David Brigati, MD is a fellow in adult reconstructive surgery at the Dell Medical School at the University of Texas at Austin. Upon completion of his fellowship, Dr. Brigati hopes to go into practice in the Fort Worth area.

Dr. Brigati, a Texas native, performed his orthopaedic residency at the Cleveland Clinic. He performed his undergraduate work at Washington University in St. Louis and attended medical school at the University of Texas Health Science Center at San Antonio.

The following is a recent Q&A that TOA conducted with Dr. Brigati about his views on the future of orthopaedics in Texas.

TOA: What was it like to leave Texas for your residency and train at the Cleveland Clinic?

David Brigati: It was an incredible privilege to train at Cleveland Clinic on so many levels:

(1) The amazing medically and surgically complex patients that come to a quaternary referral center.

(2) The 61 diverse teaching staff specialty practices, including 12 high-volume joint surgeons each with their own styles/techniques.

(3) The well-rounded hospital settings including academic referral, orthopedic-focused subspecialty, small community, and county-funded trauma.

(4) The massive infrastructure care delivery innovation with vertical integration of a full suite of health resources including a tiered system of 11 hospitals, an inpatient rehab / skilled nursing center, their own home health providers, and a network of community outpatient health centers for preoperative optimization and outpatient follow up.

(5) Not least of all was the gem of a city itself with an unbelievably low cost of living on a resident salary, incredible performances by the Indians and the Cavaliers (both treated by Cleveland Clinic Orthopedics, a nice perk), and the most welcoming House Staff Spouse and Family association that I have ever seen!

I couldn’t be more pleased with my residency. I will never forget these once-in-a-lifetime training experiences that I was lucky enough to land and look forward to joining an incredible cast of alumni that I will interact with for decades to come.

TOA: What brought you back to Texas for your fellowship?

David Brigati: While I was born in Candyland (Hershey, Pennsylvania), I grew up in Fort Worth, Texas since the age of 9. This was also where I met my fantastic high-school sweetheart wife. After four grueling years of long distance undergraduate training (I was at Washington University in St. Louis and she was the University of Texas in Austin), I was eager to come home for medical school in San Antonio, which is where we eventually married during my fourth year. Five wonderfully cold years of residency plus an additional research year in Cleveland during which we added my two daughters Eloise (4) and Penny (2.5) to the family only made the decision to move closer to my parents, in-laws, siblings and cousins easier.

Since fellowship is a match, I was ecstatic to learn I could return to Texas one year earlier while getting to train with some incredible faculty in Kevin Bozic, Karl Koenig, and Randall Schultz at the brand-new Dell Medical School at the University of Texas at Austin. After the year in Austin, I intend to return back home to my favorite place on Earth, Fort Worth, Texas to start a joints-focused practice surrounded by my extended family.

TOA: Your focus is arthroplasty. Have you witnessed any major trends in arthroplasty since the beginning of your residency?

David Brigati: A better question might be: What hasn’t changed in hip and knee replacement during the seven years I have been in orthopedics? While the fundamental surgical principles and overall good outcomes remain, everything else has been flipped on its head! I began residency right when Cleveland Clinic was finishing the design of their hip and knee replacement “Carepath,” which is aimed at reducing unnecessary interprovider care variation while encouraging the adoption of evidenced-based best practices, and right before they started their first delve into the Bundled Payments for Care Improvement initiative.

It was mind-boggling to watch mid- and late-career established joint surgeons wrestle over having to abandon what was considered outdated dogma from their past and the modern “uncomfortable” best practices that would result in reduced costs while maintaining their outcomes. I watched our average length of stay plummet from 3.5 days to 1.2 to 2.3 days, depending on the hospital, in just over eight months! I watched our message change from “you may need a couple weeks at a skilled nursing facility” for 66 percent of our patients to “home with your loved ones help is the best place to recover” for 85% percent of our patients again over about 8-12 months.

Then, just when I thought that the massive infrastructure vertical integration approach of Cleveland Clinic was the only path forward to survive in these daunting modern times, I joined the young and agile Dell Medical School in Austin. These folks are taking it to a whole new level … forget just focusing on hip and knee replacement SURGERY, they are solving the much more important societal need for 360 degree musculoskeletal health! I stand side-by-side every day in the “lower extremity” clinic with a social worker, physical therapist, nurse practitioner, physician assistant, radiology technician, medical assistant and joint surgeon caring for a wider range of pathology than was ever previously possible. As surgeons, we all have patients every day that we say to ourselves, “I wish I could help this person, but I can’t change their social situation and mental health that are driving down their quality of life.” This is exactly what the Dell Medical School at the University of Texas at Austin is doin … and doing well!

TOA: As somebody who is finishing up his fellowship and about to go into practice, how do you view the future of orthopaedics in Texas?

David Brigati: The future of primary and revision joint replacement is bright, and I am thrilled to be finishing fellowship training soon. Texas is a great place to practice because all three major models are available, including academic/employment/salary-based opportunities, small group private practice, and large both single and multi-specialty private practices. I can’t say the same is true in other markets that I have seen, so I’m counting my blessings. Yet with great choices comes big decisions. There are certain tenets of modern practice success that I believe I will need to find as I try to identify my best future opportunity more or less in this order: (1) integrity, (2) economy of scale, (3) multidisciplinary teams, and (4) adaptive.

Above all else in medicine, every member, partner, or associate of your practice must have the highest level of professional integrity – otherwise any reputation or success unequivocally will falter. Modern practice requires a certain economy of scale with sufficient volumes to keep the care team engaged daily in process improvement, the hospital interested in resource investment, the payers responsive to your initiatives, and patients excited about your progress. Thus, I need to identify joints partners willing to merge our care algorithms and volumes to leverage our success. Multidisciplinary teams are the only way to succeed in modern practice, and they involve diverse clinical care members, IT support for quality reporting, hospital leadership for navigating the changing healthcare landscape as it affects your practice, and contracting support to formalize care partnerships in bundled payment environments. Finally, and most challenging, is a balance that involves having enough physical infrastructure to support your busy practice while remaining agile enough to quickly change direction as the rules, laws, regulations, and policies surrounding your practice oscillate and morph. The good news is that all of these tenets are available in all three major practice types, but with important caveats that I am learning more about every day.

In summary, I am looking to join a practice with high integrity physicians who are willing to merge our best practice ideas to drive down our variability and costs while keeping up our procedure volumes and quality who are invested in a team approach to success while remaining open to the changes that will certainly come our way as physicians in the modern era.