What If Orthopedics—Not Primary Care—Was the Hub of Whole-Person Care?

Presented by Commons Clinic

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A 55-year-old patient walks into an orthopedic clinic with knee pain. He’s overweight, has borderline diabetes, and struggles to stay active. He’s tried injections, physical therapy, and over-the-counter meds. Now he’s being told he needs a knee replacement.

Surgery goes well. Post-op x-rays look perfect. The patient recovers.

Yet months later, he’s still in pain and dissatisfied with his outcome.

This scenario isn’t rare, occurring in about 10% of patients.

In the past, musculoskeletal care has treated problems as if they exist in a vacuum — disconnected from other body systems. We wait until someone’s arthritis is bad enough for surgery, then we operate. We tell patients to lose weight, stop smoking, and improve their diets but do a poor job supporting them through this process. We overlook how anxiety and depression negatively impact outcomes. We perform technically sound surgery but fail to address the underlying metabolic, behavioral, and social factors that are critical to obtaining favorable results.

Achieving desirable outcomes requires an integrated approach. Successful treatment of MSK conditions (surgical and non-surgical) is inextricably linked to overall health.

It’s easy to dismiss “whole-person” care as some unreachable, empty ideal. It’s not. It’s the logical evolution of next-generation care delivery — and MSK is the perfect gateway.

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Flipping the Script

Instead of trying to build a whole-person care model from primary care outward, what if we started with MSK and worked our way outward?

MSK conditions are among the most common reasons patients seek care. They’re directly tied to cardiometabolic health, weight, and mental well-being. And they’re also a major cost driver for both employers and the government.

Despite their flaws, VBC programs have taught orthopedic surgeons a critical lesson— we can’t treat MSK conditions in isolation. The success of our treatments, both surgical and non-surgical, depends on identifying and addressing the full spectrum of factors that influence musculoskeletal health.

Traditionally, advanced care models are built around primary care as the “hub,” with specialists forming the spokes. PCPs dictate how patients flow through the system — incentivized by capitation (or some other form of VBC) to reduce the utilization of expensive services. What if we’ve been thinking about this backward?

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Fresh out of training, I would have dismissed this kind of thinking prima facie. The surgeon's mindset is that a chance to cut is a chance to cure. If we perform a technically sound procedure and our x-rays look good, our job is done. Or so we think.

Over fifteen years of experience have taught me that patient factors are every bit as important as surgical proficiency. Surgeon performance is tightly clustered — and we still can’t agree on what the “perfect” x-ray looks like. But one thing is certain: the patients we treat are complex — a combination of modifiable metabolic, lifestyle, and psychosocial factors that don’t exist independently of one another.

Modifiable risk factors aren’t a hindrance. They are opportunities to improve the odds in our favor.

Consider:

• Excess weight is linked to degenerative and inflammatory conditions and increased treatment complications.

• Tobacco smoking is associated with lower bone mineral density, increased joint disease activity, and poorer treatment outcomes.

• Anxiety and depression are frequently co-morbid with MSK conditions — 20% of patients with arthritis experience anxiety and depression, and the odds of having back pain are 50% higher for patients with depression.

• MSK manifestations of diabetes include soft tissue fibrosis, erosive arthropathy, and impaired healing.

Almost every organ system affects musculoskeletal health — and vice versa.

As a result, MSK pain is often the “canary in the coal mine” of declining health, while conditions like hypertension, diabetes, and osteoporosis are the “silent killers.” Patients live with these cardiometabolic conditions for years without experiencing symptoms severe enough to prompt a doctor's visit.

Physical pain is different. Back and joint discomfort prompt action and hint at broader systemic issues. Can we use this association to our advantage?

Can we flip the script and leverage MSK conditions as a natural on-ramp to whole-person care?

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Building Out a Multispecialty Clinic

Using musculoskeletal conditions as a gateway to whole-person care may seem spurious. Can we really expect MSK specialists to think beyond bones and joints? In reality, this awakening is already happening.

Health optimization is now widely regarded as a critical component of achieving favorable orthopedic outcomes. The challenge is to expand this approach beyond surgical episodes and begin thinking of musculoskeletal conditions as the entry point to a broader view of overall health.

Here’s how it could work:

Phase One - Foundation: MSK Optimization & Adjacent Specialties

Assuming orthopedics is our established gateway, the first step is to optimize function, pain relief, and long-term MSK health. Starting with tangential specialties lays the groundwork for a holistic model.

• Weight Management & Nutrition - Instead of generic weight loss advice, patients are offered structured programs, including access to dieticians, medical weight loss (GLP-1s), and adaptable exercise plans.

  (Specialties: Nutrition, Bariatrics)

• Behavioral & Mental Health - Chronic pain, depression, anxiety, and catastrophizing all worsen MSK outcomes. Integrating CBT, mindfulness, pain management strategies, and mental health screening leverages the mind-body connection for improved outcomes.

  (Specialties: Mental Health)

• Physical Therapy & Injury Prevention - Strength, mobility, and balance are correlated to long-term surgical and non-surgical outcomes. Injury prevention, gait training, and PT-guided strength programs are key MSK preventative measures that reduce pain, improve function, and enhance long-term success rates.

  (Specialties: Physical and Occupational Therapy, Rehabilitation Medicine)

Phase Two — Expansion: Building Out Key Service Lines

Once MSK health is optimized, key service lines emerge as part of the holistic care ecosystem. More than complimentary specialties, these areas become integral to longitudinal health maintenance.

