“Availability and Boundaries, Can I Do It All While I Grow My Practice?”

By: Steven DeFroda, M.D.

Member, AANA Communications and Technology Committee

In February 2023, I wrote an AANA newsletter discussing the transition from fellowship to early practice. I’m sure all the upcoming Fellow graduates are looking forward to this with excitement (and likely anxiety), while some of the more seasoned AANA membership likely looks back on these days with a certain fondness; or maybe lack thereof! At the time of my last editorial on this topic I was two years into practice, my confidence both in and out of the operating room was growing (but not where it is today) and ABOS part 2 was looming on the horizon. My elective practice was slowly growing, and I was given the opportunity to pick up an additional operative day for elective sports and leave behind the world of trauma which I had been covering one day a week as my practice grew. This was an exciting time, but also one filled with anxiety and concern; mainly, how do I essentially double my surgical volume from one full day of elective cases a week to now two.

I would imagine many new and recently new attendings were in the same scenario as myself just 1-2 years into practice; focusing on growing your practice, slowly emerging from the constant stress of board collection and figuring out how to run your practice efficiently. If you were like me, many “big picture” goals may have been put on a pause, goals like research, national organization involvement and finding your “niche.” You also may be at a point where the first job out of fellowship isn’t working out and you’re questioning if you made the right decision or not, maybe your current position won’t allow you to meet the goals you have set for yourself. Oh yes, and let’s not also forget balancing family life and where all that fits in the grand scheme of things. Obviously, everyone is in a different situation, but the phrase “jack of all trades, master of none” comes to mind. How do we, as high-achieving surgeons, excel in all the areas that we would like to and more as we transition and grow as physicians? These areas are different for everyone but include (and are not limited to): surgical skills, practice volume, research, leadership positions locally and internationally, teaching, team coverage, consulting opportunities and finally, and maybe most importantly, family.

In my prior editorial I wrote “the best ability is availability,” and I typically tell my trainees to never say no to an opportunity. While I still firmly believe these maxims, these so-called “opportunities” may be different for everyone. As you grow as a surgeon and physician, I believe it is important to take stock in your goals and aspirations, constantly adjusting and re-calibrating to see if you are on track. As surgical trainees we were often faced with schedules that were not our own, working grueling hours to master a challenging and ever-evolving craft. Now as an Attending you have the power to shape what you want your practice to become. Ultimately for me this comes down to boundaries and deciding the direction you want to steer your career. To go back to my own example, I knew that my goal was to grow my clinical practice, effectively needing to double my elective sports medicine volume, while also keeping an eye on developing my “niche” in hip arthroscopy. While patients don’t just show up overnight, the over-arching goal of our profession will always guide us straight: first do no harm. If you take great care of your patients and their family members, your practice will grow organically, and you will grow as a surgeon with it (it also helps that a lot of hip arthroscopy patients have two hips!). This will give you the ability and flexibility to achieve your goals and milestones. At the same time, if your priority is coaching all of you kids T-ball games (one of my passions outside of the OR), then you must be honest with your time and abilities and set up those guard rails where conflicts could exist. This is where supportive partners (both in practice and in life) are crucial to your success.

There is no secret recipe in our chosen career path, and everything we do requires passion, precision and most importantly time! For me personally it comes down to the availability piece of the pie, but more specifically how do you be precise and optimize that availability? It comes with the realization that for the first time in your medical career you have the control over your interests. You’re no longer the Resident or Fellow, or even the junior attending ready and willing to take on everything and anything. If your goal is to be busy surgically, you should work to improve your clinic volume and efficiency, as this is where the patients come from. If you want to be an NIH-funded researcher then you must carve out that availability to be in the lab or in your office writing grants and perhaps adjust your clinical practice accordingly. Maybe you want to be a top-tier team physician, or the head team doctor at your institution. If so, then your availability must be spent on the sidelines forming those bonds and relationships. And if your goal is to make it to every sporting event or kids’ concert, then that too comes from maximizing your availability and setting those boundaries with regards to your clinical schedule. 

Taking this back to my own personal experience, I was able to expand my clinical practice by enhancing that availability. Opening more spots in clinic has led to more patient visits, which leads to more surgical cases. However, there are no free lunches (just ask your reps). This comes at the expense of my “administrative time” causing me to perform research-based tasks “after hours” when my family is asleep. When I take the 30,000-foot view of my practice, it is far from a finished project, but I am very happy with its overall trajectory as I begin to progress and advance my career, working towards improving and perfecting my ability. Ultimately, I would answer my own question in the title by saying: “Yes you can do it all while growing your practice,” but remember that every task that you spend time on potentially takes time away from another. For myself that may mean 1-2 less cases during T-ball season or missing a family event for a national meeting. When we think about things like work-life balance, there really is no balance, but more like a continual re-balancing as priorities and goals change. The most important thing in my opinion while continuing to grow your practice, is being honest with yourself, as well as others about what your priorities are, as this will make them much more attainable in the long run. You can do it all, but this will mean different things to different people.