Karen S. Guice
Principal Deputy Assistant Secretary of Defense
for Health Affairs, US Department of Defense

Born 1951 in El Paso, Texas.

Dr. Karen Sue Guice serves in two prominent policy roles assisting US military leadership in developing strategies to achieve the health mission of the Military Health System (MHS).

As the principal deputy assistant secretary of defense for Health Affairs, US Department of Defense, Dr. Guice helps formulate, develop, oversee, and advocate the policies of the Office of the Secretary of Defense regarding all military health concerns. She also acts as a liaison for other offices within the Office of the Secretary of Defense, the military departments, Congress, and other executive branch agencies to develop, coordinate, and integrate health care policies with departmental priorities and initiatives.

The Office of Health Affairs is responsible for providing a cost effective, quality health benefit to 9.6 million active-duty, uniformed service members, retirees, survivors, and their families. The Military Health Service has a $53 billion annual budget and consists of a worldwide network of 56 military hospitals, 363 health clinics, 282 dental clinics, private-sector health business partners, and the Uniformed Services University.

As the principal deputy director of TRICARE Management Activity (TMA), Dr. Guice oversees the civilian health benefit program serving military personnel, military retirees, and their dependents, including some members of the Reserve component.

For three years prior to this assignment, Dr. Guice was executive director of the Federal Recovery Coordination Program (FRCP) within the Central Office of the Department of Veterans Affairs. FRCP is a joint program of the Departments of Defense and Veterans Affairs to coordinate the clinical and nonclinical services needed by severely wounded, ill, and injured service members and veterans.

From January 2011 to May 2011, Dr. Guice served as a co-chair of the Department of Defense Recovering Warrior Task Force. In 2007, she was the deputy director for the President's Commission on Care for America's Returning Wounded Warriors, also known as the Dole-Shalala Commission.

Dr. Guice served as program director of the Outcomes and Clinical Trials Center for the American Pediatric Surgical Association (2002–2006), director of the Fellowship Department of the American College of Surgeons (February 1999–June 2002), and health policy advisor to the Labor and Human Resources Committee of the United States Senate (1997–1998), chaired by Senator James M. Jeffords (D-VT), a position that was a continuation of a health policy fellowship she received from the Robert Wood Johnson Foundation the previous year.

Dr. Guice has been a clinical professor of surgery at the Medical College of Wisconsin in Milwaukee (since 1999). She was an associate (1991–1993) and professor (1993–1998) of surgery at the Duke University Medical Center in Durham, North Carolina. She was an assistant (1985–1990) and associate professor of surgery (1990–1991) in general surgery at the University of Michigan in Ann Arbor. She was an instructor (1983–1984) and assistant professor of surgery (1984–1985) at the University of Texas Medical Branch in Galveston.

Dr. Guice has received more than $3.7 million in grants for several research projects undertaken from 1984 to 2008, including studies for the US Department of Health & Human Services' Maternal and Child Health Bureau and the National Institutes of Health (NIH).

She has authored or co-authored more than 70 research articles published in peer-reviewed journals and has written several book chapters.

Dr. Guice has received many awards and recognitions, including the Olga Jonasson Distinguished Member Award (1999) presented by the Association of Women Surgeons to a member surgeon who exemplifies the ideals and mission of the organization; the Award for Outstanding Achievement from the Office of the Secretary of Defense (2007) for her work on the President's Commission; and a Commendation from the Department of Veterans Affairs (2009) for her service as the executive director of the Federal Recovery Coordination Program.

She received a bachelor of science degree from New Mexico State University in Las Cruces (1972) and an MD from the School of Medicine at University of New Mexico in Albuquerque (1977). Her medical internship and residency were in the Department of Surgery at the University of Washington, Seattle (1977–1982). She received a post-graduate research fellowship from the Department of Pediatric Surgery at Children's Hospital Medical Center in Cincinnati, Ohio (1982–1983). She received a master's degree from the Sanford Institute of Public Policy at Duke University in Durham, North Carolina (1996).

Elizabeth Ghaffari: Was there anything in your family background that led you into medicine?

Karen Guice: No. I'm still not quite sure why I became interested in medicine, but when I was about thirteen years old, I announced that I wanted to be a physician and had some interest in research as well.

Ghaffari: Would you tell me a little bit about your family. Was it large? What did your folks do?

