In orthopedic surgery, building a successful program is often framed around growth strategies, partnerships or scale.
But Paul Tornetta, MD, said the most important factor is far more fundamental, and far less complicated.
“It sounds like a cop-out answer,” he told Becker’s, “but it starts with hiring the right people.”
For Dr. Tornetta, chair of orthopedic surgery at Boston Medical Center and a longtime leader in academic orthopedics, the difference between strong programs and struggling ones rarely comes down to structure alone. Instead, it’s rooted in the people who make up the organization, and the values they bring to patient care.
Clinical excellence, above all
At a time when research output, reputation and innovation often shape recruitment decisions, Dr. Tornetta is clear about his priorities.
“The No. 1, 2 and 3 things on your list of 10 is clinical excellence,” he said.
Without it, he argues, no amount of academic productivity or institutional prestige can sustain a program long term.
That standard extends beyond technical skill. He looks for surgeons who are thoughtful in their approach to care, particularly those who are not overly aggressive in recommending surgery and who take the time to guide patients through all available options.
“Our job as surgeons is sometimes to operate, but every time to talk to patients about whether surgery is needed,” he said.
Building around the right fit
For academic programs, the challenge becomes more complex. Faculty are expected to balance clinical care with teaching and research, often pulling them in competing directions.
“You’re looking for a very different type of surgeon,” Dr. Tornetta said, noting that not all clinicians are interested in or suited for academic work.
Rather than trying to mold individuals into roles that don’t fit, he emphasizes careful vetting upfront, identifying surgeons whose skills and interests align with the program’s needs.
“It’s very hard to fit a square peg in a round hole,” he said.
Recruitment, he added, is often driven by reputation as much as process. Strong programs tend to attract strong candidates, creating a cycle that reinforces itself over time.
“Strong departments are self-replicating,” he said.
Mission also plays a role. At Boston Medical Center, where care is delivered across a diverse and often underserved patient population, physicians are often drawn by a shared belief that all patients deserve high-quality care, regardless of background.
“You’re not going to come work here unless you believe in that mission,” he said.
Culture is built, not managed
Once the right people are in place, culture becomes the differentiator. At Boston Medical Center, Dr. Tornetta describes his role less as a top-down leader and more as an enabler, someone responsible for creating an environment where faculty can do their best work. “My job is to make sure my faculty get as much of what they want as I can possibly get for them,” he said.
That includes advocating for resources, supporting collaboration and, when necessary, pushing back against institutional barriers. It also means fostering a level of trust and collegiality that extends beyond formal structure. In trauma care, where decisions are time-sensitive and multidisciplinary, that trust becomes essential.
“I can count on every single one of my partners, and they can count on me,” he said.
Where programs break down
Despite growing demand for orthopedic services, many programs struggle to scale effectively. According to Dr. Tornetta, the issue is rarely a lack of opportunity, but rather breakdowns in collaboration.
Growth, he said, is most often limited by ego, territorialism and misaligned incentives between departments.
“Do what’s right for the patient, and everything else works out,” he said.
That principle becomes especially important in complex care environments, where orthopedic surgeons rely on close coordination with trauma, vascular and plastic surgery teams. Without shared goals, even well-resourced programs can stall.
Partnerships and the problem of alignment
As health systems continue to pursue partnerships and consolidation, Dr. Tornetta sees similar patterns emerge.
Successful partnerships, he said, depend less on structure and more on alignment, particularly around goals and definitions of success. “If one group is focused on quality and outcomes and the other is focused on volume and dollars, that’s not a good marriage,” he said.
Even when partnerships are formed with good intentions, misalignment at the leadership level can create long-term challenges. In some cases, administrative decisions made without a deep understanding of clinical realities can unintentionally lower the overall standard of care.
“The reputation ends up going to the lowest common denominator,” he said.
The leadership variable
Beyond recruitment and partnerships, Dr. Tornetta points to another often overlooked factor in program success: leadership stability.
Changes at the executive level, he said, can quickly disrupt even high-performing departments, particularly when new leaders bring different priorities or lack familiarity with the clinical environment.
“A change in leadership can bring about a dramatic change in resource allocation,” he said.
That reality, he noted, is one reason some physician-led groups operate independently, where decision-making remains closer to the clinicians delivering care.
The foundation most leaders overlook
For leaders building or scaling a program, Dr. Tornetta points to one often overlooked starting point: financial stability.
“You have to make sure your finances are in order,” he said, noting that resources ultimately determine what level of clinical and operational support a program can sustain. Without that foundation, even the best clinical vision can be difficult to execute.
From there, he returns to the same principle that defines his approach to leadership. “Without clinical excellence, you will never build a great program,” he said.
A simple, consistent principle
Despite the complexity of modern healthcare, Dr. Tornetta’s framework for building a successful orthopedic program remains straightforward.
Hire carefully. Align around patient care. Build a culture of trust. And protect the resources needed to sustain excellence.
“It doesn’t matter the setting,” he said. “If you do what’s right for the patient, it will benefit you, your department and your institution.”
In an environment often defined by competing priorities, it’s a reminder that the strongest programs are not built on strategy alone, but on people, purpose and a consistent commitment to doing what’s right.
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