The decision not to operate is often one of the most consequential choices orthopedic and spine surgeons make. Leaders told Becker’s that while surgery can offer life-changing benefits, the right answer is not always an operation, particularly when conservative treatment, patient risk factors or quality-of-life considerations point in another direction.
Question: When is it the right call to not perform surgery? And how do you make that decision in a system that financially rewards operating?
Editor’s note: Responses have been lightly edited for clarity and length.
Judy Baumhauer, MD. Professor of Orthopaedic Surgery at University of Rochester (N.Y.) Medical Center: It is the right call not to perform surgery when the patient isn’t medically optimized and surgical complications may occur due to this. Perhaps more controversial, when the patient is functioning at a high level and surgery hasn’t been able to be shown that it would improve function above the already high level. This is one of the concepts that CMS is hoping the Hip dysfunction and Osteoarthritis Outcome Score, Jr. and Knee injury and Osteoarthritis Outcome Score, Jr. scores will tease out. It is more complicated than just function as pain, alignment and stability may have some influence on appropriateness for surgery.
“Doing the right thing” is always the right decision. Operating when there is heightened risk of complications, costs the system as in the case requiring medical optimization. Operating when the patient is “too good” for surgery, minimal pain, good function and no room for improvement with surgery is when nonoperative treatment therapies are appropriate. This doesn’t mean that a year from now the patient might not be a surgical candidate, just not now.
Harpreet Bawa, MD. Orthopedic Surgeon and Joint Replacement Specialist at DISC Thousand Oaks (Calif): One of the great advantages of most orthopedic and musculoskeletal procedures is that they are elective in nature and rarely life-threatening. This allows for thoughtful, unhurried decision-making. When discussing surgery with patients, I thoroughly review all conservative options alongside definitive surgical treatments, and we carefully weigh the risks in the context of each patient’s individual medical history. For some patients, the risks of surgery may simply outweigh the potential benefits.
While the healthcare system does incentivize procedural volume, physicians carry a deeper moral and ethical obligation, to their patients and to society at large. The reality is that operating on patients who are not yet appropriate candidates, or who have not exhausted conservative treatments, leads to poor outcomes, high dissatisfaction and ultimately undermines both patient trust and a physician’s long-term reputation.
Justin Bundy, MD. Spine Specialist and Orthopedic Surgeon at Georgia Carolina Orthopedics (Augusta, Ga.): Choosing not to operate is often the hardest, and most important, decision in surgery. If the expected benefit doesn’t clearly outweigh the risk, or if surgery won’t meaningfully improve a patient’s quality of life, then the right answer is to step back. Financial incentives exist in every healthcare system, but good surgeons have to anchor decisions in evidence, outcomes and the responsibility to put the patient’s long-term interests ahead of the procedure itself.
Chris Comey, MD. Neurosurgeon at Legacy Brain & Spine (Marietta, Ga.): In my practice, surgery is reserved for patients with pain that is ruining their quality of life and has failed to respond to reasonable nonsurgical approaches. The only time a patient is offered surgery sooner is if they present with weakness or loss of function.
Clearly, this is at odds with a production-based compensation system. However, over the years I have enjoyed a very busy practice precisely because of a judicious use of surgery. In contrast, more aggressive surgeons can struggle to maintain a practice because patients are put off by any suggestion that they are “knife-happy.” Money and revenue take care of themselves as long as you strive to do the right thing for the right reasons.
Stephen Dell, MD. Neurosurgeon in California: Alone among advanced industrialized nations, American medicine operates as a commercialized system. The result is predictable: Adjusted for inflation, the percentage of gross domestic product devoted to healthcare spending is approximately twice that of other developed countries. Unlike 75 to 100 years ago, many people now enter medicine expecting to earn high incomes. It is unrealistic to expect otherwise, regardless of moral appeals. Traditionally, physicians’ family incomes in Western civilization were relatively modest. Reversing today’s incentives would require a gradual, systemic shift in both financial and nonfinancial rewards.
As for the question itself, one can define the “right” decision as both technically and morally correct. Any procedure should have a substantial probability of reversing the clinical syndrome while carrying a relatively modest risk of adverse outcomes or complications. This standard rejects the rationale that a procedure should be performed simply because it “might work.” Yet despite overwhelming statistical evidence, ineffective therapies often persist.
