SUPPLEMENT ARTICLE
My First Year in Academic Practice: If I Could Turn Back
Time, What I Would Do Differently—10 Years Later
Frank A. Liporace, MD
Summary: “Joining a practice for the first time after training,
whether in academia or the private sector is fraught with challenges
and a learning curve. Postgraduate education has not sufficiently
taught anyone how to manage the nuances of this new arena, or
completely how to become successful. Success is not solely a func-
tion measured by reportable taxable income. Respect by colleagues,
patients, partners, and staff are just as important, if not more so, and
the financial attributes will be realized if the tangibles and intangibles
discussed are appropriately executed in the correct environment.”
Although the preceding statements were made as reflecting on the
first year of practice, they hold true 10 years later, and always. This
article discusses what can be learned from a decade of “doing” even
when having “planned well.” Some concepts that have not changed
are maintained throughout, some have been updated from experi-
ence, and some have been completely changed. Just remember, what
you do should be dynamic and adaptable over time, but the princi-
ples, if sound from the start, never change.
Key Words: practice management, starting practice, career
(J Orthop Trauma 2015;29:S9–S11)
WHAT I LEARNED
Staffing Your Practice
The hiring of staff (medical assistant, secretary, physi-
cian extender, etc) is unchartered territory for most new
attending physicians. Important qualities to review are experi-
ence in similar practice settings and references. The inter-
viewee should be comfortable with you reaching out to all his/
her references by telephone to get a gestalt of how that person
functions. If they are apprehensive of you making personal
contact with past employers, then this is a true “red flag.”
Over the last 10 years, I learned that, “what you think
you see is not always what you get” with staff. The fact that it
is important to follow up on professional references remains
unchanged. Once hired, it is necessary to closely monitor
punctuality, attendance, and ability to get the job. Addition-
ally, it is imperative to carefully monitor how consistent your
staff is and how they represent you to patients, insurance
Accepted for publication August 13, 2015.
From the Department of Orthopaedics, Orthopaedic Trauma Research,
New York University/Hospital for Joint Diseases, Jersey City, NJ.
The author reports no conflict of interest.
Reprints: Frank A. Liporace, MD, Orthopaedic Trauma Research, Depart-
ment of Orthopaedics, New York University/Hospital for Joint Diseases,
377 Jersey Avenue, Suite 280A, Jersey City, NJ 07302 (e-mail:
Liporace33@gmail.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 29, Number 11 Supplement, November 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
careers, colleagues, and family members. This must be done
in a way that is not overbearing but efficient. It is necessary to
hold staff accountable for “the good and the bad.” Having
a suggested way to answer the phone that includes identifica-
tion of who is answering is important because this is a very
subtle way to make the individual on the other line feel a con-
nection, but is also a way to identify a troubled employee
when you receive a complaint. Also, scripting a concluding
comment that offers further assistance to the caller is impor-
tant. Setting reasonable expectations for work hours/reim-
bursement, respecting privacy, and having a contingency
plan when an employee is out becomes your responsibility.
Equally important is understanding when an employee
is not living up to these expectations or poorly representing
your practice. At that juncture, it is important to privately
address this with the employee, often in the presence of your
practice manager or a representative from human resources. It
is necessary to be succinct, have direct examples of where
you have concern, and patiently allow adequate time for
response to your concerns. Having someone else present in
a closed room setting can help alleviate an employee’s feel-
ings that there is a personal attack and offers both parties
a sense of protection from wrongful accusation.
At the conclusion of such a meeting, it is important to
document the date and time of the meeting and define the
outcome of each point of discussion. For those areas in which
identified improvement needs to be done, an action plan must
be clearly outlined. This gives the employee the satisfaction
of goals and protects you from being accused of having
unrealistic expectations or never identifying the problem(s). If
patterns of similar behavior continue, then a follow-up with
a formal plan of remediation that is written and signed by all
parties is necessary, especially in the event of ultimate
employment termination. If there is significant improvement,
a follow-up meeting should also be conducted to identify and
recognize that the employee’s efforts have not gone unno-
ticed. This is an important quality as a leader to show that
you acknowledge the progress of those who work with you.
Educating
Recognizing the level of the audience, respecting
allotted time allowance on the podium, being appropriately
confident but not arrogant, and sticking to evidence-based
medicine is paramount and unchanged throughout history.
As your reputation for expertise gets more defined, it is
important to maintain your old lectures, constantly update
them, practice them, and make the slides more succinct.
Although articles may be cited throughout, brief, poignant use
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 Liporace J Orthop Trauma  Volume 29, Number 11 Supplement, November 2015
of statistics and graphs is most helpful, and use of supporting
case examples really “drills the point home.” Listing statistics
and reading them is not effective to leave an impression.
