Dr. Zvara discussing a case with Jennifer Tripi, CA-2. “UNC is home to over 60 core program residents and fellows in pain medicine, regional anesthesia, pediatric anesthesia, and research,” Dr. Zvara said. “Our residents are truly the heart of our program.”

Most of us (if not all of us) are currently dealing with personnel issues, particularly with difficulty in recruiting/retaining. Such difficulties are heavily borne by departmental leaders who are simultaneously accountable to physicians that work under them and to hospital administrators above them. The average tenure of an anesthesiology department chair is less than five years, and the incidence of burnout is high (Anesthesiology 2011;114:181-93). Staffing problems aside, what are the unique pressures that chairs face, and are these pressures surmountable, given a pandemic that refuses to fade away, a labile economy, and a politically polarized society? Addressing these questions for us this month is a successful, veteran chair, Dr. David Zvara, who leads the highly regarded department at the University of North Carolina at Chapel Hill.

Dr. Zvara, a pleasure to have you. What was your path to chairman?

I always thought I might be interested in being a chair someday. So, I tried to put myself in a place where, when the time was right, I might have a shot. After residency and fellowship, I served four years in the United States Air Force. I was deployed in Operation Desert Storm. After that, I took my first job in an academic program. I did some original research, got involved in education, and worked hard as a clinician. My focus was cardiothoracic anesthesiology. Eventually, I led the fellowship program and became Division Chief in Cardiothoracic Anesthesiology at Wake Forest. In 2006, I was lucky enough to be selected as chair at The Ohio State University.

All of us face decision points in our career, and a couple were pivotal for me. The first was the decision to explore an academic practice. After completing my military service commitment, I applied to both private practice and academics, and I chose academic practice thinking that if I didn’t like it, I could always switch. It turns out I loved the variety of opportunities afforded in academia. There is simply no reason to be bored or under-stimulated at work. Having opportunities for career advancement via activity in education, research, quality, and/or service, and being at the forefront of clinical discovery and care, I feel that I made the right choice.

My second (and largest) inflection point was accepting the offer at Wake Forest University. At the time, my wife and I had no connections to North Carolina. Of the many positions that I explored, from Mississippi to Michigan, Texas to Iowa, this was the lowest paying job. So, no friends, no family, and the lowest pay. Yet, I took it. Why? Because it offered the greatest opportunity for mentorship. I knew I wanted to grow my career in leadership and this was the epicenter in the 1990s. In a span of 18 years, 12 physicians from Wake Forest became chairs of anesthesiology. I was a part of this. I worked side-by-side with some really great folks: Butterworth, Prielipp, Gravlee, and Wall, to name a few. Wow. I am grateful for the mentorship of Dr. Frank James and his decision to take me on with, basically, nothing on my CV.

What is the biggest problem you face at this moment?

Right now? Staffing, hands down. This is the worst workforce shortage we’ve experienced in 30 years in practice. A Rand Corporation study predicted a shortfall of CRNAs and physician anesthesiologists come 2020. What it did not foresee was COVID, early retirements, extension of parental leave to non-maternal caregivers (a good thing!), and the extension of CRNA training programs from two years to three. Add this all up, and suddenly we are way short of staffing goals. ORs are closing due to a lack of staffing. Think about that.

What issues do you see as most pressing for departmental leaders nationwide?

This is a fascinating question. The answer depends on whether one is asking about our immediate horizon or about the longer term. In the immediate future, issues related to staffing are most pressing. Frankly, I don’t see us coming out of this post-acute pandemic recovery and achieving a normal state for 24-36 months. Hard to believe.

That said, problems like this are transient – it will end. When asked a version of this question by faculty or resident applicants, I jokingly say that we have 100 problems! We have 100 problems today, we’ll have 100 problems tomorrow, and we’ll have 100 problems 10 years from now! I just hope they’re not the same problems!

What are the long-term concerns? To me, it is the need to develop leaders and thinkers in anesthesiology. The discipline of anesthesiology will be here forever – no anesthesia equals no surgery. So, anesthesiology will be with us as long as we are human. The real question is, what role will physician anesthesiologists play in this specialty? Who will lead us forward in our profession? How will they be trained? What values will they hold? How will we continue to push the boundaries of new knowledge and disseminate this knowledge? I believe that physician anesthesiologists must lead this effort and thus define the specialty. Innovation in our field rests on the shoulders of physicians and scientists. It is up to us to step up and lead. We need to train technically expert caregivers and health care system leaders.

What has been your biggest success at UNC?

We’ve done a fabulous job of recruiting and retaining diverse talent from all over. Sure, we have an advantage at UNC: we are in a great location, the bricks and mortar are pretty, and UNC is a top research institution. But there has to be more to retain people. We’ve emphasized educational innovation and patient safety/quality improvement (PS/QI) research. We are active in every discipline of anesthesiology. People want to join us at UNC because they feel like they’re part of a winning team and that their career development is readily attainable.

