Future-proofing group practice with Dr. Elizabeth Carr

Dan King [0:00]I am really delighted today to be joined by Dr. Elizabeth Carr, clinical psychologist and founder of Kentland Psychotherapy. Elizabeth, welcome to the show. It's so good to see you again. Dr. Elizabeth Carr [0:10]Thank you, Dan. It's great to see you as well. Dan King [0:12]So we'd love to hear the basics on Kentland Psychotherapy. How long has it been around? How many team members? Give us the basics. Dr. Elizabeth Carr [0:18]We have been around now for 20 years. We have a little over 20 clinicians, therapists, talk therapists, psychologists that do testing and prescribers. One psychiatric nurse practitioner and two psychiatrists. We have an office manager admin. We have an assistant to her who's a client care coordinator doing all the screening calls. And we have a college student who's a communications and PR major who's helping us with our kind of comms department. Dan King [0:45]Well, a lot to dig into there, but maybe let's start with what do you feel makes Kentlands distinct as a practice? Dr. Elizabeth Carr [0:51]We are in a new urbanist community, kind of like the Truman Show or celebrations in Florida. And because of that, it feels like even though we're in the suburbs of Washington, D.C. on the Maryland side, it feels like we're in a small town. There's a central commercial area where there's a movie theater, a Whole Foods, another grocery store, about 26 restaurants, and a thousand family households that surround it within walking distance of that central commercial area. And we are in that central commercial area. We design our marketing efforts almost like you would if you were in a small town, even though we're in an urban area. And we target people in a very small catchment area because of that. Dan King [1:29]And you only have the one location. Is that correct? Right. Dr. Elizabeth Carr [1:33]Yeah. Dan King [1:33]There's a level of focus, which is so, you know, looking at your website, looking at what you've built, there's a level of focus, which I see both in that and in your answer just there. When you combine that, like, I think part and parcel of that is community support and sponsorship. Is that a fair statement? Dr. Elizabeth Carr [1:47]Absolutely. Dan King [1:48]So many practice owners have the desire to expand, to go to multiple locations, right? But this, I think, is core to your distinctiveness. Dr. Elizabeth Carr [1:55]Well, you know, it's interesting because we started, when I started, and I, of course, like many people thought I was just going to be a solo practitioner, I was subletting from a woman on Main Street. She calls me one day and says, my husband has a job in another state, and I had to walk up and down the street and find another space about a block away. Sublet from somebody else, that got too tight and small. And then another therapist and I took on a space together on Main Street. She's using half the suite. I'm using half the suite. But eventually, I wanted to hire someone that saw kids and teens. And that's what she did. And I didn't want to create internal competition for her. So I walk up and down the street again. And I find the building that we're currently in. That the top floor is for rent. So we started renting that building. And what I have found, this is a long-winded answer, but I would say what I have found is eventually we moved into all three floors. And even having three floors is a little bit like having three locations. And I've talked with the clinicians about the fact that they know the other clinicians on their floor, but they feel sometimes that they don't know the clinicians as well that work on the other floors. And we're all in the same building and it's like the size of a house. So part of it is I really do want a cohesive staff. And I think that's very challenging when you have two or three locations across town. [3:11]The Importance of Environment Dan King [3:08]It's as if you've sort of expanded vertically rather than horizontally. Dr. Elizabeth Carr [3:12]Exactly. Dan King [3:12]Which is probably consistent. I'm not an expert on new urbanism, right? But that you're, again, this focus on community, right? I think it makes it easier as a patient to know not exactly what you're getting into. That's a slightly separate subject. But I think every practice, you know, one of the core themes that has come up in so many interviews is that need to brand yourself distinctively, right? And so part of the core, like even the choice of name and lens, I think factors into this, yes. Dr. Elizabeth Carr [3:39]You know, there's a show right now on streaming that's called, I think, Virgin River. And it's this small town and there's a small town dock and everybody knows the small town dock. I think people love that feeling. And we do our very best to create that same feeling where we have the central location, for the reception desk. And she's sweet and lovely and smiles and says hi to people as they come and go. And I think that's really important. And we put