Successful spine and orthopedic leaders constantly evolve with shifting mindsets and look past assumptions that may hold back their work.
From the assumption that hospital settings equal the best quality to the belief that volume drives profit, here are the assumptions that leaders are rethinking for the better.
The 25 leaders featured in this article are speaking at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, set for June 11-13, 2026, at the Swissotel Chicago.
If you would like to join the event as a speaker, please contact Carly Behm at cbehm@beckershealthcare.com.
As part of an ongoing series, Becker’s is connecting with healthcare leaders who will speak at the event to get their insight on thought-provoking questions within the industry. The following are answers from event speakers, lightly edited for clarity.
Question: What’s one assumption about your patients, your practice, or your field that you’ve had to unlearn in the last two years?
Todd Albert, MD. Hospital for Special Surgery (New York City): For most of my career, I operated under the assumption that complex orthopaedic and spine surgery belonged in the hospital and that anything beyond a straightforward decompression needed the full safety net of inpatient infrastructure just down the hall. The last two years have decisively unlearned that for me. I’ve watched skilled teams perform multi-level cervical and lumbar procedures, total joints, and increasingly sophisticated spine cases safely in the ambulatory setting, with shorter recoveries, lower infection rates, meaningfully lower costs, and patient experience scores the inpatient world has never matched.
Stepping into the role of CMO at Legent Health, the new national ASC platform launched by HSS and General Atlantic has only deepened that conviction: the migration of musculoskeletal care out of the hospital and into purpose-built ambulatory surgery centers isn’t a niche trend, it’s where our field is going. The assumption I had to let go of is that “hospital-grade” and “highest-quality” are the same thing. For the right patient and the right procedure, the ASC is now the highest-quality setting we have.
Kevin Bozic, MD. Dell Medical School at the University of Texas at Austin: One assumption I’ve had to unlearn is that our primary job as clinicians is to deliver healthcare, when in reality our goal is to improve health. It’s become clear to our team that health outcomes are driven as much or more by factors outside our four walls as what we do inside it. The highest-value health systems are those that invest in proactive care, behavior change, and addressing the non-medical drivers of health, not just delivering the most services. This realization has refocused our efforts on measuring what matters to patients and organizing care to support long-term musculoskeletal health, not just episodic treatment.
Tan Chen, MD. Inova Health (Springfield, Va.): I used to think that when patients came to see a spine surgeon, they were there for surgery. Over the past couple of years, I’ve realized that’s not what most people want at all. They’re looking to understand their problem, get answers, find reassurance and figure out how to get back to living without constant pain. From their perspective, feeling heard, understanding their options and knowing they’re making the right choice matter most. That’s changed how I practice, with more focus on listening, guiding and only recommending surgery when it truly makes sense.
Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): I used to tell patients the facts and that they were not candidates for surgery and send them off. But I have come to the realization that patients are also in need of compassion. Patients need to feel they are heard and I have increasingly appreciated the importance of non operative and alternative options for patients with spine problems.
Sean Gipson. CEO and Division president of ASCs at Remedy Surgery Center (Hurst, Texas): The ASC assumption that quietly broke is more volume equals more profit. For years, ambulatory surgery centers operated under a straightforward premise: increase case volume and profitability will follow. But over the past two years, that assumption has quietly unraveled.
The ASC leaders who are still measuring success primarily by case growth may be missing a more uncomfortable reality: not all volume is good volume, and some of it is quietly unprofitable.
Several converging pressures have disrupted the traditional volume-driven model. One of the first factors is that the payer mix is shifting quickly. Commercial reimbursement, the previous financial backbone of ASCs, is under increasing pressure. At the same time, Medicare and Medicare Advantage volumes are rising and the result, even as total cases increase, is revenue per case is declining.
