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Buying Land & Building Practice from Scratch — with Edward D. Buckingham, MD (Ep. 208)

Hello, and welcome to Beauty and the Biz where we talk about the business and marketing side of plastic surgery, and buying land & building a practice from scratch.

I’m your host, Catherine Maley, author of Your Aesthetic Practice – What your patients are saying, as well as consultant to plastic surgeons, to get them more patients, more profits and stellar reputations. Now, today’s episode is called “Buying Land & Building Practice from Scratch — with Edward D. Buckingham, MD”.

Deciding WHERE you do surgery is a big decision that affects your time, resources, profits and sanity. 

And the answer to that question changes as you change. For example:

  • You have a killer deal with a friend of yours to use his OR; however, it’s a 30-60 commute depending on traffic
  •  You use another surgeon’s OR in your building, but they continue to raise the fees and you’re feeling exploited
  •  Your surgical coordinator is struggling to get you blocked times at the hospital and so on.

That’s usually when you start dreaming of taking back your life and enjoying autonomy to do surgery wherever and whenever you please, while even adding more surgeons to help pay for it if you choose.

⬇️ Click below to hear “Buying Land & Building Practice from Scratch — with Edward D. Buckingham, MD”

This week’s Beauty of the Biz Podcast episode is an interview I did with Dr. Edward Buckingham. He’s a facial plastic surgeon with a BA degree in accounting and in private practice, in a gorgeous new office in Austin, TX.

He decided it was time to upscale and play a bigger game, so we talked about:

  • The myriad of construction and permit issues of buying land and building a practice from scratch
  • The timing challenge between the end of your lease and the start date of your new office being “move-in ready” 
  • Bringing on other surgeons to buy in to his practice so he can enjoy life/work balance
Managing Nurse Injectors and Staff, Buying Land and Building Practice from Scratch


Buying Land & Building Practice from Scratch— with Edward D. Buckingham, MD

Catherine Maley, MBA: Hello and welcome to Beauty and the Biz, where we talk about the business and marketing side of plastic surgery, and buying land & building a practice from scratch. I’m your host, Catherine Maley, author of “Your aesthetic practice, which your patients are saying”, as well as consultant to plastic surgeons to get them more patients and more profits.

Now, today’s episode is an interview I did with Dr. Edward Buckingham, who has a lot of experience buying land & building a practice from scratch. He’s a facial plastic surgeon with a BA degree in accounting, which I’m sure we’ll talk about, and he’s in private practice in a gorgeous new office in Austin, Texas, which we will absolutely talk about.

Now, Dr. Buckingham attended the University of Texas for his medical degree and his general surgery internship at the University of Texas Medical Branch at Galveston, before he endeavored on buying land & building a practice from scratch.

Now, he then completed a fellowship in facial plastic and reconstructive surgery in Albany, New York. Now, he’s won several awards for his academic achievements as well as numerous publications and presentations, and has been a guest instructor for the facial rejuvenation course given by the AAFPRS.

He even has a wife who practices ophthalmology and oculoplastic surgery with the eye physicians of Austin. So, he is knee deep above the neck surgery. So, Dr. Buckingham, welcome to Beauty and the Biz.

Edward D. Buckingham, MD: Thank you so, much, Catherine. It’s great to be here. I really appreciate you inviting me.

Catherine Maley, MBA: Yeah, it’s been a while since we’ve caught up.

So, I wanted to ask just a quick journey from, how did you get from New York to Austin, Texas, because I know you’re not from there. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I’m not from here. Mentioned I’m from Dakota, but I got to New York. From Texas and back to Texas, all because of that lovely wife of mine, Dawn. She’s a ninth generation Texan and there’s no way you take the girl out of Texas.

You can’t take Texas out of the girl, nor the girl out of Texas. It’s all, it’s all a lie. It just goes both ways. So, you I’m, I’m here from South Dakota in Texas because my wife is from here and it’s a great, great spot to be. I couldn’t be happier to be here, but it’s all because of her.

Catherine Maley, MBA: Nice. All right.

Because that has to be kind of a social change from South Dakota to Texas. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah, it’s quite a bit of difference. I got quite a shock. I went to SMU for my undergrad, so, that was my first introduction to Texas. And I went straight from rural because everything in South Dakota’s, rural to Dallas and SMU is not exactly the school for the.

So, I, it was, it’s quite the shock when I first went to s SMU and, and then I met Dawn and she taught me some Texas manners, and so, hopefully those are still kind of rubbing off a little bit, so…

Catherine Maley, MBA: Oh, that’s fantastic. So, do you like barbecue?

Edward D. Buckingham, MD: I love barbecue and, and even more so, Mexican food and margaritas.

Catherine Maley, MBA: Nice, nice. Okay. So, let’s talk about when you came to Texas. I, I’d just love to hear, how did you get to solo practice? Did you go direct directly into it? Did you join a multi-practice? What’d you do? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I did, so, as you mentioned, I did my fellowship with Ed Williamson Albany, and of course he’s a great entrepreneur.

I know he’s been on your show quite a bit and helped you with all kinds of things. And so, he really was instrumental in giving me that kind of added benefit on top of my already accounting degree and my business knowledge. And because I had the benefit of a wife who was joining a single specialty ophthalmology group, we were able to support ourselves financially.

So, that gave me the opportunity. To just hang a shingle, which is what I always wanted to do. So, I went straight from fellowship to Austin and basically just started to practice from scratch.

Catherine Maley, MBA: Oh, no kidding. I actually know your area well. I ha I used to have some real estate there and I sold at the wrong time.

I might add, but that’s another story. So, I mean, Austin just took off. How long were you in practice before you saw the surge of Austin? Did you know Austin was going to be what it is today, or? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I mean, Austin has always been popular and growing, but I also lived back here in the nineties and my wife has lived here since about 1976 or so.

Mm-hmm. And so, it went from town, 300,000-person town to around 2 million now, and it was probably. One, three or so, when I moved here and it’s just been growing exponentially. So, I don’t know that I anticipated the growth that was going to happen. We certainly knew it was growing, but we came again. We just came here.

My wife graduated high school here. She has family here. So, it was just more of picking a spot because of family reasons, more so, than anticipating the business possibilities and positiveness about that. But it turned out, it turned out well. Sometimes it’s better to be lucky than good.

Catherine Maley, MBA: Good point. And did you always do reconstructive as well as cosmetic or how, how is that going to work out? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, when you started practice and you hang a shingle, you do everything you possibly can to earn any dime you can. So, I did everything and anything. When I first started, I actually subleased spaced from my wife’s ophthalmology practice. Two, two half days a week in Austin, because that’s all the patients I had.

