Every orthopedic group is feeling it now: the quiet squeeze between rising demand and a shrinking willingness to work the way the last generation did.
Patients are living longer. Musculoskeletal needs are growing. But the pipeline of surgeons, and the way surgeons want to practice, has fundamentally changed.
Leo Spector, MD, orthopedic spine surgeon and CEO of Charlotte, N.C.-based OrthoCarolina, sees the shift from both sides of the exam room.
“We have an aging population, people living longer, so there’s more demand for services,” he said. “That doesn’t necessarily change the supply side.”
What has changed, he believes, is the surgeon workforce itself.
In the wake of COVID-19, many senior physicians have begun recalibrating their priorities. At the same time, younger generations are entering practice with a different definition of sustainability.
“You’re seeing much more of an emphasis on work-life balance, life experience, as opposed to work accomplishment and financial accumulation,” Dr. Spector said.
He is careful not to frame the shift as decline, but as generational reality. “I’m not saying one is good or bad,” he said. “It just is reality.”
However, the operational impact is undeniable. To replace one retiring surgeon, practices increasingly need more than one hire.
“To replace one of our senior surgeons that are retiring,” he said, “we really need 1.5, sometimes two surgeons, as far as their work capacity.”
From autonomy to employment
Orthopedic surgery has long carried a reputation for independence, a specialty shaped by entrepreneurial practice models and physician ownership.
But Dr. Spector says recruitment today is being pulled by a different gravitational force: stability.
“Orthopedic surgeons tend to be a little bit more on the independent, entrepreneurial side,” he said. “But you’re starting to see more of a gravitational pull toward employment.”
Many younger surgeons, he noted, are willing to trade autonomy for predictability.
“I’ll give up some of that entrepreneurship,” he said, “but in exchange, I’ll get some work-life balance, I’ll get more security.”
Hospital employment, academic systems and even private equity-backed platforms are all part of that evolving landscape.
Retention is built, not assumed
At OrthoCarolina, recruitment is only the first challenge. Keeping surgeons engaged over decades requires deliberate structure. The practice, which remains physician-owned and physician-operated, has built governance models designed to foster long-term investment.
“We have a recruitment and retention committee,” Dr. Spector said, focused not only on filling needs, but on what happens after surgeons arrive.
The goal is early engagement and meaningful ownership. “We try to make a structure that creates an easy buy-in,” he said. “They earn equity ownership over time that vests, so there are financial incentives to stay longer.”
Physicians are brought quickly into committee leadership and decision-making, reinforcing that they are not employees, but stakeholders. “They feel invested,” he said, “and feel like they’re not an employee, but they are a shareholder of the company.”
Just as importantly, retention strategies must evolve with career stage. “The shareholder surgeon in the first couple of years is not the same mid-career as they are late-career,” he said. “Those physicians need different things at different stages.”
The Goldilocks challenge of alignment
As practices scale, preserving surgeon independence becomes more complex. OrthoCarolina now has more than 115 shareholders, a size that requires balance between autonomy and standardization.
“If people have pure autonomy, then you lose all the efficiencies and economies of scale,” Dr. Spector said. “Because then you have 115 practices.”
The challenge is finding what he calls the “Goldilocks” middle ground. “We want you to have enough independence and autonomy,” he said, “but enough uniformity that we get economies of scale.”
Too much control risks eroding the very independence surgeons value. Too little risks fragmentation.
“We want to be the best of both worlds,” he said. “That is a tough thing to get just right.”
Why physician leadership matters
Dr. Spector’s perspective is shaped by his dual role: practicing spine surgeon and CEO. That connection, he believes, protects organizations from drifting too far from their purpose. “I was just in clinic yesterday, seeing patients,” he said. “So we never lose that connection to what our purpose is, our why, which is caring for patients.”
OrthoCarolina’s mission, he added, is broader than clinical outcomes alone. “Our mission is to make lives better,” he said, “for our patients, for our teammates and for our practitioners.”
As a practicing physician, Dr. Spector said he remains closely connected to patients, practitioners and teammates alike. That perspective also informs how he leads surgeons, who he noted can often be highly independent and strong-minded by nature.
Leading them effectively requires understanding the daily realities of call, patient care and the pressures of modern medicine. The organization, he said, made a deliberate choice to keep that clinical lens embedded at the top.
“We had to have that philosophical conversation,” he said. “Do we want to hire a professional CEO, or do we want to hire a physician shareholder CEO?”
OrthoCarolina chose the latter.
The missing piece: telling the long-term story
For groups struggling with recruitment and retention, Dr. Spector believes the gap is often not compensation, but vision. “We’ve got to be able to communicate to prospective partners the long-term vision,” he said.
Early-career surgeons are often drawn to hospital packages with debt support and guaranteed salaries. And after years of delayed earning, those offers can feel irresistible.
“We all graduate college. Our friends go off and get jobs, and we go to medical school and get more debt,” he said.
By the time physicians finally reach practice, guaranteed salaries are “eye-popping,” and it becomes easy to think only in the short term. “You lose sight of what you want your long-term career to be,” he said, “and not just worry about those two or three years.”
The responsibility of private practice, he argues, is to help young surgeons see beyond the immediate offer and understand the full arc of a career. “We’ve got to be able to tell that longitudinal story,” Dr. Spector said.
Because the decision is rarely about the first two or three years. It is about the decades that follow. “It’s a marathon,” he said. “It’s not a sprint. You’ve got to be able to articulate what the marathon of your career looks like. Don’t worry about the first couple of miles.”
