Duke GI Oral History: Anna Mae Diehl, MD

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Dr. Cynthia Moylan: It's my great honor and pleasure to interview Dr. Anna Mae Diehl today. She is a hepatologist, physician, scientists, runner, mother, grandmother, friend, collaborator, and really I'm honored to come to talk to her about her tenure as Chief of GI at Duke between 2004 and 2014. I remember the first day I heard you were coming to Duke. Your biggest fan and husband, Dr. Lou Diehl told me all about you. He said that you had started this amazing program at Hopkins, that I had to meet you, that you had struggled against all of these male dominated figures there to build this amazing program. I was lucky enough to meet you then and I'm lucky now to be your friend and collaborator, so thank you for being here. I wondered, as we recruited you here to Duke, what was it that brought you here, and why did you want to start a new path in your life? What was it that brought you to Duke?

Dr. Anna Mae Diehl: Yeah, it's interesting. I never really had the desire to be a division director. I got a call from Pascal Goldschmidt who was the chief of medicine at the time, and he had had a lab above me while I was at Hopkins, and I borrowed his equipment a lot, so I thought out of respect, I should sort of go down and see Duke when he asked me to go down, even though I protested loudly at the time that I was probably not movable for a variety of different reasons, but I would go down. When I got her, I left by sort of saying, "Who knew?" What I found was a division that had enormous diversity, both in the appearance of its faculty members, so there were actually women GI faculty here. There we`re people of color here, but there was also diversity of interest.

There were people that worked in the pancreas. There were people that were expert clinicians. There were people that were liver experts, and so it was a diverse division. People seemed to respect each other, and realize that kind of it takes a village. That you need a bunch of different kinds of people working together. I thought,  "Wow, what a great group of people. It would be really wonderful to sort of assemble a team of people that could tackle different aspects of the problem, and get resources to help facilitate progress in a number of different areas in GI." So, I came because I thought that would be a good opportunity, and that it would actually be achievable given what was already here.

Dr. Moylan: So, your tenure began after five previous division chiefs, all of whom were male. Did you have any reservations about that, or find any hurdles in the fact that you were a woman taking over this role?

Dr. Diehl:  I didn't, and probably that's just because either I'm inherently desensitized, or if you thought about that all the time, you'd never do anything, because there were so few women in gastroenterology, and even in internal medicine when I came along. I think if one had paused and thought too hard about how different you were than the people that were already there, nobody would have ever come in. So, I guess I didn't really focus on gender. I never thought of the people before me as being different because they were male and I was female. I thought they were different because they were, most of them, either very strong clinically and endoscopically, and that's not my area of expertise, or they were leaders in the pancreas, or in luminal GI from a basic science point of view, and I was coming in as a liver person.

I saw my major difficulty in coming into the GI division is a classical divide in many GI divisions, by that liver and GI are very separate and they sometimes have very mutually antagonistic relationships. I did not sense that here. I thought that was a plus, but I did feel different, in that I hoped that I would be able to craft a leadership team that would reassure the bulk of people in the GI division who were non-liver people that I was actually their advocate and their ally.

Dr. Moylan: Okay. I know one of the first things you did when you came here to the GI division was to really try to keep good faculty in an academic center, and specifically here at Duke. I know you did that to try to compete with community practices, to try to compete with other institutions down the road. And, part of that was going to the Department of Medicine to increase clinical faculty salaries so we could be competitive.

Dr. Diehl: Right.

Dr. Moylan: Do you think that that was really essential to the mission of Duke to keeping good faculty? And why did you think that that was important?

Dr. Diehl: Yeah. I think that sort of speaks to the earlier question. In many GI divisions, not just Duke, the model was that you would get young people out of their training who were quite talented. You didn't have to pay them as much money, and somehow you would try to convince them that there was something extraordinary about being in this environment. They would work tirelessly to be outstanding clinicians, and some would kind of fall into that habit and stay and stay and stay, but most of the really talented ones would, after a while of doing that, say, "I'm just not going to do this anymore. I'm going to leave." Then they would go into the community, and they would be the clinical, the master clinicians, the experts.