Those in the audience can access the referenced source for
those specifics if necessary, but most frequently, you want the
audience to leave your lecture with 1–2 well-defined clear
messages.
Also, with greater experience, our support of evidence-
based medicine can be exemplified by showing cases that you
may have performed that did not have an expected result. You
can cite learning from the experience, literature, and time. This
is a great learning tool and also helps the audience relate to you.
All too often, potential “up and comers” fall short
because they did not follow the simple “rules of educators” that
were defined in the last edition.1 Mastering these skills will help
when asked to lecture at larger forums (ie, American Academy
of Orthopaedic Surgeons [AAOS], OTA, AO courses, etc) with
an audience that is often filled with attendees who may have
more years in practice than you do. Arrogance is never well
received, it is assumed that if you are being asked to lecture,
that you are an expert. When answering audience’s questions,
sarcasm, editorialization, insulting comments, and defining how
you are “better than everyone else” will not effectively get your
message across. Finally, having well-organized lectures without
too many words per slide, effective case examples, and being
within the time allowed are paramount.
In this era of “publish or perish,” do not get lulled into
having others write your manuscripts without you taking an
active role in study design, results evaluation, and editing.
Also, do not just publish to publish. As you gain experience,
publish higher levels of evidence, publish unique techniques
with results for common problems, and finally publish what
you are most comfortable treating.
Billing and Coding
More than ever, whether salaried or not, receiving
collections attached to your name for the work you do is
important. It may have a direct impact on your income, it is
a way for your hospital and chairperson to evaluate your
necessity, and it is important to learn how to honestly and
effectively receive payment for the services you deliver.
There are a variety of courses offered by the AAOS and
OTA to help with learning how to code and answering some
of the “gray areas” in this arena. You must also understand
the services at your disposal within your department because
the ultimate billing and its potential legal ramifications are
completely your responsibility. Practices offer coders, collec-
tors, and reviewers (to ensure that you document correctly)
but all do not offer the same level of services so it is important
to know what is available to you.
Billing must be done timely and match your dictations
and office notes to be paid. Modifiers are important to allow for
payment of multiple procedures, staged procedures, procedures
linked with evaluation and management codes, multiple proce-
dures done on different days within the initial 90-day period, etc.
Also, when planning elective surgeries, timely coding of the
proposed procedures and prenegotiation/precertification is
imperative because you may not be compensated if the rules
of the respective insurance company are not adhered to.
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Even after a decade, there is always room to learn.
Currently, the proposal of ICD-10 also offers a whole new
area that is necessary to learn and mandatory training is
required by most institutions. Even if there is a delay from
the proposed October 2015 institution of ICD-10, it is poten-
tially inevitable. Many nations use this system for database
collection and the United States may be the first that will use
it for billing documentation.
Another addition to the landscape has become under-
standing Accountable Care Organizations, gain sharing, and
Hospital Consumer Assessment of Health-Care Providers
and Systems (HCAHPS). These are all tied to your
reimbursement, your institution’s reimbursement, and public
record. Each of these could be a full-day symposium, but
getting training in all is imperative to practice medicine in
this era.
WHAT I WISH I KNEW
How to Deal With Partners
Remember, your partners are part of your team. You do
not have to do everything if there is someone who can do it as
well or better. Especially in academic practice, there are
frequently subspecialists who can deliver the highest level of
care based on the pathology being treated. Remember, you
too are a subspecialist, and the same rules apply. Sharing and
referring patients appropriately can deliver the highest level of
care, instill a feeling of camaraderie within the practice, and
also encourage others to refer to you. Trying to do every case
will only get you the reputation of being a competitor and
have others continuously scrutinize you, waiting for your
downfall, instead of encouraging and helping you as you
mature in your new role.
Time Management
With everything, time is limited but expectations can
seem to be unlimited. Balancing clinical practice, research,
educating locally and nationally, and family obligations are
difficult but necessary. Trying to define a daily and weekly
schedule to incorporate all of the above and adhering to it is
important to have a long, sustainable career. This includes not
always accepting every speaking engagement.
The New “Chain of Command”
The role of a chairperson changes as you transition
from a resident to faculty. The chairperson expects that you
represent the department professionally, teach effectively,
publish, and deliver revenue. In return, you should look for
a department with leadership that you believe is not punitive,
fosters a young practitioner’s career, and is well respected
within your hospital and nationally.
Remember that your senior partners within the practice
and within the division deserve respect, can be a valuable
resource when treating patients, and can be very helpful when
negotiating hospital politics on your behalf. Remembering the
following 5 rules will truly help your experience (Table 1). It
is okay to ask advice; It is okay to learn from others and have
them be mentors to you; It is okay to learn the “hospital
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 J Orthop Trauma  Volume 29, Number 11 Supplement, November 2015
TABLE 1. Five Golden Rules of the New “Chain of
Command”—These Have Not Changed.