I’d be lucky if I had one or two. And then I also had a space up in a small town called Lano and one in a place called Horseshoe Bay, which are about 30 miles west of Austin and about 50 miles west of Austin because there was a family medicine group up there that had about 18 doctors in it. They didn’t even have a dermatologist in town.

And so, I literally went up and did a day a week in those clinics and they referred me anything on anywhere that needed anything other than they was skin related other than a rash. So, that was, that’s what I told them. I’m like, I’ll do anything but a rash because I’m not a dermatologist. I don’t know what to do.

But if you’ve got a sip, a cyst, or a lump or a bump or a lipoma or a cancer of any kind, I took anything and everything. And then I did a lot of shoe leather. I literally just went around and. Talked to dermatologists and most surgeons and just basically built a, a referral practice just getting people to just send me a skin cancer here and there.

And they would literally send me one and I’d do the repair, and then they would figure out if I did a good job or not. And they’d be like, okay, he looks like he knows what he’s doing and they send me another one. And then soon enough it became another one and another one and another one. And then from there, those patients turned into cosmetic patients.

And so, then the cosmetic side of things slowly grew. So, I would say, You know, initially I did a whole lot of reconstructive work and or anything else that I could, you know, provide a good service for folks. And then this, then the cosmetic side just slowly built from there. And now I do about 90% cosmetics and about 10% skin cancer reconstruction.

But, and that’s, and that’s really all we do now for, for me in particular, is just aesthetics. And then the only thing, non-aesthetic that I do, Skin cancer reconstruction. We’re going to talk about bringing on partners and things like that later, but I, I let my junior associate do some of that and I’ve got a fellowship too.

And so, the fellows do kind of the lumps and bumps now too. But I still really enjoy doing those reconstruction. So, I continue to do that even though I’m 20 years in practice now and could easily kind of get rid of that. But I just, I choose not to, I say that I do facelifts to put my kids through college and I do skin cancer for my soul.

Catherine Maley, MBA: Okay. When, give me the timeframe between the time you like, there’s a grind to what you were doing. You’ve got three locations, they’re 30 miles apart, 50 miles apart. How long did you do that? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I did the two satellite offices until I got busy enough whereby, I could keep myself busy in Austin, and that took about four to five years.

And then I slowly leaned away from doing those little satellite offices.

Catherine Maley, MBA: But I hope people hear that because the, a lot of the surgeons in today’s world think they’re going to jump right in. And I, I don’t think you can do that. I think, I mean, it takes a minute to get your bearings and actually more than a minute.

It takes years, you know? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: It does. And it, it’s interesting because obviously things were different when I started practice. I see. We’ve actually had quite a few young surgeons move into Austin. Mm-hmm. And, and open practice for themselves. And they really hit the social media hard and kind of get referrals through that.

And they become really a heavy injectable practice. I mean, when I, when I started practice wrestling wasn’t even FDA approved yet. We had, we had human collagen products, and so, the injectable business was not what it is today. And so, that, that’s what I see the young people doing now is they basically become injectors and then they convert those patients over to aesthetic patients at surgical patients at some point.

But that, and, and obviously I’m not in their practice. I don’t know that for a fact, but I don’t do social media myself. I, I just don’t have time and I just don’t enjoy it. So, but other people in my office will kind of follow those newer surgeons in town, and that’s kind of the impression that I get, is that they’re heavy injectors and then I’m sure they’re getting into the surgical aspect as they get a little more mature.

Catherine Maley, MBA: No, I know several of them and that’s exactly what they’ve done. So, whereas you did recon and got and like actually enhanced your surgical skills, they’re actually going another route and doing social media and getting the nonsurgical and then hopefully transitioning that to surgical. So, there’s no one way to do this is the point, you know? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: No, that’s definitely not you. You do anything you can to pay the bills and worry about, worry about the rest later.

Catherine Maley, MBA: Right. The building that you just left, the, that was super nice building, super nice neighborhood. Were you, how long had you been in that building? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, I’m in my third oh, my third practice in Austin.

Okay. I, I leased space for about the first eight years and then ran out of space and then leased another space for another 10 years. And so, 18 years in, well, it was really about 14 years in, I decided to actually look for land and start the architectural process and permitting process and all that to build the current building that I’m in.

But I had two previous lease spaces before that, so, I’ve just, I just moved into this new building that you’re referring to. Yeah, this last, last march. That is, that is, you know, my building that I own.

Catherine Maley, MBA: So, before you got to that big building, you had a pretty solid practice. Like what, what, what made up your practice? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, I had about 3,500 square feet. I had a little office procedure room, but nothing that I could do. Level two anesthesia. So, I was using a surgery center full-time and it was just me and a nurse injector. And a nurse doing lasers. And so, that worked. And then I decided to bring in a junior associate. And the timing was planned so, that I would be moving into the new building as the junior associate came on.

And that, that timing was a little delayed because of construction delays. But we basically were just busting at the seams at the old space when you, when you bring in. So, now, now I’ve got my junior associate, Dr. Aaron Smith, who’s been with me about two and a half years. My current fellow Hudson Fry is going to be joining us and starting on after his fellowship in August.

And then I have three nurses who provide injectable and laser services. So, they’ll, there’s really six providers in the office at this point, which obviously requires a little more space. And then in the new office we also have two quad SF accredited operating rooms and recovery space and all that too.

So, obviously that requires a bigger square foot space than just kind of doing what I was doing.

Catherine Maley, MBA: Okay, you jumped. So, what’s the difference? Like how did you get to that point where you said, okay, I only have like one nurse injector and me making money and now I’ve decided to go big. What’s the mindset there and how much how much fear you know, excitement goes into that because that’s a big decision to make.

How do you make that decision to really jump like you did? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah, I mean the, the nurses, I mean, my nurse Renee has been with me 16 years. Okay. And I, I brought her on and introduced her into beginning to do that, just basically when I got busy enough that I didn’t want to be doing the injectable part of stuff.

And so, I started passing that on to her so, I could spend more time doing surgical stuff and, and when, and she came on 16 years ago as a clinic nurse, and then, A few years after that transition. So, but basically, she transitioned into doing injectables when I got to the point where I couldn’t accommodate everybody who wanted to do injectables with me in a timely fashion.

So, that kind of grew and that’s, and that’s basically how we determine when we’re going to transition to new nurse. So, I bring in nurses to clinical practice because they need to learn about facelifts and skincare and taking care of post-op patients and understanding. What a patient is talking about when they say they have heavy, you know, heavy eyelids and just facial aesthetics in general.

So, I’m, I believe that a nurse needs to spend some time learning that prior to being allowed to move into the actual aesthetic provider world. And so, we convert nurses who are better in our clinical practice into first doing lasers, then neuromodulators, and then fillers. As we get basically just busy enough to, to warrant that.

