Starting Your Private Practice in Orthopedic Surgery: A Complete Guide

Why Orthopedic Surgery Private Practice Still Matters

Orthopedic surgery has long been one of the specialties most closely associated with private practice. While consolidation, hospital employment, and private equity groups have changed the landscape, starting a private practice in orthopedic surgery remains a viable—and for many, highly rewarding—career path.

If you’re an orthopedic surgery resident or early-career attending thinking beyond the ortho match and into life after fellowship, you’re probably asking:

• Is starting private practice still realistic?
• How does private practice vs employment compare for orthopedics today?
• What concrete steps should I take during residency and fellowship to prepare?
• What does opening medical practice actually look like for an orthopedic surgeon?

This guide walks you through the process from vision to execution, with a focus on the unique clinical, financial, and logistical issues in orthopedic surgery.

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Private Practice vs Employment in Orthopedic Surgery: Know What You’re Choosing

Before making a business plan, you need conceptual clarity about private practice vs employment. The decision shapes your clinical life, income trajectory, and autonomy for decades.

Core Models in Orthopedic Surgery

1. Hospital or Health-System Employment

   • Salary plus productivity bonus
   • Hospital controls staffing, call structure, and most infrastructure
   • Often less financial risk, but less long-term upside and autonomy

2. Large Multispecialty or Orthopedic Group

   • Independent group, sometimes with ancillaries (ASC, PT, MRI, DME)
   • Buy-in structure; partnership track with equity
   • Shared call, pooled resources, group decision-making

3. Solo or Small-Group Private Practice

   • You (and possibly 1–5 partners) own the practice entity
   • Direct control over operations, staffing, and strategy
   • Higher risk, but potentially higher long-term reward and flexibility

4. Private Equity–Backed Practice

   • Practice acquired or rolled up into a larger PE-backed platform
   • Often employed as a shareholder-physician with specific contractual terms
   • Short- to mid-term financial upside; less control over long-term strategy

Key Tradeoffs for Orthopedic Surgeons

Autonomy

• Private practice: You decide patient volume, clinic templates, OR block utilization strategies, staffing, ancillary services, and growth.
• Employment: More institutional policies and committees; less control over clinic operations and support staff.

Income and Risk

• Private practice: Income strongly associated with productivity and business efficiency; you carry overhead and some financial risk.
• Employment: More predictable salary; less exposure to overhead and payer mix.

Practice Style and Niche

• Private practice can be ideal if you want to:
  • Develop a focused niche (e.g., sports, hand, foot/ankle) with a tailored patient experience
  • Build a branded patient-facing identity
  • Add services like in-house PT, bracing, ultrasound, or office-based procedures

Lifestyle

• Hospital employment often provides more support for call coverage and compliance.
• Private practice requires time on management, staff issues, and strategy—but can offer more flexibility once established.

Resident/Applicant Takeaway: During orthopedic surgery residency and fellowship, actively explore all models. Talk to attendings in solo practice, group practice, and hospital employment—and ask about what they’d do differently.

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Planning Ahead During Residency and Fellowship

Effective planning for starting a private practice begins well before your first attending job.

Build the Right Clinical Profile

As a future private practice orthopedist, your clinical value is your greatest asset. Priorities:

• Bread-and-butter competence: Community-based private practices often require comfort with common procedures:
  • Arthroscopy (shoulder, knee)
  • Basic trauma (hip fractures, ankle fractures)
  • Common degenerative and reconstructive procedures
• Strategic subspecialization: A well-chosen fellowship can:
  • Differentiate you in a competitive market
  • Make you valuable in a group that needs your skillset
  • Examples:
    • Sports in a growing athletic community
    • Hand in markets with older demographics or high worker’s comp volumes
    • Joint replacement in areas with aging populations

Action Step: In PGY-3 to PGY-5, track your case log and identify gaps. Intentionally seek rotations to fill those gaps based on your anticipated future practice.

Develop Non-Clinical Skills Early

Orthopedic surgery residency focuses largely on operative and clinical training, but private practice requires broader competencies.

Targeted skills:

• Basic finance and accounting: Balance sheets, profit and loss (P&L) statements, overhead, cash flow, EBITDA.
• Billing and coding: CPT and ICD-10 codes, global periods, modifiers—especially for high-volume procedures you anticipate performing.
• Leadership and team dynamics: Running a clinic team and OR staff effectively.
• Communication and patient experience: Key to building and maintaining referrals.