Guice: My own family was just my mother, my father, and my brother. But my mother's family was large—she was one of ten children, so I had a very large extended family with lots of cousins, aunts, and uncles in Las Cruces, New Mexico, which is where we lived. My father's family was from Louisiana. Most of them had stayed in the South, so I would not see them on a regular basis. My mother's family had a profound influence on me and my growth as a person.

My mother finished high school in the post–Depression era, then immediately went to work as a secretary. During the war, she supported her mother and her younger brother. Her father died when she was thirteen, so she grew up without a father for most of her life. She was ninth in a family of ten. My own father died when I was nine. My mother went back to school after his death. She probably had the most influence on me because she was a strong woman who went back to college and graduated in three years with honors. She was a pretty fierce woman. She decided she wanted to teach school, so that her schedule would be better synchronized with ours—she could have summers off and was able to take time off for school vacations with us. She did that basically to have a closer interaction with her kids.

Ghaffari: Would you tell me a bit about your college education?

Guice: I went to Baylor University in Waco, Texas, for my first year in college, but I got sick over that first summer—something called coccidioidomycosis, a fungus infection in my lung that is prevalent in the Southwest. I was in the hospital for a couple of weeks, and my internist said, “Why don't you stay at home for the next semester? You're going to feel weak. You should take a lighter load in school.” So, I decided to transfer entirely to New Mexico State University in Las Cruces. I earned a bachelor of science in chemistry, finishing early—in December of my senior year. I immediately began graduate school because, at that point, I had not yet been accepted to medical school.

Ghaffari: What made you choose New Mexico School of Medicine?

Guice: It may have been the only place I applied—close to home and all that. I was admitted to medical school after I had started graduate school in the spring semester. I went to the University of New Mexico that fall for four years of medical school.

Ghaffari: Where did you go after medical school?

Guice: I knew I wanted to do surgery and had applied to several surgery programs. The process is that you go around, interview, and send in your rank-ordered list of preferences. The surgery programs do the same for the candidates. Somehow, the matchmaking happens. I was lucky enough to have been selected to join the internship class for the Department of Surgery at the University of Washington in Seattle. So I headed off to the Pacific Northwest and spent the next five years doing a surgery residency program.

My residency, from 1977 to 1982, was just a typical hard-core surgery residency—taking care of patients, learning by doing, but in a tiered way, so you have progressive responsibility until you become the chief resident, and you're the boss. It's something like an old-fashioned apprenticeship.

In my fourth year, I began dating another surgical resident, Keith Oldham. We fell in love. He proposed, and we got married all in the space of four months. He was one year ahead of me, a chief resident, who was going off to Cincinnati, Ohio, to do a pediatric surgery fellowship. We spent the first year of our marriage apart—he in Cincinnati and I in Seattle. As newlyweds, we were pretty strapped for cash, so we saw each other just a handful of times over the year.

After my residency, I joined him in Cincinnati, where I was a research fellow from '82 to '83 for the Pediatric Surgery Division of Children's Hospital. I think Keith and I had at least two publications accepted during that year by peer-reviewed journals. Also, I took classes at the University of Cincinnati—some courses in electron microscopy, among others. It was just a case of “I'm interested in learning” as opposed to having to do it for a degree. It was an opportunity. Then we both had to look for “real jobs.”

Our first foray into the working world had us both on the faculty of University of Texas's Medical Branch in Galveston. I was an instructor, then assistant professor, in the surgery department there. Keith was recruited to go to the University of Michigan in Ann Arbor. We were there for six years, during which time I rose from an assistant to an associate professor of surgery.

We were recruited by Duke University Medical Center to join their faculty in 1991. I was planning to take a sabbatical while I was at Duke University. While we were getting our laboratory squared away, I found something called the Sanford Institute for Public Policy, named for Terry Sanford, the former president of Duke and former governor, and former senator, of North Carolina. This was the beginning of the Clinton health care reform era. I really just got tired of sitting around the cafeteria with everyone whining about how bad health care was. I thought, “You can't complain if you're not willing to be part of the solution.” So I thought one thing I could do was to go to policy school. I talked to the admissions people, thinking—of course—that surgeons can do everything. Audaciously, I said to them, “I can be a full-time surgeon and do this program.”

