When I first started my practice, I thought admin was the absolute devil. If you’ve spent any time in a physician Facebook forum, you know the refrain: “Those darn admin — that’s where all the money goes.” I get it. But after years of building and scaling my own private practice, I’ve landed somewhere different. There’s a happy medium. Some degree of administrative and operational support isn’t optional. You’re going to need a biller. Eventually you’ll need HR. You can’t get that number down to zero — but the ratio matters enormously, and it’s something I obsess over.

So how do you know when it’s actually time to bring on an office manager? Here’s how I think about it.

The two ways it usually goes

The first path is hiring an office manager right out of the gate. Nothing wrong with that — just know they probably won’t earn their keep for a while. What they will do is make the practice run smoothly while you focus on medicine. Back when I was a hospitalist working seven on, seven off, it would have been wonderful to have someone handling a little bit of everything: setting up my phone so I wasn’t doing it after a 12-hour shift, fixing the schedule, chasing a vendor invoice, remembering to check the mail. All of that would have freed me up to just practice medicine.

The second path is the one I chose: stay as lean as humanly possible. The downside is real, though. A physician’s time is worth — let’s round up — about $200 an hour. At some point you look in the mirror and ask, “Why am I, a $200-an-hour employee, doing a $25-an-hour task?” Sometimes there’s a good reason. Maybe you want to learn the process so you can spot the bottleneck. But eventually that question gets harder to answer.

The three roles (they’re not the same job)

In a small practice, one person does everything. But as you scale, these actually split into three distinct titles:

Office manager. Front-desk operations — scheduling, check-ins and check-outs, the day-to-day, buying supplies, making sure you don’t run out of vaccines. This person is usually tied to one clinic location, maybe two.

Practice manager. A level up. Sometimes called a regional manager. They handle hiring and firing of MAs, HR and benefits, vendor contracts, compliance and HIPAA, credit-card processing requirements, and KPI tracking. (What’s your missed-copay rate at the front desk, and how do you fix it?)

Administrator / COO. High-level decisions. Should we open another location? Should we hire another physician — not just another medical assistant, but a physician?

Most small practices need an office manager first, and maybe a practice manager down the road.

The way I did it: I took a strong MA and elevated them to lead MA — half office manager, half medical assistant. I did that deliberately, because once you hand someone a “manager” title, the temptation is to say, “I don’t room patients anymore. I don’t pick up regular phone calls.” Yes, you do. When the practice is small, we are all doing twenty things. We are all plunging the toilet if it absolutely needs it.

You are the bottleneck (more often than you think)

Here’s the hard truth. At some point you have to admit: maybe I’m the bottleneck. Maybe I’m doing the $25-an-hour task while my staff waits on me to write the SOP, or waits for guidance on whether to order more tetanus shots or keep doing shingles vaccines.

If your schedule is full and you’re waking up at 4 in the morning trying to fit it all in — you’re the bottleneck. One hundred percent. You need to get out of your own way and start offloading, whether that’s to an office manager, a practice manager, or eventually a COO.

The revenue math

An office manager can make sense even with a single clinician just starting out. A practice manager is different. In my experience — and this is a broad stroke, so yes, you might be the exception — you usually don’t need one until you’re north of about $1.5 million in top-line revenue.

Why? Practice managers in my area are six figures. You’re probably paying around $100K, maybe $75K if you find the right person cheaper. That is a lot for a practice that isn’t bringing in a million a year. If you’re doing $900K and you pay $100K for a manager, that’s over 10% of your entire top-line revenue going to one person who isn’t generating revenue — they’re just making your life easier. In my opinion, you’re too small.

How to find the right one

I’ve had far better luck hiring people who didn’t come from healthcare.

Let me explain. My very first practice manager came from a surgical clinic with tons of experience — and that turned out to be the problem. She was stuck in “this is the way we always did it.” But that old place was four surgeons who’d been steady for twenty years. I was trying to double in size every year. Completely different scenarios. She’d tell the front desk, “Just type the credit card in” — which is twice as expensive in processing fees. That didn’t fit my vision at all. That hire was on me. I hired the wrong person for my goals.

Now, if I were stagnant — if I just wanted someone to answer the phones, handle complaints, and keep things steady in their bubble — that experience would have been perfect. There’s absolutely a place for that. That’s exactly what you pay people well to do: put out the fires and handle the “I can’t believe they did that” moments. (Even Mark Zuckerberg has talked about waking up to phone notifications thinking, “They really did what?” That’s what you’re paying those people to absorb.)

My current regional practice manager came from the gym-and-wellness world. She helped scale a company from essentially no sales to around $500 million as one of the key people driving hiring and growth. That sounded like a fit for an organization I want to scale aggressively.

Try them out, then hand off well

When I hired my current manager, I told her: “You’re going to start as a medical assistant.” She paid her dues for three to six months while I handed her tasks in a defined, structured order and watched how she performed. That’s how I should have done it the first time. Instead, I threw my first practice manager straight into the deep end — “Here you go, hit the ground running.” Mistake.

A few things I’d insist on now:

A warm handoff. What are the goals? What are the boundaries? When do you expect them to check in?

Clear thresholds. My business partner and I have agreements. Below a certain dollar amount, just buy it — don’t even tell me. Above it, we talk. Hiring a physician, hiring a mid-level, opening a clinic — we agree on those together. New EKG machine? Who cares. Just buy it.

One-on-ones and KPIs. Especially early on. What are you measuring? No-show rate. Percentage of new patients. Where they’re finding us. How many new ads we’ve put out. How many urgent cares we visited this week with cookies and business cards. What doesn’t get measured never gets attention.

The bottom line

If you’re the bottleneck, you need to hire someone to get it off your plate. There’s no single right way to do it — the right way is your way, for your market. I personally grinded it out and probably should have hired a practice manager a lot sooner, because I spent too long doing $25 tasks while my time was worth $200 an hour. Once you understand what these roles do, write the SOP, offload the work, and get out of your own way.

But know your market. If you run a practice of ten surgeons and you don’t want to grow, that’s a totally different situation than mine. If you want to be the most sought-after plastic surgeon in the world, I’d hire a pure extrovert who lives and breathes online reputation and influencer marketing. Know what you’re looking for before you hire.

For me, the signal is simple: when I’m the bottleneck, it’s time to offload. And you are the bottleneck far more often than you think.