Practical Ideas:

• Attend local/state medical society or specialty society (AAOS, subspecialty societies) workshops on practice management.
• Ask your program director to connect you with alumni in private practice willing to discuss financial and operational realities.
• Take advantage of free webinars from specialty and practice management organizations on topics like contracting, collections, and compliance.

Networking for Your Future Practice

Network intentionally, not randomly:

• Referring physicians: Primary care doctors, rheumatologists, podiatrists, chiropractors—future referral sources.
• Hospital administrators and OR directors: May influence future OR block access, ASC ownership opportunities, or recruitment to the area.
• Fellows and senior residents: Potential future partners or collaborators in your region.

Action Step (Fellowship Year): Identify 1–2 geographic markets where you could realistically see yourself practicing and begin researching:

• Demographics (age distribution, sports participation, industries)
• Orthopedic surgeon density
• Hospital systems and existing practices

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Designing Your Orthopedic Practice: From Vision to Business Plan

Once you commit to opening medical practice in orthopedics, you need a concrete blueprint.

Step 1: Clarify Your Model and Scope

Key questions:

1. Solo vs group from day one

   • Solo practice:
     • Maximum control and brand ownership
     • Higher vulnerability to call burden, coverage gaps, and cash flow fluctuations
   • Starting with a small group:
     • Shared overhead and call
     • May require alignment on vision and compensation

2. Service mix

   • Clinic-based:
     • New patient evaluations and follow-ups
     • Office-based procedures: injections, fracture care, ultrasound-guided procedures
   • Surgical:
     • Hospital-based surgeries (trauma, joint replacement, complex cases)
     • ASC-based surgeries (sports, ambulatory joints, hand/upper extremity)

3. Subspecialty identity

   • Position yourself as:
     • General orthopedist in a smaller or underserved community
     • Subspecialist (sports/hand/joints/foot & ankle) in a metro area
   • Your messaging should reflect what you want to be booked for.

Example:
You’re a sports fellowship–trained surgeon in a suburban area near several high schools and a college. Your practice vision:

• 60–70% sports cases (ACLs, meniscal work, shoulder instability)
• Emphasis on rapid-access injury clinics and integrated PT
• Secondary focus on basic trauma and degenerative knees/shoulders

This vision drives your space needs, staffing, marketing, and preferred hospital/ASC affiliations.

Step 2: Create a Business Plan

A business plan doesn’t have to be a 100-page document, but it must answer:

• Market analysis:

  • How many orthopedists in your catchment area?
  • What subspecialty gaps exist?
  • What are the main hospitals, ASCs, and primary care groups?

• Service lines and projected volume:

  • Projected clinic visits per day by year (e.g., 12–15/day in month 1, ramping to 25–30/day)
  • Expected surgery mix and volume

• Revenue projections:

  • Use realistic reimbursement assumptions from:
    • Medicare fee schedules
    • Local payer data (from colleagues or consultants)
  • Model average reimbursement per:
    • New patient visit
    • Established visit
    • Common procedures (e.g., knee arthroscopy, rotator cuff repair, carpal tunnel release)

• Expense projections:

  • Rent and utilities
  • Staff salaries and benefits
  • Malpractice premiums
  • EMR and practice management software
  • Billing/collections (in-house or outsourced)
  • Supplies, implants (if applicable), and equipment leases

• Capital needs and financing:

  • Start-up costs for space buildout, equipment, initial payroll buffer, and marketing
  • Potential lenders (banks experienced with physician practices, SBA loans)
  • Whether you’ll need a line of credit for early cash flow

Step 3: Legal and Structural Foundations

Work with a healthcare attorney and accountant familiar with physician practices.

Key decisions:

• Entity type:
  Most practices use an LLC or professional corporation (PC/PLLC) for liability and tax reasons, sometimes with multiple entities (e.g., one for practice, one for real estate, one for ancillaries).

• Tax planning:

  • Choosing S-corp vs other structures
  • Planning for retirement accounts (e.g., 401(k), cash balance plans) once profitable

• Contracts:

  • Hospital/ASC medical staff and block time agreements
  • Payer contracts with commercial insurers
  • Equipment leases
  • Office lease agreements
  • Employment agreements for staff and any associate orthopedists

Tip: Start credentialing and payer enrollment early—often 3–6 months before seeing your first patient—to avoid an early period of working out-of-network unnecessarily.

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Operational Essentials: Infrastructure, Team, and Workflow

Orthopedic private practice has unique operational demands: high imaging utilization, procedure-heavy clinics, and OR coordination. Getting operations right from day one can make or break your first years.