our admin people and their pictures and some descriptions about them on our website so that even if you're a prospective patient and you're calling in, you already can see what the person looks like that you're talking to. And I think that's really important. Dan King [4:23]That's gonna create a really, a feeling of warmth and coziness, right? Dr. Elizabeth Carr [4:26]Exactly, exactly. Dan King [4:28]And I think that environment, I mean, environment shapes human behavior so deeply, but in a therapy practice, right, human behavior is at the core of everything we're doing. And the location shapes the practice. Dr. Elizabeth Carr [4:39]And I'll give you three examples of that. One, we have 26 restaurants within walking distance, which means that people can come for couples therapy and then leave and go for dinner and talk about how the session went without even moving their car. We have lakes within walking distance in our neighborhood with paths around them. So it's very common for therapists that see kids or teens to go for walks with their client around the neighborhood. Third example, because we're so close, it's one of the benefits to our clients who have minor children coming to see us that they don't always have to get them in a car and schlep them somewhere. We have high schoolers and even middle schoolers that walk to their appointment and their parents don't always have to come with them. And I'll share a little story about that. One day I was in the upstairs waiting area arranging and organizing our lending library. And three girls look like middle schools with the giant colorful backpacks on come walking into the waiting area. And the one that seemed in charge looks at the other two girls and points at the couch and says, sit right here. And they follow her instructions. They sit down. She tosses her backpack on the floor and walks to the bathroom, comes back out and says to her friends, this is my therapy office. And they leave. They were probably just coming home from school and she had to go to the bathroom. And she felt so comfortable at our practice that she thought it was fine to come in and use the bathroom just because it's part of her home, in a sense. And that just makes my heart sing. I loved it. Dan King [6:01]Yeah, that feeling a sense of belonging and deep connection to the place where we get therapy is going to, it's going to deepen the therapist-patient alliance. Dr. Elizabeth Carr [6:11]Yeah. Dan King [6:12]I think there's such interesting insights for practice owners if they're starting out or even if they're just building a new location on an existing practice. This is kind of the thoughtfulness, right, that can enhance the impact of the service as well as your marketing. Dr. Elizabeth Carr [6:26]Y es. And the other thing is, like, for me personally, because we are in the D.C. Metro area, sometimes I see specialists and I have to drive down to Bethesda and I have to go into a parking garage and I have to pay to park. And I just hate all that stuff. And I really love that our clients don't have to deal with any of that. Dan King [6:41]You know, I, this is a minor little digression. I have never owned a car. This is like an interesting thing I talk about with some people sometimes, and they look at me like I'm crazy. And there's a way in which I think vehicles, you know, they obviously are necessary and practical in so many cases. I'm not saying people should never own a car. And, and there's a way in which they disconnect you from an environment. They're a form of separation. Dr. Elizabeth Carr [7:05]Absolutely. You know, I feel that because I live in the neighborhood where this office is, it seems like overkill to get into a giant, whatever, 5,000 pound combustion engine vehicle to bring me and my laptop to work. And so I've wrestled for a while with how can I do that? I don't always have the time to walk, but I don't want to use a car to get there. And this is one of the reasons why we ultimately ended up buying this buggy, this replica of a Ford Model T. It's entirely electric. It's basically on a souped up golf cart chassis. And it is so fun to take it to work. But, you know, it feels a little bit like you're in a bicycle because it's all open and the air is coming past you as you drive there. And it's so fun. It feels like the right scale for this commute. And it gives an opportunity to put the name of the business on it. And so it also functions like a rolling billboard every day. Dan King [7:54]Neat. And so because there's such a small service area, ultimately, people in the community are going to have seen it. Dr. Elizabeth Carr [8:01]Oh, yes. Everybody's seen it. Dan King [8:02]And speaking of the importance of environments, one of the other things, both part and parcel of the theme of local service of care that we've been talking about, but also the environment around the practice, walking psychotherapy. This is not something I see too often. Can you speak to that? Dr. Elizabeth Carr [8:18]There is some thoughts that when you are, you think about