Pediatric Orthopaedic Compensation Is Being Asked to Do More Than Pay a Salary
Pediatric orthopaedic surgery has reached a point where compensation is no longer just an accounting exercise. It has become a lever for recruiting surgeons, keeping them in academic practice, and steering departmental behavior toward operative care, nonoperative care, research, and teaching. In this 2025 perspective, a group of pediatric orthopaedic leaders argues that pay structures must be designed around the actual mission of a pediatric program, not around a narrow view of clinical volume alone.
The article draws from two decades of conversations among division chiefs and from the lived experience of surgeons who have hired, evaluated, and compensated large numbers of colleagues. Over the past decade, the five authors collectively oversaw compensation for approximately 100 pediatric orthopaedic surgeons each year. Their central message is straightforward: a high-performing pediatric orthopaedic program depends on hiring, developing, retaining, and promoting outstanding surgeons, and compensation policy can either support that goal or quietly erode it.
The stakes are practical. Pediatric orthopaedic surgeons do not simply generate visits and procedures; they also manage congenital, developmental, traumatic, and neuromuscular conditions, often across long arcs of care. A compensation system that rewards only a single metric risks pulling surgeons away from educational work, complex cases, or the nonoperative management that defines much of pediatric orthopaedics. In an academic setting, that distortion can weaken the very program leaders are trying to build.
Pay Structures Need to Match the Work Pediatric Orthopaedists Actually Do
Compensation models in surgery often center on productivity, but pediatric orthopaedics does not fit neatly into a purely volume-driven framework. Some surgeons carry heavy operative loads, while others devote substantial time to clinic-based decision-making, consultation, teaching, and program building. Educational work, mentoring, and research are not side activities in this field; they are part of the infrastructure that keeps care safe, current, and reproducible.
A compensation plan that treats these contributions as invisible will predictably send the wrong signal. Surgeons learn quickly what an institution values. If compensation tracks only procedural throughput, then the surgeon who accepts complex, time-consuming, nonoperative, or academically heavy work may be penalized for serving the program in ways that do not show up cleanly in a billing ledger. In pediatric orthopaedics, where the best answer is often longitudinal management rather than immediate intervention, that mismatch can be especially damaging.
The authors frame surgeon leaders as the people most able to correct this drift. Division chiefs and other leaders are not just administrators; they are the ones responsible for shaping culture, setting expectations, and deciding which behaviors are rewarded. Their role includes evaluating whether compensation models encourage excellence in both operative and nonoperative care, while also supporting research and educational missions that sustain future innovation.
Recruitment and retention are not abstract goals. They are the first test of whether a compensation system works.
Leadership Experience Matters When Compensation Becomes a Retention Tool
The perspective carries particular weight because it reflects both seasoned and newer leadership experience. Two coauthors are experienced chiefs with years of hiring, evaluating, and compensating surgeons, while two are more recently appointed chiefs building programs of their own. That mix matters because compensation policy is often inherited before it is truly understood. New leaders confront the structure already in place; seasoned leaders see which incentives survived contact with day-to-day practice and which ones created unintended consequences.
Over the past decade, their oversight of roughly 100 surgeons per year gave them a wide view of how compensation affects behavior across different career stages. Early-career surgeons may need clear pathways for growth and promotion. Midcareer surgeons may need incentives that recognize leadership, teaching, and institutional service. Established faculty may need structures that preserve senior expertise while still rewarding productivity and program stewardship. A single formula rarely serves all three groups well.
Strong compensation design also helps a division avoid the quiet losses that are hard to reverse later. If a talented surgeon feels undervalued because nonclinical work is ignored, the institution may not notice immediately. The impact may surface later as slowed recruitment, reduced morale, or a weaker academic pipeline. Surgeon leaders sit closest to those warning signs, and their judgment is central to preventing them.
Compensation Should Reward Excellence, Not Just Activity
The article argues for compensation models that motivate surgeons to contribute to a top-tier pediatric program in multiple dimensions. That means recognizing excellence in operative care, but it also means acknowledging clinic-based decision-making, research output, and educational commitment. Pediatric orthopaedics relies on surgeons who can diagnose accurately, counsel families carefully, and teach trainees while maintaining surgical quality. Pay structures that ignore that mix will inevitably favor one part of the mission at the expense of the others.
One of the quiet biological and organizational realities of pediatric orthopaedics is that outcomes often depend on time, judgment, and continuity rather than speed alone. Children with musculoskeletal disorders may need repeated reassessment, staged decision-making, or prolonged monitoring before surgery becomes appropriate. A system that rewards only immediate procedural output can push against this tempo. Compensation, in that sense, becomes a clinical instrument as much as a financial one.
The article’s perspective also reflects a broader truth about academic medicine: excellence is usually built by people who are both clinically effective and institutionally committed. Leaders who hire well, mentor well, and keep strong faculty in place create the conditions for better patient care and stronger training programs. Compensation is one of the few tools that can reinforce those behaviors at scale.
Program Excellence Depends on Retaining the Right Surgeons
The clearest operational message is that compensation policy must support retention if a program is to stay excellent. Hiring outstanding surgeons is only the beginning. Retaining them requires a system that feels fair, transparent, and aligned with the actual demands of pediatric orthopaedic practice. Promotion matters too, because programs grow when high-performing surgeons can advance without abandoning the educational and academic work that made them valuable in the first place.
This perspective does not present a single universal formula, and it does not pretend one exists. Instead, it places responsibility on surgeon leaders to build compensation systems that are fit for purpose. Those systems should reflect the mix of clinical work, leadership, scholarship, and teaching that defines pediatric orthopaedics in the United States.
The article leaves administrators with a concrete challenge: if a compensation model cannot help recruit, develop, retain, and promote outstanding pediatric orthopaedic surgeons, then it is not serving the mission of the program. The next question for institutions is whether their current incentives truly match the work they expect surgeons to do.