.

10x team members. Yeah, yeah. Right, so I went from, I was a stereotypical single doc practice. I was doing 1.2, 1.3 a year. We're looking to finish this year right at about nine and a half, maybe 10. So another 10x, I guess, almost.

Right.

Yeah, yeah, real close. Yeah. That that is an amazing story. And I think when you say a $1.2 million practice, that's like everybody. No. Right. That's not. I think the average now in the United States is about 800,000 a year. So you're half again, bigger than the kind of typical, you know, average kind of practice.

Yes.

And doing it in a small town and really a blue collar town. This isn't fancy stuff. You're doing mainly bread and butter dentistry.

Yeah, my primary practice, Smithfield, Virginia is just a town of 8,000 in Southeast Virginia, port capital of the world.

Yeah, everybody knows Smithfield. So tell us, know, kind of the for most people on the path that you are and the path of going multiple locations isn't for everybody, right? But for those who are thinking about it, it's the jump from number one to number two. From having one to having two, that seems to be a pretty big hurdle for people to get over.

So do you want to talk a little bit about some of what you did to get over that hump and some of the things that you learned?

It's a very big leap going from one to two. You're going from an office where you're working every day, you know everybody that's there, you know all the patients that are coming in, you know your systems because you created them and they're there and you can enforce them day to day. You see how everything works on a minute by minute basis.

You're listening to the phone calls to everything and jumping to the second, you know, it's a big leap. And I know there's things like, hey, what did you do and how did you get ready for it is one question. And then what did I actually do and get ready for it is a whole complete separate conversation. And looking back now, what would I do different is a third. I was fortunate in the fact that I had really good coaching on how to get things straight. You can go ahead and take credit for that now if you want. I was fortunate that I had my first location basically running on all cylinders. That is what allowed me to do what I did. And so it's just very much so a big leap of faith. Plenty of mistakes along the way. You know, as you say, the University of Hard Knox, my systems were, I guess you say they were people-based and not SOP-based and written down and look in hindsight, if you have good systems at your first location, you need to get that stabilized in writing and not be dependent on someone's institutional knowledge, if you know what I mean.

Yeah, that's really important. And it's not every system you have, but revenue cycle should be written down, scheduling should be written down, those kind of key things. Your hygiene processes and systems really need to be written down as well. So you could probably pick seven categories of systems and probably that would be enough.

Right.

And it seems like every office does things a little bit differently, right? Each office has its own bit of culture that fits within the overall culture. But they all function just slightly different. So your office, your second office, was an acquisition. And how far away was it from your first

Correct. It's about 15, maybe 20 minutes, but well, yeah, but here in the country, that's still 15 or 20 miles. You know, it's not, it's not overly close, but it's close enough to travel to, but yes, it's a completely different zip code, county, everything, but it's close enough to easily monitor. Yes.

Yeah, so close. Right. Yep. And now did you get an associate in your first location, have them there for a while, and then they went to the second location? Do I have that right?

Yes, I shortly after one of the my lessons, very first lessons, very first day of TTI was a lesson about capacity blockages and where the limiting factor was. And we quickly found out it was doctor time. And so I added a second associate early on and they filled up immediately. And so kind of trained them and got them going. And then when they opened up the second one, I moved them in there and hired another one to backfill behind them in the, I guess you call it mothership location.

Yeah. really smart things to have done. Did some of your team from office number one go to office number two?

Only on the management side, I guess. My office manager I had at Mothership, when we first acquired, she kind of was the office manager for both, which kind of worked for a little bit. It's not a good long-term solution, but it's good to kind of help get things going in the right direction. And we lost some personnel with the acquisition, which is to be expected.

Yep.

Yeah, so, and we kind of filled them with our hires and our trainers, trainees, then eventually hired an office manager to kind of fill in that role.

Yeah, yeah, awesome. And so and the doctor that you bought the practice from didn't stick around, right? He was here. was.

She stuck around long enough for me to get my associate from my first location into that second location. It wasn't long, but it was long enough.