1 It is okay to ask advice
2 It is okay to learn from others and have them be mentors
3 It is okay to learn the “hospital system” from others
4 It is okay to learn about follow-up care from others
5 You are not a senior resident anymore
system” from others; It is okay to learn about follow-up care
from others; You are not a resident anymore.
Hospital Opportunities
Getting involved with departmental and hospital com-
mittees can help you gain experience with leadership on
a local and national level, open doors for promotion, and
create relationships that will facilitate your practice. In getting
involved, you effectively have a venue to create change for
the better.
As a young surgeon, getting involved with Operating
Room Committees, Quality Assurance/Performance Improve-
ment Committees, and Purchasing Committees can provide
a crash course on staff management, supply/instrument man-
agement, and improving your institutional, as well as, personal
experience with operating room turnover, anesthesia, etc.
WHAT I WOULD DO DIFFERENTLY
Think About Part II American Board of
Orthopaedic Surgery Sooner
From day 1 of practice, organizing a database with
identifiers for all patient interactions can organize your
practice, research, and information during the American
Board of Orthopaedic Surgery (ABOS) collection period. It
can also help as you begin to work on your research. Your
database should include, but not be limited to: demographic
information; date of each interaction; diagnosis and procedure
codes; complications; thromboembolic prophylaxis (type and
timing); antibiotic prophylaxis (type and timing); etc.
Also, keeping a calendar of Maintenance of Certifica-
tion (MOC) requirements is important to allow you to stay
current, be certified, and be eligible to take your recertifica-
tion examination 3 times. If all of your application require-
ments for recertification or MOC are not met, even by the
seemingly most miniscule detail, you will lose the opportu-
nity to take advantage of the “3 strikes” for recertification.
Please refer to the ABOS (ABOS.org) and AAOS Web sites
for helpful tools in managing this process. For example, once
being board certified, you can sign up on the AAOS Web site
for MOC to help track your progress in the requirements.
Time Management and Resources (Clinical,
Research, and Personal)
Maintaining a calendar beyond office hours and surgery
by your secretary should be done to centralize your schedule
and provide you a more panoramic view of your life. Also, it
allows your staff to know where you are and how to find you
when you are needed.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
What I Would Do Differently—10 Years Later
Using your mentors, senior partners, and your chair-
person as resources on treating complex patients or conditions
that you may have never seen before can provide an
educational experience for you and deliver better, more
consistent care for your patients.
The database system previously mentioned can truly
organize your practice, ABOS part 2, your research, and
supply cases for lecture preparation. This is something that
should be done from day 1. This goes hand-in-hand with
trying to acquire a research assistant as early as possible, even
within your contract if possible, to help bear the load and
maintain efficiency.
Also, it is necessary to average a minimum of half a day
per week for administrative responsibilities. This is not
another way of saying “personal time,” this is truly necessary
for maintaining timely billing, medical records, e-mail,
research. This will help in your general overall well-being
and prevent early burnout.
Finally, when negotiating for your contract or renewal,
do not be afraid to ask for what you need. Requesting
reasonable resources (ie, support staff, research personal,
compensation package, etc) are important to have in writing
and will not jeopardize your marketability if you are respected
and the work environment is a good one. The worst that could
happen is that you are informed it is not possible at this time.
TOP 5 FINAL THOUGHTS ON WHAT I WOULD
DO DIFFERENTLY
1. Seek some more graduate student research assistance that
is free.
2. Get more mid-level provider support (PA, NP, etc) to stay
on top of patient needs (calls, prescription refills, etc) to
improve satisfaction for patients and decrease frustration
for me.
3. Actually have an administrative day.
4. Use technology for prospective data collection (tablets in
the waiting room for different outcome-scoring methods).
5. Marketing “Top Docs,” “Best Docs,” and meet-and-greets
with nonorthopedic physicians.
CONCLUSIONS
The first years in practice are full of excitement, new
experiences, unforeseen possibilities, and responsibilities that
you may have no experience. It is important to look for and
create a situation that will deliver superior care to patients,
provide quality education to trainees, advance your career,
and not destroy your personal life. The first decade of a career
can define your reputation, who you are perceived as, and
provide invaluable education to how you progress in our field.
Education is constant, whether in diagnosis, treatment,
economics, or academics in medicine. Staying ahead of the
curve and maintaining scruples should be the goal of all.
REFERENCE
1. Liporace FA. My first year in academic practice: what I learned, what I
wish I knew, what I would do differently. J Orthop Trauma. 2011;25
(suppl 3):S118–S120.
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