Clinic Space and Equipment

Consider:

• Location:

  • Easy access from major roads
  • Proximity to hospitals, ASCs, and referring PCPs
  • Adequate parking and accessibility

• Square footage and layout:

  • Waiting area, 3–6 exam rooms (depending on projected volume), procedure room
  • Dedicated casting/splinting area
  • X-ray room (if doing in-house imaging)
  • Space for in-office PT or expansion if planned

• Core equipment:

  • Digital X-ray system (if financially feasible)
  • Casting/splinting carts
  • Basic surgical instruments for in-office procedures
  • Ultrasound machine (especially for sports, pain procedures, and injections)
  • Bracing and DME inventory

Evaluate whether to lease vs buy higher-cost equipment based on your projected volume and capital constraints.

EMR, Practice Management, and Billing

Orthopedic-specific needs:

• Robust procedure and injection templates
• Integrated imaging management
• Efficient documentation workflows for high-volume sports/trauma clinics

EMR/PMS Selection:

• Consider cloud-based systems with:
  • Strong orthopedic templates
  • Integrated e-prescribing and patient portal
  • Good reporting tools (to track RVUs, payer performance, no-show rates)

Billing Strategy:

• In-house billing:
  • Tighter control but higher staffing overhead
  • Requires experienced orthopedic billers
• Outsourced billing company:
  • Faster startup; pay a percentage of collections
  • Must carefully vet for orthopedics expertise and transparency

Key Metrics to Track Early:

• Days in accounts receivable
• Denial rates (overall and by payer)
• Collection percentage of billed charges
• No-show and cancellation rates

Building Your Team

Your staff is your practice’s front line. For an early-stage orthopedic surgery residency graduate starting private practice, a lean but skilled team is crucial.

Common roles:

• Front desk/reception (often 1–2 people)
• Medical assistants or athletic trainers (2–3, depending on clinic volume)
• X-ray tech (if in-house imaging)
• Billing specialist or liaison to your billing company
• Practice manager/administrator (may initially be part-time or outsourced)

Hiring Tips:

• Prioritize prior orthopedic or high-volume clinic experience.
• Look for staff comfortable with casting/splinting and high-paced clinics.
• Invest in training on:
  • Patient flow and rooming
  • Templated documentation support
  • Authorizations and pre-certifications for MRIs and surgeries

Patient Flow and OR Coordination

Efficient orthopedic private practice hinges on:

• Clinic Template Design:

  • Separate new vs established visit slots
  • Protect time for post-op checks and urgent add-ons (e.g., acute injuries)
  • Consider one or more “rapid access” blocks weekly for acute sports injuries or fractures

• Surgery Scheduling Workflow:

  • Standardized pre-op checklists and patient education materials
  • Clear process for insurance authorization and pre-op optimization
  • Coordination with hospital/ASC for implants and equipment

Example Workflow:

• Resident evaluates:
  • How many rooms can comfortably cycle (often 2–3 rooms per surgeon)
  • Optimal ratio of new: follow-up patients (e.g., 1:2 or 1:3)
• Adjusts templates monthly based on no-show rates, wait times, and surgeon energy levels.

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Financial and Growth Strategy: From Surviving to Thriving

Most new orthopedic private practices don’t fail from lack of patients—they fail from poor financial planning or cash flow management.

Understanding Revenue Streams

Key revenue drivers:

• Professional fees:

  • Clinic visits and procedures
  • Surgical fees at hospital and ASC

• Ancillaries (depending on state regulations and Stark/AKS compliance):

  • Imaging (X-ray, MRI)
  • Physical therapy
  • Durable medical equipment (bracing, orthotics)
  • Injections (e.g., biologics, when not bundled)

Prioritize starting with core professional services and add ancillaries as volume and capital allow, ensuring strict legal compliance.

Managing Overhead and Cash Flow

Common overhead categories:

• Rent and utilities
• Malpractice insurance (often significant for orthopedics)
• Staff salaries and benefits
• Technology (EMR, PMS, PACS, cybersecurity)
• Supplies and equipment leases
• Legal, accounting, and consulting fees
• Marketing and website costs

Cash Flow Strategy:

• Secure a line of credit before opening; it’s easier to obtain while your personal balance sheet looks strong.
• Maintain a cash reserve (3–6 months of operating expenses) if possible.
• Monitor monthly:
  • Net collections
  • Overhead as a percentage of collections
  • Payer mix and reimbursement trends

Negotiating Payer Contracts

As a new orthopedic surgery private practice, payer contracting can materially affect your viability.

• Research local payer market share: Which insurers dominate employer plans in your area?
• Compare fee schedules: Aim to understand relative value vs Medicare rates (e.g., 120–150% of Medicare for commercial plans where feasible).
• Leverage volume and niche: If you can offer specific subspecialty access or reduce wait times, make that part of your negotiation narrative.

