How to Become a Orthopedic Surgeons, Except Pediatric

Where Orthopedic Surgeons, Except Pediatrics have the most money left over after rent

Median pay minus estimated federal + state + FICA taxes, minus 12 months of rent at HUD's 2-bedroom Fair Market Rent. Darker green means more money left over each year. Hover any state for the breakdown.

Education and training

Orthopedic surgery is five years of residency after medical school, and then almost universally a fellowship year on top of that. Plan for 14 years minimum from high school to independent practice. The match is highly competitive, ranking among the most difficult in medicine alongside dermatology and neurosurgery.

Undergrad should be four years of strong pre-med preparation with GPA above 3.7. Research helps but clinical exposure in orthopedics matters too. If you can shadow in an orthopedic practice, do it early. The mechanics of the specialty, screwing bones together, replacing joints, repairing tendons, are either fascinating to you or they're not. The clinical reality looks different than the conceptual description.

Medical school: Step 1 above 245 is essentially required for competitive programs, and many matched applicants are at 255+. You need strong grades in your clinical years, letters from orthopedic surgeons who know your work well, and research ideally in the orthopedic or musculoskeletal space. Audition rotations at programs you're targeting are important. Orthopedic surgery is one of the specialties where personal connections from your sub-internship genuinely influence ranking decisions.

Orthopedic surgery residency is five years (PGY1-5). The training covers spine, hip and knee reconstruction, sports medicine, trauma, foot and ankle, shoulder and elbow, hand surgery, and tumor surgery. The chief year involves significant autonomy in the OR. Call in residency is physically demanding because trauma doesn't stop at 5 PM.

Fellowship has become functionally mandatory for subspecialty practice. Sports medicine (one year), adult reconstruction/arthroplasty (one year), spine (one year), hand surgery (one year), foot and ankle (one year), shoulder and elbow (one year), orthopedic trauma (one year), and oncology are the main tracks. Most orthopedic surgeons in practice today completed fellowship.

Licensing and certification

State medical licensing after USMLE completion. Orthopedic surgeons practicing at multiple sites need licensure at every state where they operate, which is relevant for surgeons who do locum work or cover multiple systems.

ABOS certification (American Board of Orthopaedic Surgery) requires passing a written exam after residency, then an oral examination approximately 22 months after beginning practice. The oral exam is case-based and tests your management of your own patients from your first year of practice, which you submit for review. This structure is unlike any other surgical board exam and failing it is more common than people expect.

Subspecialty certification in sports medicine (through ABOS), hand surgery (through ABOS or the American Board of Plastic Surgery), or spine is available but requires additional examination.

Hospital credentialing requires operative logs demonstrating competency in the procedures you want privileges for. If you want to do total joint replacements, you'll need to document volume from training. Robotic surgery privileges (Mako, etc.) often require manufacturer-sponsored training courses in addition to the standard credentialing process. DEA registration is standard for prescribing perioperative and post-operative pain medications.

What the day-to-day looks like

The orthopedic surgeon's day is built around the OR. Operating days start at 6 or 6:30 AM with pre-op rounds, first case at 7:30. A busy total joint surgeon might do three to four primary total hips and knees in a day. A sports surgeon might do four to six arthroscopies plus one or two open procedures. A spine surgeon doing multilevel fusions has longer cases and sees fewer per day.

Clinic days are separate from OR days in most practices. You're seeing new patients, post-operative follow-ups, and acute injuries. An orthopedic sports medicine clinic will see ACL consultations, shoulder impingement, rotator cuff tears, meniscus injuries, and every variation of overuse pathology. A joint replacement clinic sees painful hips and knees and patients at various stages of the pre-op and post-op process.

Call is highly variable by practice setting. Orthopedic traumatologists who staff a level I trauma center are on call for open fractures, femur fractures, acetabular fractures, and complex trauma at any hour. Community orthopedic surgeons covering their own patient call still get called for post-operative problems, but it's a different level of urgency. Some practices contract out trauma call to a specific partner or use a rotation structure that makes each surgeon's call burden manageable.