I’ve always aspired to an ideal that can’t be measured, at least not directly. My goal is to work at a place that is viewed as one of the best in the nation, i.e., a program that is contributing to, if not leading, the national dialogue. An indirect measure of this is people who join the team. I encourage faculty and residency applicants to look at the best programs in America, interview there and see what they have to offer – and then choose UNC! When that happens, and it does quite frequently, it is magical. People who can go anywhere in the country choose to come here. I am humbled by this. Blows my mind, really.

What has been something you did that was not so successful, and how did you learn and grow from the experience?

Ha! As stated above: You want to hear about problems, I got a hundred of them! If you have a few hours, I’ll lay them all out. It’ll make you cry!

Seriously, the difficult part of my job is managing people. The areas that I’d like to “take back” or get a “do over” relate to how I interacted with people. I have at times erred in hiring decisions, or not acting swiftly enough when there are people problems. Sadly, I’d like to take a comment here or there back that hurt someone’s feelings unnecessarily. This is a hard job, and there is no point in making it harder via a terse comment or a short answer.

I assume your department receives a significant amount of financial support. How do you approach the challenging topic of budget and finances?

Another trick question!

People ask me if I have an MBA, or if an MBA is necessary for advancement to a chair position given the financial responsibilities associated with being chair. I don’t think it is. I believe the key elements that a chair must possess are:

  1. Honesty. I tell people all the time, you may not like what I say, but you can believe that what I am telling you is the truth, as best as I understand it. If your people don’t trust you, you’re done.
  2. You need to be able to paint a compelling vision for the future (and deliver it). People want to join a winning team. They want to aspire to something big and important in their careers. They need to see a pathway for their success in your program.
  3. You have to be able to do simple arithmetic. No one needs to be a financial whiz to be a successful chair, but you must understand basic math! If there is a deficit, then you need to have the interpersonal skills to secure from others the resources necessary to make it happen. So, one needs simple math and some real people skills. These are inseparable when running a business like anesthesiology that is dependent on financial support from the institution.

With so many faculty, how do you maintain departmental unity and faculty happiness?

That’s a tough one. When I came in 2008, we had 38 faculty and about 38 CRNAs. Today, we have 90 faculty and 95 CRNAs. In 2008, we worked in one location. Today, we are spread across multiple hospitals, ambulatory surgical centers, pain clinics, and more. We try to stay connected through grand rounds, departmental newsletters, faculty meetings, and social activities.

Happiness is another issue. I know that as chair I must be transparent, honest, and responsive. All of our people want to feel valued. That’s squarely my job. In addition, we try to do “pop-up” lunches periodically, a holiday party, or a graduation, and we buy a couple hundred tickets to a Tarheels baseball game and football game each year.

It’s hard for a chair to promote “happiness,” but it is remarkable easy for a chair to bring a department down emotionally. Stay focused. Be honest and support your people. Always support your people.

Regarding the lack of longevity seen in anesthesia chairs, particularly in academia, why do you think this is occurring, and what can be done to mitigate it?

At one time, the average age of a new chair was 47. Bringing people into the role at about this age seems right in that a person might reasonably expect to be a chair for 10-15 years. There is a lot of stress with the job and a never-ending to-do list. A new chair must learn, early on, that this job is a marathon and not a sprint. You can’t solve all the problems in one day. Don’t let email destroy your life. I do not check any messages between 7 p.m. and 5 a.m. If there is a crisis, people know to call me. Otherwise, I’ll see it in the morning.

Have you personally found it “lonely at the top?”

Not really, but there is an adjustment. As a “regular” faculty member, I could joke around, develop friendships, and be one of the gang. As a chair, one must remember that you are the boss. You set salaries, determine bonuses, and allow opportunities. One can’t be seen as playing favorites. And, sadly, jokes don’t play as well coming from the boss. So, there is a separation from the people with whom you most relate. That said, other social networks emerge. So, no, it’s not lonely, just different.

Who is going to take your place – meaning, are we properly training the next generation of leaders?

Yes. I have complete confidence in the next generation of leaders. Not a single worry there.

What advice do you have for aspiring leaders in anesthesiology, whether academic or private?

Performance matters. If you want to separate yourself from others and emerge as a leader among your peers, you must deliver. One must be an outstanding clinician – that is a given. But you must put in the extra time, the extra work, and the extra hours to go above and beyond in research, education, administrative contributions, or PS/QI. There’s no shortcut.

What interests do you have outside of clinical medicine?

I have a wonderful family. My wife and I just celebrated our 40th wedding anniversary with our children and grandchildren this past summer. Nothing like it. I am so lucky.

Oh, yes, and golf. Definitely golf.

Any parting words for our readers?

Aspiration and ambition are wonderful qualities when appropriately channeled. We need folks at all career stages to think, “what next?” and “how can this be better?” I love the energy I find in those people who aspire for something better. Sure, there are many demands, and the clinical care isn’t getting easier, but there is a world of discovery out there. Lastly, probably the thing I enjoy most as a chair is the opportunity for mentorship. A chair is like a coach. You are not the quarterback or the star receiver anymore. You’re directing others, and sometimes the team rises to great heights and it is terrific.