While I think we should train people to go into the community and be populated by all of our progeny who are outstanding clinicians, we need to have master clinicians at the mother ship. The only way you do that is you retain people who started out to be very good clinically, were trained, and turned out to be at the top of their program by the end of it, but then acquired more and more clinical experience. And, often in kind of niche areas, where patients were rare and Duke, as an academic institution, or as a large hospital practice, or whatever, could provide some sort of specialized expertise that would recruit a certain type of patient in. So, we didn't want those people that were the most talented leaving.

How would we be able to fill that void? Also, how would we train people to become outstanding clinicians? I think one of the things that I worried about the most as I took over the position was that people would first see me as a liver doctor, not a GI doctor, and that I wouldn't understand these issues, because hepatologists at the time we're getting a lot less money than a gastroenterologist. So, there wasn't much competition out in the community for hepatologists, but there was a lot of competition out in the community for outstanding gastroenterologists.

The second issue about the importance of being a master clinician, and valuing that, because I do basic research, and so people might think that I didn't understand or value, thought that it was a lesser form of life if, "All you did was take great care of patients." You mentioned my husband when we started. He is my role model. He is my kids' role models. I think they want to grow up and be like him, not like me. He's an outstanding, he's a master clinician. If you get sick, you want a master clinician taking care of you. So, I wanted master clinicians in our division.

Dr. Moylan: Your dedication to excellence in research, as well as in mentoring, has been recognized by many, many awards. Most recently, you were the recipient of the Elizabeth Hurlock Beckman Award, which is a national award given to people, and academic faculty members inspired by former students who seek to create a lasting benefit to the community. What were your goals, and strategies, and philosophy as a mentor? And for those of us who are now becoming mentors?

Dr. Diehl: Well, I think here I've benefited enormously from being a parent. I actually see the role of a mentor as being very much a parent, and anybody, like you who's been a parent kind of gets it. A good parent, the kids think you don't do anything, right? Because they don't realize all the things that didn't happen to them because you showed up today. Only after they get to be parents do they realize what being a parent really is. I think I was inspired by Mother's Day, you know, kind of?

Dr. Moylan: Mm-hmm (affirmative)

Dr. Diehl: Good mothers set their children up for success. They analyze their children, not from a perspective of being judgmental, but from really trying to figure out what drives that person? What gives them their most fulfillment? Because I believe that people like to do what they do well. So, if you can get people to admit what it is that they like to do, and do well, and sometimes they tell you what they think you want to hear, but actually what do they really want to do? Then, help them do that. The world is a better place because you facilitated that. So, there's all kinds of things that need to be done, and the best people to do them are the people that want to do them.

Dr. Moylan: Do you think that that affected your leadership style as the division chief?

Dr. Diehl: I think it did. I'm a big believer in the ... I guess I was athletic growing up, so I played on a lot of teams. I came to realize that teams are made out of different kinds of people. A baseball team with nine catchers doesn't go very far, and so what you want to do is be smart enough as a catcher to know that you can't play right field, but you know somebody who does it really well. And There's no need to be intimidated by people that are expert at something you're not. In fact, you want to create an environment that would inspire those people to want to work with you, and then you get fine people that do different things working with you and you have a great team of people.

I was really fortunate as a division director to have outstanding people in the leadership. So as I said, when I came, there was an expert in the pancreas who was a physician scientist who happened to be the chief of GI at the VA. He had skill sets that I didn't have. Why woUld I not want to have that? There was a person, Stan Branch, who was an outstanding clinician, a master clinician. He knew about endoscopy. If I had to pick out a colonoscope, I wouldn't know which end to hold, right? So, thank god Stan did that, and did it well, and had wonderful training programs in that. So, I think the key is recognizing, knowing enough to know what you don't know, getting somebody who seems to know about that, trusting them, empowering them, and letting them take it from there.

Then as a result, what we grew in the GI division was not just people who did liver research. We grew people who did liver research like yourself, but we grew outstanding therapeutic endoscopists, and we'd grew master gastroenterology clinicians. We grew people with expertise in inflammatory bowel disease. I couldn't have grown those people. It took a team of people, including experts in those diseases. So, I think as a parent, what you know is that you can't do everything. You kind of divide the labor. I just used the same model.

Dr. Moylan:  So I asked Steve Choi, who was one of your former mentees, who is now the Chief of GI at the VA hospital here something kind of funny that he remembered. He said the first time he came to your office, he was sitting waiting for you, and he was looking over at the magazines, and he noticed a magazine called Cheerleader Today. He thought, "Hmm. I don't think Anna Mae was a cheerleader." But, maybe truly you do, that you needed to read Cheerleader magazine because you needed to be a cheerleader for everybody else. Was that why you had it, or was it some other reason?