The physical demands of orthopedic surgery are real. The spine cases involving fluoroscopy expose you to radiation over a career. Total joint replacement is physically demanding on your hands, wrists, and back. Orthopedic surgeons who do 20+ years of high-volume joint replacement often develop their own musculoskeletal problems. This isn't speculation; it's what your senior partners will tell you.

Career progression

Orthopedic surgery attending starting salaries are among the highest in medicine: $500,000-$700,000 for most new attendings in private or employed positions. Sports medicine orthopedics in high-demand markets with major sports team contracts can start higher. Spine surgeons doing complex instrumented fusions also start near the top of the range.

Five to ten years into practice, established orthopedic surgeons in productive settings earn $700,000-$1,200,000. The highest earners are doing high-volume joint replacement or spine surgery with ownership stakes in ambulatory surgery centers (ASCs). ASC ownership by orthopedic surgeons is a major wealth driver because procedure technical fees, which go to the facility rather than the surgeon in a hospital setting, flow to the surgeon when they own the facility.

Partnership in private orthopedic groups and ASC buy-in are distinct transactions. The group partnership provides a share of professional fee revenue and overhead. The ASC buy-in provides a share of technical fee revenue. The latter is often where significant wealth is built. Buy-in costs for ASC ownership vary enormously, from $100,000-$500,000 depending on the center's size and profitability.

Academic orthopedics pays less, typically $400,000-$600,000, with protected research and teaching time. Academic spine surgeons at high-volume centers can do better if their RVU production is high.

Salary progression

Highest paying states

Where the jobs are

Salary negotiation

Orthopedic surgery contracts are among the most lucrative in medicine and also among the most aggressively contested. Hospitals want orthopedic surgeons because orthopedic procedures are highly profitable for facilities. Private equity has been aggressively acquiring orthopedic groups, changing the ownership and compensation landscape.

RVU productivity for orthopedic surgeons is high: median wRVUs are around 12,000-15,000 per year for most attending orthopedic surgeons, with high-volume joint replacement and spine surgeons exceeding 18,000-22,000 wRVUs. Know where your expected production falls relative to MGMA benchmarks before signing.

ASC ownership and access is the most important non-salary negotiating point. If a practice has a surgery center and doesn't offer new partners a path to ownership, that's a significant financial concession. Push hard for a defined timeline and price for ASC buy-in.

Call stipends for trauma and emergency orthopedic call are negotiable and should reflect the burden. Weekend trauma call at a level I center might pay $2,000-$5,000 per weekend of coverage in competitive markets. Facilities that can't staff trauma call will pay more.

Tail coverage runs $100,000-$200,000 for surgical specialties including orthopedics. Get this covered by the employer if at all possible. Non-competes should be scrutinized carefully: an orthopedic surgeon who can't practice within 25 miles of a mid-size city has effectively been pushed out of their market if they leave the employer.

What the data doesn't tell you

Orthopedic surgery attracts a specific type: people who are mechanically minded, who like immediate tangible results (hip replacement takes a person who couldn't walk and makes them functional in weeks), and who can handle a training program that is physically and emotionally demanding. The culture of orthopedic surgery has historically been aggressive and hierarchical, and while it's changed, vestiges remain.

The financial opportunity is real and it's one of the highest in medicine, but the path to maximal financial success requires strategic practice positioning. The orthopedic surgeons who build significant wealth are those who own their OR time (ambulatory surgery center ownership), build high-volume elective practices, and avoid being purely hospital-employed without equity participation.

PE-backed orthopedic groups are offering attractive initial compensation and partnership structures, but what you're buying into in a PE-owned entity is different from a true physician-owned practice. The exit strategy of the PE firm in five to seven years has direct implications for your practice situation at that point. Understand the ownership structure deeply before signing.

The specialty is changing with robotics. Mako and similar robotic platforms are increasingly standard for total joint replacement and require training and credentialing. Surgeons who embrace the technology and become proficient have advantages in marketing and patient acquisition. The technology also changes the procedure itself in ways that will continue to evolve.

Frequently asked questions