Open a new Search campaign in Google Ads and three settings are already switched on before you've typed a single keyword. Search partners send your ads to other websites. AI Max widens your keywords and writes new copy for you. And the location setting reaches people outside your area who happen to be interested in it.
Each one exists for a reason: more reach, more clicks, more volume for Google to work with. For a store selling sneakers nationwide, that might be fine. For an orthopedic practice that spent Chapters 6 through 8 choosing exact searches, pricing each ad group and writing headlines in its patients' words, all three quietly undo that work on day one.
A New Orthopedic Campaign Leaks Budget Three Ways Before It Shows a Single Ad
Think of the daily budget as water in a pipe. It's supposed to arrive at one place: exact procedure searches, from people in your area, answered by your own headlines on your own procedure pages. Each default opens a hole along the way.
Each hole also breaks the math from Chapter 7. A knee replacement bid priced near $6.95 a click assumed the click came from a real search on Google, by someone who can reach your office, landing on your knee page under your own headline. A click from an unnamed site, a rewritten ad or a reader two time zones away doesn't carry that value, but it costs the same.
None of the three is a scam, and none is permanent. They're switched off at launch because a new orthopedic account has a small budget, a short list of valuable searches and no booked-consult history yet. It can't afford to spend its first month finding out where the holes are.
Search Partners Put Your Knee Ad on Sites You Didn't Choose and Can't Judge Yet
Search partners are websites outside Google that show Google's search ads in their own search results. Google says a Search campaign may show on searches from thousands of different sites, and partners are included in every new Search campaign unless you opt out.
The problem for a new orthopedic account isn't that partner traffic is always bad. It's that you can't tell. Google's help page is plain about it: outside of Performance Max, Google Ads doesn't tell you which partner website showed your ad. A knee replacement click from Google Search and a knee replacement click from an unnamed partner site cost you the same, and on day one you have no booked consults to judge either by.
So partners start off. Later, once the account is booking consults steadily, you can switch them on for a test, segment the campaign report by network to see partner results on their own line, and keep them only if that traffic books surgery consults at a cost you'd accept from Google Search. Clicks alone prove nothing. Booked consults decide.
The test doesn't have to be all or nothing either. Google lets you exclude individual partner sites, but since it won't name the sites in a Search campaign's reports, the practical choice for most orthopedic accounts is simpler: partners on for the test period, then either kept or switched back off as a group.
AI Max Rewrites the Keyword List, the Headlines and the Landing Page You Picked
AI Max arrives already switched on in each Search campaign you create. Under that one checkbox sit three separate powers.
- Search term matching lets your ads show on searches Google considers related to your keywords, even when you chose exact match. That's broad match by another name, inside a campaign built to avoid it.
- Text customization drafts ad text of its own by reading your site and the ads you already wrote. Google switches it on by default as well.
- Final URL expansion lets Google swap in a different landing page, say the general orthopedics page, when it decides that fits the search better than your knee page.
Put those against the last three chapters. In Chapter 6, Isolation (our name for it) held a short, hand-picked list of procedure searches. AI Max widens that list. Chapter 8 wrote headlines from what patients praise. AI Max writes its own. Chapter 4 sent each ad group to its own procedure page. AI Max can pick a different one.
There's a mechanical reason too. Google's setup instructions add a catch: those three features are designed to run under Smart Bidding that bids for conversions. The knee, hip and spine bids in Chapter 7 are typed in by a person. AI Max and manual bidding aren't built to work together.
So AI Max comes off at build, text customization with it, since Google now folds that feature into AI Max. In the method, AI Max comes last in the rollout, after Exploration and Performance Max have proven the account's conversion data. Orthopedics adds another reason for caution: a tool that writes ads from your whole website can quote the wrong page. Chapter 13 covers what that means for a practice with an injection or pain management page.
"Presence or Interest" Shows Your Knee Ad to Someone Planning a Trip to Nashville
Google's location setting has two options. Left alone, Google reaches two groups: people physically around your practice, and people anywhere else whose searches or reading suggest an interest in your city. Google recommends that mix. Switch to Presence and only the first group counts: people who live in, work in or routinely spend time in the places you target.