So, right now we’ve got, you know, Renee, who only does neuromodulators and fillers, and then I’ve got another nurse, Sarah, who does some lasers and she does neuromodulators and a little bit of kind introductory fillers. And then I have a third nurse who’s the newest one in, and she’s basically only doing lasers at this point, but as the other one gets busier and we have more people, then she’ll transition the neuromodulators and fillers and then we’ll backfill behind her, hopefully someday with the fourth individual doing that.

So, that’s how we kind of handle the decisions on doing the nursing, the, the ansary, non-physician providers as far as bringing on a junior associate. It’s part of an exit plan to bring somebody in. And I know you want to talk more about that, so, I don’t want to spill the beans on that too much. I’ll let you bring the questions forward on that.

But essentially, you know, my clinic is booked until, well, right, right now, if you just call up and want an appointment with me, and I, I don’t mean to be braggadocious here, so, I don’t, please, please don’t. It’s just making a point. But my first available clinic is in the clinic appointments in December right now.

And so, and it, and it’s been six to eight months booked out for quite some time. So, you have to think at some point that. You’re losing patients because they’re not going to wait six months to see you. And so, you can either let them go to somebody else in town or you can bring somebody else in to see them. And I, I probably waited perhaps a little too long to do that, but it just, you have other influences in your life and decisions going on that make you kind of figure out when you’re going to do it.

And so, you know, we did it, like I said, about three years ago is when we really started looking, or three and a half years. And then Aaron’s been with me for about two and a half years. And it, and it’s worked out great. So, she’s really busy and doing well and getting busier all the time. And I think that when she rolled right in, just because I basically, and I know some surgeons structure this differently.

They bring in junior associates and they say, here, you do all the insurance work. I’m doing all the cosmetic work. I don’t think that that’s really a fair arrangement. They need to be able to generate, you know, good revenue and do what they can do too. So, basically, Anybody who calls our office for a cosmetic appointment, we offer them myself or Erin.

And if they don’t specifically want me, we encourage them to see Erin cause her clinic schedule’s more open than mine and that’s allowed her to get really busy. I think she did 50 or 60 facelifts her first year in practice with us.

Catherine Maley, MBA: Nice. And is there a different price, caring structure for you versus her? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: No. You know, I don’t want to give the impression that she’s somehow an inferior surgeon to me, and I know that there’s. It can be some differences in opinion. Just say, you know, look, you’ve been in practice 20 years and everybody knows you, so, you should charge more. But we talked about it, and between just the two of us making a decision, we didn’t feel like there was anything inferior in her quality.

She’s excellent surgeon and has great training, and so, we, we charge exactly the same.

Catherine Maley, MBA: Just my 2 cents. I wouldn’t look at it that way. I would look at it as there’s premium pricing to get somebody like you who’s got the experience. And it’s just if you, if you want to wait and pay more, you know, for the experience, go with Dr. B if you’re in a hurry and price is an option, or price is an objective then go with plan b. I, I personally like to give the patients a choice, but it’s sold as, If you want Premier, you know, Aaron’s great, but if you want the guy, you’re going to have to wait for him and pay more. Just saying. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah. Yeah.

No, that, that’s probably good advice. I’ll take that to our next manager’s meeting and see what everybody has to say about that.

Catherine Maley, MBA: It’s not saying excuse mediocre, it’s saying you’re the best. And you extra and wait for it. Yeah. Okay. And then any staff tips, because you’ve had a lot of staff like everybody, you know any tips on, especially when you’re hiring nurses, any tips on how you’re finding them and keeping them motivated? Also, how did this affect your decision on buying land & building a practice from scratch?

Because nurses can be a little on the touchy side. Once they’re around for a while and they start thinking they have a following and it’s all about them. Have you had any of those issues? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, you are referring to the nurse injectors then? Yes. Yes. So, I mean first of all, they have a non-compete and so, they can’t just leave, which is important, you know, in any situation where you’ve done, and again, I’m not bringing in a nurse injector who’s fully trained and, and doing her own thing, and she just comes and joins my practice.

I’m taking somebody who’s never injected anything in their life and training them up myself. And so, that, that is important for allowing a non-compete to stick is that you have to actually have provided some training that they couldn’t have gotten elsewhere, that, that makes them beholden to you to some degree.

So, not that they couldn’t leave and, and go outside the radius to the non-compete or move wherever they want to. So, that’s just a, that’s just a part of it. The other part of it is just treating them really well. Both treating them well as far as, you know, just personally and making a friendly, fun environment and, and being a good boss but also treating them well financially.

So, I don’t know that my nurse injector could go out on her own and make, you know, more than what I’m paying her. I mean, I’m, I’ve got the building and the advertising and cover everything else, and she’s paid a base hourly wage as well as a pretty generous commission. And she brings home, you know, six figures in a good way.

And I think that’s, that’s a pretty good number. So, I think that they don’t, they don’t want to leave. They, they’re, they’re in a great work environment. They’ve got great support staff. It’s a fun office. We have a lot of fun, and they’re financially rewarded in such a way that they have no motivation to leave.

Catherine Maley, MBA: How do you have fun? I keep saying to the practices in today’s world, it can’t be all stress, you know, it just can’t be all. A lot of patients or a lot of people don’t want to deal with the stress anymore. They want their life fun, especially like some of the younger people. I came from a big, strong work ethic from the Midwest and it, we weren’t.

We weren’t there for fun, we were there for work. And it seems like that has changed a bit. Like what do you do for fun? I always say, we’ll have a taco truck pull up if everyone reached the goal that month. Like any ideas there? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: You know, it’s not that we do necessarily anything special to have fun.

We just have fun. I mean, we encourage people to laugh and enjoy their work environment. Patients frequently comment because they’ll, they’ll be in a room and we’ll be doing some stitch removal or doing a dressing change or something like that, and they’ll just be staff members outside the door just cracking up.

And I think that there are some people who would, who’d be like, wow, you know, you guys tone it down a little bit. But patients love it. We just encourage it. And so, we just, we just joke and laugh and have fun. Our staff has a great relationship with each other. I mean, just this past weekend about seven or eight of them all went out on a boat after work on Friday and just, you know, they just enjoy each other’s company.

So, it’s not that we, it’s not that we do anything specific. We just encourage a fun work environment and it, it, a lot of it has to do with just the people. I don’t, I don’t think that that’s something. That you just flip a switch and bring on overnight. It’s a slow, steady process and bringing in good people and keeping good people and getting rid of, of grumpy people and just encouraging that culture and that that’s really what it’s all about.