Harel Deutsch, MD. Co-Director of Rush Spine Center (Chicago): The key quality of a good physician is putting the patient’s welfare ahead of any self-interest. In a system that may financially reward operating, I stay grounded by considering a standard many patients ask about: Would I recommend this treatment for my own mother? If the answer is no, then the right call is to not perform surgery.
Christopher Dodson, MD. Head of Orthopedics at Vincera Institute (Philadelphia): The “right” call to not operate is rooted in my identity as a physician first and foremost. When the expected benefits to the patient do not clearly outweigh the risks and potential complications, then I don’t ever recommend surgery. In a system that financially rewards surgery, choosing not to operate is guided by professional integrity, which should always place the patient’s welfare above any financial or personal gratification.
Jeff Gilligan, MD. Neurosurgeon at Elite Brain & Spine of Connecticut (Danbury): One of the most important decisions a spine surgeon makes is deciding when not to operate. Surgery is not always the right answer, whether because the likelihood of meaningful improvement is low, as can be the case with some patients with chronic neck or low back pain, or because the risks outweigh the potential benefits due to age, frailty or medical comorbidities. These conversations can be difficult for both patients and surgeons and often are not resolved in a single visit. It may take multiple appointments to understand a patient’s goals, expectations and risk profile before concluding that surgery is not the best option. Taking that time is important because patients deserve to feel heard and thoroughly evaluated, not simply dismissed because surgery is not being recommended.
As for financial incentives, I do not think there is a perfect payment structure that can completely solve the issue. Ultimately, surgeons must remain committed to doing what is right for the patient, even when that means recommending against an operation. Discussing challenging cases with trusted colleagues can help maintain objectivity and reinforce our responsibility to put patient outcomes above procedural volume.
James Mooney, MD. Complex and Minimally Invasive Spine Deformity Surgeon at Virginia Commonwealth University (Richmond): One of the ways I approach the decision to operate is to imagine each patient as my close family member or loved one. In this framework, would I still offer or recommend the operation? In my practice, the goal is to avoid surgery for as long as safely feasible. Financially, there can certainly be pressure to broaden indications over time, but in the long run, operating on patients unlikely to benefit ultimately leads to worse outcomes, diminished trust and harm to both patients and the practice itself.
Above all, surgeons have an obligation to place the patient’s interests first and to operate only when the anticipated benefits clearly outweigh the risks. That decision must remain individualized, thoughtful and grounded in what is most likely to improve the patient’s quality of life and long-term function.
Ali Oliashirazi, MD. Professor and Chair of the Department of Orthopaedic Surgery at Joan C. Edwards School of Medicine Marshall University (Huntington, W.Va.): There are times that, despite severely arthritic X-rays, the timing is not right to “make a pretty X-ray.” Arthroplasty procedures are elective operations. As such, waiting for preoperative optimization is key, including correcting Hemoglobin A1c and nutritional deficiencies, or addressing conditions such as anxiety, depression and fibromyalgia, or awaiting a rash or a psoriatic plaque around the incision site to clear.
Sometimes a patient is extremely deconditioned preoperatively, and allowing time for physical conditioning prior to surgery is essential for a successful outcome. Lastly, occasionally a patient’s family believes the patient is doing poorly, declining and no longer enjoying life as before, yet the patient reports they are doing great. It is the patient’s own perception that matters, not the opinions of those around them.
Jonathan Oren, MD. Co-Chief of Orthopedic Spine Surgery at New York City-based Lenox Hill Hospital and Associate Director of the Combined Spine Surgery Fellowship at Northwell Health (New Hyde Park, N.Y.): First, I ask whether the patient’s symptoms clearly correlate with the anatomy seen on imaging. Surgeons create value by addressing a specific problem, decompressing a nerve, restoring stability or realigning the spine. Without a clear anatomical target, surgery should not be performed.
Second, I consider the severity and duration of symptoms. Patients with newer, less severe symptoms and no neurologic deficits often improve with conservative treatment, while those with significant myelopathy, progressive deficits, severe weakness, constant pain or long-standing disability are more likely to need surgery.