Another factor is that the wrong cases are moving the fastest. The industry anticipated a migration of higher-acuity procedures into ASCs. While that is happening, the fastest growth has come from lower-acuity, lower-reimbursing cases, diluting our overall margins. Additionally, labor costs are no longer variable. Staffing was once a lever that could flex with volume. Today, labor costs are structurally higher and far less responsive. Premium pay, contract labor, and retention investments mean that incremental cases don’t carry the same margin they once did.
Supply costs that come with higher acuity cases are eroding contribution margins. Implants, pharmaceuticals, and disposable supplies have seen sustained cost increases and reduced availability in many cases. Without aggressive supply chain management, case-level profitability can disappear, even in high-volume environments.
Throughput does not equal profitability. Many ASCs still optimize speed and block utilization without fully understanding profitability at the case or surgeon level. High utilization of low-margin blocks can create the illusion of performance while masking financial underperformance. It’s painful at the end of a large-volume day that results with the same margin on a two-procedure spine day.
The new operating reality is high-performing ASCs are shifting away from volume as the primary success metric and instead, focusing on case mix index optimization, payer contracting and alignment strategies, profitability by surgeon, service line and block time and cost discipline at the case level.
This is a much more complex operating model, but it is also a more honest one. Operators that do not understand their numbers on this complex level are going to be left behind in today’s competitive industry.
The bottom line is that the ASC market hasn’t lost its growth story, but it has lost its simplicity. Leaders who continue to chase volume without interrogating their margins are at risk of scaling inefficiency. Those who adapt by aligning growth with profitability will define the next phase of ASC performance. Because in today’s environment, more cases don’t guarantee better outcomes, financially or operationally.
Tyler Goldberg, MD. CEO at North American Orthopedic Concierge Association: I used to assume that if you did the right thing for the patient, the system would generally support it. Over the last two years, I’ve realized that’s not how it works. There’s often friction at every step, especially from payers whose incentives aren’t aligned with care. That was a hard shift, because as physicians we’re trained to trust the system we operate in. What I’ve had to unlearn is the idea that we control our practice just by practicing good medicine. The reality is, if you don’t intentionally design your model, you have far less autonomy than you think.
Alejandro Fernandez. CEO at Synergy Orthopedics (San Diego): The assumption I’ve had to unlearn in the last two years is that change is inevitable and slow. In orthopedics, AI adoption has accelerated quickly, and practices that delay risk falling behind on efficiency, access, and patient experience. At Synergy Orthopedics, we’re already using AI scribes, AI-assisted MRI imaging, and AI phone support, and we’re moving toward AI automation for billing and records management, because the competitive advantage now comes from adapting early.
Megan Friedman, DO. Chair and Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): One assumption I’ve had to unlearn is that our role as anesthesiologists is limited to clinical care inside the operating room.
In reality, being a strong clinician is no longer enough. Anesthesia sits at the center of perioperative operations, with visibility across the OR, GI, cath lab and other procedural areas. We see, in real time, how cases move, where delays occur, and where inefficiencies exist.
Over the past two years, it’s become clear that when anesthesia is not actively involved in operational planning, decisions are made without a full understanding of how the system actually functions. The highest-performing environments are the ones that leverage anesthesia not just for patient care, but for throughput, scheduling alignment, and day-to-day operational decision-making.
The shift is recognizing that anesthesia is not just a clinical service. It is a key operational partner, and being effective today requires both clinical excellence and active engagement in how the system runs.
Nikolas Jannetta. Director of Operations at National Spine and Pain Centers (Miami): A healthy financial margin and a full patient schedule makes a healthcare practice successful. At least, that has always been the assumption. As director of operations for multiple interventional spine centers and associated ASCs in the Southeast, establishing a scalable business model that prioritizes best-in-class clinical outcomes is the principal focus. Leveraging advanced technology to enhance physician decision-making is the first step toward the goal of making both our patients and our financial margins healthier.
When met with operational knowledge or performance gaps, incorporating an automated systems-based approach can increase detection and response time to suggest proper evaluation or action, alerting physicians to potential unseen operational or knowledge gaps, without over-burdening the team or requiring increased labor costs. The deliberate design of an autonomous yet collaborative administrative engine empowers physicians while preserving their unwavering autonomy over decision-making. While physicians are still at the core of every decision-making process, their abilities and clinical outcomes are enhanced by partnering with the power of technology, without compromising financial margins.