Not that we don’t do other things. I mean, I, we used to do lunch for a staff, for example when they’re having a birthday and it just became expected that they’re like, oh, it’s my birthday. We’re going to do lunch. And granted, when you go from 12 employees to 24, that gets to be allotted lunches. And so, we changed that where we probably do more times than I bring in lunch than not, but it’s always a surprise.

We just, we just, the day before we just say, Hey, Dr. Buckingham’s buying, you know, barbecue for lunch tomorrow, or whatever. It’s, and, and then we just, you know, same thing because our office hours, we close the office at noon on Friday. And so, that, that allows people to do some of the things that they need to do, like go to the bank and get a haircut.

And go to doctor’s appointments and things like that. And so, they really, and it also enjoys us to just every now and then we’ll just say, you know, Hey, we’re going to go to the, the local wine bar and hang out for a couple hours and, you know, tabs on Buckingham Center. And the staff love that. We just go enjoy each other’s company and I pay for some drinks and make sure everybody gets home safe.

Catherine Maley, MBA: I love the idea about Friday shutting down Earlier, I used to say, oh, but you’re going to miss a bunch of patients. And I’ve, I’ve done mystery shopping forever, and frankly Fridays are they’re quieter, so, why not? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Why? I mean, that’s a great perk. And you don’t have to disrupt the, the regular working day, you know, it’s just, they, they get to leave early to run errands.

Catherine Maley, MBA: I love that idea.

Edward D. Buckingham, MD: Well, and we, and we start our office at seven 30 every day too. So, I never understood why we start surgery at seven 30 at. So, we start every day whether it’s clinic or the operating room at seven 30, and then we see our last patient at four. And I, I don’t personally eat lunch, so, we don’t take, we don’t close the office for lunch at all.

We just rotate staff through and they get to go take their lunch break while we’re working. And so, that allows me to be, you know, ultra-efficient and we just rock and roll all day long and keep it going. And that way we get to work before Austin. Traffic gets too crazy and hopefully leave before Austin.

Traffic gets too crazy. Now, operative days go past four, but the but the clinic closes at four, so, operative days, you got to do what you do. If you got surgery that ends at five or six you just do that. But I also. Don’t believe in operating till nine. I know some folks are just, they’ll book surgery till nine or 10 o’clock at night and just work, work, work, work, work.

I just, I don’t have it in me. I enjoy my personal life too much for sure.

Catherine Maley, MBA: Now I’m talking about Austin traffic. I remember when I first get, but like I was there 10 years ago or something and I remember saying to my boyfriend, What are they going to do with all this traffic? Like there are no highways, there’s no buses, there’s no trains.

Like is there any plan? By the way, is there any plan for infrastructure? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: They, they’re, they are talking about light rail. It is extremely expensive. And you can’t just put tunnels and subways. In Austin, Texas, the entire ground is rock. And so, I mean, you could, but it would be dynamite underneath city blocks in order to accomplish that.

I’m not sure that that’s such a great plan. So, they’re talking about putting in some above ground light rail, but mostly just. Expanding roads and doing what they can. But yeah, it’s, it’s a little bit of a problem. We have, as you know, rivers and, and what, what they call lakes which, and coming from, you know, the mountain area, this wouldn’t be a lake, it’d just be a little bit wider river.

Right. But we, but we call them lakes around here. Yeah. But there’s multiple water crossings. And so, that, you know, obviously is an issue with traffic too. Because you have to build big, giant, wide bridges to accommodate that. And that just gets tricky. So, it is, it’s, it’s a problem and it’s not Progressing as quickly as anybody I think, who lives here would like for it to be progressing.

Catherine Maley, MBA: For sure. Well, I know half of California moved there and I remember there was a saying that said, don’t buy Texas real estate with California eyes. And that because the real estate was so, different now you guys are catching up to California prices. So, things have changed a lot. So, let’s talk about your new building because that was a really big commitment you made, but you have that accounting degree, so, I’ll bet that helped you crunch the numbers to decide how you want to do that.

How far is your new, your brand new, gorgeous building from your previous building? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Only about three miles. We, we’ve, if you Yeah, we’ve, we’ve stayed in basically the rolling wood Westley Hills area, which I know you’re a little familiar, great area. So, yeah, it’s, it’s on the west side of town. It’s in the kind of horseshoe of the median income being where it needs to be.

So, that’s where we kind of have stayed. So, yeah, I mean, I basically just knew that I needed quite a bit more space and I always wanted to bring my operating rooms in house and so, When I was about five years into my previous 10 year lease, I just started looking for land and then found basically the last piece of land that was kind of near 360, which is considered kind of the inner, inner part of the Westlake area and got that land under contract and did our due diligence as far as understanding what the impervious cover is and how big of a building we could build.

And we went through the architectural schematics of multiple different designs. And decided on something that was just ground parking and smaller, because we looked at doing an even bigger building with the first couple floors of being structured parking. I had a building consultant who assisted with, you know, kind of understanding.

He knew what it would cost to do structured parking. Versus doing surface parking and what the square footage of the building would be. And we crunched the numbers to determine what maybe rental rates would be with that additional square foot with the additional cost of structured parking and just settled on a smaller building with surface parking.

But, but you’re exactly right. You just do that. You just, you know, crunch numbers. And even with my accounting degree, I don’t know that I know enough about. Doing that sort of number crunching, because not only do you need to be able to do that, but you have to understand that if you build a parking garage that’s two stories and X number square feet, that it’s going to be about this amount per square foot to build it.

And then you have to extrapolate and take those numbers from there. So, it’s really, you really need to console to kind of help you with that sort of stuff.

Catherine Maley, MBA: For sure. Just gimme some of the mistakes made that others could learn from. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Huh? In, in, in regards to what? The building the construction. Right. Well, hindsight is 2020.

Mm-hmm. We, we still, even though we’ve been in the building for a year, have not finished our punch list. And I, I don’t want to go into too much of it cause I’m trying to keep this a happy conversation. But we’re having significant issues with our general contractor, our general contractor’s having significant, significant financial issues as it is sometimes in the construction world.

When interest rates go up, you’ve got yourself over leveraged and extended, and all of a sudden you get yourself in trouble. And, and our contractor has gotten himself in trouble. So, so, we’ve got, you know, some subs that haven’t been paid and some liens and there’s lawyers involved. And so, I guess if you take hindsight in consideration, I would say hire a really experienced federal contractor that you know is going to be in business and is going to be able to weather the storm.

And even if it costs you a little bit more, it’s probably worth it. Even though I didn’t necessarily go with the low-cost general contractor, and when I hired him, he was in in great financial shape and seemed like the best decision to be made. But I think that from a building standpoint, at this point in time, that that was the, the biggest issue.

