Duke GI Oral History: Dawn Provenzale, MD


Dr. Deborah Fisher: I'm Deborah Fisher, and I'm an associate professor of medicine at Duke in the Division of GI. This is my mentor, Dr. Dawn Provenzale who has been mentoring me since I came here for GI fellowship in 1999 and remains a mentor and also a colleague and a dear friend. I'm very honored and excited to interview her for this history project today. To get started, what first attracted you to Duke?

Dr. Dawn Provenzale: Thank you. It's been a pleasure working with you these 19 years. We've walked many paths, and I'm delighted to see you in your current position being so successful. What attracted me to Duke? There were opportunities here for someone with my interest. When I finished my fellowship, this whole idea of measuring patient-related outcomes in gastroenterology was rather a new idea. We didn't really look at things quite from that perspective in research arena in GI. Although there were well-established models for this in general internal medicine, that really hadn't trickled down to GI or really hadn't spread into many of the other medical subspecialties.

I wrote to several GI division chiefs, and I was particularly interested in coming back to the Northeast having done my residency at the University of North Carolina in Chapel Hill. Ian Taylor was very interested in the kind of work that I was doing, and there was a core of individuals here, there were a few faculty members who had been interacting with the general medicine, primarily Health Services Research and Development group at the VA, who had an infrastructure for doing this kind of work, but they were largely internal medicine-based and primary care-based. So he offered me the opportunity to come and work with that group which is how I got my research start in outcomes research.

While I had done some work before, mostly around decision modeling, there really wasn't the opportunity to interact in the same way with other investigators doing similar work. Nor was there a well-defined research infrastructure which was provided by the Health Services Research and Development Center of Excellence in the VA. That was my opportunity.

Dr. Fisher: So you've really been a pioneer in health services and outcomes research in GI and actually started and still direct the very first GI health services research training program. Tell us the story of how that started and how it's developed.

Dr. Provenzale: That was an interesting story because, as I mentioned, there was that well-defined group who had been quite successful at the Durham VA, the Health Services Research and Development group. They had a program for MD fellows in which they had a certain number of training slots a year. I think it was about four at that time. In a particular year, there were two slots that were unfilled, and I thought, "Well this is a great opportunity to start training the next generation of researchers in GI who would then do health services or outcomes research."

So I had the opportunity to advertise and identify potential candidates for these slots, and there were two fellows that applied. Ultimately, we engaged at that time one of those fellows who has subsequently been extremely successful in his career. Actually at this point, he is our clinical chief of GI in the VA health care system. He is the program director for gastroenterology for all 153 VA medical centers as well as an accomplished outcomes research and clinical trialist.

So that's the beginning. Then after that as we started to train people here and then through networking and opportunities through the GI societies, I started to meet others around the country who had this same interest, and we talked. There were individuals in Houston, Minneapolis, Chicago, and various parts of the country who had an interest in developing this kind of research. We were all sort of in our early stages of our careers so we shared what we thought were best practices. We learned from others, and we created a network of individuals with this type of research interest. Each of them subsequently went on to train other young people. Over a period of five to 10 years, we developed a very nice core of researchers throughout the country who would collaborate, who would mentor each other, and who would assist in developing these kinds of programs.

Dr. Fisher: And you've mentored some of the people outside of Duke as well as part of this effort.

Dr. Provenzale: That's true. There have been several around the country, and I continue to do that actually, and I continue to mentor some of my early mentees. I continue to interact with them on a monthly basis, or as needed. That's been a great opportunity both for ... It's been great for me to see the progress and success of those who are outside the institution, and also people like you who've stayed here. I've greatly enjoyed watching my mentees grow and develop into independent researchers that can actually lead the field in research both locally and nationally.

Dr. Fisher: That's great. We've talked some about your role in the developing, initiating, developing, continuing, and really even disseminating the health services and research training in gastroenterology. How have your research roles and administrative roles evolved in your time at Duke more generally?

Dr. Provenzale: As I mentioned earlier, I early on became VA-based because of the well-established infrastructure for this type of research. Over the years, my own research has become more and more VA-based. Even when I was funded by NIH and NCI, my research focused on veterans with the goal of improving the outcomes and care of veterans.