like EMDR, we're trying to get things to go back and forth across the corpus callosum as people are talking about the traumatic experience. There are some thoughts that when you're walking and you're swinging your arms and you're moving your legs, a similar thing is happening. And I don't know all the deep science of that, but I can tell you that people love to be outside. And some of our clients, some of our teen clients are more comfortable having a conversation side by side looking ahead than sitting stagnant, stationary, staring at each other, especially sometimes the boys. So for all of those reasons, I think giving it as an option is really helpful. The challenge with walking therapy is that sometimes it's going to rain and you have a booked appointment. So you really have to have that reserve space. When we offer those appointments, it is during a block where the therapist has an in-office reserve space. So there's always a backup plan in case it's raining or. Or the weather just doesn't allow for it. But it's such a nice thing to be able to even spontaneously say, do you want to go for a walk today? And to be able to do that. We also, right across the street from our building, we have a playground. So sometimes little kids, it's really helpful to go to a playground and be physically active while they're talking about what's going on. And so we have all these resources. And that speaks to this issue of how important it is to think about what you want your practice to be as you're choosing a location. Dan King [9:39]And the D.C. Area is kind of a swamp, so I'm sure there are times where it does rain. And sometimes maybe just the decision about, oh, is it raining? Not so much that we can grab an umbrella and maybe still do it, right? Dr. Elizabeth Carr [9:50]Right. Or I wanted to be on the deck to talk to you today, but it's covered in yellow pollen. And so there are those challenges that you just have to work around. But we carpe diem when we can. Dan King [10:00]It's interesting. So you're talking about movement. And movement, especially for younger boys, movement can be such an important part of the mental health journey, right? And yet, it's funny how we have such fixed expectations that people sit in a chair and have this conversation that is no doubt affected by that environment, by that choice. Dr. Elizabeth Carr [10:20]R ight. And we know that doesn't work very well for kids at school. So why would we try to do that in therapy? We even have a room that has a footstool that spins. And some of these kids, they just love to sit on this and spin while they're talking. Great. We also have dedicated play therapy rooms, animal-assisted therapy, where we chose very intentionally one of our biggest rooms because it's a golden retriever. It's not a small dog. And so you need enough space for the therapist, the child, and the dog. We really want each therapeutic space to fit the needs of that population. Dan King [10:49]It strikes me that with all of these different innovative ideas and physical space, services offered, do you have a creative process that you consciously use to generate ideas? How do these ideas come to the surface, do you think? Dr. Elizabeth Carr [11:01]So I think I am a secret closet wannabe decorator. And so I. It comes very naturally to think in terms of this is the population, what would they want to be surrounded with? What's the environment that's going to help the therapist create the most special, unique, beautiful, functional environment to do exactly what they need to do? The biggest challenge for me was when we had a dedicated testing room because it has to be bland and boring inside, but I didn't want it to be ugly. And so that was a fun challenge to do. But I think our space, we have compliments on our space so often that we have now on our social media account something called Tuesday Tour, where we choose one room and take several pictures of it and post it on social media every Tuesday. And people really like that because you want to see inside. People want to know what they're getting into. I think even on your website, you should have pictures of your space because people need to be able to see themselves there in therapy. They want to see you. They want to see the space. Dan King [11:57]Before we started recording, you were talking about your team and how they're often feeding into your creative process. So it's clear this skill set, this instinct you have for design is factoring into your creative process. But so is your team. Yes. Dr. Elizabeth Carr [12:11]Absolutely. We have a clinician, Daniela, who does PCIT. And I had seen a picture on Pinterest once of what was probably a children's museum that looked like a little miniature city. I'm sure most people here have been to one of those if you have kids. And I just loved this picture so much. I wanted to create that for her when we did one of our build-outs. But I'm not a play therapist, and I'm not a child therapist. And so I have to work with her to, to figure out, okay, that's the picture