The Engineer in the OR: Why I Had to Break the System to Fix It

Welcome to The Incision Point

I am an engineer first. I am a surgeon second.

Most people look at a joint replacement and see a medical procedure. I look at it and see a mechanical system. I see vectors, load-bearing surfaces, and friction coefficients.

But for the last 20 years, I’ve also been looking at the healthcare system itself. And what I saw was a machine that was poorly designed, inefficient, and bleeding energy.

I saw a system where the “administrators” outnumbered the “revenue generators” (the surgeons) by a margin that defied basic economic physics. I saw a model where innovation was stifled by bureaucracy, and where “value-based care” was just a slogan hospitals put on billboards while raising their prices.

So, I did what any good engineer would do. I decided to redesign the machine.

Defining “The Incision Point”

In surgery, the incision is the precise moment of entry. It is the exact point where we cut through the surface to fix what is broken underneath. It requires conviction. It requires a steady hand.

That is the philosophy behind this newsletter, and why I’m calling it The Incision Point.

We are living in an era of noise. The medical industry is covered in layers of administrative fat, opacity, and fear. To get to the truth, and to actually fix the problems facing surgeons, patients, and entrepreneurs, we have to cut through that surface layer.

This newsletter is that cut.

The Path of Most Resistance

My path to this point, founding the Indiana Orthopedic Institute (IOI), designing implants for Stryker and Enovis, and leading the American Association of Hip and Knee Surgeons (AAHKS), was not a straight line. It was a series of calculated risks.

It started at Rose-Hulman Institute of Technology. I remember sitting in the auditorium as a freshman. The speaker looked out at us, a room full of valedictorians, and said, “Look to your left. Look to your right. One of you won’t be here next year.”

That moment taught me something that has defined my entire career: Excellence is not an accident. It is an output of relentless inputs.

I carried that engineering grit into the operating room. While others were satisfied with “good enough” outcomes, I was obsessed with the variables.

• Why did this implant fail after 15 years?

• How can we alter the geometry of this tibial baseplate to match human kinematics?

• Why are we keeping healthy patients in a hospital bed for 3 days when the data says they heal better at home?

These questions led me to the world of Technology and Innovation.

Technology as a Weapon for Independence

When people hear “innovation in surgery,” they usually think of a shiny new robot. But true innovation isn’t just about gadgets. It’s about using technology to disrupt the business model of care.

For me, technology was the lever that allowed me to break free from the hospital monopoly.

Take the OARA Score (Outpatient Arthroplasty Risk Assessment), for example. Years ago, the establishment said, “You can’t send joint replacement patients home the same day. It’s too dangerous.” They were operating on fear. We decided to operate on data.

I co-developed the OARA score, a scientifically validated algorithm, to predict exactly which patients could safely go home. We didn’t guess. We engineered a risk model.

This piece of “technology” didn’t just improve safety; it disrupted the entire market. It proved we didn’t need the massive, expensive hospital infrastructure for 90% of our patients. It allowed us to move care to Ambulatory Surgery Centers (ASCs), lowering costs by 50% while improving outcomes.

That is the power of technology. It turns “impossible” into “standard of care.”

Burning the Boats (to Build a Rocket Ship)

A few years ago, I had an “aha moment.” I was sitting in a boardroom at a major health system. I looked around the table and realized I was the only person in the room who actually touched patients. I was the only person generating the revenue that paid for everyone else’s salary. Yet, I had the least amount of control over how that care was delivered.

I realized I couldn’t fix the machine from the inside. The friction was too high.

So, I left. I walked away from a prestigious academic director position. I sat out a restrictive non-compete. I started IOI with a vision to create a Vertically Integrated Practice, a model where the surgeon controls the entire value chain, from the first clinic visit to the implant design, to the anesthesia protocol, to the recovery.

We are now building this physical reality at Innovation Mile in Noblesville. We aren’t just building a clinic; we are building an ecosystem where research, engineering (in partnership with Rose-Hulman), and high-volume surgery happen under one roof.

What to Expect Here

I am writing this because the “Medical Industrial Complex” thrives on complexity. They want you, whether you are a patient, a fellow surgeon, or an entrepreneur, to think the system is too complicated to change.

I am here to tell you that it is just an engineering problem. And engineering problems have solutions.

Here at The Incision Point, I will be sharing:

• The Business of Medicine: How we are scaling IOI and navigating Private Equity without selling our souls.

• The Science of Surgery: Deep dives into implant design, biomechanics, and why “precision” matters.

• High-Performance Leadership: How to manage a business, a family, and a surgical caseload without burning out.

If you are a surgeon who feels like a cog in the wheel, this is for you. If you are an entrepreneur looking at healthcare, this is for you. If you are someone who refuses to accept the status quo, this is for you.

Welcome to The Incision Point. Let’s get to work.

R. Michael Meneghini, MD

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If you liked this, share it with a colleague who is tired of the bureaucracy. Next, I’m breaking down the exact math of “Value-Based Care” and why most hospitals are doing it wrong.