Wellbeing, Culture, and Sense of Self: Redefining What it Means to be a ‘Good’ Surgeon
Duke has long been recognized as a leader in surgical education and training, with a history of building multi-talented and skilled physicians and researchers who bring their passion for quality care to the communities they serve.
Now, faculty and residents in the Department of Surgery are exploring what matters most to surgeons-in-training, and establishing a new curriculum that seeks to redefine what it means to be a ‘good’ surgeon.
The Time is Right
In 2022, Ryan Antiel, MD, MSME, joined Duke as an assistant professor of surgery in the Division of Pediatric General Surgery. He had a two-pronged goal of providing exceptional pediatric surgical care as well as conducting research in an environment that thrives on, and promotes, thought-provoking surgical innovation.
Dr. Antiel has a research background that focuses on parental decision-making when faced with uncertainty and end-of-life issues for critically ill fetuses and neonates. With his work rooted in moral philosophy and theology, and having recently completed his own residency and fellowship training, his interests have since extended into how surgical training shapes residents’ character and ethic.
“I recognized that even in my own training, aspects of what it meant to be a good physician outside of technical skills weren’t being addressed, either because of time constraints or patient loads, or it was being addressed in a piecemeal fashion that really wasn’t effective,” says Dr. Antiel.
“There was a void around issues of character. ‘Who am I becoming through this process? Why am I doing this?’ I thought about, ‘how can we even just have a space to heal and have real, honest dialogue about the difficulties of this training and profession?”
The missing key, explains Dr. Antiel, is a synergistic integration of these principles being woven throughout the surgical education curriculum.
With satisfaction and sense of purpose among physicians and residents across healthcare specialties being at critical lows, and burnout being at a critical high, promoting these philosophies in the current class of surgical trainees is crucial.
“We’re desperate for this sort of environment, and the time is right,” says Dr. Antiel.
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The Origin Story
Early into his time at Duke, Dr. Antiel began having conversations with both the Department of Surgery’s Research Administration team as well as Elisabeth Tracy, MD, Assistant Professor of Surgery in Pediatric General Surgery and Director of the General Surgery Residency Program, about what an initiative that sought to address professionalism, well-being, and ethics in surgical training would look like.
What he recognized immediately was that building this type of program and study could not be accomplished without buy-in, input, and collaboration from the residents themselves.
Thomas “Clark” Howell, MD, MSHS, is a General Surgery Resident at Duke, currently in his research year. After graduating from the UNC School of Medicine, Dr. Howell completed a Certificate in Theology and Healthcare from the Duke Divinity School.
The certificate program, he says, allowed him to think more critically about finding meaning in work and being able to empathetically connect with and understand patients of all kinds of traditions and backgrounds.
Dr. Howell says that he felt “a calling” to surgery but admits that he harbored a fear about who he might become amidst his training.
“I was concerned about this transformation that was going to happen during residency,” explains Dr. Howell. “I was worried that somehow during residency, I would lose sight of the art of medicine, that physician-patient relationship, and the empathy and courage to do the right thing.”
The Project on the Good Surgeon
Developed and led by Drs. Antiel and Howell and Program Coordinator Abby Van Vliet, MTS, the Project aims to combine, “a formal curriculum, small group discussions, and one-on-one mentoring to enable surgery residents to form the habits and practices necessary for navigating an increasingly hostile work environment.”
The Project integrates the arts and humanities to look at healthcare professions through a more humanistic lens. Discussions around art, poetry, history, theology, and philosophy, to name a few, are designed to inspire thoughtful dialogue as they relate to each resident as both a surgeon and as an individual.
"My understanding of medicine is defined by my own worldview. We must be in conversation with people that are different from us."
-Dr. Clark Howell, General Surgery Resident
The Project’s core values are rooted in maintaining residents’ mental health and well-being, empathy and compassion toward patients and their families, and sense of self in times of stress and difficulty.
While these issues and philosophies are addressed in undergraduate and medical school studies, they are not typically large components of residency. This often means that once residents enter their rigorous training, they can be left feeling isolated, or an emotional disconnect from themselves, their loved ones, or patients.
The Project on the Good Surgeon aims to combat that.
