Culture Focused Practice

 Hey, Dr. Tara Vossenkemper here, and you're listening to the Culture Focused Practice podcast. Thank you for being here with me.

This is gonna be an awesome episode. Maybe I'm biased, but this is fucking it. This is what it's all about. So let's say you build your practice, the team, the vision, the structure. You're feeling great when you do it.

But now, you kind of hate your job. You hate your role. You feel stuck, you feel resentful. You're over it. You don't know what to do. You look successful on paper, but you feel trapped.

So this episode is for all of my group practice owners, especially, and leaders included who have realized they're the ones who built a cage and now they have to figure out how to get out of it.

Welcome to the owner's room.

If you want more unfiltered episodes like this where we just talk about all the shit that goes on with leadership and ownership, make sure you hit subscribe. The more you do that, the more it also hits people who need to hear the same message.

And for those of you who don't know, the owner's room is question and scenario based. So it's not teaching training, listicles, bulleted items . it is a question slash prompt that I answer live in real time, no prep behind it other than right before I hit record, I choose the questions, followed by running through a very realistic scenario and just talking out loud about how I might approach this and what I might do in that situation.

So on that note, we'll do five questions, and today I actually have two scenarios for you. There are two, because I could not decide. Both of these are so real and I've heard about them so frequently over the years that they, it feels relevant doing too. So I'm hoping that at least one of them speaks to you.

Okay. Owner's room. Let's do it.

Question number one, what parts of my current role feel heavy, draining, or frustrating? Oh my goodness.

Honestly, right now everything feels suffocating. What I don't mean is that the setup is totally wrong and I'm doing all of this shit that I hate. What I do mean is that I don't think I realized the extent to which I would feel overwhelmed when my right hand person left for maternity leave.

It's like that story of the person who holds a, you know, four ounce cup of water out in front of them, and initially they're like, this is so easy. Like I can hold this water all day. And then an hour later versus five hours later versus 10 hours later, you check in and their whole body is on fire.

It kind of feels like that where when my integrator stepped out, it was planned. She was thoughtful and thorough, and all the things that needed to get delegated, got tasked to the appropriate person. That felt great.

But her continued absence and having to also maintain some things that I don't really like doing, like ensuring our hiring pipeline continues moving and being involved in the hiring process to a much more thorough extent than I typically am. I'm tired.

I'm tired, and it feels like there's not any, like I don't have any room for a break. Kind of I don't, honestly, I mean, with her being gone, it's really hard to take a break, so to speak.

It's almost like a giant, giant balloon, let's say this balloon takes up the entire square feet of a room. And if it was inflated all the way, it'd be easy to sort of push out of the way. 'cause you just hoist it up and then you like walk out from underneath the balloon to get to the door.

But imagine that balloon is like halfway deflated and so you push up, but there's not enough air that the whole balloon lifts. It's just that you're pushing up the section that you're under and so you're trying to figure out where the door is and like pushing this balloon up over and over and over to try to get to a wall, you know, to find, okay, if I can find a wall, then I can find the edge of the room, then I can find the door eventually.

You can't really see anything. You're just surrounded by something that you have to carry. That's what it feels like. So, I don't know, maybe that's not fair to say suffocating, but it doesn't really, I don't know if it feels heavy necessarily.

I can't exactly think of the right word. But that example with the deflated balloon feels like it nails it. That's what it's like with her gone.

And so I think the part of my current role that feels heavy is the ownership of things that I don't typically have. I don't like that piece. And there's actually another part that pretty consistently feels heavy is payroll. Not necessarily doing it, although maybe that's some of it, but just in general like compensation structures and bonuses and assessing them and you know, all of that always just like weighs on me, sort of feels heavy.

Yeah, there's that current, current sitch.

Um, question number two. What expectations, internal or external have I built this role around? So, clarifying, my role at my practice is a visionary.

And so for me, the responsibilities entail LMA, leadership, management and accountability of my direct reports, high level finances, part of feeling heavy right above me, high level decisions, big ideas and relationships, and culture. That's my role at my practice.

Okay, so you won't see this, but I just paused for like five minutes to think about that question because I didn't have something that came up for me right away as an answer.

So the expectations I think that I have are around my I engagement. I think that I, internally and maybe externally, I think that I've done it so much that it's probably an external expectation at this point.

But I think that I have embedded myself into the culture of the practice in such a way that I am not sure how I will extricate myself and maintain the culture of the practice. And so if my goal as visionary is to continue to remove myself from the day to day and continue to remove myself from anything to do with employees outside of my direct report, which at some point is just going to be my integrator. I am not sure how that looks here.

