Q: What role does the Duke Anesthesiology Residency Program play in global health?

Global Health - DARE BlogA: Dr. Brad Taicher takes us on his journey abroad to provide a snapshot of how our department and residency program make a real difference in the lives of others.

It’s March 11th and we’ve safely arrived in Guatemala City, Guatemala for the sixth time in as many years to help evaluate and care for a group children undergoing general and urologic surgeries. This year’s anesthesia team is comprised of Stephanie Jones (CA-3 resident), Dayna Seguin (CRNA) and Becky Motykiewicz (CRNA), as well as three local anesthesia residents who will anesthetize with us throughout the week (Drs. Miguel Gonzales, Amilkar Garcia and Yolanda Castaneda). On our first day, we saw 80 plus children come through the clinic to be evaluated by our surgical team for appropriateness, and by our anesthesia teams to ensure they are medically optimized, and plan for the week ahead.

Why Guatemala? It’s the poorest country in Central America, and one of the poorest in the world. The public health system in Guatemala is well developed, but bankrupt. It lacks sufficient resources to provide care for all in need, creating an enormous backlog of patients, many of whom have no chance of ever receiving the surgeries they need through the public health system. There are about 4.5 million people in and around Guatemala City; more than 90 percent of whom rely on the public system and only two significant public hospitals to handle major surgeries. These two hospitals are only provided enough funding to purchase supplies to do elective operations in the mornings for about half of the year. When they run out of supplies, it’s emergency surgery only. There is no pediatric fellowship training here for those who are interested, so when I’m here, I’m usually the only pediatric anesthesiologist in the country. Pediatrics is an interest for many here, but a job for few. And for perspective, Guatemala is a country of children with greater than 50 percent of the population less than 18 years old.

In the United States, we may encounter patients who lack the skills to cope with the stress of their surgical encounter. In Guatemala, it is the opposite; patients have overdeveloped coping skills secondary to the conditions of their upbringing and the ubiquitous violence. It is often said that Guatemalan children don’t cry because they have long ago run out of tears. Our mission brings hope to these individuals and families while simultaneously seeking a sustainable model by supplementing pediatric training for local providers and collaborating on research and quality improvement endeavors with local institutions.

In addition to Guatemala, Duke teams have traveled to Ghana, Haiti, Philippines, India, and countless other countries. We are grateful for the phenomenal support provided by our department, hospital, and university over the past six years and the opportunity to include our own trainees and CRNAs on our mission trips. We are excited to continue our collaboration here in Guatemala, and look forward to another successful trip!

Brad Taicher, DO, MBA

Guest BloggerQ: What role does the Duke Anesthesiology Residency Program play in global health?
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Q: Is leadership teaching offered for residents of Duke Anesthesiology? If so, what is the department’s preferred model?

Drs. Ashley Grantham and Jennifer HauckQ: What is leadership in anesthesiology?

A: Hauck: For the leadership development program for the residents, we use the Duke Healthcare Leadership Model as our guide. Each of the five core competencies (integrity, emotional intelligence, teamwork, selfless service, and critical thinking) and the core principle of patient centeredness are integral to leadership in anesthesiology.

A: Grantham: There are many different definitions of leadership. For our program, we felt that implementing a values-based approach to leadership was really important. The Duke Healthcare Leadership Model and our view of leadership in anesthesiology follow the servant-leadership model, where leadership is viewed as a type of service to others.

Q: Why is learning about leadership important for residents in anesthesiology?

A: Hauck: Residents are presented with leadership opportunities and challenges every day.  Whether aligning a team in the OR to help a patient, or leading a patient’s care team through a complex pain management plan, or leading a call team of residents and CRNAs, residents are continually called to lead. These leadership skills become even more critical as residents become fellows and attending anesthesiologists.

Q: Who has had an impact on you as a leader?

A: Grantham: I’ve worked with so many great leaders over my career. I respect Dr. Donna Petherbridge’s ability to connect with people and lead a diverse team at NC State.  From my doctoral advisor, Dr. Audrey Jaeger, I’ve learned how to challenge people to grow while remaining supportive as a leader. Here at Duke, I’m impressed with how many individuals exhibit leadership skills on a daily basis. The individuals helping with the leadership development program, including Drs. Joseph Doty, Nancy Knudsen, Anthony Galanos, Mark Stafford-Smith, and Brandi Bottiger, have had such a positive impact on me as we’ve worked to plan this curriculum.

A: Hauck: I have learned from so many great leaders in my education and training.  The first leader to inspire me was Dr. Erin Reid, a hematologist and professor of medicine at UCSD.  As her clinical trials coordinator, I admired her ability to influence others and bring teams of people together through her genuine investment in building relationships and by treating each colleague and patient with respect as an equal individual with a valued opinion. At Duke, Dr. Stafford-Smith has modeled and taught me how to use emotional intelligence to understand my team and to adapt my leadership approach accordingly. I have learned about resiliency and integrity in leadership from Dr. Dean Taylor, professor of orthopedics and founder of the Feagin Leadership Program.  I admire and appreciate the strengths and unique styles of the many leaders who have mentored me throughout my career.

