For 20 years prior to the pandemic, Scott Boden, MD, achieved something many academic departments quietly struggle to sustain: He hasn’t lost a single faculty member, except to retirement or disability. “I pretty much had a 20-year period where I had 100% retention,” he told Becker’s.
Now chair emeritus of the department of orthopedics at Atlanta-based Emory University School of Medicine and former chief strategy officer of Emory Healthcare, Dr. Boden believes the future of orthopedic and spine access will depend less on recruitment headlines and more on whether health systems understand what actually keeps surgeons in place.
Because in academic medicine, retention is not automatic. It is engineered.
It’s not just generational — it’s structural
Over decades in leadership, Dr. Boden has watched workforce expectations shift.
“With the caveat that generalizations don’t reflect every individual,” he said, “I would say many of the younger surgeons we’re recruiting want the rights, privileges and accolades of senior orthopedic surgeons, but don’t seem to think they need to put in the same number of hours to achieve it.”
He is careful to frame that observation within broader societal change. The world has evolved, he noted. But the demand for orthopedic and spine care has not.
Still, he cautions against oversimplifying the conversation into work ethic alone.
“You can’t take somebody who’s been practicing 40 years and has gained efficiencies and expertise and speed and know-how,” he said, “and drop somebody who’s just out of fellowship into that spot and expect them to produce the same amount of productivity, even if they were working the same hours.”
Replacing a 65-year-old surgeon with a 35-year-old surgeon is not a 1-to-1 transaction.
“It’s not just the attitude or work ethic,” he said. “It’s also the reality.”
Older surgeons retire at peak efficiency. Younger surgeons are still building theirs. Systems that treat those transitions as simple full-time equivalent swaps risk miscalculating both access and output.
The employment shift — and its academic paradox
When Dr. Boden speaks with residents and fellows, he hears less appetite for navigating the business mechanics of orthopedics than in prior generations.
“I think people are tending to want to be more in an employed environment,” he said, “rather than learning and wrestling with sort of the business of orthopedics.”
Entrepreneurial surgeons remain, but many who might once have pursued ownership are leaning toward employment, where administrative burden and financial volatility are absorbed by larger organizations.
“Worrying about that stuff takes time,” he said. “And then that disrupts work-life balance.”
For academic medical centers, that preference creates a paradox. They offer institutional support and perceived stability, but they cannot replicate certain economic advantages available in private practice, particularly ASC ownership.
“The delta in passive income between having ASC ownership in private practice and what a large not-for-profit health system can pay orthopedic surgeons while staying within fair market value is probably bigger in orthopedics than almost any other specialty,” Dr. Boden said.
That compensation gap is increasingly a retention pressure point for academic departments.
The role no one trains you for
Dr. Boden believes one of the largest gaps between training and practice has little to do with surgical skill.
“When you enter a practice, you probably don’t have a lot of experience with governance,” he said, “and sort of managing culture groups so there’s no infighting.”
Early in his career, he assumed politics and cultural dysfunction were unique to academic medicine. Over time, he realized those dynamics are just as present in community practice.
“There’s just as many challenges and politics and lack of experienced leadership in community practices,” he said.
Those vulnerabilities, he noted, can make some groups attractive targets for private equity acquisition. But once private equity enters, retention can become more complicated, particularly if younger physicians feel they have less control over the direction of the practice.
Leadership development, in his view, cannot be incidental.
That belief led him to help create the American Orthopaedic Association’s Emerging Leaders Program in the early 2000s, which is designed to identify surgeons within their first decade of practice and equip them with skills in negotiation, communication and strategic planning.
“There were definitely younger people that had leadership potential,” he said, “but there was no way to engage.”
Two decades later, he helped endow the program to ensure its longevity. “I just love engaging and helping with young leaders,” he said.
Retention is built on structure, not slogans
Dr. Boden’s 20-year retention record, he emphasizes, was not the product of luck. It required confidence in local leadership and transparency, “not always good news,” he said, along with a system perceived as fair. But fairness alone is not enough. Flexibility matters.
“You need flexibility for the uber performers,” he said, “and for those that are maybe lower performers but serve other purposes, in a way that makes everyone feel valued.”
Rigid standardization can push away top producers. Too much variability can create inequity. Sustainable leadership, he suggests, lies in setting guardrails without eliminating autonomy.
The operational piece most systems underestimate
Looking ahead five to 10 years, Dr. Boden believes access to orthopedic and spine care will hinge less on recruiting slogans and more on operational discipline. Orthopedics is inherently high volume. That reality demands an efficient outpatient infrastructure.
“In order to provide the best patient experience and enable orthopedic surgeons to be maximally productive,” he said, “it requires an efficient outpatient operation.”
That includes advanced practice providers, including physician assistants, nurse practitioners and, in some cases, athletic trainers, deployed thoughtfully based on subspecialty needs.
If outpatient workflows are inefficient, burnout follows. If high-performing surgeons are not adequately supported, turnover accelerates.
“Figure out who the real productive clinicians are and make sure that they’re supported,” he said. “When they’re maximally productive, they’re going to be happy. They’re not going to be burned out. They’re going to feel valued.”
The formula may sound simple. Execution rarely is.
But in Dr. Boden’s view, the future of orthopedic access will not be decided by generational debates alone. It will be decided by whether health systems build environments where surgeons can spend their entire careers, not just their first contract, and remain both productive and engaged.