And so I think there's something internal for me that's like, if I'm not involved in this, how will it go? I think also this is such a key difference for entrepreneurs who are operators versus owners. I wish that I could clearly just be an owner and not an operator at all, and I think I'm probably moving in that direction.

But I don't know if I want no engagement with my group because I love my group and I love my people. Or if I just want less engagement. Or if my engagement is a result of attachment related needs of my own. So it's not even about what's healthy for the group, it's just reflective of my own stuff. I don't know yet.

It still feels kind of messy, but I definitely think from all of that, there are expectations, again, internal for sure, probably external at this point, that are about a engagement and specifically visionary engagement with the group, with the team, et cetera.

I say that like I'm really involved. I'm really not, aside from, you know, right now, again, my integrator being out and I'm doing way more with hiring related stuff and you know, interviews and all that. But that's not the norm and it.

So it's not even like I'm, you know, checking in with my team every week, or they expect me to reach out and let them know what's going on. All I do is quarterly meetings. Which are state of the practice meetings, and we do those after we have our full day quarterly with my leadership team, and I also do a monthly check-in email, but that's it. Most of the communication comes from my DCO, my director of clinical ops, and my integrator.

And so it's interesting to hear myself say that I think it's the engagement piece that is the expectation because my level of engagement at this point, even compared to two years ago, three years ago, four years ago, is so much less and so much better for me. But I still think there's something there that gets like caught up, you know? So there you go.

Question three, what boundaries am I afraid to set because I think I'll disappoint someone? Ooh.

This is interesting. So I don't know if I'm afraid to set boundaries because of disappointing someone. Maybe, but that doesn't feel like it's it. I think it more so feels like boundaries around my role, and then I'm afraid people might feel abandoned. Which kinda gets to the engagement piece, you know, the ex internal expectations around engagement.

I don't think with my full team, like my staff or my clinical team, but I think with leadership, there's probably something in there that's wrapped up. I don't want people to feel like I am not available to be helpful when needed, or that I maybe don't care, or that they are going to be overwhelmed and I am not gonna potentially help them troubleshoot. How do we alleviate some of this pressure?

So I think some of the boundaries that I'm afraid to set are about increasing the workload past the point of capacity for the people that might, boundaries might impact. I think that that might be some of what's going on. So less about disappointing and more about wary of capacity and ability for the people around me with the workload.

Okay. Question four, what identity have I tied to this version of being the boss? Oh my God, these are really good questions. What identity have I tied to this version of being the boss? Man, it's always fucking comes back to emotional caretaking for me.

I want the people around me to feel okay. I want them to be okay. That doesn't mean we don't have hard conversations. They're not held accountable, like not any of that. That all still happens. What I mean is, are you good? Are we good? Are you good? What's going on for you? How are you feeling? Like I wanna know that they're okay

if I'm not engaged, I feel like I can't keep my finger on the pulse of how my people are doing. And also then how the culture is faring.

So I think there's probably, you know, I almost think about exploratory factor analysis and you start to see what variables or items cluster together. There's probably something around emotional caretaking engagement and culture that like hang out together.

I don't even think that I would say the identity is, I, I'm an emotional caretaker. I'm not trying to like own that and have that be a thing. I think it just happens, like it's sort of, oh fuck here that thing is again.   

It's very, very old. It's very, very much a default way of being in the world. It used to be people pleasing. It's not that anymore. It used to be martyr. It's not that anymore. It used to be preoccupied attachment. It's not that anymore.

But it still is there, and so I don't actually know if that tendency or that default to have like an emotional caretaking lens, so to speak, will ever go away.

I don't know. And I think I'm saying this because I don't feel shame around this part of me, but I don't necessarily feel proud. Like it's not something that I'm like, yeah, I emotionally care take my team. That's not it.

But it does feel like it's part of how I show up as being the boss. It's, it's just there, it's in the mix and I can't help that it's in the mix. And if I were just to cut it off entirely, I would feel like I was severing a really crucial part of myself and my own humanity. And so I think there's probably some evolution that needs to take place with that part. Like there has been over the years, you know, maybe some more evolution that needs to take place.

And it's still there. It's just there with me right now. So that is the part of my identity that feels tied to. That version of being the boss again, the engagement, the emotional caretaking piece, the culture piece, et cetera.

For the record, I think that if I didn't have emotional caretaking, I would still see culture with the same level of importance. I think that my way of engaging with it might change though, so I wanna really clarify that lest do you think that I would not give a fuck about culture? No, it definitely would not happen. But my relationship with maintaining culture would probably evolve.