How has it changed? Well over time, I've had opportunities to advance into leadership roles within VA research. Currently, I'm the Director of the VA Cooperative Studies Epidemiology Center in Durham. In that role, I'm a research administrator. And so, I do assist others in obtaining their research funding, developing their research proposals. Our center provides infrastructure for research. It's very well-aligned actually with my mentoring role. It's really just an extension of mentoring in a different way with the opportunity to, again, work with people throughout the country to develop research projects and programs.

Dr. Fisher: What have you enjoyed most with your time at Duke?

Dr. Provenzale: I've enjoyed opportunities and mostly I'd say I have been delighted with the opportunity to build the careers of others, you and several others who are here, as well as individuals who are now scattered throughout the country and throughout the world who started here and trained in part of our outcomes research. Again, it's been an opportunity. Many of them have leadership positions themselves including Andrew Muir, our division chief who was also one of my fellows in the outcomes research program. It's been very rewarding to see the success of others and to have been a part of building that.

Dr. Fisher: What have been your biggest challenges either when you first arrived and started building it or even as the research environment has changed over the years and the funding environment?

Dr. Provenzale: That's an interesting question. When I first came, there wasn't a lot of outcomes research in GI. So sort of first convincing the GI community both locally, but even more so nationally that this type of research was important to improving outcomes. Gradually over time, the type of outcomes or health services research not only became accepted but embraced by the GI community. As I said, sort of in parallel, there was this core of researchers developing. Then there were opportunities for funding both within the societies and nationally to sustain that kind of research.

I think one of the challenges that's ongoing is sustainability. How do we sustain this line of outcomes, patient-reported outcomes research in challenging funding times? Funding cycles come and go and sometimes they're more challenging than others, but maintaining it is always something to be thinking about, both for your own research program and, for me as a mentor, the programs of others. I think that we've had the opportunity in outcomes or health services research to demonstrate that our research results have value. They have value to patients. They have value to the health system. They have value to payers.

Continuing sort of a collaborative relationship with our health systems, our payers, and our patients has helped to sustain some of that, but I do think that moving forward, establishing our relevance to a particular group, payers, our health systems, et cetera, is going to be very important. It may mean and it has meant to some extent, sort of changing our paradigm a little bit to thinking about outcomes as ways of measuring quality and measuring satisfaction on the part of many stakeholders. Trying to create models that will allow us to effectively partner with those who can support us and we can thus in turn support them I think will be a continued challenge, but I do see it as the way forward.

Dr. Fisher: Finally, what accomplishments in your career are you most proud of?

Dr. Provenzale: Well I think that the accomplishments that I'm proud of are highly integrated. We developed and nurtured this idea of outcomes research and health services research, but as part of that in order to sustain that, I had the opportunity to develop the careers of young people and train the next generation who has trained the next generation of researchers. I think together and combined, I'm proud of that. I'm delighted to see my young people -- I call all of my mentees, regardless of their age, my young people -- do well in their individual careers and really advance the field in terms of methodology, in terms of moving into different clinical conditions, whether they are my area of expertise or not, and really developing a foundation for future research in this area.

Dr. Fisher: Thank you so much. It has really been delightful. I've heard some of these stories, but some I haven't heard as much detail and I'm so happy that we're going to record them so everybody can hear them. You're just such a giving person and giving as a mentor, but also you really get your joy and satisfaction from seeing others do well and helping grow things as networks. I hope that as people are listening to this, they really understand how much you've done because you're very modest and always giving the group credit, but really what a force of nature, a force of progress you've been in this field both in GI, I think ultimately effecting policy that improved patient care, and really establishing the types of training programs, like you said, for the next generation and the next generation. I would definitely not be a good mentor if I hadn't had such an excellent role model.

Dr. Provenzale:  Well thank you. It's been a pleasure providing a little bit of history and context, but again, I mean one of the reasons I came to Duke was because of the well-established infrastructure that was here that was VA-based. It's really about team science and collaboration. I appreciate the opportunity to make a small change and move things forward in that direction.

Dr. Fisher: Thank you.

Dr. Provenzale:  Thank you.