Consider professional help (consultants, group purchasing or contracting organizations) if you lack experience in this area.

Marketing and Referral Building

Organic growth is ideal, but it doesn’t happen by accident.

Physician and Community Referrals:

• Visit nearby primary care, urgent care, and sports medicine clinics personally.
• Offer:
  • Direct cell number for urgent consults
  • Same- or next-day slots for acute injuries
  • Simple referral pathways (online form, dedicated phone line)

Digital Presence:

• Professional website highlighting:
  • Your training (orthopedic surgery residency, fellowship)
  • Services and conditions treated
  • Online scheduling and patient portal access
• Search engine optimization (SEO):
  • Use natural language including terms like “orthopedic surgeon,” “sports medicine,” “joint replacement,” and local geography
  • Consistent listings on Google Business Profile and major directories

Patient Experience:

• Short wait times and clear communication
• Easy access to imaging and PT
• Structured post-op care protocols and education

Positive online reviews and word of mouth will become your most powerful marketing tools within 1–2 years.

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Long-Term Strategy: Evolving Your Orthopedic Private Practice

Once your practice stabilizes, shift from survival mode to strategic growth.

Adding Partners or Associates

Bringing on another orthopedist:

• Increases call flexibility and clinic coverage
• Expands your ability to grow OR volume
• Requires:
  • Clear partnership tracks
  • Transparent compensation models (productivity, collections-based, or hybrid)
  • Cultural alignment around patient care and ethics

Considering Ownership in ASC and Ancillaries

For many orthopedic surgeons, ASC equity is a major long-term wealth driver.

• Evaluate ASC opportunities carefully:
  • Case mix and reimbursement
  • Governance structure
  • Partnership terms and buy-in costs
• Work with health law counsel to ensure regulatory compliance.

Similarly, consider adding or expanding PT, imaging, and DME services when patient volume and payer environment justify it.

Exit Planning and Succession

From early on, envision your long-term path:

• Do you see yourself:
  • Growing a group you’ll eventually sell?
  • Maintaining a smaller boutique practice with a controlled panel?
  • Transitioning into teaching, consulting, or partial retirement?

Document policies for:

• Physician buy-ins and buy-outs
• Governance and decision-making
• Ownership interests in ancillaries and real estate

This makes the practice more stable and attractive to future partners—or future buyers, including health systems or private equity.

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FAQs About Starting a Private Orthopedic Practice

1. Is it realistic to start a private practice right out of residency or fellowship?

Yes, but it’s more challenging than joining an established group or hospital. Success depends on:

• Strong clinical training and a clear service offering
• Willingness to learn business fundamentals
• Adequate financial planning and capital
• A market where there is room for another orthopedist

Many surgeons spend a few years as an employed physician or in a group practice before starting a solo or small group, but going direct to private practice is still feasible with proper preparation.

2. How much money do I need to start an orthopedic private practice?

The range is wide, but start-up costs often fall between $250,000 and $750,000, depending on:

• Geography and rent
• Whether you build out new space or lease an existing medical office
• In-house imaging vs contracted imaging
• Initial staffing level and salary structure
• Technology choices (EMR, digital radiography, etc.)

A detailed business plan, created with an accountant and practice consultant, can refine this number and help secure financing.

3. What are the biggest mistakes new orthopedic private practitioners make?

Common pitfalls include:

• Underestimating start-up and early operating costs
• Overbuilding space or over-purchasing equipment too early
• Neglecting payer contracting and credentialing timelines
• Ignoring practice metrics (denials, overhead, A/R days)
• Failing to invest in patient experience and referral relationships

Proactively seeking mentorship from established private practice orthopedists can help you avoid many of these issues.

4. How should I decide between private practice vs employment in orthopedic surgery?

Consider:

• Your risk tolerance and desire for autonomy
• Your interest (or lack thereof) in business and leadership
• Family and lifestyle priorities
• The specific job offers and markets available to you

Shadow attendings in both models, review actual compensation and call structures, and think in 10–15-year horizons, not just first-year salary. For many surgeons, a hybrid career path—starting in employment, then transitioning to private practice (or vice versa)—is also a reasonable option.

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Starting a private practice in orthopedic surgery is demanding but can be uniquely fulfilling if you value autonomy, entrepreneurial challenge, and the ability to design your own clinical environment. With thoughtful preparation during residency and fellowship, a clear business plan, and disciplined early execution, you can build a thriving practice that serves patients well and sustains you throughout your career.