Q: If you could describe leadership in three words, what would they be?

A: Hauck: To influence others.

A: Grantham: To paraphrase a Ralph Waldo Emerson quote, I would say a leader is “someone who inspires.” Leadership then becomes about selflessness, empowerment and transformation.

Q: How can residents build their leadership skills at Duke?

A: Hauck: Through the Leadership Development Curriculum, our residents will have the opportunity to reflect on their own leadership strengths and those of their team members. During their three years, residents will participate in nine workshops where they will learn and practice leadership skills, and then have the opportunity to apply these skills to their clinical practice.  While a curriculum will add structure to learning leadership, I strongly encourage residents to continue to learn to be the kind of leader they envision through relationships with mentors.

Ashley Grantham, PhD and Jennifer Hauck, MD

Guest BloggerQ: Is leadership teaching offered for residents of Duke Anesthesiology? If so, what is the department’s preferred model?
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Q: How is Veterans Affairs an integral part of Duke Anesthesiology’s Residency Program?

Dr. Dana Wiener is seen here doing warrior pose outside of the Durham VA Medical Center Blue Star Memorial. She participated in a yoga pose challenge for charity, which she unfortunately lost to another contender but won in authenticity since she takes care of warriors each day.

Dr. Dana Wiener is seen here doing the “warrior” pose outside of the Durham VA Medical Center Blue Star Memorial. She participated in a yoga pose challenge for charity, which she unfortunately lost to another contender but won in authenticity since she takes care of warriors each day.

A: “To care for him who shall have borne the battle and for his widow and his orphan” was declared by President Abraham Lincoln in 1865 at his second inauguration and remains the motto of the U.S. Department of Veterans Affairs (VA).  Though I am not a veteran (30 percent of VA employees are veterans), I have been proud to serve these amazing patients in my own way for almost 30 years at the Durham VA Medical Center. We are located right across the road from Duke University Hospital, but our learning environment is very unique.

Duke Anesthesiology’s Veterans Affairs Anesthesiology Service Division consists of 21 physicians and 17 full-time CRNAs, as well as physician assistants, nurse practitioners, health technicians, RNs and administrative personnel. We provide care in the operating rooms (OR) as well as non-OR sites, such as Gastroenterology (GI), Interventional Radiology, Electrophysiology Lab, Cardiothoracic (CT), Pain Clinic, Surgical Intensive Care Unit (SICU), Transesophageal Echocardiography (TEE) service, and 4B/Short Stay Unit.  With the aging veteran demographics in North Carolina, the conflicts in the Middle East and the health care needs in our country, the VA division’s workload is exploding. Last year, we performed more than 8,000 anesthetics; following the national trend, our non-OR cases comprised almost 30 percent of our caseload. Based upon standard productivity calculations, we are currently the fifth most productive VA anesthesiology service in the nation. We administer anesthesia for almost every specialty you can imagine, except for obstetrics and pediatrics. We are even increasing our workload in some minor specialties such as podiatry, oral surgery and radiation oncology.

Veterans Affairs is an excellent place to train due to many factors: complex patients and cases, variety and severity of disease, and unique patient medical issues such as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use, geriatrics, and other disabilities related to military service. In fact, the VA is the largest provider of health care training in the United States. In FY 2014, VA clinical training across the nation involved more than 120,000 interns, residents, fellows and students in more than 40 professions. In Durham, the VA funds the salaries of eight of our anesthesiology residents and fellows annually.

The VA is also a leader in local and national research and innovation. Several members of our division participate in cutting edge research involving data analytics, epidemiology, quality and safety, chronic pain, opioid safety, post amputation pain, and other areas of perioperative medicine. Did you know that the first long-term successful kidney transplant was performed at a VA hospital and also that a Durham VA researcher developed the nicotine patch?  Our VA division is also administratively active. Anesthesiologists lead the Pharmacy & Therapeutics Committee, the Transfusion Committee, Critical Care Committee, and the Interdisciplinary Pain Clinic.

Despite all of these wonderful accomplishments, the VA still has a lot of work to do to fulfill President Lincoln’s plan. Our number one priority is increasing access for more than 11 million living veterans and to do it in a way that respects all of the unique needs and challenges that this population faces. As a distinctive microcosm of the Duke Anesthesiology Residency Program, the VA division rotation will expose residents to an awesome responsibility to assist the men and women who served our county and, quoting President Lincoln, “borne the battle.”

Dana N. Wiener, MD

Guest BloggerQ: How is Veterans Affairs an integral part of Duke Anesthesiology’s Residency Program?
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Q: How does the Duke Anesthesiology Residency Program prepare their residents for oral exams?