Ready. Yeah, very good. Long enough, right. So she was flexible on exit, but the practice wasn't performing as well as it could. And so. Right, right, right, right.

Right, right. So that's why I didn't want her to stick around for too long. But it was, but yeah, we were able to institute some of our systems slowly. That was one of those hard knocks learning things. It was not slow enough. That was, I thought I could go in and just take my systems and lay them out and everybody's happy and hey, we can be successful and existing employees don't necessarily like change. So that might have attributed to some of the turnover, but yeah, it was just a slow office that they were just on cruise control and kind of on their downhill slide, I guess would be the right word.

So then Dr. Cook, going from two to three to four to five, my guess is that road got easier as you learned what to do and what worked and what not to do.

It did, it did. Every baby's a little different. And so, yes, two to three was a lot easier than one to two. We had some of our systems in place. We learned from our mistakes. We were able to retain and practice number three, which was another acquisition. We retained pretty much everybody. And I think almost everybody, we've lost maybe one out of the five or six people that were there. So we retained a bunch of them. And the ones we've lost are retired. They were just older and they just retired outright.

Yeah. So one of the lessons of acquisitions is that the closer how the practice operates to your processes, your systems, your culture, the better. The more it's different, the harder it is for team to adjust to it. They bought into the treatment philosophies. They bought into the culture that's there. And you come in and try to change it, there's always some resistance. And often you end up losing, and we joke about it, but it's maybe a little more accurate than just a joke, that you lose everybody but one. You never know what you'll get.

That was true with the first practice. We lost everybody but one.

Yeah. And luckily they don't go all at the same time. But some of the things that you mentioned is the faster that you try to shoehorn them into your systems, your culture, your stuff, the more likely you are to shake some out, which isn't really the intention. If they're good employees, obviously we want them to stay with us. We want them to be even more successful than they were before we got involved.

Right. Right. You know, and that's in that like to answer the first question, going from two to three to four is it was easier with the infrastructure we had in place was this we had a very lean, I guess, executive team or, you know, corporate level kind of team, meaning two of us as we've hired as we moved from like to the four of them to get a full-time bookkeeper, finance person, but jumping up to five added a layer of complexity that we not necessarily were ready for. It's just things start to add up.

And number five was kind of a de novo, correct? Meaning a new start. It was an empty room.

It was very much a de novo, which again, you learn. But you learn that you probably should build some things prior, infrastructure-wise, to get ready for that kind of growth.

It really stretched your team to the breaking point and you, to some degree, because you're actually in that practicing.

Correct. I was in that being at de novo and not having somebody to go in there. I didn't have an associate that I could spare. So yes, I went back, you know, chairside full time for a couple of months to get it going. Not ideal. You can see the effect on across the enterprise. And, so I, I thankfully have fixed that problem, you know, so, now I'm back being Chief Clinical Officer like I should be.

Yeah, good.

So let's dig into that for just a minute, Dr. Cook. If it's okay, I'd love to just have you tell our listeners a little bit more about what you identified. You know, obviously we look at one office manager leading one or two locations. It just requires a completely different skillset and a different infrastructure to have five, right? So what did you find was needed to develop your teams, to develop leaders within your teams? And I look at it this way too. You know, if you have one or two locations, you may have three or four hygiene providers.

Correct.

But when you get to five, you could have 10 to 20 and it's a completely different ball game, a different animal, just different communication cadence, leadership structure, all that changes a little bit. Maybe just give our listeners a little hint behind the curtain at that, if you would.

Well, yeah, it's, I've always thought meetings were, you know, overrated and why do I need to meet about that? You know, especially when there's this one office, we hardly had any, any meetings. but now you see it's like, man, get everybody on the same page. You've got everybody thinking along the same lines. I can't tell you how many different meetings I am in during a, during a week's time. And then that's, and I'm at the senior level, my, you know, regional manager means she's got meetings every day to kind of touch, you know, have touch points with the office managers there, to be able to observe what's going on in the offices and it's a different beast.