I have in my mind, but what does she need? For example, I want to use all the space vertically, but she therapeutically needs the clients to be able to reach all the stuff. And so that creates a design element because it's going to drop everything downward, but it needs to do both. It needs to be beautiful, but it also needs to be functional. And you have to work with your team to really know because you can't be an expert on everything. Just same with the testing room, you know, to say that you can't have a lot of like art on the wall or distractions, it needs to be very bland and boring, and ideally not near a window where there's a lot of traffic going by, things like that. And so I have to lean on them to give me feedback on what they need because the specialists know what they need. And I'm not a specialist in everything. Dan King [13:17]Were there specific questions that you asked in order to generate that conversation? Did she come to you with these ideas? How did it happen? Dr. Elizabeth Carr [13:24]Sure. I say to someone, like in this case, I am going to build a room that I want you to be able to use for play therapy, sanitary therapy, be PCIT, that kind of thing. And here are the limitations. Like, for example, there wasn't space for there to be like a two-way mirror with a second attached private room. So that's one limitation that we're dealing with. But other than that, it can kind of be whatever. Here's my inspiration picture. I need some feedback from you on how to make it work for you. And people really appreciate that. Dan King [13:51]I'm curious. You've been doing this for 20 years now, right? You built something distinct, right? You built something in a community that has a real presence, that has a real reputation. What's next? What continues to excite you? Dr. Elizabeth Carr [14:02]For me, what excites me right now is the idea that I'd love for this practice to go on another 20 years, 50 years, 100 years, And I'm not going to be around that long. And so the next question is. What structures do we have to build for it to possibly be able to do that? A lot of my attention these days are putting in systems into place so that things are memorialized. And even if someone takes over after me, they have my value system and aligned with my vision so that it can continue on and serving the community the way it is. Dan King [14:37]Well, what kinds of systems can help achieve that? Dr. Elizabeth Carr [14:39]Well, you know, I met with an exit planner years ago, and one of the things that they talked about is nobody wants to buy a business that the owner works in 40, 50, 60 hours a week. And that was interesting and sort of news to me and made me realize that I kind of had two jobs at the time, two full-time jobs, because I was seeing about 20, sometimes 25 patients a week. And I was running a growing practice that had probably at the time 15 clinicians, which really ultimately was kind of like two full-time jobs, except I felt like I wasn't doing my best at the leadership one because I was tugged at patient care. And he said, well, you have to stop seeing so many patients. And I said, well, I pay myself the same way I pay my clinicians. You know, if I pay my clinicians 60%, you know, I realize I'm an owner, so maybe I'm paying myself 80% of the split, but that's how I'm paying myself. So how do I pay myself if I'm not seeing clients? He said, you have to think about it in a completely different way. I think that has really made it possible for me to give the full time and attention where now my focus is, how do I support all of these clinicians and the community? What do they need to be successful? What does the community need that we're not currently offering? And all my attention is there now. Dan King [15:51]Do you miss seeing patients? Dr. Elizabeth Carr [15:52]Well, you know, I kept just a few because I thought I would miss it. If I went to zero, I thought I would miss it. And honestly, I thought that it would feel like a hassle to keep doing continuing education and pay to renew my license if I was seeing zero. But my typical caseload now is between two and five appointments a week, which is very manageable with running the practice. Dan King [16:11]I think the exit planner is generally right. Yeah. How you get to that place is very often a difficult challenge. So it sounds like part of doing that is making a commitment to be the full-time operator, leader, whatever term you want to use. What else is involved in doing it? Dr. Elizabeth Carr [16:28]The other thing is you have to give away and hire people to do things that don't need to be a CEO-level thing. For example, during that time, I was still returning all prospective patient phone calls. I thought I was really good at it. Unless it was a deal breaker that we didn't pick insurance, we closed the deal on every single call, basically, and I was afraid to give it away because I thought that conversion rate would go down. But because I was seeing patients in the day and working on some leadership things, I was