After more than four decades in orthopaedics, I’ve seen the landscape of medicine transform in ways few of us could’ve imagined in training. Today’s medical professionals, regardless of specialty, face choices that go far beyond patient care. Our professional fulfillment, autonomy and integrity hinge on where and how we choose to practice.
This isn’t just an orthopaedic conversation. These crossroads are now familiar to physicians in nearly every discipline. As co-founder of one of the nation’s largest independent groups, The Centers for Advanced Orthopaedics, and MedVanta, the nation’s largest physician-owned, fully integrated MSK platform, I’ve experienced firsthand the models reshaping our field.
Here’s what I wish someone had told me when I was starting out.
Understand the Landscape: Four Models of Practice
The first is hospital employment. Large systems like Johns Hopkins or MedStar offer structure, salary and a defined path. But that predictability comes at a cost – bureaucracy, limited autonomy, and often, decisions made far from the bedside.
Next, there’s the “payvider” model, where insurance companies have moved from reimbursing care to delivering it. UnitedHealth’s Optum now employs nearly 10% of U.S. physicians. But who truly governs your practice in this model – the doctor, or the shareholder? The growing pressure to meet corporate metrics often sidelines the physician voice and, worse, patient priorities.
Private equity has also surged into medicine, drawn by the promise of consolidation and profit. Between 2012 and 2021, private equity acquisitions of physician groups jumped more than sixfold. Many enter these arrangements seeking equity and exit – but are met instead with production quotas, cost-cutting and little clinical control. When the firm flips the practice for profit, physicians often bear the brunt of the next round of trying to squeeze out even more profits.
Then there’s independent practice. It’s shrinking, down from 75% of the workforce a few decades ago to under 25% today. Rising costs, reimbursement cuts and technology demands make it a steep hill to climb. But it’s not extinct – it’s evolving.
At The Centers for Advanced Orthopaedics (CAO), we banded together across 25 practices to preserve what matters most: the physician-patient relationship. Yes, it’s hard work. But for many of us, it’s the most meaningful work, and we’ve enjoyed a 10% compound annual growth rate since our inception in 2013.
Know the Economics and the Tradeoffs
Orthopaedic surgeons are often cited as among the highest earners in medicine, but the picture is more complex. In the last decade, practice costs have outpaced income growth, and the share of fees retained by physicians has plummeted.
In fact, according to the U.S. Bureau of Labor Statistics Consumer Price Index, cumulative inflation rose 92.3% from 1998 to 2024. Over that same period, Medicare physician payment rates declined 10.76%. That means we’re being reimbursed significantly less today – not just in relative terms, but in absolute dollars for delivering more complex, more regulated and often more scrutinized care.
Ancillary services like physical therapy and imaging have helped keep practices afloat, but even those are under pressure.
Understanding your worth – and how value is created and captured – is essential. Not just for your bank account, but for your peace of mind.
Embrace the Evolution of Care: You’re More Than a Surgeon
The role of the physician is evolving – and in orthopaedics, that evolution is accelerating. Today, we’re not just surgeons; we’re comprehensive managers of MSK disease. That means shifting our mindset from simply performing high-quality procedures to proactively managing musculoskeletal health across the continuum – preventing injuries, guiding recovery and managing chronic conditions with the same level of attention we give to the OR.
Value-based care demands this transformation. It’s no longer just about delivering excellent surgical outcomes – it’s about avoiding unnecessary surgery through smarter diagnostics, more conservative treatment plans and a deeper investment in long-term patient wellness. We’re called to deliver better outcomes more efficiently and with greater empathy.
Protect Your Life, Not Just Your Livelihood
The most important decision you’ll make isn’t about salary. It’s about where and how you want to live.
Choose a place that brings you joy. Surround yourself with colleagues who reflect your values. Remember that your spouse or partner isn’t just along for the ride – they’re an integral part of the journey. And always, always treat your staff with respect. They are the heartbeat of any practice.
Reputation Is Everything
Warren Buffett famously said, “It takes 20 years to build a reputation and five minutes to ruin it.” In medicine, your name is your license. Guard it fiercely. I’ve seen brilliant doctors sacrifice it chasing golden handcuffs, only to find themselves trapped in toxic cultures with no way out.
Final Words
Healthcare is changing faster than any of us can predict. But your compass should remain steady. Know your worth. Protect your integrity. Choose partners who lift you up. Stay nimble. And never forget: you are not just a physician. You are a steward of care and a comforting guide through uncertainty.
The path isn’t easy. But with eyes open and values intact, it can be deeply fulfilling.
