Orthopedic surgery has long been driven by a simple equation: more procedures, more productivity, more revenue. But for surgeons working inside that system, the math can start to feel unsustainable.
For Tyler Goldberg, MD, an orthopedic surgeon at Texas-based Austin Orthopedic Institute and founder and CEO of the North American Orthopedic Concierge Association, the realization came after years of practicing at full speed.
“Orthopedic surgeons build lots of value for the system, but we don’t get to really take part in that value,” Dr. Goldberg said. “We get declining reimbursement, increasing administrative workload and hospital consolidations. That ultimately leads to burnout.”
Rather than accept the status quo, Dr. Goldberg decided to experiment with a different model of care, one that intentionally slows the pace. Today, his concierge joint replacement practice limits surgical volume and emphasizes access, transparency and deeper physician–patient relationships.
Rewriting the incentives
Like many surgeons, Dr. Goldberg spent years operating within healthcare’s productivity-driven framework. Compensation tied to relative value units rewards volume above nearly everything else.
“The model for an employee is they work on RVUs,” he said. “They do a volume of work, and then they get paid.”
But over time, he saw how that model creates a system where surgeons are expected to generate patient flow into vertically integrated health networks while seeing steadily tightening reimbursement.
“They’ve realized the way to get patients into the system is by decreasing the orthopedic surgeon,” he said. “And the only response lever he has is to run faster.”
For many younger surgeons, the pressures push them toward hospital employment. But Dr. Goldberg questions whether that path aligns with the years of training required to become a surgeon.
“Why does somebody do four years of college, four years of medical school, five years of residency and a year or two of fellowship to be an employee and never understand the value that they have created and who they’ve become?” he said.
Slowing down to care more deliberately
Dr. Goldberg’s concierge practice deliberately caps the number of joint replacements he performs each year. That decision, he said, allows him to focus more deeply on each patient’s experience. “Patients want access, and they want to know that their care is a little more deliberate,” he said. “They don’t want to feel like they’re on the assembly line.”
The model also prioritizes something many patients struggle to find in traditional healthcare settings: clarity around cost. “Things are always expensive until you understand the value,” Dr. Goldberg said.
Concierge surgery provides price transparency and predictable costs, he said, allowing patients to understand their financial responsibility before moving forward with surgery. “What concierge essentially is, is having access and having all of the things that you will need anticipated for and cared for,” he said.
That access extends beyond the operating room. Patients can reach their surgeon directly during recovery, something Dr. Goldberg believes can meaningfully reduce anxiety. “If I’m golfing on a Saturday morning and a patient calls me, I stop golfing and pick up the phone,” he said. “That’s my obligation to my patients.”
Rediscovering the career he imagined
For Dr. Goldberg, the transition has reshaped how he experiences medicine. “It’s definitely reinvigorated my career because this is the style of medicine that I went to medical school to do,” he said.
Instead of rushing through packed operating schedules, he now practices more deliberately, with time to focus on both patients and personal balance. “I envisioned these great relationships with patients and enjoying my work,” he said.
Without that balance, he warns, the volume-driven system can slowly erode physicians’ sense of purpose. “You start spinning more and more,” he said. “Then the next thing you know, you wake up and think, ‘What have I built here? I’m just a cog in the wheel.’”
A model that may not stay niche
Concierge surgical care remains uncommon in orthopedics, but Dr. Goldberg believes alternative care models will continue to emerge as surgeons search for ways to maintain autonomy and sustainability. “I think hybrid models, direct contracting, bundled pricing and surgeon-led care initiatives are the future,” he said.
As reimbursement pressures continue and healthcare systems consolidate, he expects surgeons will increasingly explore new ways to structure their practices. “At some point surgeons will say, no,” Dr. Goldberg said.
When that moment comes, he believes innovation will follow. “Necessity is the mother of invention,” he said. “That’s when orthopedic surgeons will become creative and figure out that there are alternative models.”
For Dr. Goldberg, building a new approach was less about disrupting the system and more about preserving what drew him to medicine in the first place.
“This is a great profession,” he said. “You just need to play the game differently.”
