Michael Knudsen, MD, spent years learning how to make the right diagnosis, choose the right operation and perform it well. Then, he became an attending and discovered how much of being a surgeon happens outside the operating room.
“You suddenly own the entire experience,” Dr. Knudsen told Becker’s. “Not just the indication, but also the expectations for the patient. You own the team. You own the complication.”
Dr. Knudsen, a shoulder and elbow surgeon at New York City-based Columbia University Irving Medical Center and NewYork-Presbyterian, said his training prepared him well clinically and technically. What surprised him was how quickly technical responsibility became something broader.
Independent practice meant building and leading a team, managing complications, developing referral relationships, understanding the business of healthcare and deciding what kind of career he wanted to build.
“Training teaches you how to become a surgeon,” he said. “But an independent practice requires you to really learn how to become a leader.”
When the complication is yours
Few parts of that transition are harder to prepare for than a complication. Residents and fellows learn how to recognize and treat complications. As an attending, Dr. Knudsen found that knowing what to do clinically was only part of the challenge.
The surgeon must understand what happened, communicate honestly with the patient and family and determine what comes next. There is also a responsibility that is harder to teach: managing the emotional weight of a complication while continuing to care for everyone else on the schedule.
“Training can teach you how to treat a complication, but it’s much harder to actually carry one on your own,” Dr. Knudsen said.
There is no perfect script for that experience. Complications are rare, he said, but an inevitable risk of surgical practice, and one of the clearest reminders that technical independence does not prepare a surgeon for every dimension of the job.
Your ceiling becomes your team
Another adjustment comes from realizing that independence depends heavily on other people. As a resident or fellow, Dr. Knudsen worked within teams and systems that attending surgeons had already built. Once he entered independent practice, creating that infrastructure became part of his responsibility.
He learned that a high-functioning practice cannot depend on the surgeon personally controlling every task. It requires identifying good people, communicating expectations, giving them ownership and building systems that allow each person to work effectively.
“Your ceiling as an attending eventually becomes based on the quality of the team around you,” he said.
That team extends across the patient experience, from staff answering phones and scheduling surgery to medical assistants and advanced practice clinicians. Their work may happen outside the operating room, but Dr. Knudsen came to see it as inseparable from the care delivered inside it.
Independent practice, he learned, also means knowing what not to do alone.
Choosing what kind of career to build
Becoming an attending brought another question that technical training could not answer: What did Dr. Knudsen want his career to become?
His answer was academic medicine.
He acknowledged the trade-offs. Compensation matters. Administrative demands compete for physicians’ time, and teaching, research and other academic responsibilities are not always compensated. But Dr. Knudsen does not believe career value can be reduced to compensation alone.
Academic medicine allows him to combine complex surgical care with research, teaching and mentorship. A question encountered in practice can become a research project. A resident can eventually become a colleague. A lesson taught to a fellow can influence patients Dr. Knudsen will never meet.
“At the end of the day, you can’t take money with you,” he said. “But through teaching, research and innovation, you can have a career that far outlives yourself.”
That reach is central to why he chose academics. He did not want his professional identity defined solely by the number of operations he performed. Yet sustaining that model presents its own challenge.
Dr. Knudsen said academic physicians are increasingly expected to excel as clinicians, educators and researchers while taking on administrative responsibilities and remaining financially productive. Institutions that value academic work, he said, need to create protected opportunities for physicians to actually do it.
For young surgeons weighing different practice models, Dr. Knudsen does not see the question as whether academics is inherently better or worse. It is whether the rewards of the environment match what motivates the individual surgeon.
The advice he wishes he had heard
Now that Dr. Knudsen trains residents and fellows himself, one of the lessons he emphasizes has little to do with an operation.
“You don’t have to have your entire career figured out on day one,” he said.
Finishing fellowship can create an unspoken expectation that years of training should culminate in a clear blueprint for the decades ahead. Dr. Knudsen’s experience has been different. A first job can reveal what a surgeon values, what kind of practice fits and what environment allows them to do their best work. Those answers emerge through experience, and they can evolve.
He wishes someone had told him that earlier.
That does not make the responsibility lighter. Dr. Knudsen tells trainees that “pressure is a privilege,” reflecting what patients entrust to their surgeons and why the work demands so much of them.
Training can teach a surgeon how to diagnose, operate and respond clinically when something goes wrong. The rest of the job requires a different education: learning to carry the complication, build the team, choose a career and lead through responsibilities no technical curriculum can fully rehearse.
Dr. Knudsen is still learning that part. He thinks young surgeons should know they are allowed to be, too.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