But to your point about what, to get to that level, get someone up to a level, is for us, you know, in dentistry, we didn't get any of the training to do that. It's not something that was pushed on us. And my regional manager, she kind of grew up with me in the office. And so she didn't have that experience. And so we had to seek training. You know, how does this look? How does it work? How do you lead? You know, that's a skill that is not taught.

And you know, I think that's one of the things that you excel at. And it's very different leading when you're in the same office as everybody and when you're not. And one of the things that I think you really did, and I know it wasn't easy because I was I was watching it happen. But you did a really good job of giving up things, right, giving up control, depending on your team at a higher level.

Right.

Letting them stumble and fail and learn from things. And when you first start to do that, it's very uncomfortable. I thought you managed that process really, really, really well.

Yeah, when you have one location and you're the owner doctor and you're working and most of the time you're also the de facto office manager, you don't have a separate office manager at that point, you make an office.

You may have somebody with the title, but they're not really functioning as a man. Right. Right.

Right, you're still making all the decisions. You're doing all the time off requests. You're doing all the evaluations. And so you're responsible for everything. Yes, it's after doing that for so long, it's very difficult to sit there and hand off those decision making processes. And it's still hard. just to let you know after even with five locations, it's hard to sit there and let others decide. But there is a level of trust is like, they're going to make good decisions. You have trained them well enough or they have been trained well enough to know that, you know, proper decisions, you know, in good decisions for the betterment of the company. But there's lots of things are really fun to hand off.

I have no interest in planning a Christmas party.

Hahaha. Yeah, nice.

And so now I don't have to worry about where it's held or who's, you know, how the catering is, or I just was given an invitation just like everybody else was. And I am, I've learned that at our level now is I'm responsible for, you know, five to seven decisions a year. You know, my decisions need to be, company-defining decisions. And all these other little decisions of which vendor do we use and, and, know, any of those other decisions need to be handed off to somebody else.

Yep. Nice.

So I have a scenario question that I'm gonna ask because I know there's probably listeners thinking it. And I've had people bluntly ask me the question very directly, but I think it's an important question. And it might catch you a little bit by surprise, but my question, sometimes people say, "Why would Dr. Cook want to do all that? He had a $1.2 million practice. Why would he wanna go through all the trouble and aggravation?"

So Dr. John, could you kind of walk through just a little bit maybe like why doctors decide to look at an enterprise rather than just being a producer doctor and Dr. Cook, maybe you can personalize that with what was your decision behind that? And again, I think probably a lot of dentists, a lot of our listeners may not understand what this means to valuation of what Dr. Cook spent his time building. So let's answer that question because people are thinking it, they're like, why would you wanna do all that? Why would you wanna go to the trouble?

So you can make a very, with a $1.2 million practice and if you're thoughtful about expenses and staffing, you can make a very, very, very good living doing that. And that practice, the average practice sells for about 70 % of collections. And so that practice would be, you know, $1.2 million practice might be worth $750, $800, maybe $850. And, and you have, you don't really have a business, you have a job, you got to be there every day. And you've got to do all of the dentistry that's done. So when you start to build an enterprise, your income may not go up much. In fact, I remember your wife at a rooftop restaurant saying, is there going to be more money? And so your income...

Remind us why we did all this again, is I think it's what she said.

Yeah, right. So your income may not go up very much, at least initially, because you have some additional debt and you have to get things.

Well, be honest with you, it will most likely go down initially.

Yeah, a little bit. And so, but then every single bit of growth and every single loan payment, right, your net worth is going up. And so a $10 million practice might sell for, you know, might sell for $9 million. Okay, so you've 10x your wealth. And so now there's debt.

And when the debt's paid off, right, that's going to be a 10X. And the debt may never be paid off, right? You may just continue to grow. You may just continue to borrow. We recommend people have their debt in tranches so that, you know, that first loan stays that first loan and it gets paid off. And now that is really when you see your income go up. And so that's typically year five, six or seven, depending on how aggressive you are on paying down the debt. And so

Right. Right.

