Ugochi Okoroafor-Ridgway, MD, spent years learning how to become an orthopedic surgeon. But nothing in her training prepared her for the possibility that the best way to practice medicine might be to leave the system she had been trained to work in.
At her former hospital-employed practice, patients moved through her schedule so quickly that some encounters became difficult to remember. She realized how much the pace had affected her only after former patients began seeking her out at her new practice.
“Oh yeah, Dr. O, you took care of me,” they would tell her.
Sometimes, she couldn’t remember treating them. “I was moving so fast all the time that everything was just a blur,” Dr. Okoroafor told Becker’s.
She had little control over her schedule, faced mounting productivity expectations and felt increasingly constrained in how she delivered care. After becoming a mother, she began questioning whether she could sustain that arrangement for the rest of her career.
The answer eventually led her to establish Niche Hand Surgery and Orthopedics, an independent practice in Fairfax, Va.
But the experience also exposed what she considers a fundamental failure in medical education: Surgeons are trained extensively to practice medicine, yet often receive little preparation to control the business of delivering it.
The breaking point
Dr. Okoroafor describes her experience in hospital employment as what she calls a “factory medicine mentality,” where financial performance depends heavily on increasing patient volume and surgical productivity.
“Basically, all your purpose is to increase revenue, and the only way to do that as a physician is just see more patients and do more cases,” she said.
She felt she was chasing RVU targets that continually moved further out of reach. Even basic control over her workday was limited. She said she did not have the computer access necessary to modify her own schedule, leaving those decisions to administrative staff.
The lack of autonomy became harder to accept as she considered the personal sacrifices she had already made during medical training.
“I realized I’m not going to be able to live my life in the way that I would like to live it if I stay here,” she said.
Initially, she explored joining an established private practice. But many groups in the Washington, D.C., area were large enough that she worried the experience would be little different from hospital employment.
Eventually, she concluded that starting her own practice was the only way to regain the control she wanted.
The reaction was hardly encouraging. “Everyone I talked to was like, ‘Don’t do that. Nobody does that. That’s a bad idea,'” she recalled.
A few independent physicians offered a different perspective, including a former solo practitioner who helped guide her through the process.
Today, Dr. Okoroafor sets her own schedule, does not impose RVU benchmarks on herself and has more time to develop relationships with patients. “Now I actually know all of my patients,” she said. “It just feels like this is how medicine should be practiced.”
The career path medicine doesn’t teach
For Dr. Okoroafor, the difficulty of leaving hospital employment reflects a larger problem: Many physicians never see independent practice modeled during training. Her clinical rotations took place in hospital settings, and the attending physicians she worked with were hospital employees. Starting a practice was not presented as a career option.
When she finished fellowship, hospital employment seemed like the natural next step.
“There’s a complete absence, at least in my medical education, of training on business,” she said.
She believes medical schools should teach business fundamentals that apply to all physicians, beginning with employment contracts. Surgeons may enter their first jobs without understanding compensation terms, restrictive provisions or the consequences of leaving an employer, she said. Some do not realize they should seek legal review before signing.
She also wants trainees introduced to independent practice, direct specialty care and other business models through coursework and brief rotations with community physicians.
The objective is not to persuade every surgeon to become an entrepreneur. It is to ensure they understand the choices available before making decisions that can shape decades of their careers. Dr. Okoroafor has since launched her own consulting firm, where she helps physicians navigate the process of opening their own practices.
She said much of that guidance addresses questions medical training never answered: What needs to happen first? Which professionals should be involved? How does a surgeon turn an idea into an operating business?
Independence has its own price
Leaving hospital employment solved one set of problems. It introduced another.
Dr. Okoroafor had never hired an employee, managed billing or built a referral network. Suddenly, all three were her responsibility. She assembled her team one person at a time, learning which positions were necessary as the practice developed.
One of her most expensive lessons involved billing. She initially used an electronic medical record system with an integrated billing service. But she said inadequate claims follow-up resulted in thousands of dollars in lost revenue. She eventually hired a dedicated biller to improve oversight and accountability.
Attracting patients required an equally hands-on approach. Rather than relying solely on online advertising, she visited other independent practices, introduced herself to physicians and shared her contact information with potential referral partners.
Over time, those relationships generated referrals, including from urgent care centers familiar with her work. The experience taught her that independence requires far more than clinical expertise. Surgeons must also understand staffing, finances, marketing and the relationships that sustain a business.
Yet she believes those challenges are manageable with the right guidance. Her advice to younger surgeons is to avoid navigating the process alone, particularly when it comes to legal and financial decisions.
The next threat to private practice
Dr. Okoroafor’s concerns about physician independence have become more urgent as reimbursement pressures intensify. She believes continued Medicare payment cuts, combined with rising practice expenses, will force orthopedic surgeons to reconsider their dependence on traditional insurance reimbursement.
“I think the practices that are going to be sustainable moving forward will have to have a component of direct care or fully direct care,” she said. Her practice currently operates under a hybrid model, and she sees direct specialty care as an increasingly important option.
She also believes patients are becoming more receptive to direct payment as they confront high deductibles, unpredictable bills and difficulty obtaining accurate cost estimates.
Even when her office contacts insurers to determine what a patient will owe, the estimates are not always reliable, she said. For some patients, knowing the price of a service upfront may be preferable to receiving an unexpected bill weeks later.
The implications extend beyond independent physicians. Dr. Okoroafor believes hospital-employed surgeons may not immediately recognize the effects of reimbursement reductions because they do not directly manage collections. But health systems facing lower payments may respond by increasing productivity expectations.
In that sense, the pressures that drove her away from hospital employment could become more widespread.
The choice surgeons deserve
Dr. Okoroafor does not believe independent practice is right for every surgeon, but she believes all should have the knowledge to pursue it. Hospitals, too, could learn from independent practices by giving employed physicians greater control over their schedules and working conditions.
For her, ownership has restored what productivity pressures had eroded: time with patients, clinical autonomy and a sustainable career.
She hopes future surgeons recognize what she had to discover for herself: Hospital employment is a choice, not the only choice.
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