Hiring Another Associate Won't Fix Your Practice

Most owners hire an associate expecting them to grow the practice. Dr. Mark Mouw thinks that's the mistake.

"Most associates aren't there to build your practice. You build your practice."

Mark has been in practice 25 years. He and his wife opened as a mom-and-pop shop, and he hired his first associate 18 months in. He's had 16 associates since, runs five doctors across two locations outside Omaha, and his longest-tenured associate has been with him 16 years. In 2016 he co-founded Chiro Matchmakers with Dr. Allen Miner (Ep 42). They now place 250+ chiropractors a year.

So he's seen a lot of hires go sideways.

What's the difference between a business builder and a caregiver associate?

Mark sorts associates into two types. Business builders, about 25% of chiropractors, want to own something someday. Caregivers, about 75%, want to take great care of patients, get paid well, and go home. They don't want the headaches.

The old model assumed everyone was a builder. Pay a new grad $30K with a path to $50K, they learn for two years, then they leave and open three miles down the road. That worked because most grads back then were builders.

It doesn't work now. Most grads coming out don't want to own a practice.

Which is why his biggest warning is about the mini-me. Same school, same technique, same philosophy, same drive. "They're gonna be with me forever because they're like me." Then 18 months later they're your competition. His advice: hire the person who's 180 degrees from you. Someone who wants to stay 15 to 20 years and take care of the patients you bring in.

You still want a builder in two cases. You need a managing doctor because you're stepping back into another business, or you're planning an exit in the next one to three years. The easiest buyer for your practice is someone already working in it.

When can you afford an associate?

Mark's first question is whether you can bring in enough new patients to feed another doctor and the CAs that come with them.

His second is the money. He hears from owners running $250K practices who want an associate for time freedom. They take home maybe $100K. A good associate today won't come for under $90K to $95K, and A-players run $90K to $115K. That's asking the associate to make what you make.

His rough line: around $500K in collections it starts to get interesting, if margins are healthy. Above $750K, the money's usually there. Either way, you need the runway to pay a doctor for about six months before they break even.

Why is it so hard to hire an associate right now?

Mark's numbers show five to six associate jobs for every available associate.

Two things caused it. A wave of older docs left the profession during COVID, and chiropractic school enrollment dropped, so recent graduating classes have been much smaller. Meanwhile practices grew. Associates are now interviewing at two to seven places at once.

And the A-players aren't on Indeed. They already have a job they're doing well at. Most won't move for $5,000 more. They'll move for $15,000.

What works is a hiring funnel with real hurdles. For a CA role, Mark's practice took 214 applicants through a cognitive assessment, then a behavioral assessment, then a team interview, and he personally interviewed nine. A virtual interview where two minutes late means you're out. One question is simply whether you looked at their website. Then an in-person shadow, then a homework video they have to respond to within 48 hours. Then a background check on every single hire.

"We can't hire on gut."

What should you pay to keep a good associate?

For caregivers, it's salary. Mark ranks what associates look for as money, then technique (full-spine manual is the easiest placement), then location. And the only thing that can buy you out of a bad location is money.

His own doctors all make over $100K. The two who've been with him 10+ years make $150K to close to $200K. "Because they're damn good. They keep patients, they do a great job, and I don't have to be there."

Common questions

Q: Should I hire an associate who wants to own a practice someday?

A: Only if you need one. Dr. Mark Mouw recommends a business-builder associate if you need a managing doctor or you're planning to sell in the next one to three years. If you want someone to care for your patients for the next decade, hire a caregiver. A builder will usually leave to open their own clinic.

Q: How much does an associate chiropractor cost to hire?

A: Mark Mouw says a solid associate won't come for under $90,000 to $95,000 today, and A-players run $90,000 to $115,000. Owners should plan for about six months of salary before the new doctor breaks even. If paying that would cut into what the owner takes home, it's usually too early to hire.

Q: Why is it so hard to find an associate chiropractor?

A: According to Chiro Matchmakers' data, there are five to six associate positions for every available associate. Older doctors left during COVID, enrollment dropped, and practices kept growing. The best associates usually already have jobs and aren't searching job boards, so posting on Indeed rarely reaches them.

Q: What should a chiropractic hiring process include?

A: Mark Mouw uses a written job description, a cognitive assessment, a behavioral assessment, a short virtual interview, an in-person shadow, a 48-hour homework response, and a background check. Each step is a hurdle. If a candidate can't clear them while they're excited about the job, they won't be a great employee once they have it.

Q: How much should I pay chiropractic assistants?

A: Mark Mouw says CAs in high-performing, low-turnover offices earn roughly $22 to $26 an hour in the Midwest and $24 to $28 elsewhere. His senior team members are salaried with bonuses tied to KPIs and quarterly rocks. Underpaying is how practices lose good CAs to the next job.