Finally, I weigh the risks of the procedure against the patient’s overall health. Frailty, significant cardiopulmonary disease and uncontrolled chronic conditions can increase the likelihood of complications and poor outcomes, even with minimally invasive surgery. While financial incentives exist, the patient’s needs must come first. Our mission is to be healers, and keeping that focus ultimately benefits both patients and surgeons.
Brandon Ortega, MD. Orthopedic Spine Surgeon at Long Beach (Calif.) Lakewood Orthopaedic Institute: The decision not to operate hinges on one central question: Do the patient’s symptoms actually correlate with the imaging findings? Degenerative changes are common and often incidental. What matters is whether the structural pathology is genuinely driving the clinical picture. When the pain distribution doesn’t follow the level of compression, when there is significant psychosocial overlay, when the patient hasn’t completed a meaningful trial of conservative care or when the anticipated functional benefit doesn’t justify the operative risk, surgery is not the right answer, regardless of how compelling the MRI appears.
The financial incentive to operate is real, but it is a shortsighted lens. A poor outcome on a marginal indication carries consequences that far outweigh the revenue from any single case, to the patient’s well-being, to your professional reputation and ultimately to the trust that sustains your referral base.
James Rizkalla, MD. Clinical Assistant Professor of Orthopedic Surgery and Medical Director for Orthopedic Research of the Texas A&M School of Medicine and Baylor University Medical Center (Dallas): The hardest decision in spine surgery is often deciding not to operate. Surgery should be performed when the patient’s symptoms, functional limitations and pathology align, not simply because an MRI shows abnormalities. Financial incentives exist throughout healthcare, but they cannot be the primary driver of clinical decision-making. Focusing on outcomes, patient trust and doing what is best for the individual patient ultimately leads to a more sustainable practice than chasing procedural volume.
A surgeon’s reputation is one of their most valuable assets, and it takes years to build but can be damaged quickly. Performing operations that are not clearly indicated may increase short-term volume, but poor outcomes and dissatisfied patients ultimately erode trust among patients, referring physicians and colleagues. In the long run, maintaining credibility and consistently doing what is right for the patient is far more important than performing an additional surgery.
Neil Shah, MD. Attending Orthopedic Spine Surgeon at BronxCare Health System (New York City): I work primarily with an inner-city patient population in New York City, where access to spine care is often delayed. Many patients also fear spine surgery and worry that even a temporary inability to work could jeopardize their jobs. While those realities factor into treatment planning, surgical decision-making ultimately comes down to what will best improve a patient’s quality of life.
Every patient deserves care that helps them maintain a dignified quality of life. Surgery may achieve that more quickly, though with its own risks, but it is not always the right choice. For some patients, physical therapy, home exercise programs and multimodal pain management can provide similar benefits over time while avoiding the disruption surgery can introduce. My priority is always the approach that best serves the patient as a whole.
Vladimir Sinkov, MD. Founder and CEO of Sinkov Spine Center (Las Vegas): A simple answer is that surgery should not be performed unless there is a good reason to do it. With few exceptions, most spine problems are treated nonsurgically first. For elective spine surgery, a patient generally needs four things: symptoms bothersome enough to justify invasive, potentially painful and risky treatment; an anatomic abnormality that surgery has a reasonable chance of improving at reasonable risk; failure to improve with appropriate nonsurgical care; and no major contraindications, such as serious medical or psychological issues, inadequate postoperative support or lack of financial coverage.
Surgery often reimburses spine surgeons more per hour than nonsurgical care, but the goal should always be the most clinically appropriate treatment. That approach produces better outcomes, greater patient satisfaction, stronger community trust and more referrals, which can support a busier and more financially successful practice over time. This model has worked for independent spine surgeons for decades. However, as more physicians become employed by hospitals, venture capital firms or insurers, referral patterns can become less patient- or provider-driven. Guaranteed patient flow, RVU quotas and productivity bonuses may create pressure to generate more RVUs, with less referral-based accountability if a surgeon is seen as more aggressive in recommending surgery.
Matthew Webb, MD. Bone and Joint Clinic at St. Tammany Health System (Covington, La.): Surgeons who strive to treat people with respect and always put the patient first will find that patient-centered shared decision-making pays dividends in the long run. Whether together they make a decision to operate or to not operate, so long as surgeons’ patients and their families feel heard, respected and involved then those surgeons will find their waiting rooms filled with people who trust them.