returning phone calls typically between 7 and 9 at night. And you know, if somebody calls at 9 in the morning, they may have found another practice before you can get back to them at 7.30. I was killing my nights. So I decided to start letting Petra, our office manager, call people back. And I realized pretty quickly that she was doing great, and it was fine, and it didn't have to be me. So I think the question that you have to ask yourself always is, does this have to be me? This thing I'm about to do, does this have to be me or can it be somebody else? Or can I memorialize it so people know how I want to do it so it can be repeated without me in the future? Dan King [17:27]And it makes sense that that would be a key question, both for understanding how to create more space for yourself to be the full-time leader, but also going back to exit planning, how can it be done without me? Isn't that the perfect question for exit planning? Dr. Elizabeth Carr [17:43]Exactly. Exactly. And for people who aren't thinking at all about selling their practice, if you just don't want to feel like you're working 40, 60, 80 hours a week, you should think like you're doing exit planning. Because when you put all those steps in place to sell a business, you could just keep it and have a business that's not killing you and you get off the hamster wheel. Dan King [18:04]A business that's not killing you? What are you talking about? That's a crazy idea. Dr. Elizabeth Carr [18:08]Crazy idea. Yeah. Dan King [18:09]Really interesting. Yeah. And it's true. Even if you're not going to sell the business, there is going to be an exit at some point, right? None of us are, as you said, here forever. So what are some of the range of possibilities there? I mean, you and I have talked a little bit about this, but you know, you don't necessarily need to sell to a company like ours. There's a range of different possibilities. How have you started to think about those possibilities. Dr. Elizabeth Carr [18:30]So one of the challenges for me is that I love the idea of it going back to the clinicians at some point, like a collective. The problem is twofold with that. I'd say the challenge is twofold with that. One is that there's potential for too many cooks in the kitchen. And I think that always can be a problem. And the other is that I want to recruit people to be in the practice who stay a very long time. And in order to find the people who want to be in a practice like ours long time, part of what I'm looking for is people who do not aspire to run things. If they wanted to run things, they would have their own practice, right? So I want to find people that want to be in a team, want to be kind of taken care of, want to know somebody else is dealing with it when the HVAC goes out or the internet's not working, or there's a complaint from a client that's not even their client, but they have to call them back. They don't want to deal with any of that stuff. And so if I've effectively hired people who want to be in a group practice and not in a leadership role, then how do you pull from that population to hire within if you lead or to sell the practice? Because probably most of them have no interest in buying this practice and doing all the things that I do to run it. And I'm very skeptical of a lot of the stories that we all hear about large venture capitalists, private equity institutions that buy things and then ruin them and run them into the ground and the clinicians are unhappy. And that feels like a betrayal to me. So I wouldn't want to do that. I would only want to sell someday in the future, I think, to someone who's very much values aligned, possibly a similar group practice of the same size and quality that's local where the owner just wants to expand or possibly find. One person in-house that has the right temperament for that to run it where they're still honoring everybody's input and making the clinicians a priority the way I try to do so that it feels relatively seamless if I were ever to have to leave. Dan King [20:31]I think some of the ways that I think about these transitions and totally understand the dilemma that you're wrestling with, some of the ways that I think about this transition, sometimes I think about it a bit like a job interview where there are certain scales, right? So we need to do due diligence on anyone who applies for the role. And you're right. There's a very different skill set to running the day-to-day of a whole business as opposed to just being a clinician, right? There's a very different skill set involved. And it's pretty rare. Part of the reason growing group practices can be so challenging is it's very rare that you find a clinician that does have those strengths. And so part of the the sort of core ethos of what we do. And part of the reason I do it is I've come to believe that there can be partnerships and you have to be very careful and thoughtful about how you structure those. But there's just certain business skills that most clinicians generally aren't going to bring to