Okay. Fifth and final question. What am I afraid will happen if I start shifting out of it? I mean, I think the culture will breakdown. That's funny. That's a good, actually segue question from the last one. I think that I'm afraid that the culture will erode or that people will, hmm, maybe feel like, I don't care.

I'm not sure if that's it exactly, but definitely afraid that something with the culture will start to, ooh, crumbles not the right word. Maybe start to fray at the edges a little bit or start to, you know how billboards are really bright whenever they're first put up, but certain ones, if they stay in the sun, they start to like fade.

I'm afraid that might happen, that the culture will start to like fade and it won't feel as vibrant and healthy, you know? Really. So, I think that's what I'm afraid of will happen if I start shifting out of it.

You know what else I just realized? This is going back to the identity piece actually. Like what identity have I tied to the version of being the boss? I think that another part of my identity that I haven't like actively tied, but I think just is tied to how I show up as a boss is my turning all the stones over and some of my fear around if I start shifting out of it again, question five, I think these things are related, is that nobody else is gonna be flipping stones, and so one of the things that I am good at is seeing problems in the distance.

I'm not good at forecasting how I'm gonna feel about the implementation of a system, for example, or of a change, but I am good at saying that's gonna be a problem. This is probably gonna turn into this. This is probably gonna be problematic.

I don't know if I yet trust that my leadership team we will be able to do that as effectively as I can. And as I'm talking out loud right now, I'm realizing that even if they can't, they are good at catching problems and so them not catching a problem as quickly as I might is not the same thing as them not seeing a problem happen and being able to fix it. I trust that with them.

So there's something about letting go of the, seeing things further in advance. And I'm afraid that the problems won't be caught as soon, but it's kind of moot because they'll end up being caught, period. And then leadership will tend to it at that point because that's what they fucking do, because they're awesome.

Oh, this was hard. Oh my gosh. This was way harder than I thought it would be. Like I didn't. This is harder than I thought it would be. I'm just surprised. So that is the five questions. I'm gonna shift over to the scenarios. Let me give you really brief overviews of these scenarios, because like I said, I'm gonna do two because they're so good.

The first one is being in a role that your team relies on you for everything. Hear me out. The second one is the flexible relational workspace with crazy high autonomy, but then no accountability. I know people have done both of these things, so that's why I wanna do two scenarios.

So let's do real life scenario number one.

You've built a solid practice with a team that relies on you for everything from onboarding to conflict mediation. You say you're the visionary or maybe the CEO, but you're also running payroll, reworking job descriptions and covering for therapists who need one more week. You didn't mean to build this role, but now you're afraid if you change it, the whole thing might fall apart.

Man, I feel like there's probably many of us who have been in this situation.

I have two thoughts. My first is that this reflects a need for a revised accountability chart. This needs to evolve, so whatever is currently happening with your group and all the things that you're taking on as your own. My question would be, let me see your accountability chart. What are the main seats or what are the seats in your practice, and what are the core responsibilities for those seats?

That's where my brain goes first and foremost, because if you're doing things that you shouldn't be doing and they should live somewhere else based on your accountability chart, that's one conversation. Compared to you are doing the work of three different seats, like your name is in three seats.

The scenario reads like there's just one role, but my thought is that if you clarified your accountability chart, it probably would be two, if not three seats that you were sitting in.

So that's first and foremost is just clarity on that accountability chart. The second thing that comes up for me is this last sentence. You didn't mean to build this role, but now you're afraid if you change it, the whole thing might fall apart. I relate to that hardcore, I feel like if you listen to any of the questions above, you see that I relate to that.

My response is that you don't need to make giant sweeping changes. You could do it strategically, and so the strategy could be a couple of different things.

One is that you identify the thing that is most weighty and heavy for you, and you figure out who should own this based on your revised accountability chart. You know, this task lives under what responsibility with which seat? That's one thing.

The second strategy is that you identify the thing that takes up the most time. So it might not be the most weighty or the heaviest necessarily, but it is leaching all of your time. Same thing then from there.

What is the thing? Or maybe there's two. You know, what are the things that are taking up the majority of your time? Which seat is that responsibility under?

So if you go through that process and you find that the thing that's the most weighty actually should live with visionary or that the tasks that are really time sensitive should live with visionary.

I would start to set parameters on how much time was spent where. And so something like conflict mediation, for example, as a visionary, a that's way below your pay grade. And I don't mean that with any shade or judgment at people who are not paid what you are, if you're even paying yourself right now, actually as a group practice owner, you might not be.

So my point is, conflict mediation is not the best use of your time. So this actually is strategy number three. What is the best use of your time?

If you have a vision, if you have, you know, something moving forward that you're after, everything you do should be pointed towards you reaching that vision. If conflict mediation is driving you forward to your vision, then you should do it. If it's not, then you should not do it.