Dr. Diehl: I can't even remember Cheerleader magazine, but I do think that is the job of a leader. Leaders should be the biggest advocates for their team. I think, again, I kind of learned this by on the job training as being a parent, like we all do, but again, I had a great role model. My husband, he was in the military, went all the way up through these command schools and whatever. Kind of the principle there is you always take care of your people. I think you have to always take care of your people. I can honestly say, when I was the division director, the GI division was the first thing I thought about in the morning and the last thing I thought about at night.

I was always trying to figure out how to, I wouldn't say protect people because that sounds paternalistic, and that's not what I was, I hope, but rather to how do we get the most we can to enable this person to apply all of the tremendous talents that they have to make things better? Because, the regrets are that you can't get enough resources to help everybody.

Dr. Moylan: So you've been able to be a true bench to bedside researcher. You've built this amazing program in liver disease research here. Were there hurdles that you had to overcome when you first came to be able to build this true bench to bedside program? Is there anything specifically that you remember?

Dr. Diehl:  I think that the tension for all of us that wear multiple hats in academic medicine is trying to figure out how to get enough hours in the day to get everything done. That's a challenge that I had, but everybody has that challenge. I was kind of dropped into a place I knew nothing about. So, I didn't know who knew what in basic science, or who knew what in clinical things. I didn't know the structure of the institution. I had to learn all of those kinds of things. Fortunately, again, there were many people around me who helped me. Who told me what the scoop was, and guided me in the right direction. That could not have happened without that. But, when I sized up the GI division and I said, "How can I leverage our existing strengths, and sort of visualize this as short, intermediate and long term goals?"

Clearly, if someone from the outside were to look at Duke GI in 2004, they would have said one of our greatest strengths was our clinical expertise. We were taking care of patients, a lot of patients, and we were doing a lot of biopsies in every tissue, and yet we were not systematically saving that as tissues, even though we saw these people repetitively. There was a great opportunity to apply some of the things that were happening in basic science to human tissue. But we had, even though we acquired these tissues and we followed these patients, we weren't systematically saving what we could have interrogated. So, I thought it would be a really good idea to create a bio bank, and we biobanked around the area where we had basic expertise, so that we could use the tissues that we biobanked, because we had to convince people that this was a good idea because it's expensive, and it's time consuming, and it adds a layer of complexity onto the delivery of a clinical product.

I think we did that. We have been very successful with the liver biobank, as you know. The goal there was to, again, take our day job and help us twofer. We were all doing this already. If we just added a little bit of incremental resource on, we could actually save it, and then we could prove to people that if we did it the right way, we would generate information out of it. And then, we would have that information available, so that when young people came along, they could ask what would be sort of sophisticated questions that you wouldn't be able to ask if you already didn't have this resource. The idea was to build something together that wouldn't take too much extra sweat, because we were already doing that work, and organize it a little bit better with the intent that a lot of different people could tap into that.

I think you tapped into it. A lot of other people tapped into it. Then, we used it as a model in other diseases. We created parallel biobanks along the same thing, as more people came online and were doing research in other tissues. I think that was, I think, a great, I would hope, part of my legacy in the GI division was doing that. I think people benefited from that. It got us a networked with people outside of the GI division that came, all sort of realized how we could piggyback research onto patient care. We really needed to do that because our clinical demands were so heavy, as were all of our other clinical partners, and yet all of us wanted to advance knowledge. All of us wanted to do something better than we were doing.

How could we work together to do that? I think collaborations that hadn't existed have formed. We have great collaborations with pathology, great collaborations with radiology, all of which grew out of these efforts, of we're all seeing these patients, why don't we just store this stuff? Start to work together. Figure out how we can mutually build resources around it. I think that's sort of the idea. It seems like that was a good idea.

Dr. Moylan: It seems like it was a good idea. It's still works today, so that's good.

Dr. Diehl: Yeah.

Dr. Moylan:  I guess sort of the simple question. Is there a part of the job as division chief that you enjoyed doing the most, or that you remember enjoying doing the most?