Helen “Sunny” Ladd, the dean of the school, said, “No, you can't. We won't let you.” But I was intrigued, and after several years, I just went ahead and applied anyway, thinking, “Okay, if I get accepted, then I'll figure it out from there.” I did—they accepted me into a one-year program. I got permission from the Department of Surgery chair to take a year's leave of absence. It was a combined-degree program, and they counted my medical degree as one of the degrees, even though it was received years earlier. They let me do a master's degree in public policy in a year.

Ghaffari: You also became a full professor at Duke. Is that right?

Guice: I was the first woman to be appointed professor of surgery at Duke.

Ghaffari: What was the surgery-related work you did while on the Duke faculty?

Guice: When I was on the Duke faculty, most of my time was spent doing clinical care, practicing surgery, and bench research.

Ghaffari: What is “bench research”?

Guice: In clinical research, you use clinical materials such as your patients' or patient records, to try to solve clinical questions. Bench research is different—it is research done in a controlled laboratory setting using nonhuman subjects. My area of research—beginning when I was in Galveston—was gastrointestinal diseases. I started with a model of acute pancreatitis, trying to understand that better. When I was at Michigan, my focus changed a little bit because a mentor of mine there was a pulmonary expert. We changed the model to one where I could induce a form of respiratory failure. It's called pulmonary inflammatory response, where your lungs get damaged because of a biological process elsewhere. I developed an animal model of respiratory insufficiency induced by pancreatitis in order to look at the mechanisms by which the pancreas could make the lungs fail.

Ghaffari: Who was your mentor at Michigan?

Guice: It was Dr. Peter Ward, the chair of pathology there. He was just a wonderful guy—very welcoming and really interested in fostering intellectual curiosity. He said, “Come. Here's my lab. You can work in it. Here are the things I can help you with.” He was very supportive, and while we were there, I successfully competed for and obtained an NIH grant for that particular field of study.

Ghaffari: How did you happen to get the health policy fellowship at the Robert Wood Johnson Foundation?

Guice: I was halfway through the public policy master's program when I got a call from a friend of mine, Dr. Charles Rice, who had been on the faculty of the University of Washington when I was an intern. He's currently the chancellor at USUSH.¹ He said, “You can't do this public policy degree program without some sort of a practical experience. I think you should apply for the Robert Wood Johnson Foundation Health Policy fellowship,” as he had done several years before. So, I used the same philosophy, “Well, I'll apply. If they don't accept me, that's okay, too.” And I was fortunate enough to be selected.

It was one-year fellowship. I was working for Senator James M. Jeffords, who was chair of the Senate Labor Committee—currently called the Senate Committee on Health, Education, and Labor. He asked me to stay on for an additional year so that I would have one full Congressional cycle covering two years in Washington, DC—from '96 to '97.

Ghaffari: That was your first public policy experience, was it not? Did you like it?

Guice: It was my very first exposure to practical public policy work. You go to school to learn all the tricks of the trade, and fortunately for me, I got to put that into practice in a very meaningful way. My focus was on health care quality. We had a couple of legislative proposals with Senator Lieberman. I think I still have a bill somewhere that I wrote for the senator, and he autographed it for me at the top.

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Then my husband decided to accept a job at the Medical College at Wisconsin in 1999. We had two small children—two boys. Christian was born in '89 while we were at Ann Arbor, and Brian was born in '92 while we were at Duke. When they were still little tykes, it was relatively easy for me to commute back and forth to DC from Durham. It would have been a little more challenging to fly halfway across the country to DC from Wisconsin. So, for a lot of reasons, we decided that I would rejoin the family in Milwaukee, which is what I did.

Ghaffari: You didn't yet have a job in Wisconsin, so what did you do?

Guice: Our professional society, the American College of Surgeons, is located in Chicago. I started working with them and became the director of fellowship. I would commute down to Chicago and back home every day, three hours on a train. That position gave me a good understanding of how the professional society worked.

Ghaffari: How did you handle the two young tykes, the work, and the commute?

Guice: We had one nanny for the whole time we were in North Carolina. That consistency of child care was extraordinarily valuable. However, she did not make the move with us to Wisconsin—she didn't want to go where the snow flew. So, we started over with new nannies. One night, the family was having dinner when we mentioned that we'd had to dismiss the current nanny for some reason I can't remember. Our older son, Christian, said, “Well, there goes number nine!”