And then, but that, that’s a hindsight issue and that that was just a decision that could have been better. I think that the other advice I would give is that we had a really extended timeframe for permitting. And it was because of an intrinsic property issue whereby we had a couple of different watersheds in the property and we didn’t have any zoning in the city of Boston to accommodate for those two separate water watersheds.

And so, the city just didn’t do anything. They just sat on the plans and said, well, we don’t have any zoning for this, so, we’re just going to sit on these and not do anything. And I, being naive, just felt like they were just being slow. It didn’t occur to me to hire an attorney. Who had inside leverage with the city to push the process along.

So, that’s what we finally ended up doing as I hired a real estate attorney who’s been in Austin for a long time and has poll, and we went down and met with the city and actually got them. Because they weren’t even telling us that this is the issue. They just, they just weren’t doing anything. And so, we finally all sat down in the room and they said, well, this is the issue.

And we were able to come to a pretty quick resolution and, and get permitting on the road. So, I think that that would be the, the thing that I would tell people is that if things don’t seem like they’re moving, Find an attorney who has leverage within the, within your system and push it along…

Catherine Maley, MBA: …and who’s played the game before and knows who to go to get things done.

How, because I know the last time I saw you at a meeting, everything was delayed, delayed, delayed, the permits. How long did it take you to actually go from, I guess, ground to up and running? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, from breaking ground up and running? Mm-hmm. It’s probably two to two and a half years. Again, patience.

Catherine Maley, MBA: You need some patience that you have to really allow for these time delays, right? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: You do. When I started the process and the permitting and construction, I had about five years left in my lease when I was looking for land. And so, we actually a little bit, sorry about the background noise a little bit. I, at, at the surgery center cause I was doing skin cancer and so, we got cleaning crew kind of rolling in.

Great. So, anyway, but I thought that my biggest problem was going to be that I was going to have to find a, a sublease to fill my right, my space. And I would definitely err on the side of knowing that you might have to either pay double rent or find this a subtenant sublease because as it ended up, I ended up holding over on my lease for about four and a half or five months.

And literally, I mean, I, I had the ability to stay as long as I wanted to, but my, my landlord was none too pleased. And so, it, it got a little bit contentious at the end. And, and basically, we got, we literally got out of our old lease space and were supposed to be moving into the same buildings into our new building simultaneously.

And as it turned out, we didn’t have a certificate of occupancy from fire marshal to get into the new building. And so, for a week, I, I just saw post-op patients in one of my general in one of the plastic surgeons in town who’s a colleague, just saw patients who needed to be seen in his office, in her office.

And then we got finally a week later got ours too and actually were able to move in. It was a little, little stressful.

Catherine Maley, MBA: Yeah, I’d say so. But now that you’re in, how many square feet did you go in? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, our, we, we occupied the first floor of the building. So, the first floor is 7,500 square feet, but there is, there is some common area for stairs and elevators.

So, The actual space that we occupy is around 6,900, right around 7,000. And then the building has got two stories. So, the upstairs is tenant space. That’ll is, is in the process of being built out. Because of course it’s nice to have some money being generated for a building that you own that isn’t just being generated by you.

Catherine Maley, MBA: Right. But then don’t you have to what do you call it when you have tenants come in and you have to rearrange things? What do you call that? Retrofitted or something for the tenant. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Well, you, you have to do the, the build out. I mean, it’s just shell space and so, Right. And, and there’s a couple ways you can have a tenant that comes in and they’re like, yeah, I like shell space.

Just gimme some tenant improvement dollars. And they just kind of take that money and do the real build out. We, we looked at that for a while and we weren’t getting anybody to really bite. And so, we actually did the architectural plans and we’re in the process of building out the top floor ourselves and then just getting a tenant to come into the, to the finished space.

And then of course, as we’re in that process, we get a tenant come that comes along that wants to customize their space. And so, we’re just actually signing a piece for somebody who’s going to take what we did and undo some of it and do it on their own, whatever.

Catherine Maley, MBA: So, anyway. But don’t you have a say in that because they, you don’t want them doing any crazy stuff upstairs, right? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Oh, I absolutely have a hundred percent what they do. I have a hundred percent saying who’s up there what kind of business they have. I mean, obviously I don’t get to control what business they have, but I get to control what businesses go up there. And what their finish out looks like as far as the quality of what they’re doing, all of that stuff.

You bet I have a hundred percent control over, over what goes on up there.

Catherine Maley, MBA: So, you have a nice exit strategy from what I can tell. You’re now a landlord. You have a beautiful practice where you can bring on more providers, more revenue generating providers. Do you have and I know you, do you have an exit strategy? Also, how did this affect your decision on buying land & building a practice from scratch?

I don’t know how far out it is. I mean, are you, are you like winding down or are you just getting started? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I am, I am steady right now. I don’t have any plans to wind down in the next year or two or so. So, nothing’s really firm on the horizon, but yes, so, and again, this, this is different business models and different people have different opinions.

I know multiple people who believe in separating out all of their business aspects. So, they might have their operating rooms as one business and their surgical practice is one business and the nurse injectors is one business and they’re. Philosophy on that is to have multiple profit centers and multiple things to sell, to sell.

I basically looked at that and said that it doesn’t really matter because your bottom line is your bottom line from business to business. And so, you can take all of that money and put it in one bucket and you look at your, your EBITDA and your whatever X factor that is to sell that. And it is, it is what it is.

And so, I chose to put all of my operating and revenue, my nurse injector revenue, the surgeon revenue, everything all in one bucket. And then, in my opinion, that makes it easier to bring on somebody who wants to buy in because they can see that there’s all of this other revenue that’s flowing to the bottom line that they don’t currently get a piece of, because they’re not an owner.

The only thing that the surgeon gets a piece of when they come into a practice, typically is whatever percentage of money of their own money that they generate that you give them. So, you have to have something else that they’re not personally generating this, flowing to the bottom line to make it a reasonable situation where they want to buy in.

So, as I was bringing in my junior associate and I was talking to people a, about what they had done. Because I know there are multiple examples of bringing in junior associates and the junior associate says, I’m not going to buy in. It’s not worth it. I’m leaving. I’m going to go open my own doors or do whatever I’m going to do.

And it just doesn’t work out. And so, people told me, they’re like, yeah, you can’t just get a practice valuation and expect them to buy in. And I disagree. And that’s exactly what we did. We set parameters and, and Erin came in and she did her two years and she got her board certification and then we got a practice valuation and we said, Hey, this is the number.

And she said, great. And, and that’s it. So, she bought 20% of the practice just about, well, middle of March, we closed on that. So, and, and that’ll be a great investment for her. There’s obviously a lot of revenue that’s being generated by other individuals and it goes to the bottom line and now she’ll get 20% of all of that.

