Orthopedic surgery has undergone a dramatic transformation over the past several decades, with advances in technology, surgical techniques and outpatient care reshaping how surgeons practice. But declining reimbursement, growing payer influence and consolidation have introduced new challenges, prompting leaders to reconsider their roles and the future of the specialty.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What has changed the most about being an orthopedic surgeon since you entered the field, and how has it affected the way you practice?
Joseph Alhadeff, MD. Chief of Orthopedic Surgery at Lebanon (Pa.) VA Medical Center: I’ve been in practice for over 25 years, so there have been too many changes to list, but I would say that there are two competing forces for change. Clinically, things have improved significantly over the years with the advent of better operative techniques, robotics, pain management protocols and patient management that outcomes and length of stay for joint replacement patients and joint arthroscopy patients have improved dramatically.
Patients have gone from staying in the hospital or skilled nursing facilities for a week to being discharged the same day or just spending a day or two in the hospital with better pain control and faster rehabilitation. Technological and clinical advances allow us to take better care of our patients, and it is exciting and challenging to keep up with all the advances and in some cases contribute to them. On the negative side, there has also been an explosion of over-regulation and insurance over-reach. The amount of paperwork and documentation, prior authorizations, care denials, delays in care and limitations of care has grown so much that today, the biggest impediment to an orthopedic surgeon providing optimal care to patients is the insurance companies, rather than the disease process or injury.
Kevin Bozic, MD. Chair of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin: When I finished training and entered into practice, our identity was largely defined by the operations we performed. Today, I see our role more broadly: helping patients improve their musculoskeletal health, with surgery as one of many tools we have at our disposal. That has led to the creation of multidisciplinary teams around patients’ needs and goals, and to measure outcomes from the patient’s perspective. The transition from fee-for-service to outcomes-based payment has been slow, but it gives us an opportunity to align how we’re paid with what we’re trying to accomplish for our patients.
Pablo Castaneda, MD. Professor of Orthopedic Surgery at New York City-based NYU Grossman School of Medicine and Baylor College of Medicine (Houston): The greatest change I have witnessed is the growing disconnect between the value physicians create and how we are compensated. We have developed extraordinary surgical capabilities, yet reimbursement continues to decline relative to the complexity, cost and long-term impact of our work. We increasingly measure productivity rather than value.
But I believe we are approaching a far more profound transformation. AI will fundamentally change how we diagnose, make decisions, communicate with patients and deliver care. Much of what traditionally required specialized medical knowledge will become widely accessible and increasingly automated. This presents an extraordinary opportunity to redesign healthcare around outcomes rather than encounters and procedures.
It has changed how I think about my own practice. I increasingly focus on the value of clinical judgment, long-term outcomes and how technology can improve access and efficiency.
The next revolution in orthopedic surgery may not occur in the operating room. It may come from fundamentally rethinking what physicians do, how we deliver care and what society should pay us for.
MaCalus Hogan, MD. Chair of Orthopedic Surgery at the University of Pittsburgh School of Medicine and Chief of UPMC Orthopaedic Service Line (Pittsburgh): Few changes have transformed orthopedic practice more decisively than the rapid migration of surgical and procedural care to outpatient settings. This shift is being driven not simply by reimbursement pressures and value-based care, but by surgeons and patients demanding better options and by innovation across pre-, peri-, and postoperative care.
Given the enormous scale of orthopedic and musculoskeletal care, this momentum will continue to accelerate, requiring physicians, payers and health systems to deliver exceptional outcomes with greater efficiency and at a competitive cost. Those that do will not merely survive; they will thrive and grow.
Earl Kilbride Jr., MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: There have been two big changes since 2002 when I finished training. First, digital radiographs and the EMR have been widely implemented. At this point, even a small office is oftentimes fully electronic. Certainly the benefits, such as accuracy and completeness are easy to see. However, the notes went from a readable, logical depiction of the patient’s condition to a choppy EMR produced note.
The second and probably bigger issue is the takeover of the independent physician. Employment by healthcare systems has become incredibly popular. As an independent provider, the deep pockets of the system continues to isolate the independent doctor and makes it challenging to compete in the same market. We have to be mobile and innovative to continue to compete for those same patients.
Emeka Nwodim, MD. Orthopedic Spine Surgeon and Managing Partner of Centers for Advanced Orthopaedics, Bay Area Orthopaedics & Sports Medicine Division (Hanover, Md.): What has changed the most for me since becoming an orthopedic surgeon is mindset. What began as a relatively narrow, yet fundamental, focus on clinical expertise, patient care and the ambition of surgical perfection, has evolved into a more comprehensive perspective on medicine.
Clinical expertise, patient care and the ambition of surgical perfection remain foundational to my practice. However, I have come to appreciate that relationships, strategic partnerships, leadership, operational efficiency, preparation and foresight of future opportunities to optimize the practice and business of medicine for clinicians has now gained equivalent priority.
Mark Wolgin, MD. Orthopedic Surgeon in Sterling, Colo.: The quality of care has gone downhill. Now, doctors are lumped in with mid levels and we’re all called “providers” as if we are interchangeable. However, as mid levels are cheaper and more plentiful, they are doing more of the care, but there is a difference. The main issue is insurer control of care, where the effective control of care is done by a for-profit entity with a pure conflict of interest. Any money spent on care is less profit for them. And don’t get me started on worker’s compensation. The quality of care there is abysmal, where denial is more the rule than the exception. Patients are literally starved into accepting a settlement, but unfortunately, it has become an employment program for attorneys.
AJ Yates Jr., MD. Professor and Chief of Orthopedic Surgery at UPMC-Shadyside Hospital (Pittsburgh): The greatest change since starting residency 42 years ago has been the rapid evolution of information dissemination via EMRs, the Internet, AI, emails and texts; news travels faster than can be assimilated, as predicted in 1970 by Alvin Toffler in the book Future Shock. Textbooks, once prized possessions, are foreign to current residents. This has led to a paradoxical contraction of acceptable treatment options controlled by on-line study guides that value brevity over history and depth concerning topics that were once found page by page.
Other changes have included loss of autonomy through consolidation, rigid sub-specialization, volume driven practices due to reversals in compensation, and marketing practices focused on form, not function. We remain in a relatively punctuated equilibrium of surgical techniques that were rapidly accepted in the ‘80s, such as basic total hip and knee design and composition, pedicle screws, arthroscopy, fracture fixation, and microsurgery, with advances on the margin readily absorbed by surgeons without retooling and that made practices such as traction management obsolete over my time in medical school and residency. Radical re-training is, however, around the corner, and beyond my career horizon by only a few years, with the inevitable changes to be wrought through AI, nanotechnology, tissue printing, robotics and biologics. Most importantly, there has been a time management-driven drift from seeing and knowing the patient as a whole person rather than a collection of reparable parts that are technological challenges.
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