I said, “It can't be nine.” And he just ticked them off. He said, “There was so-and-so and so-and-so and so-and-so and so-and-so.” Keith and I looked at each other and said, “We're probably going to need to chat.” So we got the boys off to bed and said, “You know, this probably isn't a good idea for them. They're at the age where they need more consistency.” We were looking to replace the wonderful person we'd left behind in North Carolina and just couldn't find anybody to measure up to her standards. She really had spoiled us. At that point, I decided to leave the job in Chicago and the commute. It just wasn't fitting well with our family and what the family needed at the time.

So, I started doing some health services research, specifically looking at children's surgery and working on a national trauma database for children. The research was assessing what were the unique requirements for pediatric trauma and then what was being done for pediatric trauma across the country, trying to come up with guidelines about what and where children should be taken for trauma. The key concern was, “Are their needs different than adults?” I did that through a grant from HRSA² for a program for emergency medical services for children from 2002 to 2007.

The nature of this research allowed me to be more flexible with my hours—working while the boys were at school during the day. I got to take them to school and pick them up frequently and go to their events. It met the family needs while they were impressionable young men.

Ghaffari: When and how did you come to serve on the Dole-Shalala Commission?³

Guice: That was from March through July of 2007. During the time I was working on the Robert Wood Johnson policy fellowship in DC, I got to know a woman by the name of Marie Michnich, who was a former RWJ fellow working for the American College of Cardiology. Do you know how it is with some people that you immediately hit it off? And she and I hit it off and developed a very nice friendship. In fact, our families started going on vacations together. Marie and her husband, Brian, had a daughter in between my son's ages, so both families would go on a rafting trip down the Rogue River or America's Creek in Alaska or take a sailboat vacation to the Queen Charlotte Islands. We had a little network of friends with kids that would join together to do these adventure things. It was fun for the kids, and the parents had a good time, too. I came to know Marie and her family very well.

My family was on a vacation when I received an e-mail from Marie telling me that she had just been named the executive director of the president's commission and that she was looking for a deputy director. I remember distinctly going to talk to my husband—I think he was shaving—to say, “What would you say if I told her, ‘Well, if you're asking, I'll accept.'” And he said, “If that's what you want to do, that's fine.”

So that's what I did. I told Marie, “Your search is over—congratulations!” And she replied, “I was hoping you'd say that. I was baiting you a little bit.” I did the commission with Marie, and that led to a whole series of new adventures.

Ghaffari: Did you relocate to Washington?

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Guice: No, it was just for four months. I was going back and forth between DC and Wisconsin. The other thing that happened when I was doing my health services research, before the president's commission role, was that my mother had had a fairly debilitating stroke and was living with us in Milwaukee. She was paralyzed on the left side, so that meant balancing in my mother's medical needs. The boys were a little older and were able to help out somewhat. That's how we worked through the four months. Afterwards, I went back to Wisconsin and picked up my research.

Ghaffari: What were the next series of new adventures?

Guice: Keith and Christian had decided to climb Mount Denali in Alaska, so they had gone off that summer to go mountain climbing. It was in July of '08, and I was working alone at home when the phone rang. It was Secretary of Veterans Affairs James Peake. He said, “I need you to come run a program.” I responded, “Okay. What is it and what do you want me to do?” We talked a little about the assignment, and then I asked, “If I say ‘yes' to this, sir, when would you want me?” he said, “Tomorrow.” I distinctly remember saying, “Well, sir, my husband and I generally talk about major career moves, and I can't reach him until he comes down from the mountain. So you're going to have to wait a few days.” He thought that would be fine.

Keith and Christian successfully scaled Denali, came back down, and we had our little chat. Again, my husband, who's been very patient with all of this, said, “If that's what you want to do, okay. It's fine with me.” That's how I wound up back in Washington, and I've been here ever since.

Ghaffari: What was the assignment from Secretary Peake?

Guice: It was the role of executive director of the Federal Recovery Coordination Program—my first foray into the Veterans Affairs field, although I had worked in VA medical centers during my residency and as a surgical faculty member. I knew the VA, but from the practitioner's side. This was my first exposure to working within the big bureaucracy of a federal agency like the VA or the Department of Defense.