But remember, we're now investing. when when when we say income will go down, well, the income may may go down, but your expenses also are less because you're not you're not investing as much in other things, right? You're investing in dentistry. And so as far as kind of

Right. Right. Well, it's a trade-off income versus net worth, but we can get to that in a second.

it is. Yeah. Yep. And so that's the goal is to try to keep income as level as it can be and have the net worth go up. The other principle that you followed to a T really is add something, take a day out of the chair, you know, and you slowly whittle down until now you're just in the chair occasionally. And so you're available for the de novo, you're not at all. Okay. What's your right thing?

I'm in the chair when they need me to fill in. I am there as a backstop.

Ideally.

Right? Keep your license up. Yeah, right. Vacations, maternity leaves, maybe somebody's sick or gets hurt, you can step in. But as you already mentioned, when you do that, and now your energy is focused on one practice, the performance of the others can start to slide a little bit. As your next layer of leaders get better and better, that will happen less and less. But that's pretty typical that it does.

Okay. So, Wendy, to put my spin on this, the first part of my answer is going to be, "Why not to do it?" Don't do it because you're bored. You know, because it's, you know, it's, it's, that's the wrong mindset. Don't do it thinking it's going to be easy. And just because I've got a really well profitable first office, you know, mothership, this is easy. I could do it again. Place number two. It's not, don't do it because you think you'd be working a whole lot less, at least not initially. I work a lot more now than I did when I was in the chair. so my first answer is, you know, yeah, it's different. It's much easier on your body. Sometimes not so much easier on your brain, but depends on what's going on. But it's, those are reasons. Don't do it. Do it for the right reasons.

Initially. It's different work, much easier on your body.

And to be quite honest, the reason I'm doing it now is because I find fulfillment and fun in it. It keeps me going. It's, I don't mind sitting at night working on the computer because it's, it's, you know, it's interesting and exciting. So do it for the, I'm doing it for the challenge and for the fun. It's just a different part of my career that I got to. but to,

You've also shared with me that you really appreciate the fact that you're having a bigger impact on your communities, having a bigger impact for your team, having a career growth potential for people on your team.

And the mentorship you get, your camaraderie with the other doctors that you're working with, the ability to, as a friend says, collapse time for them. What took me 20 years to figure out, I can kind of help them get there within just two as your clinical mentor. so I've got eight associates now. So it's... it's exciting to kind of see some of the changes that they make. And then, so why did I do it to the last part of your question, Wendy was.. After I joined TTI or specifically the Hygiene Diamonds aspect of it, I went from that $1.3 million practice to a $2.5 million practice overnight, at one location. And so I sat back and looked, it's like, all right, what's my end game going to be?

And an associate can't buy a 2 million dollar practice. It's just, it's, it's not possible. And so it's like, what can I do to make, to find an end somewhere? It's not anytime soon. And to make my, my practices and my enterprise more appealing to somebody is to make it large enough to be noticeable.

And so, but now things change. So now I'm looking at it as like I am creating a business that I don't necessarily have to sell. Everything sells eventually. you know, it's everything kind of passes along, but there is no end game for me at the moment because I can just continue doing what I'm doing. And I'm energized enough to be able to do it. And you can live off of the cashflow of the business and not have to sell.

Yeah. I love that. So Dr. Cook, you mentioned you started with Hygiene Diamonds, then you joined our Blue Diamond program, then you joined our CEO Mastermind group, and now you're involved in our Spark group for groups. Just so our listeners know, there is an ascension path that makes sense as you're trying to do that. And early on, you mentioned the value of coaching, and we certainly don't want people to feel like they have to figure this all out on their own because just like you said, for your doctors, you're collapsing time for them.

We're trying to collapse time for other dental practices that want to do something similar, right? So that's kind of our mission. So I know probably our listeners are wanting to know what's next for you. Like we're, and you kind of just share that a little bit, but I'm not going to be honest with you. You know, in 2019, we usually will have a conversation like this with our doctors. Just wait, like once you see Hygiene Explosion, you're not going to believe what's possible. It's possible. But the Dr. Cook of 2019, would he have ever been able to foretell where you are now?