the table. And similarly, many investors, many people from outside of the space aren't going to be values aligned, aren't going to bring another element to the story, which is necessary. There just has to be a hard driven approach in a business like this. If we're going to care for our patients if we're going to care for our clinicians. And so I've come to believe, and I think there's all kinds of ways to slice the onion, but hopefully you slice the onion in a way that doesn't produce tears. And that means a partnership, right? Where different people can bring different skills to the table and we all get to use our gifts. Dr. Elizabeth Carr [21:52]Right. And that's one of the things coming back to this question of too many cooks in the kitchen. If everything is a committee decision, that's going to be a problem, but that doesn't mean, for example, there's a lot of things that I'm pretty good at, say, for example, social media and communications and marketing. And there might be someone who would be good at that one piece and. But not good at other management issues. And so part of what I'm thinking about, and this is sort of a five to 10 year plan is who might have some narrow skill sets, like in the Navy, we call them collateral duties, where they could just have one little piece over here and somebody else has this other little piece and somebody else has this other little piece. And when we couple it all together, it creates the hole. Dan King [22:30]I think it's beautiful. I really appreciate your willingness to talk about something as sensitive as a succession plan, because these are conversations we just so often don't have, right? And they become these kind of shrouded areas of secrecy. And as a result, our decision-making just doesn't have the sort of scrutiny that we would want for a decision that's this significant. Dr. Elizabeth Carr [22:49]Right. And my husband and I are trying to travel more and more. And if we were killed in a plane crash or something, I wouldn't want 20 plus people to be instantly out of a job. I think, you know, people say that they think of their business like their baby, but I think if you do, then you need to have a godparent for your business, right? There needs to be somebody who says, at least in an emergency, I will step in and steady the ship until we can all figure out what we're going to do next. We are already in the process of getting that nailed down because I think that's our responsibility as employers to have that security and emergency plan in place for our team. Dan King [23:25]Yeah, no, I think it's super important. As we come towards the end of our time together after a very rich conversation, you mentioned travel. So I always love to end on a human note and ask people when they're not working, because I think in this space, it's so important to have a rich life outside of work. It will make you better at the work you do. What's fun for you outside of work? And what are three places on the travel list? Dr. Elizabeth Carr [23:47]So you've probably seen during this episode, my dog walking up and down the stairs here behind me. He is quite a mama's boy and he doesn't like to be left out of the fun. And so we purchased an Airstream travel trailer, you know, the Silver Bullet campers. And we do a lot of our travel right now with him in the U.S. And we have an upcoming trip planned to go to Oregon and and Vancouver, Canada. I'm really excited about that. We love to find waterfalls. We love to do hikes. It's definitely a passion for us. And interestingly, to me, it's not a bifurcated, I'm working around it on vacation. We have an arrangement now in terms of my partnership with my husband that when we're traveling, he does all the driving and pulling the camper. And we have a hotspot in our Ford truck that is very powerful. And I can do a lot of work. I get a ton of work done when we're on our drive days. So even when we're on the road, I'm very available to our staff, but I love to update the website sitting in my camper next to water. You know, I've seen these things about how it's good for the soul to look at water, and I absolutely think that is correct. And we do that as much as we possibly can. Dan King [24:53]Well, speaking of looking at water, the one little bit of travel advice I will give you is when you're in Vancouver, if you haven't been before, you got to hike Stanley Park and when the body of water is English Bay that you have to look You will see park and water next to each other in one of the most, I think it's the most stunning part of North America, or it's out there anyway. Dr. Elizabeth Carr [25:11]There are so many beautiful places in this country, and part of the bucket list is just to see as many as we possibly can. Dan King [25:17]Well, listen, thank you so much for this very enlightening conversation. Really just appreciate the creativity and the focus and the distinctiveness of what you built. It's awesome, and I'm confident there will be all kinds of interesting insights for listeners. So thank you, Elizabeth.