And this is, let's just say another strategy you can adopt or one you could use, thinking about your role as the guardian of the vision and charting that course and then sifting every task that you're doing through that lens.

Onboarding, for example. Hell no. Don't do that as a visionary, I'm speaking like someone who isn't doing it right now. I'm actually not doing the onboarding piece. I'm doing the hiring process piece, but same point.

The onboarding itself, like training somebody up if you're bringing on a clinician, for example, right, training somebody up to be able to effectively do clinical work for you at your practice, there is a high probability that there is a person at your practice you could trust to do this thing.

I think my point in all of these different strategies is you identifying what can and should be offloaded in accordance with an accurate accountability chart.

I would absolutely revisit my accountability chart, make sure that there are the accurate seats for the current practice, and then use that to make decisions about all the shit that's on your plate. Strategically. And so then when you go to do something like this, you don't have to say, I'm getting rid of all of these things to the team at once.

What you might do is present the accountability chart, clarify some of the roles that you've adjusted. Say why. I always give context because I personally like context. I like to know the why, and I want people to understand why I'm doing certain things. Most people don't like when you make changes, so if you give them that, why, and it might be, I am super overloaded, I'm drowning, I can't get shit done, I can't move us forward, I can't maintain the culture of the practice, whatever it might be. Then you say, for that reason, I have rethought and restructured the accountability chart for our group.

Here are the changes I made. Again, here's why, and so from this point forward X, Y, and Z are gonna go live with this role. And that role is this person A and B are gonna go live with this role because here are their responsibilities and that role or seat is filled by this person. And then at that point, your job is to delegate appropriately.

When somebody comes to you and says, I need help with this conflict, mediation me and so and so aren't getting along, boop, kick 'em out. Say, you know what? Thank you for letting me know. I'm gonna bump you over to this person because I'm really trying to live out this accountability chart for my own sake and sanity. As well as for the sustainability and longevity of the group. You know I adore you, so I hope you don't feel like I'm pushing you out. I'm pulling in such and such person right now. They're CC'd on this email.

So now you're not playing middle person for any conflict disputes. You're putting it to the right people and then you are distancing yourself.

I think one more thing that's coming up for me right now that I just wanna say, abrupt change without context is really unsettling for people. I think if you make any change, whatever it might be, and you are providing the rationale, which can absolutely be personal, I mean, I think you should level with your team about what's going on for you and give them the specifics of what has changed and give them a timeline.

So like, you know, the next month is gonna be a transition for these people in these seats, so I'm gonna be a little more involved. But at that month mark, they're gonna be the go-to people entirely, and I will only be involved should they pull me in. And if you all are unsure of what to do and you make a mistake and you send the email to the, you know, quote wrong end quote person, it's really not a big deal. We'll help direct you to where you should go and then at some point it's gonna stick for you.

I think that's how I would handle that. So that's real life scenario number one. I probably could keep talking, but I think that's enough for first scenario.

Lemme skip to the second. I love the scenario. Real life scenario number two. You created a flexible relational workplace. No micromanaging, high autonomy. We're all in this together vibes. But now you find yourself resentful because team members are taking liberties or they're checking out. You realize you never actually built clear expectations or accountability because you didn't want to seem too corporate.

Show of hands, who's been there? I know some of you have who are listening. No judgment.

I. I don't know if I've ever been in this exact spot, but I do know when I very first started my group, I didn't feel like I deserved to set structure or rules. Like I started with 10 99s, so of course that's a little bit messy, you know? But even when I switched over to W2, it was really hard for me, and I think to some extent it still is, to claim ownership of being the boss and deciding things regardless of how other people might feel or regardless of how it might come across, or regardless of if it seems corporate.

But here's what I can say. I understand wanting this. I understand wanting no micromanagement, high autonomy, we're all in this together, vibes, et cetera. One option honestly is you change your business model entirely and you have people rent space from you. Then you've got high autonomy, you've got no micromanaging. You've got, we're all in this together vibes, but you don't feel resentful anymore.

I mean this sincerely, and I'm not trying to push y'all outta group practice ownership by any means, but I have done consulting with people, and this is the outcome that they came to, is that they didn't want to build a group. They didn't want to hold people accountable. They did not want to have an employee processes and procedures manual.

They just wanted a collective feel. And so they changed their business model entirely and they have people rent space and now they have this shared group and kind of this collective that has a very clear intention around it. And then folks join who wanna be a part of that vibe.