Martin Jenter, DO. Henry Ford Providence Novi (Mich.) Hospital and Michigan Outpatient Surgical Solutions: What did I unlearn? I migrated back to private practice and needed to rely on my own reputation and not expect easy referrals from a built-in facility-owned referral base. Nothing is guaranteed in your own practice; you have to work for it.
Vamsi Kancherla, MD. Specialty Orthopaedics (Gainesville, Ga.): One major assumption I’ve had to unlearn in the last two years is that more complex spine pathology always requires traditional open surgery in a hospital setting. Advances in endoscopic and ultra-minimally invasive techniques have demonstrated that well-selected patients can achieve excellent outcomes with much faster recovery times when performed safely in an ASC. This evolution has been transformative for both my practice and my patients.
Jeff Lehmen, MD. SSM Health Spine Surgery Center (Jefferson City, Mo.): One thing I’ve had to unlearn about my patients is that with the rise of AI tools such as ChatGPT, spine surgery information is far more accessible to patients than ever before. Individuals can now quickly learn about diagnoses, surgical options, risks and recovery expectations, often arriving to my clinic with a baseline understanding of their condition. This increased access promotes more informed, engaged discussions and shared decision-making between the patients and us. However, it also introduces challenges, as not all AI-generated information is accurate or tailored to the nuances of their individual case. As a result, we play an essential role in validating information and guiding patients toward evidence-based, personalized care.
Michael Lewis, MD. Henry Ford Health and Wayne State University (Detroit): Honestly, I assumed AI would make everything more clinical. More data, fewer real conversations. What I’ve found is that the opposite is true. When AI supports the analytical “heavy lifting,” it provides expanded opportunity and capacity for the human side of our work: conversations about purpose, about trust, about why we chose this work in the first place. As an anesthesiologist, I’ve noticed that my interactions with colleagues and stakeholders have become more emotionally honest, not less. The technology didn’t crowd out connection; it made room for it.
Paul Lynch, MD. Founder and CEO at US Pain Care (Scottsdale, Ariz.): One assumption I’ve had to unlearn is that standardizing physicians leads to better outcomes and efficiency. For years, we’ve tried to make doctors practice the way we think they should — same protocols, same workflows, same expectations. What we’ve learned at US Pain is that this approach often suppresses performance rather than improving it. Physicians aren’t interchangeable units — they have different strengths, philosophies, training and clinical instincts. When you force uniformity, you lose the upside of what makes great doctors great.
Instead, we’re starting to build systems around the individual physician. Using tools like predictive modeling and behavioral profiling, we can understand how each doctor naturally practices — and then design the clinic, staffing, service lines, and even scheduling around that. The result is better outcomes, higher efficiency and lower burnout. The future of ASC operations isn’t forcing doctors into a system — it’s building a system that reflects the doctor.
Brian Nwannunu, MD. Texas Joint Institute (Dallas): One of the main assumptions about my patients (and patients in general) that I have had to unlearn early in my practice is that patients no longer want to be “told” what to do when it comes to their bodies or when they may need surgery. Even if it is the best option for them. As a hip and knee replacement specialist, when I see X-rays with end stage arthritis I know that a hip or knee replacement will make the patient better and improve their quality of life. In the early years of my training, I often times would witness my Attending flat out tell the patient they need surgery and move to the next clinic room. Although that may have worked in a large academic setting where the system was set as such and the patients may have had limited options, in the community based private practice setting, if a patient doesn’t build report with their surgeon and trust the treatment recommendation then they will just go across the street to one of the other 15-20 Orthopaedic surgeons in the area.
I learned patients have options and they come in to my office very educated on various treatments recommendations. They no longer accept the paternalistic “talking at them” approach of the past. Instead, my patients prefer to make informed decisions for themselves after they are given the facts regarding their condition and the possible treatment options that can help.
