I spent thirty-three years doing surgery, and most of it well. What I never did — and what I now realize would have been worth more than half the rest of it — was reach the buyer who actually cared about my outcomes data.

I trained at good places. Then I went out on my own — solo private practice from day one, no group to back me, no institutional brand to ride on. I went door-to-door introducing myself to colleagues — not just surgeons in adjacent specialties, but ophthalmologists, gynecologists, internists, anyone whose patients might one day need what I did. I published as much as I could from a solo schedule that didn’t lend itself to publishing. I gave lunch-and-learns to any group that would have me. I sat in surgeon lounges and built real relationships with the people who could refer me cases. I sent prompt, detailed referral letters back to every primary care physician who trusted me with one of theirs. I signed insurance contracts that promised volume that never quite arrived. I did all the things you do when you are trying to build a surgical practice on the strength of your work — and only on the strength of your work, because solo means there is nothing else to lean on.

And I built a good practice. By the standard measures, I was successful. My outcomes were strong. My patients were well taken care of. My referral base was loyal. My EMR slowly filled with data — case after case after case, year after year — recording in granular detail what I had done and how it had gone.

None of that data ever did anything for me.

The gold mine I didn’t know I was sitting on

By the time I had been in practice ten years, I had performed thousands of procedures. By twenty years, tens of thousands. Complication rates. Reoperation rates. Length of stay. Functional outcomes at follow-up. Risk-adjusted by patient comorbidity. Compared against published benchmarks. All of it, quietly accumulating in my EMR — a record of decades of clinical work that I could have stood behind in front of any audience.

No one outside my immediate referral base ever saw it. No payer ever asked for it. No employer ever requested it. No patient who wasn’t already mine ever knew it existed.

I was sitting on a gold mine. I just didn’t know what mining it would have looked like.

The wider buyer of healthcare — the self-insured employer with $40 million in annual medical spend, the regional health plan trying to identify which surgeons in their network actually do what they say they do, the benefits broker advising employers on where to send their highest-cost surgical cases — those buyers never had a channel to find me. They could not see my data. They could not compare it to anyone else’s. They could not pay attention to surgical quality even if they had wanted to, because the infrastructure for paying attention to surgical quality at the individual-surgeon level did not exist.

So they did what buyers do when the data isn’t there. They paid for access (the network contract), they paid for the procedure (the bill), and they hoped quality came along for the ride. Sometimes it did. Often it didn’t. Either way, I never heard about it.

What patients don’t see

When patients pick a surgeon, they look at the things they can find. The med school name. The aggregator star rating. The proximity to home. The insurance accepted.

They don’t see — because they can’t — the years of perpetual investment that distinguish a good surgeon from a great one. The workshops attended on weekends to learn a new technique. The new technologies adopted because they’re better for patients, not because they’re billed at a higher rate. The case reviews after every imperfect outcome to understand what could have been done differently. The reading that continues a decade after the last formal training ended.

Great surgeons want the best results for their patients. That commitment is what separates the surgeon you want from the one you can find on a directory. And it is almost entirely invisible to the systems patients use to choose.

This is the second invisibility that SurgiQuality addresses. Your outcomes — risk-adjusted, fairly compared, drawn from the work you actually do — are the visible manifestation of all the perpetual investment that nobody saw you make.

What I did that worked — and what I’d do again

Before I tell you what I’d do differently, let me say what I would do the same. Because the traditional playbook for building a surgical practice is not wrong; it is just incomplete.

I would still focus on training first — there is no marketing strategy in the world that compensates for not being a good surgeon.

I would still choose the practice environment carefully — solo versus group, private versus employed, hospital affiliations. These shape what you can do for thirty years; do not pick lightly. For me, solo was the right choice — but it sharpens the very problem this letter is about, because solo means your outcomes are the only signal you have.

I would still go door-to-door. I would still spend the first few years of practice introducing myself to every other physician in town who might one day refer a case. The conversations I had in those years built relationships that lasted decades.

I would still publish. Even from private practice. Even when it was hard.

I would still give the lunch-and-learns. I would still talk to anyone who would have me. I would still sit in surgeon lounges and stay until I knew everyone’s name.

I would still close the loop. Prompt referral letters. Direct feedback. Real follow-through. Most surgeons under-invest in this; it is the single highest-leverage retention move you can make with a referring physician.

What I would add — what I now believe would have been worth as much as half of the rest of it — is everything I missed.

The buyer I never reached

I never sat down with a self-insured employer. I never offered to walk a CFO through my outcomes data alongside what their employees were currently paying for surgical care that may or may not have been delivered by the right surgeon. I never built a relationship with a benefits broker who advised mid-market employers on where to steer their cases. I never approached a regional health plan with a proposition that started with “here is the data on what I do, and here is why directing your highest-cost cases to surgeons like me will save you money.”

I did not do this because I did not know the door existed. The buyer side of the healthcare market was opaque to me. I knew patients. I knew referring physicians. I knew payers as the entity that paid me, slowly, after I had submitted three appeals.

I did not know the buyer.

I now understand that the buyer was waiting. The self-insured employer paying for a hundred knee replacements a year would have paid attention to a surgeon who could prove a complication rate one-third the regional average — if anyone had bothered to translate the data into terms the employer could use. The regional health plan that wanted to steer its highest-cost spinal surgeries to outcomes-superior surgeons would have paid for that capability — if any individual surgeon could have offered it credibly.