And we, and she and I live by the same formula, so, I think that you have to be fair with your junior. So, just like when she came in and I said, look, I’m not going to do all the cosmetic and let you do all the recon. We’re going to, we’re going to let whatever comes in and wants to go to you, go to you. Because I wanted her to be able to generate.

As much revenue as she possibly could, even though she gets obviously the lion’s share of that. But now that she’s bought in I u I used to just take a salary and then whatever was left over, I just took draws whenever I wanted to. Right. Because I own a hundred percent. But obviously when you bring in another owner, then that’s not the case anymore.

You have to split it with whatever ownership percentage they have. And so, also to make it fair, I live by the same formula she does. So, up to a certain revenue amount, I get 40% of what I bring in. Above the next threshold, I get 45 and above the next threshold, I get 50 and less overheads running more than 50%, and then it gets reduced down.

But over a certain threshold, you get to, you get to take home, you know, everything up to what the expenses are. So, just like for her, part of her earnings is going to the bottom line. Same with me. Part of my earnings are going to the bottom line. So, she gets 20% of what. It goes to the bottom line that she generates and she gets 20%, that goes to the bottom line to what I generate.

So, it’s just a fair situation. We both get to benefit and it makes it enticing for somebody to want to buy in and feel like they’re getting value for their money and, and it allows me, I think, you know, I think the biggest problem that doctors do, and I’m not saying this is necessarily in the plastic surgery world, but you know, you see doctors all the time who build this practice for their entire career for 35 or 40 years and then they go, oh, I’m ready to retire.

I’m going to still my practice. Well, it doesn’t have any value if you sell it when you’re gone. Your practice is your practice because of you and what you built. And so, you have to bring in a junior associate and allow them to build their practice under your name and what everybody’s doing to come in that they recognized how, how you know good you are and let them build their practice with that, and you need to step away incrementally.

It wouldn’t also be fair for me to have Aaron buy in at 20% and then go, okay, hey, thanks so, much for the 20%. I’m going to go work two days a week. That just doesn’t work. So, that, that’s kind of the philosophy. But as far as I, so, I do, I do have a plan. Obviously, I’ve got Dr. Fry who’s starting up in August and my, my hope is that he will be equally as successful and busy as Aaron was after two years.

And then he’ll want to buy in as well, and I’ll let him buy in 20% as well. And then I figure sometime between 60 and 62, I’m, I’m about to be 55 now, so, sometime between 60 and 62 I’ll probably start working a half a day, a week less, and I might take a little bit more vacation. But as long as I’m having fun, I’m planning on working until, what I don’t want to be is the guy that the patient walks in the room and they go, wow, I heard he was the man.

But I think he’s probably a little too old now. I don’t know. I don’t know that he’s got, I don’t know that he’s got the stuff anymore. I will not be that person. I’m not going to work till 75 80 and be that guy that, that people think has have the tremor when they’re trying to operate.

Catherine Maley, MBA: Yeah, I think it’s a while before you get to that point.

And there are still some surgeons, this is what they do that, I mean, they are going to die on the surgery table and they know it. I think a lot of surgeons in today’s world though, are really trying to figure out, is that really what I want to do? But then they have to figure out how to. How do you pass your practice onto somebody else? Also, how did this affect your decision on buying land & building a practice from scratch?

So, I like what you’re doing. It’s unu like, let’s just go one step further. Let’s say you brought on somebody else then, so, you’ve got two associates at 20%, then you brought on another person at another 20%. Now you’re like, is that the plan to keep giving people 20% or is it maxed out at the two or? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Actually, so, so, I have a daughter who’s a first-year medical student who is. Most likely, obviously she has a lot to go through before she determines what she wants to do, and then she still has to match into an ENT residency and a fellowship and all that sort of stuff. So, there’s hurdles there. But if you asked her today what she was going to do, she’d say that I’m going to do facial plastic surgery.

And so, so, that’s the plan is for her to potentially come in and be that next 20%. Mm-hmm. But I, I won’t be in a situation where I don’t have operational control from an ownership standpoint. Until I’m ready to say that, gee, if something happened, I would be ready to retire at this point. Mm-hmm. So, cause I’m just, I’m not, I’m not going to have built the company and, and lose control from a voting shareholder standpoint.

Catherine Maley, MBA: You know, because the nuance there is you are somebody who gets it, like you understand the business and the marketing and a lot of other surgeons don’t want to, they’re not interested in it. They, they’re fine just being the associate forever. So, is, are you tr teaching them, like, ed Williams was so, good about teaching fellows, this is the business side, this is how you do it.

Are you doing that as well? And hoping one of them will. If you did want to step away, could they fill your shoes because you, those are big shoes to fill. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Well, obviously not immediately, but I, I certainly anticipate that Aaron’s going to get busier and busier. Her word-of-mouth referrals are going to get more and more.

I assume that Dr. Fry’s going to have the same scenario where he’ll be busier than most his first couple years out. And then as he builds his practice and starts to build a clientele that come to him, because he’s such a nice guy and such a great surgeon, that by the time they’re in practice for 10 years, Then yeah, might, they’ll be able to fill my shoes.

But there’s no way that anybody’s going to come into the practice and fill the shoes of a 20-year surgeon when they’re in their first five years of practice. It’s going to take multiple years for them to build up and, and get to the point where they’ve got a waiting list for six months of people that want to come see them as well.

It just, it just takes time.

Catherine Maley, MBA: Right, but then who’s going to, like, is it a democracy then? Is it a dictatorship? Because right now I would think you have the final say so, in the big decisions made when you have three people under you all at 20%, I just wonder how that works out when with all the different personalities and egos, does it work out well? Also, how did this affect your decision on buying land & building a practice from scratch?

If you’ve got set up strike.

Edward D. Buckingham, MD: Yeah. So, I don’t, I don’t think I answered your question on teaching fellows the business side of things, but a hundred percent absolutely. I mean, we, we say that when the fellows come and interview with us is that one of the reasons why you would want to do this fellowship is because you’ll actually learn the business aspect of medicine.

We have a board document that basically says, these are the things that we expect you to know when you finish your fellowship. And, and half of that is clinical stuff. And half of it is related to marketing and accounting and staff management and HR and every other thing you can think of as far as what it takes to run a practice.

And, and I don’t, I don’t hold them personally responsible from the standpoint that I go, Hey, have you learned this yet? Hey, have you learned that yet? And I’m not going through checking the box. I just give it to them and go, look, this is your responsibility to learn this stuff in your, in your 12 months that you’re here.

If you don’t do that, too bad on you. I’m not going to be your parent. I’m not here to be your parent. I’m here to give you the opportunity to learn. And if you take the initiative to learn, you have every resource to be able to do that. So, that, that is definitely part of it. But in an, in answer to the other question, I, I don’t know how, but, but it, it is not a dictatorship.