I’ve had very surgery-adverse patients who were reluctant to proceed with another surgeon, seek out my advice as a “second opinion” because they felt the other surgeon was not giving them the opportunity to speak about their concerns. My approach with these types of patients is more of a “shared decision making” or conversation when it comes time to discussing surgery. My patients have a chance to be heard and share any concerns or reservations. This approach is very successful particularly with apprehensive patients and although my recommendation may ultimately be the same as their first surgeon encounter, the shared decision making quality of the conversation typically helps the patient feel more at ease with proceeding with surgical intervention.
Kevin Plancher, MD. Plancher Orthopedics (New York City): I used to assume that patients coming in with “internet research” were misinformed and needed to be corrected. I have learned it reflects engagement and a desire to participate in their own care. Now I listen first and guide toward a collaborative plan that results in strengthened trust and improved outcomes.
Ronjon Paul, MD. Endeavor Health (Schaumburg, Ill.): Earlier in my career, I assumed patients primarily chose a spine surgeon based on technical expertise and reputation. Over the past few years, I’ve had to rethink that. Today’s patients are far more informed, but also more overwhelmed. They’re looking for clarity, judgment and trust along with surgical skill. That’s shifted my focus toward helping patients understand when surgery is appropriate, and just as importantly, when it’s not. It’s also made clear that delivering on that expectation requires a supportive system and infrastructure — one that prioritizes access, patient education and continuity — so those principles are consistently translated into the patient experience.
Theresa Pazionis, MD. Temple Health (Philadelphia): One assumption I’ve had to unlearn is that the rapid expansion of predictive analytics and robotics would inherently elevate the overall standard of spine care. While many of us in spinal deformity have long appreciated the importance of fundamentals, there is now a broader misconception that technology itself can serve as an equalizer. In reality, predictive models and robotic platforms are only as effective as the surgical judgment, indications, and technical execution that guide them.
In my own practice and in training, I’ve become increasingly focused on reinforcing “good carpentry” first- respect for alignment principles, tissue handling, and sound indications – before layering in advanced technology. Robotics can enhance precision, and predictive analytics can refine risk stratification, but neither substitutes for a deep understanding of deformity correction or surgical strategy. The priority must remain preserving technique and judgment, with technology serving as an adjunct rather than a replacement.
Faisal Rahman, PhD. President and CEO of APAC Partners: Today’s patients’ implicit partner is the web and they come in with various correct and incorrect information. I ask all our physicians and nurses to listen first and then answer their questions. This actually saves time in the long-run. When possible, use AI as a gate keeper to screen patients and as a companion to ensure follow-up care.
Ken Rich, MD. Raleigh (N.C.) Neurosurgical Clinic: As I head into semi-retirement and no longer participate in surgery as the primary surgeon, I thought my past patient would move onto the younger doctors in our practice. Even though they know I am no longer doing surgery, patients are requesting to come back and talk to me about problems and get guidance. It’s quite a compliment that they appreciate my knowledge and experience as much as they do.
David Russo, DO. Columbia Pain Management (Hood River, Ore.): One assumption I’ve had to unlearn is that the biggest constraint in spine and pain care is clinical uncertainty. Increasingly, the limiting factor is not diagnosis or technique, but the administrative architecture around care. Prior authorization, site-of-service rules, and network design often shape what patients receive more than clinical judgment does.
That realization has shifted how we structure our practice. We focus on preserving clear physician accountability, minimizing unnecessary handoffs, and building care pathways that are both clinically sound and operationally executable. When those elements align, care becomes more predictable for patients and more sustainable for the practice.
Kutaiba Tabbaa, MD. University Hospitals of Cleveland: I really could not say there is only one assumption but multiple assumptions including changes in Medicare reimbursement and regulations. One major assumption I’ve had to unlearn is that pain intensity and physical damage are not always directly proportional and whatever interventional therapies we perform we are always short of better outcomes because of the lack of emphasis on the biopsychosocial patient involvement. Our emphasis at our center works on addressing all these issues together and the combination between successful interventional therapies associated with medical management, physical wellness, mental self-awareness and, above all, total patient participation.