Dr. Diehl: Yeah. I enjoyed that part of it. I think getting to know people. On the beginning when I first came, I didn't know anybody on the GI faculty. I brought people in individually. I said, "Well, you guys know a lot about me. Tell me about you. What is it that you like to do? What's limiting you from being successful?" Everybody could give me a litany of things that were limiting them, but I really had to push people, to say, Tell me what it is that you'd like to do? What do you want to do?" People wanted to tell me what they thought I wanted to hear.

I think the true sign of success is by the end, people were more than happy to tell me what they thought, and so I think that's good. Getting people to realize that everybody has something special. Don't disavow that. Embrace that. Then, you have to trust that your leadership will see that that's a valuable asset potentially for that group, and help you optimize your ability to do that. So that was the most fun. Trying to figure out what I thought people could be. What they wanted to be and then figure out how we could go from here to there.

Dr. Moylan:  I think when you first came here, you wowed everyone with your talk that you had to give. I think maybe you gave a grand roundS speed talk. You have a reputation of knowing lots of details, remembering everything, knowing the nitty gritty, but then having an amazing talent to have people in the audience, clinicians, medical students, nurses, be engaged even in basic science. How did you get that skill, and do you think that that has been something that has really helped you achieve who you are today? You know, being able to bring science to the masses in an enjoyable way?

Dr. Diehl: What's interesting, because one of the meetings that I had earlier today was with a new collaborator that I've had just for the last couple of years in MGM, he's the former chair of MGM, Jack Keane, and he knows RNA binding proteins. Well, two years ago I didn't know what an RNA binding protein was, and Jack was kind enough not to embarrass me about how little I knew about them. We just put in an application to the Keck Foundation, which has these kind of outside the box grand thought things. I would have never thought that I would be doing a proposal like that, let alone with somebody who knows about RNA binding proteins who's a master PhD scientist. What we were talking about is being childlike, I guess.

I would say my greatest asset is that I don't know so many things that I'm not biased by what is supposed to be the explanation. So, I have to actually figure it out, because I don't inherently know. I was not educated in it. I didn't get trained in it. If you don't know what you're supposed to know, and you just have to try to figure it out, and you look at a bunch of data, it's kind of like being a doctor, really. Right? You see a patient and this is the finding, and then you have to put that together. Well, if you know what the disease is supposed to be, and you see that, you put it together and it's always that disease.

But sometimes there's outliers, and you have to say to the patient, you know, "You didn't read the book today. You're not supposed to have this disease because you didn't do this." But the patient is laying there with the disease. So obviously, who's wrong? So, I think my ability to explain something grows out of the fact that I don't know a lot, right? So, if I look at stuff, I can see it very well. I'm a very good observer, but if I put it together and it doesn't make sense to me, then I have to try to figure out why I see what I see. I generally consult a lot of people who I think might be helpful in helping figure that out, and in the process I learn, because I never knew that before. Since I had to go through that whole painful process, I can explain it to somebody else so that they could do the same thing.

Dr. Moylan: I think it works. Just as a final question, are there any things, or any accomplishments, that you feel especially proud of during your time as serving as chief, or anything that you would like us to remember that I haven't asked you about yet?

Dr. Diehl:  No. Well, I mean I think it's a privilege to be a leader in any capacity. It's a privilege to be a parent. It's a privilege to be a chief resident. It's a privilege to be a division director, or a chair. What is the privilege about that is that you have a group of people who trust you, basically, to have their better interest at heart. The most gratifying thing is watching the success. Seeing where the division was and where it grew, but that would not, if you're honest about it, no leader can take credit for that, really. You had to get a group of people who were willing to pull in the same direction at the same time,  which is no small feat though, because it's like herding cats sometimes, right? You get a bunch of people to come together, and the division as a whole makes progress.

I think we grew our clinical footprint, but I certainly can't take the bulk of the credit for that. I would say that goes to Stan Branch. We grew our academic mission. We had more physician scientists coming in. We had more clinician scientists coming in. Again, I trained a subset of those people, but a lot of other people contributed in that regard. We really put translational GI on the map, and I think again, other people did that. [Minal 00:24:04]. Others. Others. So, I've been privileged to be in the right place at the right time. I think people came through. I was receptive to what they might do, but they were willing to do it. That's been the fun part of it.

Dr. Moylan: Well that's good. Well, thank you very much.

Dr. Diehl: Oh, thank you, Dr. Moylan.

Dr. Moylan:  Thank you.

Dr. Diehl: Thank you very much.