• Cardiometabolic Health - Hypertension, diabetes, and dyslipidemia contribute to systemic inflammation, poor healing, and worsening musculoskeletal function. Addressing these with tailored cardiometabolic programs makes orthopedic care more effective and begins to address overall health.

  (Specialties: Cardiology, Nephrology, Endocrinology, Bariatrics)

• Bone Health & Osteoporosis - The importance of bone health is widely overlooked in traditional MSK care. Integrating osteoporosis screening (DEXA), pharmacologic and dietary interventions, and fracture prevention/liaison programs reduces morbidity and mortality associated with impaired bone metabolism.

  (Specialties: Endocrinology, Pharmacology, Radiology)

• Pain Management & Regenerative Medicine - Non-surgical management of joint and back pain requires the whole gamut of treatment options. Alternative treatments are gradually evolving from pseudoscience to viable, evidence-based options. Thoughtfully expanding to regenerative therapies (PRP, cartilage restoration), targeted pain interventions, and advanced rehab modalities creates better non-surgical alternatives for MSK patients.

  (Specialties: Anesthesia Pain Management, Regenerative Medicine, Primary Care MSK)

Phase Three — Closing Gaps: Tuck-in Services

With the foundation established and complimentary service lines initiated, more specialized and wraparound care services enhance the model. Such offerings make care more personalized, continuous, and comprehensive.

• Respiratory & Sleep Medicine - Impaired lung function, sleep apnea, and poor sleep habits affect cardiovascular health and recovery. Screening for sleep disorders, pulmonary function testing, and CPAP/BiPAP management can improve surgical outcomes and enhance physiologic resilience.

  (Specialties: Pulmonology, Sleep Medicine, Respiratory Therapy)

• Women’s Health & Hormone Therapy – Hormonal shifts associated with menopause play a significant role in bone density, joint health, and muscle preservation. Integrating hormone replacement therapy (HRT) and offering a dedicated breast health center offers comprehensive support for aging women (and builds upon Phase 2’s Bone Health Clinic).

  (Specialties: Women’s Health, Endocrinology, General Surgery)

• Neurocognitive & Balance Disorders – Cognitive decline and balance disorders increase the risk of falls, fractures, and loss of independence. Neurology-driven fall prevention programs, vestibular rehab, and dementia/memory screening support “aging in place” and reduce injury risk.

  (Specialties: Neurology, Physical & Occupational Therapy, Rehabilitation Medicine)

Phase Four — Granularity: Personalized & Wraparound Care

At this point, our multi-specialty clinic has evolved into an integrated, whole-person model of care. Next, we refine care for specific patient needs rather than broad populations.

• Precision Nutrition & Gut Health – Specialized diets, microbiome testing, and personalized nutrition plans enhance health, metabolism, and recovery. Colon cancer screening, H. pylori testing, and other gut health interventions serve as preventative measures.

  (Specialties: Gastroenterology, Nutrition/Dietary)

• Personalized Rehab & Biomechanics – Motion analysis, AI-driven gait assessments, and customized PT take recovery and fitness training beyond generic exercise sheets.

  (Specialties: Physical & Occupational Therapy, Rehabilitation Medicine)

• Lifestyle & Stress Management – Burnout, chronic stress, and autonomic dysfunction impact pain, recovery, and long-term mobility. Integrating HRV tracking, breathwork, and resilience training adds another layer of care.

  (Specialties: Mental Health, Lifestyle Medicine)

Phase Five — Healthspan: Maintenance and Longevity

Once we’ve built a robust, patient-centered model, our final step is to shift from lifespan to healthspan. At this stage, the clinic doesn’t just aspire to fix problems, it prevents them by optimizing health for the long haul.

• Advanced Imaging – Whole-body MRI, cardiac calcium scoring (coronary artery calcium), cardiac stress testing, and AI-enabled dermatographic screening allow us to identify problems and intervene early.

  (Specialties: Radiology, Dermatology, Cardiology)

• VO2 Max & Cardiovascular Fitness Programs – Focusing on aerobic capacity, strength, and metabolic fitness can further extend healthspan.

  (Specialties: Physical Therapy, Rehabilitation Medicine, Sports Performance)

• Precision Medicine & Genetic Testing – Comprehensive lab testing can help us understand genetic and biologic predispositions to oncologic and metabolic disease.

  (Specialties: Functional Medicine, Genetics, Hematology/Oncology)

• Annual Performance & Health Optimization Exams – A comprehensive yearly assessment that integrates MSK, metabolic, and functional health into a single, actionable plan. Tailoring our assessments over time and offering a holistic model of care ensures nothing falls through the cracks.

  (Specialties: Multiple)

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Why It Works

Following this phased approach, we’ve gradually built a full-service, whole-health clinic.

Most multispecialty care models struggle because they try to do too much at once. By contrast, our model grows organically, using MSK as an entry point and scaling strategically based on a logical progression.

Our roadmap:

• Start with a high-impact, high-demand specialty — MSK health.

• Expand logically based on related conditions & risk factors.

• Gradually layer in advanced services as the clinic matures.

• End with a fully integrated healthspan & longevity clinic.

Backing into a multispecialty model—instead of forcing a fragmented approach—allows us to create something that’s both scalable and sustainable. We’ve laid the groundwork for complete service line expansion into 360-degree, wrap-around care that incorporates all specialties and organ systems.

Skeptics will say it can’t be done. I’d argue that our approach is not only the gateway to whole-person care — it’s the future of next-level healthcare delivery.

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Ben Schwartz, MD, MBA

Editor-in-Chief, The Surgeon’s Record

Commons Clinic Senior Clinical Fellow