Ghaffari: What part of your background did they recognize that would be valuable to them?

Guice: The recommendation came out of my time with the Dole-Shalala commission. I think the interesting skill set for them was the ability to listen to all of the discussions and deliberations that formed the backdrop to a recommendation, to develop a recommendation out of all that, and then to be able to translate that recommendation into a program.

Ghaffari: What was the FRCP experience like for you?

Guice: It was very interesting. First of all, it was getting to know the VA. The program had been moved from VHA, the Veteran's Health Administration, up into the office of the secretary, so I worked directly for Secretary Peake. That was important because the Federal Recovery Coordination Program is really a “one VA” program. The people who work for it are trained in both the health care aspects of what VA provides, as well as the benefit side and the DOD components.

The observation from the commission was that we transfer people between facilities an awful lot. While someone's in a facility or a particular catchment area, they have case managers to help them. But, when they leave to go to a new facility, all of the case management team has to get re-created. At that point, there are too many opportunities for things to get dropped or not completed or have expectations changed.

The recommendation from the commission was that—for the most severely wounded, ill, or injured—if you could have someone stay with that family and that individual throughout all the transitions as they went from one in-patient facility to another or in-patient to outpatient or from active duty military to veteran status, then that would provide the consistency they needed, as well as an ability to do long-range planning for these families and individuals to pull together everything that had to happen in a very smooth and cohesive way. That would provide significant improvements over the way things were being handled at that time.

The hypothesis was that a consistent care manager would be of great value to the service members and their families. The nice thing about this program is that it actually delivers on that promise. I wouldn't say 100 percent, because no program is 100 percent, but to a good percentage. We did the first-ever satisfaction survey for the program, and it came back with an 80 percent satisfied rating, which I think is good for a brand-new program.

We were really creating something that had not existed before. There was very intensive training provided to the staff and employees. It was a major challenge figuring out how to make a program work in a big bureaucracy that had several “stovepipes”—organizational or functional domains that were hard to penetrate. You had the VBA⁴ over here, the VHA⁵ over there, and the Department of Defense along with four services—Army, Navy, Air Force, Marines. We tried to balance the needs of the program, which really reflected the needs of the client, with all of these different programs and offices within the bureaucracy. That's what was so interesting.

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When the program was set up, there were entry criteria that were fairly generous. But, the niche that the program best served was those service members with complex injuries or illnesses who required multiple engagements with health care providers and benefits to effect healing and recovery. They ranged from people who had devastating burns to those who had devastating PTSD⁶—physical as well as psychological injuries. But the problem these people faced was the same: during any transition, we need to make sure the information got through, that the benefits were aligned and delivered, and that they received follow-up and follow-through care. So much of what we did was simply to make sure that stuff got done in a way that made sense for the recovery of the individual and the needs of the family.

In my opinion—and I'm probably really biased—the program works really well.

It's a new concept, and a fairly unique program. People still have a hard time wrapping their heads around it. I couldn't understand how everyone couldn't see it as clearly as I could. After talking to a number of individuals, they value this additional resource so highly that some of them never wanted to give up their federal recovery coordinator, even though they didn't need the FRC anymore. They said, “This is just my safety line. I know that if I need something, this person will get it for me, or tell me how to get it, or help me get it.” Essentially, we gave them the ability to reach out, understand all of the programs, and understand what things needed to be put together for their individual recovery plan.

Ghaffari: Do you see that there might be applicability of the program concept across all medical professions at the national level, not just veterans?

Guice: You're asking “Why wouldn't any medical program want to do that?” The answer depends on the payment stream. It's not that the private sector manages the transitional problems better than the military or the VA health system. It doesn't, but the real issue for the private sector is “who's going to pay for it?”

If you're a hospital person, you're going to be paid by the hospital, so you will only focus on services provided by that facility. You're not necessarily going to look at what happens if an individual is taken to another hospital or went to another hospital because they have Medicare or TRICARE.

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The ability to provide better coordination of care within the federal health system has some unique aspects because the payer is the federal system. I think that concept would be very hard to replicate in the private sector—not that you couldn't do it, but the question is “who pays for that service?”

Ghaffari: Did you find that the program produced any significant cost savings?

