One of my favorite sayings about building a practice came from one of my partners early on: you have to kiss a lot of frogs.

It sounds simple, maybe even a little cliché. But in medicine, especially early in your career or when you are reshaping your practice, it is incredibly true.

When you start out, you cannot afford to be overly selective. You have to cast a wide net. That means saying yes to cases that are not your favorite, managing conditions that are outside your long-term vision, and taking on work that stretches you clinically and mentally.

If you say no too early, you limit your exposure. You restrict referrals. And ultimately, you slow down the growth of your practice before it ever has a chance to gain momentum.

But there is an important nuance here

Starting broad does not mean staying broad forever.

You need a clear picture, even early on, of what your ideal practice looks like. That vision acts as your compass. It guides your decisions, even while you are saying yes to almost everything.

Because if you continue saying yes to everything indefinitely, it becomes unsustainable. It leads to overload, frustration, and eventually burnout.

Early in your career, though, that broad approach is necessary. You are not walking into a fully built practice. You are building it from the ground up. And that requires volume, exposure, and trust.

Your ideal practice is the filter, not the starting point

One mistake I think physicians can make is assuming that they only need to define their ideal practice once they are closer to achieving it.

But I think the opposite is true.

You need to define it early. Not because you will get there immediately. You probably won’t. But because that vision becomes the filter through which you make decisions.

Without that vision, saying yes to everything can quickly become aimless. Every referral feels equally important. Every opportunity feels like something you cannot turn down. And eventually, your practice starts getting built around everyone else’s needs instead of your long-term goals.

But when you have a clear picture of the practice you want, even the frogs serve a purpose.

You are not just taking cases to stay busy. You are building relationships. You are learning the referral ecosystem. You are identifying gaps. You are proving reliability. You are creating the conditions that allow your future practice to emerge.

The early referrals are often not the easy ones

I think this is another part of practice building that does not get discussed enough.

When you are trying to build a clinical niche, the first opportunities are often not the clean, straightforward, perfectly aligned cases. They may be the complicated cases. The inconvenient cases. The patients with higher risk factors. The consults that do not fit neatly into anyone else’s schedule.

That can be frustrating.

But it can also be an opening.

Because early in practice, people are not just evaluating your technical ability. They are evaluating whether you are reliable. Whether you communicate well. Whether you follow through. Whether you help solve problems instead of creating more of them.

And in medicine, that reputation matters.

A referral base is not built by announcing what you want your practice to be. It is built by repeatedly showing people how you handle the work in front of you.

I saw this play out in my own experience

Coming out of training, I knew I wanted my practice to focus on breast reconstruction, particularly autologous reconstruction using microsurgical techniques. That was the vision.

But the environment I entered was very different. Breast surgeons already had established referral patterns. Most reconstructions were implant-based. And from a systems perspective, things were working just fine.

There was no obvious gap waiting for me.

So I started simple. I met with breast surgeons and plastic surgeons and offered my help. No pitch. No pressure. Just a consistent message: if I can be helpful, I am here.

It took time. And when the referrals started to come, they were not the straightforward cases.

They were the tough ones. Patients who were actively smoking. Patients with prior radiation. And patients with complications from previous surgeries like mastectomy flap necrosis or implant loss.

These are not easy cases to build a practice on. They are complex, higher risk, and often come with significant expectations.

But they were opportunities.

I leaned on my training, focused on doing the best possible job for each patient, and slowly, that work started to speak for itself. Referrers began to see the value of what I could offer. And over time, those early, difficult cases turned into a steady and growing referral base.

At the same time, I was doing a lot of other work to stay busy

Lower extremity trauma. General plastic surgery. Wound care.

Not because it was my long-term goal, but because it was part of the process. I was building volume, building relationships, and building trust. I was, quite literally, kissing frogs.

Eventually, things started to shift.

As referrals grew and my niche became clearer, my practice began to resemble the vision I had from the start. More breast reconstruction. More microsurgery. Fewer cases that did not align with that focus.

But even now, there is another important lesson.

You never really stop

A practice is not something you build once and then set on autopilot. Referral patterns change. Systems evolve. People move. Opportunities shift.

You have to stay engaged. You have to remain adaptable.

That does not mean going back to saying yes to everything. But it does mean staying open, maintaining relationships, and continuing to show up with the same mindset that helped you build your practice in the first place.

In other words, you still have to be willing to kiss a few frogs. Just fewer of them, and more intentionally. That balance is where a sustainable and fulfilling practice lives.

What do you think? Did you kiss any frogs starting out in your career? Are you still kissing them? How have you built your practice? Would you do it the same way again? Let me know in the comments below!