Interest makes sense for a hotel. For an orthopedic practice it mostly buys researchers: someone three states away reading about a Nashville surgeon they'll never see, a relative researching on a parent's behalf from another country, a medical student. Google's own help pages recognize the problem. Right after recommending the broader setting, they say to consider Presence when your business falls within a sensitive vertical with strict targeting limitations. Health care is exactly that.
So an orthopedic account launches on Presence. It isn't a hunch. It's the setting Google itself points sensitive categories toward.
Surgery Patients Drive Hours. Add Their Counties Instead of Switching Interest Back On.
Here's the orthopedic wrinkle. Presence can be too tight for surgery, because surgery patients travel. In our sample of 882 orthopedic Google reviews from the example market, Nashville, 20 reviews on 14 listings came from patients who traveled to see one particular surgeon, from a 90-minute drive to what one reviewer called "a 1000 mile round trip." One wrote: "I would highly recommend traveling to Nashville to see him with any knee issues."
Six more reviews came from visitors who got hurt while they were in town. Presence already covers them. They're physically there.
The traveler is the one Presence misses. A hip patient two hours away, searching from home for a hip replacement surgeon in your city, isn't in your target area and never sees the ad.
The fix isn't to switch interest back on and pay for every researcher in the country. It's to add the places your surgery patients actually come from. Pull the home ZIP codes of the last year's surgical patients from your own practice management system, count them by county, and add the counties or nearby metros where they cluster as extra Presence targets. That list stays inside the practice: the only thing that goes into Google Ads is a handful of county names, never a patient record.
Location is set per campaign, not per ad group, so keep the travel map on the campaigns that sell surgery. In the review sample, the patients who traveled were traveling to a surgeon. A walk-in orthopedic urgent care patient with a sprained ankle goes to the closest open door, which is one more reason walk-in care gets its own campaign, with a tight radius around each clinic, in Chapter 16.
Once the ads are running, check the map against reality. Google Ads reports where the people behind your clicks physically were, place by place, on the campaign's location pages. If a county you added sends clicks but never books a consult, take it off. If surgery patients keep arriving from a county you didn't add, add it.
The Rest of the Launch Settings Take Ten Minutes and Save the First Month
The three big defaults get the headline. The rest of the launch list is short.
- Display Network: off. A Search campaign's job is searches. Display belongs in its own campaign, later.
- Broad match: off in Isolation. Exact match only, as Chapter 6 laid out. Dynamic Search Ads stay off too.
- Auto-tagging: on. It lets Google Ads, Google Analytics and the click-ID import from Chapter 1 connect a click to a booked patient.
- Call reporting: on. Calls are how most orthopedic consults get booked.
- Ad rotation: optimize, prefer best-performing ads. Let Google show the headlines that work more often.
- Brand in its own campaign. Searches for your practice and your surgeons' names get their own campaign and budget. Chapter 15 builds it.
- Language: set by your ads now. As of September 2026, Google removed the campaign language setting for Search, and ads match on the language they're written in. A practice with Spanish-speaking joint patients needs a Spanish knee ad group with Spanish headlines and a Spanish knee page behind it.
- Budget: start low. A modest first budget lets you see real click prices in your market before you commit, then raise it once the numbers come in.
What Stays Off, and What Earns Its Way Back On
Off at launch doesn't mean off forever. Each setting has its own condition for coming back.
Search partners get a test once there's booked-consult data to judge them by. AI Max waits until the end of the rollout, and even then it's a test with its own guardrails. Interest-based location stays off. The map grows instead, one county at a time, as surgery patients keep arriving from new places. Every change gets judged the same way the bids were in Chapter 7: by what it does to the cost of a booked consult, never by the extra clicks it brings.
Next: Performance Max Can Aim Your Ad at Pages You'd Never Pick
Three switches off, a surgical map drawn, and the Search side of the account is ready. Chapter 10 covers Performance Max, the campaign type that comes months later, and why it can send an orthopedic ad to pages Google won't allow ads for.
The guide home has the full sequence.
For orthopedic groups that hand us their Google Ads management, all three defaults come off before launch, and the surgical map is drawn from the practice's own patient ZIP codes.