Guice: We didn't measure cost savings, because we were trying to make sure, first, that we had enough individuals to cover project needs. We did just-in-time staffing where we would hire based on what our projected needs were. I'd do an analysis and conclude that we might need five more FTEs in the next six months based on our current referral pattern. Then, we had to pull together the educational part, make sure the program worked, get our IT solution together for documentation—all that was required to set up a program. Did we save money? That would be something to look at later. When you're just starting a new program, the priority is getting it functional.

Ghaffari: How did you get your current position as principal deputy assistant secretary for defense?

Guice: I was working in my office at the VA when one of the special assistants for the secretary of veterans affairs came over and said, “You've made the short list to be considered for the principal deputy assistant secretary for Health Affairs.” And I said, “Oh. That sounds interesting. I didn't know I'd applied, but okay.” And I'm still not sure exactly how that happened. He asked, “Do you want to be interviewed?” I remembered the philosophy of my dear friend, Marie Michnich—never ever refuse a job you've not been offered. My philosophy is you always learn something about yourself by interviewing for other jobs or exploring other employment opportunities. It makes you either grateful for what you have or it makes you think about how you want to reposition what you're currently doing. Sometimes you end up saying to yourself, “This is a job that I would leave now to go do that.” So, I said, “Sure, I'd love to be interviewed.”

That led to a series of interviews, each one of which, I must admit, I left feeling, “That's that. I won't be called back for another interview.” Then I'd get called back for another interview, and it kept escalating to higher levels of people interviewing me. First was Dr. Jonathan Woodson,⁷ then Dr. Clifford Stanley,⁸ then Robert Rangel.⁹ The next thing I knew, somebody said, “Well, congratulations—your paperwork is at the White House.” And I went, “Oh. Okay.”

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I'm really glad I made the move. It was probably a good time for me to leave the FRCP to be sure the program wasn't functioning just because I was making it function, but rather because I had instilled some longevity in it. I certainly couldn't have asked for a better set of fun things to do than to take on this job.

Ghaffari: What do you do and why is it exciting for you?

Guice: That's exactly what my husband said when I told him I was going to be “the principal deputy assistant secretary for health.” He said, “That's a very impressive long title, but what do you do?” After a bit of explanation, he then said, “Okay, I get it. You're the COO for the military health system.” That's probably a reasonable way to describe it.

We have a lot of meetings on a variety of topics. Today, for instance, was a meeting on the integrated electronic health record and another meeting about BRAC¹⁰ and how we're doing with all of our facilities moving through the BRAC process. The portfolio is quite diverse. There's never a dull moment. It runs the gamut of dealing with everyday things, such as hiring people, all the way to gathering information so that the secretary of defense can make a decision or at least be better informed. Every day is different, and frequently what I plan for the day is overcome by events, but that doesn't matter. It's fun, and I enjoy what I'm doing immensely.

Ghaffari: To whom do you report?

Guice: Dr. Jonathan Woodson, the assistant secretary of defense for Health. Part of what I do is help him get information to make decisions and give testimony. I also look at policy revisions. For example, what we need to look at in the area of graduate medical education. I'm heavily involved in trying to pull groups together, get consensus, get information, and manage information. The Pentagon is an interesting place where a lot of information transfer has to happen.

Ghaffari: How long do you see yourself in this position?

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Guice: It is a political appointment—it rises and falls with elections. So it could be another year or it could be five more years. I have no idea. My basic promise to myself is always stay effective—if you stop being effective, that's when you know you need to go do something else. As long as I'm effective and can get things accomplished, that's my own internal benchmark for how long to stay in a job.

Ghaffari: Is your family also in DC now?

Guice: No, my husband is chief of surgery at the Children's Hospital of Wisconsin, so he's in Milwaukee. Our older son, Christian, is finishing his senior year at Davidson University in Charlotte, North Carolina. He's majoring in biology with a minor in Chinese. Our younger son, Brian, is a sophomore at Wake Forest in Winston-Salem, North Carolina, trying to figure out if he wants to major in biology or political science. What's fun is that the boys are actually just seventy miles apart in North Carolina, totally by accident. Keith and I are going to go down and visit them in a couple of weeks.

Ghaffari: Do you miss surgery—the medical practice?