Nicole R. Guinn, MDA: I’ll never forget the feeling as I stepped into the elevator after finishing my oral exam. That spring, the exams were held in Boston at the Westin Hotel in Copley Plaza. The elevator was packed full of candidates in black suits, having completed the session, now heading back to our respective hotel rooms before packing up and heading home.  There was tense silence, broken finally when one guy joked, “Well, see you guys next year…” followed by nods and nervous laughter from the other candidates.

But more than anything else, I felt relief. For although I could not be sure in that moment that I had passed, I knew that the Duke Anesthesiology Residency Program had prepared me well. The oral exams, the final step towards certification as a diplomat by the American Board of Anesthesiology (ABA), is done after successfully passing all steps of the written exam and is certainly the most anxiety-provoking of the tests. Currently, the exams are all held in Raleigh, in standardized exam rooms at the ABA headquarters. The written exams test your factual knowledge, but the oral exam aims to test more elusive qualities: the ability of a candidate to adapt to changing circumstances, their judgment, ability to analyze data, and to communicate effectively. We learn these skills throughout our training, but to be able to effectively demonstrate them requires practice.

Thankfully, I had been through multiple practice oral exams as a resident. We hold these sessions twice a year, in the spring and the fall, and aim to mimic the real exams as much as possible. Each resident is examined by two members of the faculty, just like in the real exam. With several actual ABA oral board examiners on faculty, we’ve been able to use their knowledge to create a realistic exam to help prepare our residents.

Starting in 2018, in addition to the current oral exams, candidates will also take a second in-person exam on the same day, the OSCE (Objective Structured Clinical Exam), which will use standardized patients and scenarios to test skills such as communication, professionalism and interpretation of monitors. And with faculty, including myself, involved in these exams as well, I’m confident that we will again be able to successfully prepare our residents, so when that day comes for each of our trainees, confidence can be the overwhelming feeling.

Nicole R. Guinn, MD

Guest BloggerQ: How does the Duke Anesthesiology Residency Program prepare their residents for oral exams?
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Q: During the whirlwind of interview season, how will I know which residency program is the best fit for me? And, do you have any advice as to what I should specifically look for/ask during the interview process?

Drs. Gregory and EohA: You spend three years of medical school trying to figure out what you want to be when you grow-up, and then you spend a lot of your own (or your parents’) money and frequent flyer miles trying to figure out where you want to train for the job you want to have.

Duke Anesthesiology was my last interview on my marathon trail of ten interviews, and I definitely saved the best for last. The residents at dinner were genuinely happy to be there representing the program. They enjoyed each other’s company and were honest about their experiences in the program. My interview day was a blur, but I do remember our former chairman, Dr. Newman, mentioning that the residents who trained here left with a certain “Duke swagger.” I wanted that Duke swagger! They say to trust your gut when it comes to these things, and Duke felt like home.

Fast-forward four years, and here we are, hosting the interview dinners and courting the applicants. We sometimes hear whispers that our program is “malignant” and that we are “repressed.” We giggle when we hear these words because that just means that our program continues to be a very well kept secret. We are trained by leaders and visionaries that inspire us to be our very best. If you are a motivated, hard-working individual who wants a world-class education and clinical experience, we hope you will join us. We’ll set you up for success!

We were both amazed how far the Duke Blue traveled as we both looked for fellowships and jobs that extended far from Durham toward the Midwest and farther South. With the mention of where we trained for residency, the faces of our interviewers light up as they remember and mention one of their many Duke acquaintances. Our faculty fiercely advocates for us on the interview trail and many of our co-residents continue to keep in touch with our program director, Dr. Thompson, for career advice or just a friendly check-in. The training at Duke is nationally respected, and the clinical experience here will prepare you to be both an excellent anesthesiologist and a leader, no matter where you go when your adventures with Duke come to an end.

Just remember. Stay motivated, study hard, and keep learning. Every case is a learning case! Don’t get distracted by the bells and whistles of fancy dinners, free hotel rooms, and trips up to see the helipad. Be observant and see how the residents interact with each other and their faculty. Ask who makes the daily resident room assignments, how are residents evaluated, what kind of peer-to-peer learning opportunities are made available, what are the resources for research, what is the OR experience like for residents, what kind of fellowship opportunities are offered and which fellowships are the program’s residents going into?

For us, the Duke experience has given us the clinical training to take care of the most ailing patients in the hospital while helping us to define our own career goals, participate in research, and learn to educate others. The weather in North Carolina isn’t bad either. Good luck!

Eun Eoh, MD and Stephen Gregory, MD
Chief Residents, Duke Anesthesiology Class of 2016

Guest BloggerQ: During the whirlwind of interview season, how will I know which residency program is the best fit for me? And, do you have any advice as to what I should specifically look for/ask during the interview process?
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