Episode 9: The First 5 Years as an Orthopedic Surgeon (Nobody Prepares You for This)

You finish residency. Maybe fellowship. You have spent years becoming highly trained in a specific area of orthopedics.

Then you start practicing and discover that being trained for the job and building a practice are two very different things.

In this episode of Healthcare Unscripted, Dr. Hunter Greene and Dr. Dustin Richter talk about the first three to five years of an orthopedic career: the cases you actually take, the practice you thought you would have versus the one you initially build, and the parts of becoming a surgeon that training does not necessarily prepare you for.

Dr. Greene brings the perspective of private practice, while Dr. Richter practices in an academic setting. Despite those different environments, their experience points to the same reality: the first several years are largely about building.

Your Subspecialty Is Not Necessarily Your Practice

A fellowship may define your expertise, but it does not guarantee that your first schedule will be filled with exactly those cases.

For many young surgeons, particularly those entering private practice, the early years require a much broader practice. Dr. Greene notes that unless you enter a setting with an established need and existing volume in your subspecialty, you will probably need to take general orthopedic cases simply to build your reputation and fill your schedule.

Dr. Richter puts it even more plainly: a sports surgeon may perform more hip fractures than ACLs during that first year. Early practice might include trauma, carpal tunnel, and whatever else comes through the door. That broader work becomes the foundation for eventually developing the niche you actually want.

That can be difficult to reconcile with years of subspecialty training. But the practice you want at year five is usually something you build, not something you inherit on day one.

Three to Five Years Is Real

Young surgeons hear that it takes three to five years to establish a practice. It can sound arbitrary until you live through it.

For Dr. Richter, the five-year mark was roughly when his clinic and operating room finally began to reflect the practice he had envisioned. His schedule had developed. His referral base had matured. More of the cases coming through the door were the cases he actually wanted to treat.

Dr. Greene describes the same transition: eventually you look at your schedule and realize you are doing more of your specialty work and less of the unrelated work that was necessary early on.

There is no clean moment when a practice suddenly becomes established. The change happens gradually.

But the timeline matters because it gives early-career surgeons a more realistic benchmark. A first-year schedule is not necessarily a preview of the rest of your career.

Nobody Teaches You How the Patients Get to You

Clinical training prepares surgeons to care for patients.

It does not necessarily teach them how those patients arrive in their clinic.

Documentation, billing, scheduling, insurance requirements, and referral pathways suddenly become part of the job. Dr. Greene describes scheduling as a kind of “black box” early in practice. Understanding where referrals originate, what referring offices need, and how patients move through the system can have a direct impact on the practice you are trying to build.

That means building relationships intentionally.

Dr. Richter recalls visiting physical therapy practices early in his career, buying lunch, and spending about 45 minutes explaining who he was, what hip arthroscopy was, which patients might benefit, and what his rehabilitation protocols looked like.

It was not sophisticated marketing. It was making sure the people caring for those patients knew what he did.

Availability matters too. Giving a physical therapist or primary care physician a direct way to reach you, helping them get a patient seen quickly, and then taking good care of that patient builds trust. Over time, those individual interactions become a reputation and a referral network.

You Have More Control Than You Think

There is another important point for surgeons approaching years three, four, or five and realizing their practice still does not look the way they expected.

You are not entirely at the mercy of whatever appears on your schedule.

Dr. Richter points out that surgeons can actively shape their practice by building their reputation in the community, developing relationships with physical therapists and primary care physicians, and becoming more deliberate about the types of patients they see.

By that point, you have enough experience and visibility to start defining what you want your practice to become rather than simply accepting whatever comes through the door.

That shift from filling the schedule to shaping the schedule is one of the most important transitions of the first five years.

The Hard Cases Do Not Stop Affecting You

Building volume and referrals is only part of becoming an established surgeon.

You are also learning how to carry the responsibility when something does not go according to plan.

Complications weigh on surgeons. Dr. Richter talks openly about losing sleep over them and about the importance of calling partners, discussing what happened, and bringing difficult cases into M&M conferences rather than carrying them alone.

His advice is straightforward: lean on people, and when a complication occurs, identify it and manage it. Do not avoid it or hope it resolves because you do not want the complication to be real.

That may be one of the biggest differences between finishing training and actually becoming established in practice.

Independence does not mean doing everything alone.

Building the Surgeon You Become

The first five years are not simply a waiting period before the “real” career begins. They are where much of that career gets built.

You learn which cases you want to pursue and which ones you do not. You learn how patients find you. You develop relationships with referring providers, therapists, partners, and staff. You learn how your scheduling system actually works. You build judgment through cases that go well and through complications that stay with you.

And eventually, almost imperceptibly, the practice begins to look more like the one you imagined.

Dr. Greene and Dr. Richter have both spent significant time teaching residents, fellows, and early-career surgeons, and their conversation makes a strong case for mentorship well beyond formal training.

Because finishing fellowship may make you a subspecialist. Building the practice, reputation, and judgment to become the surgeon you want to be takes longer.

Watch or listen to this episode now: https://linktr.ee/healthcareunscripted