Guice: I don't. When I was working on the Hill for Senator Jeffords, I got to know a couple of people working for the Congressional Research Service. One day, they said to me, “We just can't figure out why you're here doing this work because you actually take care of patients. I mean, you actually make somebody better, so why would you be here doing this kind of stuff?” And I said, “Well, because when I'm taking care of patients, I can affect one life at a time. When I'm here doing this kind of work, if I change an ‘and' to an ‘or,' the impact can be for thousands, if not millions, of lives.” The impact is greater because of what I know and because I'm able to apply it in a different way. I feel like I'm helping more by where I am and what I do.

Ghaffari: Did you ever feel that you just wanted to throw up your hands at the Department of Defense and go away?

Guice: I've done that with every job that I've ever had. There are times when you're just frustrated that you can't get something done or you thought you had something locked up and somebody still tells you “no.” There are periods of frustration with every single job, but I think the ability to step back and look at it and say, “Now, why didn't it work? How do I change it the next time? How do I get to ‘yes'?” is something that everybody has to kind of grapple with, in any job. I remember times of great frustration as a practicing surgeon—frustration with the academic system, with a research experiment that failed time and again. Frustrations are inherent in any job, but I think part of personal growth is recognizing what's causing that frustration, then figuring out how to mitigate it and how to do it better next time.

Ghaffari: Of all the jobs or bosses that you've had, which one, if any, would you say had the biggest impact on you?

Guice: I would phrase that differently. I would say, “Which one would you go back to in a heartbeat?” I'd go back and work on the Hill again. I loved it. I had the best time. You know, there's nothing like it—it's a frenetic pace, but it was just the power of the office. When you work for the chairman of a committee, you have power. It wasn't me who was sitting behind the desk. It was that I was working for the senator, who was the chair. It was the ability to pick up the phone and say, “The senator wants this. Could you have it up here in an hour?” And it was there in an hour.

That means that you can get the information you need to really influence things. It's a dynamic situation. It's the ability to sit with people, write legislation, put a bill together, and get support for it.

I had a really great boss. Senator Jeffords was just a delight to be around. We would be in meetings where somebody would ask a question, and he'd say, “Well, I don't know. She's the expert. Ask her.” It was fun, interesting, challenging, and very rewarding all at the same time. Still, there were times I would get very frustrated with the inability to do something, but, as I said, that happens with every job you get.

Ghaffari: Have you had a lot of mentors in your life? How would you define a mentor?

Guice: A lot of people helped me, and I'm assuming that that equates to being a mentor. So when I worked at the American College of Surgeons, there was a senior woman surgeon, Olga Jonasson, who has since passed away, but she was a great supporter and a great friend. There are people who step into your lives in each of these jobs. They give you insight, support, and can help you grapple with your job at the time. There are many people like that in all my various jobs.

I would call Jim Peake a wonderful mentor when I was at VA. He forced me to do things where I thought he was nuts, but it turned out he was absolutely right. I learned a tremendous amount from that experience.

I've been blessed with wonderful friends. Marie Michnich, who was the executive director of the commission and now runs the Robert Wood Johnson Health Policy fellowship, is a wonderful mentor and friend. I can talk to Marie about anything because she has a very interesting way of looking at problems and thinking about problem solving in ways that I might not have considered.

Other people help you navigate or think differently. My husband is a mentor. It doesn't mean we don't disagree about things. He has a different perspective–I would call him much more pragmatic, while I'm probably more experimental. He kind of goes from A to B to C to D—very methodically. I go from A and then try to see if or how I might get to D without going through B and C.

We kind of balance each other off in a very good way. We give each other the benefit of our experience and problem-solving, not just with family issues but also with work issues. He'll ask me how I would handle a problem that he's got at work. And I will do the same. It's certainly been a partnership that's stood the test of time because I think we're coming up on thirty-one years of marriage now.

Chip Rice also has been in and out of my life. He started as a professor of surgery when I was an intern, and now he's the chancellor of USUHS, which is in our organizational structure under my reporting line. He's a good friend and supporter who gave me great advice. He came in and made me do something that I wouldn't have thought of doing, but it turned out to have tremendous value, both personally and professionally.

People come in and out of your life at interesting times, but throughout my career I've had good people to provide me with the support and advice and counsel all along the way.

Ghaffari: How would you describe your decision-making style?