The data I never monetized

Even if I had wanted to walk into a self-insured employer’s office with my outcomes data, I could not have done it credibly. I had the raw data, but I did not have the risk adjustment. I did not have the benchmark. I did not have a framework that translated “I did 1,400 of these cases with these results” into “this surgeon is in the top 10% of his specialty in this region for this procedure, adjusted for patient comorbidity.”

Producing that framework alone — for a single surgeon — would have been a multi-year project. The data scientists, the statistical methodology, the literature review for benchmarks, the validation work, the legal review. No surgeon does this on their own. No surgeon should have to.

This is the second gap I would close if I were doing it over today. Not just reaching the buyer, but having the credible artifact to bring with me when I walked through the door.

What changed — and why this is finally possible

Several things converged in the last few years that did not exist when I was building my practice.

First: surgical outcomes data became extractable from EMRs at scale, at reasonable cost, with reasonable accuracy. Operative notes, procedure codes, follow-up encounters, complications documented in the chart — all of it can now be pulled and structured by software, not by chart abstractors.

Second: risk-adjustment methodology has matured. Patient comorbidity scoring (the kind NSQIP and STS use) is now well-established. The mathematics of comparing surgeons fairly when one operates on sicker patients and another operates on healthier ones is no longer mysterious.

Third: the self-insured employer market has woken up. As medical spending has crossed 20% of total compensation for many large employers, CFOs and CHROs are paying attention to surgical cost-of-quality in a way they were not paying attention twenty years ago. The buyer who would not have answered my call in 2005 has the call on her calendar in 2026.

Fourth: the channel between the surgeon and the buyer can now be built — provided it is built in a way that respects both sides of the relationship. Federal anti-kickback statute and Stark law constraints mean this channel cannot work the way medical-device companies work. There is no per-case fee for routing a case to a surgeon. There is no volume guarantee. There is no payment for referrals. What there can be is a service relationship — the surgeon pays a fee to participate; the platform produces the outcomes scoring; the platform makes the surgeon discoverable to buyers who care about outcomes; the buyer’s plan members or the employer’s benefits team make their own choices about which surgeon to engage. Service fee, not referral fee. Disclosure throughout. Clean.

The new playbook

If I were thirty years younger today, I would still do all the traditional moves. Train well. Choose practice carefully. Go door-to-door with peers. Publish. Speak. Close the loop. Sit in the lounge until I knew everyone.

And then I would do four things my younger self never thought to do.

One. I would invest in extracting my own outcomes from day one of practice. Not as a marketing exercise; as an honest measurement exercise. I want to know how I am doing, by procedure, by patient comorbidity, by year. I want this for my own quality improvement first. I want it for the buyer second.

Two. I would partner with a platform that could risk-adjust my data fairly and produce a credible outcomes score I could stand behind. Not a marketing number. A real one — one I would defend in front of my chairman, my partners, and any peer reviewer.

Three. I would use that score to reach the buyer my predecessors never reached. The self-insured employer. The regional health plan. The benefits broker. The CFO. Not by pitching them on a procedure — by pitching them on a measurable better outcome at a defensible cost.

Four. I would let patients see the score, too. The patient facing a surgical decision is increasingly capable of, and increasingly demanding, the information needed to choose the right surgeon. Transparency is no longer optional. The surgeons who lean into it will dominate the next twenty years; the surgeons who resist it will be discovered when their competitors lean in.

The channel I wish I had — and why I built it

I did not build SurgiQuality because I needed a second career. I retired from full-time practice, and I could have written more books and watched my grandchildren grow and called it a life.

I built SurgiQuality because I spent thirty-three years watching colleagues do excellent work that nobody knew about, while patients paid for surgical care they had no way to evaluate, and self-insured employers paid for outcomes they had no way to influence. The information gaps in our market were not minor inefficiencies. They were the central market failure. And the technology to close them now exists.

The platform we built does what I wish someone had offered me thirty years ago:

It extracts your outcomes from your operative notes and post-operative documentation. It risk-adjusts those outcomes using published methodology you can read and challenge. It produces an outcomes score that is yours — based on your data, controlled by you, with full ability to opt out of any procedure you do not want included. It makes your score visible to buyers who care: self-insured employers, health plans, benefits consultants, sophisticated patients. It does not promise you patient volume. It does not pay you for cases. It charges you a service fee for participating. It is the door you can walk through to reach the buyer your predecessors could not reach.

One last thing

The surgeons reading this who are five or ten years into practice — the ones with the energy and the curiosity I had at that age — have a window now that I did not have then. The buyer-side market is finally awake. The technology to bridge surgeon-side data to buyer-side procurement finally exists. The legal framework that lets this happen at scale is finally settling. The next ten years of surgical practice will reward the surgeons who can prove their outcomes, in a way that the previous thirty years did not.

I built SurgiQuality so that the next generation of surgeons would not finish their careers the way I almost finished mine — with a gold mine of outcomes data, sitting quietly in an EMR, that nobody ever paid attention to.

If you are a surgeon doing good work and the wider market does not seem to notice, I would like to hear from you.