The pilot program at Duke, which launched in early 2023, is currently designed for residents to participate in while in their research years, during which they receive some respite from demanding clinical work and have protected time for dedicated research.
“We’re pushing back against the mentality that you have to give everything you have to your training and your job, and the idea that you’re on your own once you get into residency,” says Dr. Antiel.
Dr. Howell adds, “A lot of this program is based on mentorship and building a sustainable community.”
Fostering this type of community requires a variety of backgrounds, perspectives, experiences, and beliefs, both from the Project’s leadership as well as program participants.
“It is absolutely crucial that the program is not given from just one particular perspective,” explains Dr. Antiel. “I want a space where people can bring their whole selves to it, and where we can learn from people from different backgrounds.”
Dr. Howell emphasizes this point, adding, “My understanding of medicine is defined by my own worldview. We must be in conversation with people that are different from us.”
Bringing the Project into residency programming requires challenging decades-old practices and traditions. But it also brings with it the potential for powerful change and for physicians to be reminded of why they were drawn to medicine and surgery in the first place.
As an institution that has such a strong culture and identity as a leading academic surgery program, Dr. Antiel says, “It is so significant that this kind of work is happening at Duke.”
Essential to the Project’s development and implementation is the support of leadership like Allan D. Kirk, MD, PhD, FACS, Chair of the Department of Surgery, John Migaly, MD, Vice Chair of Education, and Dr. Tracy, along with the department faculty.
"The fact that someone so well regarded and respected in the field is supportive of this training initiative legitimizes the program in a really powerful, beautiful way."
-Dr. Ryan Antiel, Assistant Professor of Surgery
The team at Duke also partners closely with The Program for Leadership and Character at Wake Forest University School of Medicine, led by CEO of Wake Forest Baptist Medical Center and former president of the American College of Surgeons, Julie Freischlag, MD, FACS. The partnership allows for idea sharing and working toward ingraining these values across the profession.
“The fact that someone as well regarded and respected in the field as Dr. Kirk is supportive of this training initiative, and that the group at Wake Forest is under the leadership of Dr. Freischlag, legitimizes the program in a really powerful, beautiful way,” says Dr. Antiel.
Additional organizations across the country also see a need for this type of work. The Project has been supported by the Kern National Network for Flourishing in Medicine (KNN) through an investment from the Kern Family Foundation, based in Milwaukee, WI.
The KNN is a national movement focused on integrating four foundational elements within the profession of medicine: character, caring, and practical wisdom toward flourishing. Uplifting important programs like the Project on the Good Surgeon is part of the KNN’s ongoing efforts to connect and convene stakeholders across the health ecosystem, catalyze transformative initiatives, and influence broader policy and systems change.
“The Kern National Network has been incredibly supportive of this work, and it’s our hope that we can utilize their networks and connections as we go forward to meaningfully expand on what we’re doing,” says Dr. Antiel.
“The Project on the Good Surgeon truly exemplifies the power of an intentional, integrated approach to holistic physician development — one focused on creating clinical learning and practice environments where all can flourish,” says Kimara Ellefson, MBA, national director of partnerships and strategy for the KNN. “It’s a privilege to accelerate the vital work of cultivating wholeness, purpose, and community during this formative stage in the physician journey.”
With interest garnered across the field, the Project’s team knows that they still have work to do to establish its identity at home at Duke and to ensure its sustainability.
The key to achieving this is that the residents themselves buy into the cause, not just as participants, but as actively helping to shape the program.
“It’s really important to have resident involvement in this project,” says Dr. Howell. “One of the issues with a lot of well-being initiatives is they have been given to instead of developed with residents. So it might not actually be what someone needs.”
Dr. Antiel agrees. “The sustainability of the project is absolutely dependent on resident buy-in, and I’m really grateful that we already have several folks who have said they want to be involved in a significant way.”
For Dr. Howell, he also acknowledges that being involved in the Project on the Good Surgeon has opened his eyes to a new career pathway that he didn’t know existed before.
“I think it’s so important to build these kinds of relationships and help people find a voice for when they’re navigating a really difficult time,” he says. “I hope that I can do this kind of work wherever I end up practicing."