Guice: I like data, so I'm sort of a data-driven person. I like to have data and information to influence decisions. Then, given the current job, there's always the political aspect, both in the building and in the administration. It was the same thing at the VA. There's always the political issue of how might this decision be aligned with a strategic plan or direction. But, if you have data and you can make your arguments based on clear evidence, then you will certainly have a better chance of winning. So, I always try to have the facts straight, the data in front of me, and make decisions that way.

Of course, it doesn't work that way all the time. Sometimes you've just got to go with your gut.

Ghaffari: Among all of the careers, what's your perception of your biggest achievement?

Guice: Staying married thirty-one years and having two children. Keith and I have two great kids.

Ghaffari: You say that as if you're surprised.

Guice: Well, you know, you always look back and say, “How did that happen?” They're good people—really good. That's one of those things you never know until it's over, whether you've done a good job or not.

Ghaffari: As you've come through this career path, were there a lot of other women alongside of you in the same fields?

Guice: When I was in medical school, I think there were seven women in my medical school class. When I went to my residency, there were three of us—three women out of probably forty residents. When I was in Galveston, there weren't any other women on the surgery faculty. There were women in other places, on other faculties. There were more women on the surgical faculty at Ann Arbor, but not by a lot, and I was the only woman on the faculty at Duke for a long time. So I would say that there have been other women, but not necessarily in the surgery field. More women would have been in internal medicine or dermatology or other areas. There certainly are more women in surgery now than when I was coming through the training program and was in my first several academic appointments.

Ghaffari: As you've been invited to talk to other young women in your fields—politics, academic, medicine—what is your key advice to them about their careers?

Guice: I tell them that they should be selfish. They should figure out what they need in order to make that next career move or wherever they see themselves next. Be really sure that when they take a new job or open the door to a new possibility, it's about where they want to be and what they need to get there. I advise them to be very introspective and think about it critically. I also remind them, based on my own observations, that they can change jobs. You don't have to stay in a bad one. You can move on. The interesting thing about bad jobs is that they often teach you more than good jobs.

Ghaffari: Do you think your advice is the same kind that you'd give to men?

Guice: Yes. I think it's applicable to anybody. You need to understand what makes you happy, what kind of work brings you joy, depending on where you are in life.

For what I'm doing now, my work habits are pretty nutty. But that's because I don't have family here—my husband has his job, and he loves what he's doing. My kids are in college, and they love what they're doing. I have different degrees of freedom now than when the kids told me we had discharged nine nannies. I have different degrees of freedom now than when I had my mother in our home, caring for her, post-stroke. Your life changes, and you have to be open to change and opportunities. Some of the best jobs I've had came to me because I simply opened a door, took the risk, and applied for it. There's nothing to be lost. Being able to look at opportunities and then take advantage of them when they come your way is advice that I'd give everybody. It's worked out extraordinarily well for me. I've had great fun and hopefully I've contributed along the way.

Sometimes, you need to make opportunity happen. Take the initiative. That was a lesson I learned from Jim Thompson, who was the chair at Galveston. He taught me to pursue grant money to do the things that interested me. Jim said, “Apply to as many granting institutions as you can because, you never know, somebody might come back with money.”

It's the same philosophy about jobs. Try—you know, you can always say “no.” If somebody accepts you for a program or a job, you can always say, “Well, upon reconsideration, I've decided not to do that” or “I'm not the best person for that.” On occasion, I would be asked to go look at chairs of surgery departments. I would interview and talk to people and then I would take myself out of the running for whatever reason. But, I had the experience of going, thinking about it, and asking myself, “What would it take for me to do this job? Do I like it here? Does it feel as if I fit with this group of people?” If I had said, “No, I don't want to interview for the job,” then I wouldn't have had that opportunity to both explore what I thought I might need as a person in order to learn, be productive, grow, and contribute.

Ghaffari: Where do you see yourself in the next five to ten years?

Guice: I don't know. I mean, seriously, truly, I don't know. I turn sixty this year. My husband and I talk about this about every weekend, “When are we going to retire? What are we going to do when we retire?” Since we can't ever seem to agree, we just keep working.

We're lucky to have the option of continuing to work. At some point, he's going to want to stop doing what he's doing. He may want continue to practice, but maybe be chief of surgery for only the next five years. Interests change, and maybe we'll want to be doing something else. We'll figure it out, I'm sure. But five to ten years from now, I'll probably still be working somewhere, doing something interesting.