Every month we sit down and have a first Friday of the month in the morning, we have our manager’s meeting, and I sit down with my HR, you know, practice manager person. My business manager, my nurse manager, the fellow Aaron, and when Renee, who’s my nurse injection, can be there, she’s included too. So, whatever number of people, six or seven people, and we sit down and we talk about stuff, and I definitely do not take a dictatorial attitude towards that.

I think that everybody has positive, intelligent things to say and contribute to those meetings. And oftentimes I’ll get four or five people who think that an idea is better than mine. And if you know what, if I got that many people who think that they’re right and they. Can convince me that they are, then we go that direction now.

Absolutely. Do I have veto power? You bet. I’m, I’m the president, the CEO. I’m in charge. But most of the time there’s not anything that happens whereby I have to put my foot down and say, I know the rest of you want this, but we’re not going to do this. Usually there’s a pretty good consensus on most decisions.

Catherine Maley, MBA: That’s fantastic. And then let’s switch over to marketing. Any marketing tips? I mean, you’re in a pretty competitive area now. Any, any, anything you are doing to help you differentiate from everyone else? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: I mean, I have the advantage of word-of-mouth referrals.

Catherine Maley, MBA: Mm-hmm. You know, how much of your practice do you think your personal practice would be? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Word of mouth referral, 90% plus.

Catherine Maley, MBA: And I’m going to tell you why, because, and I’ve watched you forever. You used to send beautiful flowers to facelift patients, and you, do you still do it? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Absolutely.

Catherine Maley, MBA: Everybody. I don’t know why everybody doesn’t do that. You’ve got so, many notes and reviews and testimonials, and I think everyone was just so, surprised they got flowers and they all, I mean, how great of a strategy. It’s not even a strategy, like you just know that’s the right thing to do.

How much has that been worth to you? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Oh immeasurable. Yeah. I, I mean, you’re, you’re exactly right. We get comments all the time. They come. And they, and well of course they go, oh my gosh, my husband bought me flowers. And then, and then of course they’re like, oh, this is from Dr. Ingham. And their husbands are kind of like, oh man, thanks, thanks dude.

I should have gotten her flowers, but nevertheless, it works. So, so, yeah, it, it, and it’s and it’s not overly expensive either, so, it’s a, it’s a really nice touch. And I, I look at it as, you know, when you’re in that immediate post-operative recovery period, you don’t think yourself, that you look very pretty.

And so, it’s, it’s nice to have something pretty and that smells good to kind of take your mind off of what you’re going through. And, and it has definitely paid off immeasurably over the years. Patients, patients love it.

Catherine Maley, MBA: The secret is to get those there early on. I once had a facelift and the flowers arrived 13 days later and it kind of defeated the purpose.

I’m like, where have you been? You know? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah. Well, And it’s crazy. I, for a long time believe that the flowers had to be delivered by a florist, and we went through a bunch of florists and it just was really, really difficult to get good quality flowers that got delivered in a timely fashion. Oh. And so, yeah.

Now as crazy as it is, we just do one 800 and, and people love it because the flowers last. For like 10 or 14 days, right? Just you cannot get flowers that are that fresh. I mean, I, I’m sure there are high-end florists who have amazingly fresh flowers, but when you’re going straight from the supplier who’s cutting whatever flower it is and putting it in a box and sending it, the patients just say that they last forever.

So, as kind of not classy as it is to get flowers in a box in some way, shape or form, having, having really fresh flowers is, it makes upward, in my opinion,

Catherine Maley, MBA: Oh, it’s so, much fun. It’s such a surprise. It’s just lovely. I think it’s a great idea and I don’t know why everyone doesn’t do it, but what a great differentiator for you, you know? Also, how did this affect your decision on buying land & building a practice from scratch?

Now I know you’re not a big social media kind of guy. Are the younger folks in your office the associates? Are they into it? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah. So, so, Dr. Smith has a social media account that’s associated with the practice that, that she runs and does AR I’m sorry, Renee, my nurse. Injector has your own social media that, that she does.

And then we have someone in the practice who does our social media. Mm-hmm. It’s just not me. Mm-hmm. You, you, I mean, again, I, I don’t want to do it. I’m bad at it. I don’t enjoy it. I don’t spend any time on social media whatsoever. I have an Instagram page only because my son’s baseball games or streamed on Instagram, and I had to have one to watch his games.

It’s just, it’s not for me. So, so, yes, we’re absolutely trying to leverage social media the best we. I wouldn’t say that it’s the easiest thing in the world to do, and I still have my reservations as to how much business it actually generates. I’m sure it’s one component where people see you’re on, see you on social media, and then they talk to whoever, and then they go to your website and ultimately, they get to you because of all of those factors, and it’s really kind of difficult to tell, you know.

Which one of those elements was the first one that really brought them into knowing, into knowing you so, We just look at it, look at it as one piece of the pie that you have to do what you can to do the best you can. But I certainly don’t have a million followers.

Catherine Maley, MBA: Right? No, I’m with you. If it’s not, if you’re not into it, I would say it’s more important that you’d be genuine when you, when you do it, and if you can have a good marketing team that just shows you off in a great way where you’re not.

You’re not doing the production, you know, it’s just maybe they’re catching you at the right times and showing the day and the life of a plastic surgeon that makes more sense. But if you’re not into it, I, I just, I don’t think it’s, I don’t think it’s worth your hours and hours spending on that. It’s amazing how some doctors spend two to four hours a day on it.

I just don’t get that. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Yeah. Well, and it, and again, I, I’m, of all the things we could talk about today, The one that I am the least authority on is probably social media. And so, but it seems to me like the doctors who are really popular on social media tend to have some sort of a flare to what they’re doing.

And I am just a nuts-and-bolts kind of easygoing, you know, grew up rural kind of guy. I just, I, I can’t, I can’t be Dr. Miami, right? It would never, it would never work for me so, that I just, I can’t do it. So, we try to, we try to provide some good content that’s interesting to people that has our values embedded in it.

And unfortunately, it’s just not that flashy.

Catherine Maley, MBA: So, what would you say is the biggest challenge running and growing a cosmetic practice today? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: HR.

Catherine Maley, MBA: I hear that a lot, always.

Edward D. Buckingham, MD: It is, and, and I, and I would say that that’s probably the most, Valuable point that I can make in, in growing a practice is as soon as you get even a sniff, that you have discontent or employees that are forming clicks and talking badly about other employees.

Break it up, make sure it ends, and if it doesn’t end, get rid of them because it does not take but a half a second for a rotten apple to make the rest of the officer rotten place. And, and I’ve probably been through two or three iterations of that where I had employees that began that sort of behavior and taking after other employees and creating a hostile work environment.