So there still is a vibe and there still is this, you know, community feel, but now there's no resentment. You know, this person is, they don't need to feel resentful 'cause they're not responsible for any of the others who are there. They are responsible for who joins with the lease, obviously, but they're not responsible for performance or forms or anything related to EHR stuff or business materials or any of that stuff.

If you want to keep the group practice and you realize, no, I, I need to develop and grow in this area. I know I'm resentful, but I want this. Here's how I would start.

Uh, first I'm assuming that you have employees, like W2 employees and not 10 99s, so removing contractors from the mix entirely. I'm not even gonna go there. Let's assume you have W 2s.

I would start by reflecting where do I feel the most resentful? I know for me that resentment is my boundaries are being pushed beyond the point that I'm comfortable, like this is too much. I mm-hmm. Don't like that. I'm pissed because I didn't hold my boundary where I should have, and so I'm not resentful that someone's pushing on a boundary.

I'm mad at myself that I didn't hold it. So that feels like a key distinction because I am responsible for maintaining whatever the boundary is that I'm setting for myself or for the business.

So one is that I would spend some time figuring out what the fuck am I resentful about? What am I angry about? What did I cede on that I should not have that I did not want to? That's the first starting place. For me, that's my first starting place.

Then I would rectify that. And I would do it in the same way I do so many other things. I would have a direct conversation with my team and I would let them know some of the things I've been processing and some of the internal shifts that I'm needing to make.

So here's an example that I'm thinking about. This is years ago. People were behind on documentation and so. I have it set up so that we pay for service provided. I don't wait until we are paid by insurance to pay my people.

But people were not finishing their documentation. Early on Tara thought, Hey, well it's required within this amount of time so it'll get done. And I realized, oh shit, that's not actually taking place, and that's not the case.

And so the change became if you don't get documentation done in a certain timeframe, that session will not be paid until that note is done because I have no proof that that session took place. The documentation is a part of the clinical hour. If that clinical hour is not complete, meaning documentation is signed and done, then it did not take place to the best of my knowledge.

That's what we had to start doing. And the conversation, gosh, it's been so fucking long. I'm sure what it was like though is that we had a meeting and I introduced this to people and I said why it was important and I said why I was doing it, and then we kicked it off and that was it. It's been tweaked a little bit, but broadly speaking, that's still the process.

I don't think that you need to change everything right away. I think that what's important is that you are staying tuned into the aspects of the group or the structure that leave you feeling resentful, if that makes sense. It's about making sure that you are not giving in at any push.

And I will say this specific scenario has not happened exactly for me, like I said, but feeling resentful about things and not holding my boundaries, abso fucking lutely has happened with me on more than one occasion.

That's how I know I need to change something. So instead of it being I'm resentful, I'm gonna take it out on these people, or it's their fault, it's, oh damn it, I let my boundaries slide. Hang on. What happened? Like, where does it need to be? What am I mad about? And then I go from there.

I think a totally other piece to this that I haven't even touched on is having people around you who can do the thing that you're not good at.

I am really bad at holding boundaries around structure. One because honestly I just forget what it is. Like I kind of forget what it is. And sometimes I forget when we even decide on something because I don't need to think about it. 'cause there are people who are keeping it maintained for me. So it's two years and I'm like, wait, what do we do? Oh yeah, that makes sense. Like, oh, that's a smart idea. You know, silly.

But if you have people around you who can maintain the structure, and let's just say you're not good at it, they are maintaining what needs to be in place. And then maybe your role is to humanize it.

So if you're worried about not seeming too corporate, it might be that whenever you go to implement a change that is practice wide and it's structure related, you are very clearly letting the team know this is why we're doing this thing. Here's the reason behind it. Here's the rationale. This is the impact for clients. This is the impact for us. This is the impact for admin. This is our community based impact. Whatever it might be, you are couching what you're doing into larger impact.

So it's not just. We're making a change because I said, so It's, Hey, this is a problem for this reason. This is what we're doing about it. This is why we're doing it. Boom. And then you leave it at that, and then you put other people in place to maintain it if you are like me and don't excel at, and also don't enjoy maintaining structure.

So yeah, I think that's it.

I wanna hear from you. So if you have versions of stories like this, or if you have a scenario right now where you're like, oh, fuck, here's my situation. Send it to me, email it to me, DM me, go to the website, submit it through the contact form. I'll keep it anonymous, but I love speaking to real life scenarios for people, and I would love to pull yours into a future owner's room episode.

And you can contact me by going to the website, which is www.taravossenkemper.com.

Also, if you haven't hit subscribe, please do so. Then this conversation can just land in your ear without trying to hunt it down or something like that.

That aside, that's it. I hope this was helpful. It was great seeing you. Thank you for your time and I'll see you next time. Bye.