For decades, orthopedic surgeons interested in serious clinical research largely faced a familiar choice. They could build a career inside an academic medical center, where research infrastructure and incentives already existed. Or they could enter private practice, gaining more autonomy but often leaving much of that machinery behind.
Charlotte, N.C.-based OrthoCarolina is trying to erase that divide. The independent orthopedic group has built research into its operating model rather than treating it as an academic side project. Its research institute supports more than 260 active studies each year, with questions increasingly drawn from problems its physicians encounter in clinics, operating rooms and the business of delivering care.
For CEO and orthopedic spine surgeon Leo Spector, MD, that matters because private practices do not necessarily see the same patients, or confront the same operational problems, as major academic referral centers.
“The research questions need to come directly from the challenges of how we deliver clinical care in ambulatory orthopedics today,” Dr. Spector told Becker’s.
Glenn Gaston, MD, orthopedic surgeon and chairman of the OrthoCarolina Research Institute, sees an equally important difference in motivation.
“We do research because we want to move the needle,” he told Becker’s. “We want to affect care, and we want to change medicine.”
Research requires money, infrastructure and one of a surgeon’s most valuable resources: time. But when designed around problems a practice is already trying to solve, it can become more than an academic expense. It can become part of how an independent group competes.
Start with the question the clinic cannot answer
Dr. Gaston said most OrthoCarolina research begins with a clinically relevant question. The research institute uses a multidisciplinary advisory committee to vet ideas before projects begin. A proposal from a hand surgeon, for example, may be reviewed by physicians in joint replacement, foot and ankle and other subspecialties.
The goal is to challenge the study design before anyone spends a year collecting data only to discover the study never answered the question physicians actually cared about. “Research is baked into the culture of OrthoCarolina,” Dr. Gaston said. “The docs remain curious.”
For Dr. Spector, private practice can contribute something distinct to orthopedic evidence.
Academic medical centers are essential for basic science and studying rare, complex conditions concentrated at tertiary referral centers. Large orthopedic practices, meanwhile, see enormous volumes of conditions physicians treat every day.
Their research agenda can also extend beyond surgical technique. Prior authorization is one example. It directly affects whether patients receive care, how quickly that care happens and what it costs a practice to deliver it.
“Delivering care is not just about what we do in the clinic and in the OR,” Dr. Spector said. “It’s all that around it.”
A paper matters more when a practice can act on it
Research does not change care simply because it gets published. Dr. Gaston sees two forces that make evidence persuasive to surgeons: confidence in the data and confidence in the people who generated it.
When surgeons know the colleagues behind a study and trust the methodology, the distance between evidence and adoption can shrink.
OrthoCarolina’s work on postoperative pain management offers one example. Through research conducted with support from The Duke Endowment, physicians across orthopedic subspecialties compared traditional opioid-based pain management with multimodal nonopioid protocols. Dr. Gaston said the research found the nonopioid approaches provided comparable pain control and, in many cases, better pain control.
OrthoCarolina then incorporated the option into its electronic medical record workflow, allowing eligible patients to indicate interest in nonopioid pain management and surfacing that preference to their physicians.
“It goes from research paper to research practice-changing,” Dr. Gaston said. That is a key advantage of conducting research inside a large clinical organization: The same institution generating the evidence can redesign care around it.
Research can also tell surgeons what to stop doing
New technology creates an obvious use for research: deciding whether something deserves adoption. Dr. Gaston believes the harder test is whether surgeons are willing to use evidence against their own habits.
Without systematically measuring outcomes, surgeons can assume a familiar treatment is performing well simply because they are not looking closely enough for evidence that it is not.
“What it really takes is a surgeon who’s willing to critically look at their own work,” Dr. Gaston said. A research culture, he said, helps surgeons avoid being the first to chase every promising technique without becoming the last to abandon an inferior one. “You don’t always want to be an early adopter, and you don’t want to be a late adopter,” he said. “You want to recognize when something new is truly better and adopt it early.”
The highest-level evidence need not come from academia
One of OrthoCarolina’s most prominent recent studies tested a longstanding assumption in joint replacement. Treatment for an infected prosthetic joint has traditionally involved a two-stage exchange: remove the infected implant, treat the infection and return later for another operation to place the new joint.
OrthoCarolina physicians helped lead a prospective, multicenter randomized trial examining whether appropriately selected patients could instead undergo a one-stage exchange.
The paper became a lead article in The Journal of Bone and Joint Surgery. “That took many years of gathering all the data,” Dr. Gaston said, “but has the potential to really impact change across the world.”
For Dr. Spector, the study shows independent practices can do more than participate in research conducted elsewhere. Large groups have something academically valuable of their own: volume.
“If you’re willing to invest the time and energy to build the research infrastructure, a large independent practice has the patient volume to conduct studies that directly improve care,” Dr. Spector said.
ROI does not fit neatly into a spreadsheet
Research costs money. Industry-sponsored trials may arrive with dedicated budgets. Many of the questions OrthoCarolina wants to answer do not. A study on prior authorization has no device company waiting to finance it. Neither does every comparative study of clinical care.
Dr. Spector does not pretend the return can always be reduced to a clean financial ratio. The first return, he said, is better patient care. Others can compound from there. Research can strengthen the practice’s reputation, attract surgeons who want an academic dimension to their careers without giving up private-practice ownership and help retain experienced physicians by giving them work beyond clinic and surgery.
“Is it a dollar-for-dollar measurable ROI? No,” Dr. Spector said. “But I would say we get a great return on that investment.”
The recruiting pitch is a third career path
Dr. Spector describes the OrthoCarolina model as “pracademic:” private practice with substantial commitments to research and education. Traditionally, a surgeon interested in research, fellows and innovation could enter academia. A surgeon interested in ownership and entrepreneurship could choose private practice.
Dr. Spector wants OrthoCarolina to offer both. “There is a middle path,” he said. He acknowledged the model could produce the “worst of both worlds” if an organization adds academic expectations without enough infrastructure or layers private-practice productivity pressure onto physicians already trying to teach and conduct research.
The objective is the opposite: preserve private-practice autonomy while giving physicians enough support to conduct consequential academic work. Research and education can also provide different sources of professional meaning over a career.
“When you educate young practitioners and see research translate into better patient care, that really helps fill up your cup,” Dr. Spector said. That makes research part of a talent strategy as much as a scientific one.
The competitive advantage is the loop
The OrthoCarolina Research Institute is a separate nonprofit organization, but its value to the orthopedic group depends on how little distance exists between research and practice.
A surgeon encounters a problem. The practice turns it into a research question. Physicians test it across a large real-world patient population. The evidence comes back into the organization. Then the practice has the scale to change how care is delivered.
That loop is harder to replicate than publishing papers alone. It requires patient volume, physician engagement, research infrastructure, capital and a culture willing to question its own clinical habits.
For independent orthopedic practices, that may be the larger lesson. Research becomes a competitive advantage when evidence changes how a practice operates, and when surgeons want to work there because they have a hand in producing it.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