And it, and it took me probably the third time before I actually started figuring out that you just have to have an absolutely zero tolerance policy for that. So, Knock on wood right now, we have a really good, solid culture and everybody gets along and they’re all team players and they’re friendly to each other.

But I tell you, just especially, especially the cliques, when you get two, when you get two people teaming up against another one, you, you just, you got to call them to the office immediately. You’ll say, we don’t, we are not going to tolerate this. Stop this behavior right now, or you’re gone.

Catherine Maley, MBA: Good for you because that’s exactly what happens.

It, you can see it happening and you have a tendency to be too busy and not interested in it enough to get involved, and that’s how it grows. And then you have a big problem on your hands and by then it’s so, toxic that you’ve lost some of the others in your p in your practice who thought, no, I’m not working like this.

So, yeah, I hear you. HR has become an issue. So, on the, on the more fun side, tell us something we don’t know about you. Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: So, you already, you already took the South Dakota so, that I grew up in South Dakota. That’s kind of boring.

Catherine Maley, MBA: But tell us about South Dakota. Because I’ve never been there.

Edward D. Buckingham, MD: So, well, South Dakota where I grew up in Rapid City is an amazing place.

It’s a about 65,000 people, so, relatively rural, especially when you consider that the closest big town is Denver, which is about six hours away, and you’re the second biggest town in the state. So, it’s, it’s big enough to. Have some, some conveniences of being in a little bit of a city, but you’re 15 minutes from being out in the black hills where you can literally just kind of park your car on the side of the road and take off into the forest and never see anybody else.

It’s an, it’s an amazing forest because it’s an arid forest and so, there’s not a lot of undergrowth, and so, literally you don’t even need a trail. You can just go; I want to head west and just go. And as long as you don’t get lost and get yourself turned around you, you’ll get back to where you want to be.

So, it’s, it’s really, it was an amazing environment to grow up in. Really good, solid people. Just beautiful country. Tons of granted, obviously Mount Rushmore’s there. So, it was a really, really great place to grow up. The only problem with being a facial plastic surgeon there is you’d have to convince the goats and the cattle to have facelifts cause there’s not many people.

So, but Texas works out good for that. And I just get home, but I still have family that, that lives up there. My. Sister and brother live up there and my parents are there, but they don’t winter there anymore. They’re in their mid-eighties and they don’t like to drive on the snow anymore, so, they go south for the winter.

Catherine Maley, MBA: Like, where would they go? To Texas?

Edward D. Buckingham, MD: No. I tried to get them to come to Texas, but they had all their friends were going to the Sun City area in Arizona. So, they so, they went in.

Catherine Maley, MBA: Oh, that works. Arizona’s beautiful in the wintertime. It’s brutal in the summer.

Edward D. Buckingham, MD: Yeah. Yeah. So, but the other, the other thing you should know about me though is not really about me, but about my wife.

Because you said she was an ophthalmologist, an ocular plastic surgeon, which is true. But she left practice a couple of months ago because, She was elected for the Texas Land Commissioner. Oh my

Catherine Maley, MBA: God. Where was she when you needed help with your, your permits? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: Believe me, she, she was the one who reported the people that I needed help with the permits.

Ok. So, yeah. Un unfortunately government officials don’t have that much power, but yeah, so, she’s, she’s a statewide elected official in Texas. She runs, she runs about a two and half billion-dollar 800 employee agency that does all kinds of things that I won’t for you with everything from. Disaster recovery to running the Alamo and everything in between.

So, it’s actually the office actually predates the governor in Texas, so, so, she’s yeah, she’s pretty amazing.

Catherine Maley, MBA: That’s a pretty big deal. Yeah. Oh, congratulations. So, you’re, you’re kind of living with a celebrity at this point? Also, how did this affect your decision on buying land & building a practice from scratch?

Edward D. Buckingham, MD: A little bit, yes, ma’am.

Catherine Maley, MBA: Can you still go to dinner without being, you know, in a restaurant without being interrupted?

Edward D. Buckingham, MD: No, not really. I’m kidding. I mean, occasionally, but Yeah. But, and, and most people are pretty, are pretty cool and respectful, but we definitely see people everywhere we go that, that she knows and, and she of course wants to go up and shake hands and say hi and talk and everything too. But yeah, it’s not uncommon for us to have a dinner that lasts an hour and a half and then walking around the restaurant saying hi to people for another hour afterwards.


Catherine Maley, MBA: Oh, that must be really fun for you. Alright.

Dr. Buckingham, it has been a pleasure having you on Beauty and the biz. I’m so, I just have watched you for decades and you’re just doing a killer job on the business side. I’m you know, congratulations on your new building. I know you’ve got that business plan. I know you’ve got an exit strategy that you’re doing what you need to do.

Terrific. And isn’t your website,

Edward D. Buckingham, MD: Yes, that is correct.

Catherine Maley, MBA: Yeah. Okay. All right.

Everybody that’s going to wrap it up for us today, a Beauty and the Biz and this episode on buying land & building a practice from scratch.

If you’ve got any questions or feedback for Dr. Buckingham, you can reach out to his website at,

A big thanks to Dr. Buckingham for sharing his experience on buying land & building a practice from scratch.

And if you have any questions or feedback for me, you can go ahead and leave them at my website at, or you can certainly DM me on Instagram @CatherineMaleyMBA.

If you’ve enjoyed this episode on Beauty and the Biz, please head over to Apple Podcasts and give me a review and subscribe to Beauty and the Biz so, you don’t miss any episodes. And of course, please share this with your staff and colleagues.

And we will talk to you again soon. Take care.

The fastest way to success is to model other successful surgeons who have what you want, but you can only see their results, not the path they took to get there.

So, you continue to jump from one thing to another, hoping to find something that will work for you too, but it rarely does. So, try this shortcut instead. It’s guaranteed to move you forward. I compiled my intellectual property to grow cosmetic revenues, everything I’ve gleaned over the years into one playbook of the most successful practices and what they do to win.

Go to and let’s grow your cosmetic revenue.

-End transcript for “Buying Land & Building Practice from Scratch — with Edward D. Buckingham, MD”.

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Catherine Maley

Catherine is a business/marketing consultant to plastic surgeons. She speaks at medical conferences all over the world on practice building, marketing and the business side of plastic surgery. Get a Free Copy of her popular book, Your Aesthetic Practice: What Your Patients Are Saying View Author Profile.


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Listen in as Catherine interviews surgeons who talk about the business and marketing side of plastic surgery and listen to Catherine’s pearls from consulting with plastic surgeons since Year 2000.



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