Benjamin Weisenthal, MD. Knoxville (Tenn.) Orthopaedic Clinic: Several weeks ago, I treated a patient with a large foraminal disc herniation using an endoscopic discectomy, an 8 millimeter incision, no implants and home two hours later. Two years ago, before I learned the technique, I would have offered a fusion. The fusion pays multiples more, but the discectomy was the better operation. That gap, between what pays best and what’s best for the patient, is what this question is really about. Most patients with low back pain improve without surgery, and much of my clinic day is spent on medications, physical therapy, injections and education. But even when surgery is technically indicated, it may not be the right choice because of frailty, comorbidities, life expectancy, unrealistic expectations or a definition of success the operation can’t deliver. Sometimes the most useful thing I do is tell a patient I’m not going to operate.
Fee-for-service rewards more invasive care, and it isn’t credible to claim any surgeon is immune to that influence. What matters is structural discipline: documented trials of nonoperative management, clear criteria for when I won’t offer surgery, a low threshold for second opinions and a willingness to tell a patient who wants surgery that I don’t think they should have it. The discectomy case also highlights something subtler: Surgeons often choose more invasive procedures not because they pay more, but because that’s how they were trained, and the payment system reinforces that pattern. Adopting newer, less invasive techniques can mean accepting lower reimbursement to provide better care, and whether surgeons and the system will continue doing that remains an open question.
Peter Whang, MD. Professor in the Department of Orthopaedics and Rehabilitation at Yale University School of Medicine (New Haven, Conn.): While we are constantly being subjected to greater financial pressures, both external and internal, it is important for us to remember the reasons we went into medicine in the first place, taking care of our patients, regardless of whether or not that involves surgery. Until a new system is implemented that adequately values better care as opposed to more care, it is incumbent upon us to always put our patients’ interests first over everything else.
Neill Wright, MD. Neurosurgeon and Medical Director at Neurosurgery of St. Louis: More times than not, the appropriate treatment for patients seeking consultation for spinal disorders is conservative treatment such as physical therapy, time and pain management. While that is not as financially rewarding for the surgeon, it is certainly the right thing to do for the patient. A good litmus test is: What would that provider recommend for their own spouse, child or parent?
Matthew Scott-Young, MD. Orthopedic Spine Surgeon and Founder of Gold Coast Spine (Australia): The right decision to avoid surgery is made when the anticipated benefit of the intervention does not clearly outweigh the biologic, functional and psychosocial costs to the patient. Imaging abnormalities alone are not indications for surgery, and not every painful spine condition benefits from operative treatment. In many circumstances, rehabilitation, education, biological optimization, psychological support or observation may be more appropriate and more personalized forms of care.
In a healthcare system that can financially reward intervention, maintaining patient-centered judgment requires separating what can technically be done from what should be done for that individual patient. The willingness to exercise restraint when appropriate may represent one of the highest forms of surgical maturity.
Joseph Zuckerman, MD. Chair of Orthopedic Surgery at NYU Langone Health (New York City): The foundational component of the practice of medicine is based on the primacy of patient care, putting the patient’s needs first. The ethics and professionalism inherent in being a physician requires that surgeons remain true to the indications for the procedures we perform. Although most indications for surgery are clear, there is always some “judgment” component that the surgeon utilizes in making his or her decision to operate or not operate. However, if the decision is based on the patient’s best interest, then we would have fulfilled our primary responsibility as physicians.
Scott Zuckerman, MD. Assistant Professor of Neurological and Orthopedic Surgery at Vanderbilt Health (Nashville, Tenn.): Surgery is the wrong choice when patients haven’t tried meaningful nonoperative care, lack a clear anatomic source of symptoms or when risks outweigh potential benefits. A stable home life and financial situation also matter; without reliable support and resources, postoperative outcomes often suffer.
Aside from myelopathy, severe deficits or tumors, most of the operations we do are elective, and I try to really reinforce to patients that the choice to undergo surgery is very much their own; the surgeon’s role is to practice shared decision-making and educate the patient and their family as much as possible. Simply put, financial incentives should never influence the decision to operate. At the end of the day, no one wants an unhappy patient or complications, and that includes patients, surgeons and hospital leadership.
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