There Is a Science to Scaling Surgical Care—and It’s Not What You Think
The future of otolaryngology is not about asking surgeons to work harder or see more patients indiscriminately. It is about designing systems that reduce unnecessary cognitive load.
Bradford G. Bichey, MD, MPH, on behalf of the AAO-HNS Otolaryngology Private Practice Section (OPPS) Business of Medicine (BOM) Committee
(Author Disclosures: AI was used for editing and tone refinement after writing.)
These questions are often framed as productivity challenges and new goals that need to be met. In practice, they reflect a deeper issue of systems design—one that traditional healthcare management approaches have struggled to address effectively.
Why Goal Setting Alone Falls Short
Physicians are exceptional goal setters. Goal setting is how we navigate medical training and years of clinical rigor, and it naturally becomes the default strategy when physicians assume leadership roles. The familiar approach follows:
- Set clearer goals
- Raise performance targets
- Align incentives
- Track additional metrics
Goals matter, but an important reality remains: Healthcare in the United States is being built by highly motivated clinicians and executives, yet the system is increasingly strained by complexity.
Across surgical care, we see administrative burdens rising along with escalating labor and overhead costs. We are also seeing declining access to timely surgical care, high levels of clinician burnout, and increasing variability in patient experience. The challenge is not a lack of effort or ambition; it’s that goals alone cannot successfully scale complex clinical systems.
Two Principles Required to Scale Surgical Care
To scale a surgical practice, a multisite otolaryngology group, or a health system—without proportional increases in burnout or staffing—goal setting must be paired with two additional principles:
- Raising the floor
- Simplification through elimination
These concepts, drawn from the book The Science of Scaling by Benjamin Hardy, PhD, and Blake Erickson, are particularly applicable to healthcare delivery in the AI era. Without them, growth increases friction. With them, growth creates leverage.
What “Raising the Floor” Means in Practice
Raising the floor is not about working harder. It is about defining what the system will no longer accept. In a surgical practice, this means clearly determining:
- Which patients should no longer be seen
- Which referrals should not proceed to consultation
- Which workflows should be eliminated
- Which decisions should not require surgeon cognition
Without raising the floor, increased demand simply flows into the same system, turning surgeons into bottlenecks, overwhelming staff, and eroding outcomes. Raising the floor protects the most limited resource in surgical care: the surgeon's attention and decision-making capacity.
Simplification Requires Elimination, Not Optimization
Healthcare organizations frequently pursue optimization. Optimization, however, often preserves complexity. True simplification requires elimination:
- Removing steps that do not meaningfully contribute to clinical or operational outcomes
- Eliminating redundant handoffs and subjective decision points
- Reducing variability where consistency improves quality
As clinical operations modernize, this also means acknowledging that some workflows no longer require human execution when reliable automation can perform them consistently, safely, and with higher accuracy. This is not about replacing clinicians or staff. It is about removing unnecessary cognitive work so clinical teams can focus on tasks that require judgment, experience, and human interaction.
Applied Principles: Referral Management
Referral intake remains one of the highest-friction points in surgical care, with significant human resistance to changing workflows. It is where volume is constrained, variability is introduced, cognitive load increases, and surgeons and staff spend disproportionate time on low-value work.
Modern, rules-based, and agentic referral systems can now address this friction by automatically structuring inbound referral information. These systems apply predefined criteria for surgical appropriateness and use agents in tandem to perform multiple tasks autonomously—routing patients based on subspecialty need, urgency, and capacity while standardizing scheduling decisions.
When referral triage is consistent and well defined, surgeons see fewer inappropriate consults. Clinics focus on higher-yield surgical candidates. Schedules become more predictable, and growth occurs without proportional increases in staffing. The floor is raised using a simplified system running in the background. Importantly, these systems function within clearly defined clinical and operational constraints, reinforcing—not replacing—physician oversight.
Why This Approach Can’t Be Developed by Your EHR Vendor
By their very nature, EHRs are complex record-keeping systems designed to scale record compliance and data tracking. They steer healthcare technology adoption toward incremental improvements, such as documentation support or retrospective analytics. While these tools are helpful, they lack the necessary levers to improve system behavior.
By contrast, systems that combine raised standards with simplified workflows influence decisions upstream—where demand, variability, and cognitive burden originate.
The Future of Scalable Surgical Care
The future of otolaryngology is not about asking surgeons to work harder or see more patients indiscriminately. It is about designing systems that reduce unnecessary cognitive load. Eliminating work that does not add clinical value and allowing surgeons to operate consistently at the top of their license is key.
Organizations that apply these principles are better positioned to:
- Improve access and efficiency
- Protect clinician well-being
- Deliver more reliable patient outcomes.
The tools and frameworks now exist. The remaining challenge is whether healthcare leaders are willing to redesign systems rather than simply raise expectations. When the floor is raised and complexity is reduced, ambitious goals become achievable outcomes.
Join Us at the 2026 OTO Forum
Join us at the AAO-HNS/F 2026 OTO Forum, March 20-21, 2026, in Louisville, Kentucky, for in-depth conversations on the business of medicine and clinical excellence—open to all otolaryngologists, from residents to established practitioners, across every practice setting. Learn more and register today!
This article is part of the OPPS BOM Insights series, an initiative providing members with expert guidance on the financial and operational aspects of practice management. To suggest topics and/or contribute to future articles, email OPPS 1st Vice Chair and BOM Chair Nora W. Perkins, MD, MBA at nperkins@albanyent.com.