Yeah. No, I had no interest. I had no interest of multiple practice ownership. That was not even a consideration at the time. At 2021, would you say, hey, you've got two practices. you think you'd ever get to five? Oh, no, that's more than I think I want to handle. I'm not interested in doing that. So you ask me now, what's in my future? I have no idea. You tell me now I could have 10 practices, that's crazy. But I am building out my leadership team and I have a Director of Operations now that's, she's got a big vision, also almost as big as mine. And so we'll see, you never know. You never know what's gonna come knocking on your door.

Yeah. And I love the fact that that's your next step. And that's really what the Spark group is all about is raising the leadership capabilities and the business acumen of everybody on the executive team. And I love that you're building that up because that is how you free your time. Right. There's certain pieces that you will have to do for years yet. But in the meantime, you can peel it off by having, but by developing the people around you and you can focus on the things that really only you need to do.

Right, that's just the same but different of allowing others to do the job that I was doing. That was my goal with this recent hire was offload some of the operations that I was involved in so someone else can do it.

Yeah, awesome. That is fantastic. So are you having any fun?

Anybody that knows me in the group knows that's pretty much all I do is have fun. It's like I said, that's why I that is my purpose and what for why I'm doing it is I'm having fun doing it. It's you have to do everything for the right reason. That's my reason. It's fun and it's fulfilling. You know, when you can look and look at the number of patients that we serve can fill a football stadium. You know, it's amazing the breadth of impact you can have.

Yeah, that's a great way to think about it. Yeah, that's awesome.

Yeah.

Well, I love it. Well, Dr. Cook, Dr. John, we probably should let our listeners know if you're intrigued by Dr. Cook's journey and want to learn more, we have a great opportunity for our listeners to come join us at an upcoming quarterly practice growth retreat. We will go ahead and put that information for you on the show notes page. There's a simple link there that you can go and request a short 10 minute meeting to learn more about what that looks like and to come be a guest with us. The next retreat is in January of 2026 and it's a doctors-only retreat where it's really going to be focusing in on some of the lessons that you learned Dr. Cook and we'll be able to hear from Dr. John some really, really valuable lessons on the financial aspect of the practice. So know it's a hot topic, but even if you listen to this podcast a little bit later on, we have one of these retreats every three months. So we'd love to have you come join us, sit in and learn how you could possibly follow in Dr. Cook's footsteps and take your successful practice and turn it into a highly successful enterprise.

Yeah, I would say that was the best decision of my professional career was to attend that very first January TTI meeting and take key decision makers in your practice to it. Now, this is a doctors-only January meeting, but maybe the next one to take the key is take key key people on your practice to help with this journey because you're not going to able do it by coming back and saying, hey, guys, this is what we're doing. You know, they have to be involved.

They have to understand it. Why they have to understand the why they have to understand the how and they have to be motivated to do it right. And so and that's what doing it in a group really does really fires everybody up. Everybody goes back. They're clear on what they're doing why they're doing it how to do it and where to get help when they get stuck. You know that's the whole the whole thing. All right well Dr. Cook congratulations on all the success you've had up to now. I suspect we're going to see a lot more out of you.

Right. Right.

And going to be making really magic things happen in Virginia and maybe other places as well. So that's it for this Double Your Production Podcast. Thanks for being with us today, and we'll see you next time.

Thank you.

Thanks everybody. Thanks Dr. Cook.

Thank you. Thank you.

Thanks, Dr. Cook.

‍

Ep 156: Behind the Scenes of a Multi-Location Practice

Ep 156: Behind the Scenes of a Multi-Location Practice

Watch Now:

Listen to the Episode:

Recent Episodes

Ep 156: Behind the Scenes of a Multi-Location Practice

Ep 155: AI in Dentistry with Mango Voice

Ep 154: The Hidden Math Behind Single-Doctor Practices

Do you really need more new patients?