David Wei, MD. Orthopaedic & Neurosurgery Specialists (Greenwich, Conn.): The assumption I’ve had to unlearn is that better technology automatically leads to better adoption. I spent years believing that if you built the right tool, the right workflow and the right interface, surgeons and staff would embrace it. What I’ve learned, both in clinical practice and in my role as a physician informaticist, is that adoption is almost entirely a human problem. It’s about trust, timing, and whether people feel like the change is happening with them rather than to them. Technology is often the easy part.
Michael Verdon, DO. President at Dayton (Ohio) Neurological Associates: There is an assumption embedded in most discussions of spine care delivery that needs to be challenged: that the system, while strained, is fundamentally intact. It is not. The post-COVID environment has been altered in ways that will not self-correct, and our patients are absorbing the consequences without understanding why.
Three forces deserve more honest discussion among those of us running spine practices and programs.
The clinical brain drain is permanent, and it starts upstream of us. The mid-to-late career exodus from primary care between 2021 and 2024 was not a staffing event. It was a loss of clinical judgment that no workforce model captures. The internists who retired early were the ones who knew when to escalate, who had the relationships to get a patient in front of us in days rather than months, and who could distinguish mechanical pain from a red flag at the bedside. Their replacements are capable, but the institutional pattern recognition is gone. Patients now arrive at our clinics later, more deconditioned, with incomplete conservative trials and imaging ordered defensively rather than diagnostically. The front end of the referral pipeline is not being rebuilt.
Prior authorization has become denial by attrition. The appeals exist, the peer-to-peers exist, the published criteria exist — but the cumulative friction is the product. In spine, the delays compound: weeks for the MRI, weeks for the injection series required before the MRI is deemed necessary, weeks for surgical authorization, weeks for the appeal when the first request is denied on documentation rather than clinical grounds. The natural history of a progressive radiculopathy or cervical myelopathy does not pause for utilization review.
Patients feel the symptoms but not the system. They experience the ten-week wait, the denial letter, the requirement to repeat physical therapy they completed two years ago. They do not see that the wait exists partly because their PCP retired, or that their MRI was denied for a missing phrase rather than a clinical disagreement. They blame the front desk, the surgeon, or conclude this is simply how medicine works now. That last conclusion is the most dangerous, because it converts a structural problem into personal resignation.
We can keep optimizing on our end — ASC pathways, navigators, in-house authorization teams, direct access models — and we should. These are necessary and not sufficient. The harder work is naming the system honestly to the people who can change it: patients who can advocate, employers who purchase the plans, and the medical directors who still believe the current friction reflects clinical rigor rather than margin protection.
Awareness on our side, without translation to theirs, is just professional grievance. Translation is the work.
Aqib Zehri, MD. The Oregon Clinic (Portland): One assumption I have had to unlearn over the past couple of years is that delivering high quality spine care is primarily about clinical decision making and technical execution. Those are essential, but I have come to appreciate that outcomes are also heavily dependent on the system around the surgery.
In real world practice, not every hospital environment is built to support every level of spine complexity, and recognizing that is critical to delivering consistent outcomes. The ability to take on complex pathology depends on infrastructure, multidisciplinary support, and alignment with the hospital system.
That has made me more thoughtful about not just which operation is indicated, but whether the environment is truly set up to support that patient and that procedure in a way that leads to durable outcomes.
It has shifted my focus toward coordination, collaboration, and a broader understanding of how surgical decisions impact both patients and the system as a whole.
At the Becker's 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, taking place June 11-13 in Chicago, spine surgeons, orthopedic leaders and ASC executives will come together to explore minimally invasive techniques, ASC growth strategies and innovations shaping the future of outpatient spine care. Apply for complimentary registration now.
