At NASS 2026 in San Antonio, the Early Career Advisory Council will host a luncheon roundtable session on Navigating the Transition to Early Spine Practice: Careers, Choices, and Sustainability. At this session, early career attendees have the opportunity to engage directly with experienced faculty in small-group discussions on topics not always covered during residency or fellowship.

To offer a preview of the conversation, the early career moderators for this session have asked the faculty assigned to their topic to answer some questions. Fourman: What was the single most challenging thing you experienced when you began practicing? Was this challenge something you had considered when you initially took the job?

Smuck: I did not anticipate colleagues practicing with different (antiquated) procedure risk mitigation strategies. It was challenging to approach senior colleagues about changing/updating their procedural practices.

Truumees: I have had two jobs. For the first 10 years, I stayed at the institution in which I had completed my fellowship. In many ways, this was a huge advantage. I had senior partners that I could call with questions and for advice. Also, they were supportive of my career. On the other hand, I had five very busy senior partners in an area losing population. I ended up taking on particularly challenging cases I would not have considered in a more underserved area. I was forced to become a better clinician and surgeon.

On the other hand, it has defined my practice focus in the decades since. I have remained focused on complex and revision surgery. Sixteen years ago, I moved to Austin, which offered a very different set of opportunities and challenges. Suddenly, I was new and unknown and building a practice in the most competitive, downtown market. While Austin is vibrant and growing, outreach and practice marketing were very different challenges.

Fourman: How did you first find your patients when you began practicing?

Truumees: In my first practice, between trauma and other urgent consultations, I had a built-in patient base. I also took general orthopedic surgery call for the first 5 years of my career. While this kept me busy, I suspect focusing on outreach and spine practice building would have been smarter after the first year or so. In particular, a busy trauma and emergency spine practice, while exciting, challenges both the surgeon and their staff on the elective side. Ensuring that referring doctors receive the timely and effective communications (and how much they want) is much more difficult when the staff is constantly changing the office and OR schedule to accommodate urgent cases. There were occasions when trauma patients would become referral sources for elective spine care, but I have found this to be far less common than word-of-mouth referrals from elective care patients. The best referrals are from patients’ friends and family members experiencing similar types of spine problems to your area of spine interest. Unless you have an interest in coccydynia, for example, I would be very careful about offering coccygectomy surgery. Once your name is listed on a Facebook support group, you become an “expert.” I suspect these issues are very different for surgeons in underserved or more rural areas.

Smuck: I joined a large group in an academic center, so there was a backlog of patients that allowed me to fill rather quickly. The challenge was to avoid establishing a practice of only chronic patients from a waitlist, and allow access for acute and subacute patients. To accomplish this, I created back channels for colleagues to refer and schedule patients into my clinics, and I help open at least one clinic visit per day to allow for last minute add-ons and overbooks.

Fourman: Tell me about the relationships you had with colleagues when you started practicing? How did they work with you, and how did you work with them?

Smuck: Professional relationships grow by working together and aided by developing a personal connection. The personal connection does not need to be close, but some connection is better than none. This best develops by finding time to meet outside of work, an occasional dinner or drink after work will do. Clinically, it is important to understand your colleagues’ strengths and weaknesses, likes and dislikes. This helps to build a healthy internal referral structure and happy group.

Truumees: My initial, private practice was a multispecialty orthopedic surgery group with physical medicine and rehabilitation. In that my senior partners were very busy, as a young surgeon, I was able to find a niche as the “most available.” Helping the shoulder and hip specialists sort out any overlapping spine issues ultimately made me the “go-to” choice when a radiculopathy patient ended up in their offices. Similarly, I worked closely with the PM&R physicians assessing patients for myelopathy. In my current practice in central Austin, I get a large number of referrals from other spine surgeons. Some of this comes from answering questions and reviewing studies with them.

I invite other surgeons to operate with me when they are interested in a technique. Sometimes, they begin using the technique themselves. More often, they continue to send those cases to me. In return, I “stay in my lane.” I have excellent adult spinal deformity partners, for example. While I treat degenerative scoliosis, I send out thoracolumbar pedicle subtraction osteotomies and VCRs. Sophisticated referrers in the community know who the “go to” surgeons are for specific problems. Over time, along with close follow-up of PROMs and other outcomes measures, allows for a positive feedback loop. Our practice issues regular outcomes report cards which have continued to improve safety and quality of care offered and have been a great marketing tool.