Dr. J. Thomas Ryan

Dr. J. Thomas Ryan began practicing as a physician in Fredericksburg in 1979. He was a family practice physician with the Pratt Medical Center. From 1989 to 1990, he served two terms as the president of the Mary Washington Hospital medical staff and worked on the strategic planning for the new Mary Washington Hospital. Dr. Ryan had previously served as President of Pratt Medical Center, a multi-specialty group. In 1998, he began serving as the Executive Vice President and Chief Medical Officer for MediCorp Health System and served in the position until he retired in 2013. He attended Virginia Tech for his undergraduate degree and received his M.D. from Medical College of Virginia (MCV), which is now part of Virginia Commonwealth University (VCU). He earned a post-doctoral certificate in medical management from University of North Carolina and a master’s in health administration from VCU in 1999. He was appointed to the Virginia Tech Board of Visitors in 2013.

Dr. Ryan was interviewed by Jess Rigelhaupt on June 5, 2013, and July 22, 2013. The interview on June 5, 2013, which also included a hospital tour, was filmed by Kevin Henry and Terry Johnson of Kevin Henry Mileposts.

In addition to the transcript below, a full transcript of this interview is available as a PDF file in the University of Mary Washington’s Digital Archive.

Discursive Table of Contents

Interview 1 – June 5, 2013
00:00-15:00
First involvement with Mary Washington Hospital—Process of starting a new specialty—Patient and physician relationship—Physician and hospital administration relationship—DRGs effects on medical practice and on the business side of medical care—DRG model influences on commercial payers—Different roles at the hospital over the course of his career

15:00-30:00
Different roles at the hospital over the course of his career—Growth of hospital—Early planning of the new hospital—Formal planning of the new hospital—Advocates for new facility—Physician input in new facility—Hesitancy among some staff—Financial concerns and issues with building a new hospital

30:00-45:00
Differences in specialties, especially between family practice and other specialties—New specialties and subspecialties that were sought after for the community—Transition from a community hospital to a medical center—Coordination between administration, staff, and community to build new hospital—Growth in the emergency department, both in terms of size and medicine—Priorities for the new hospital—Types of specialties that help with emergency care

45:00-01:00:00
Physicians employed by the hospital—Staffing the hospital—Clinical integration—New technology for patient care—Labor and delivery services—Addition of the NICU—Expansion of entire OB/GYN department

01:00:00-01:09:00
Perinatologists—Importance of a large health care organization to assist training specialists—Changes and expansion of the specialized ICUs—Role of intensivists—Discussion of different perspectives on the expansion of the ICU—Different staff members who work in the ICUs

Interview 2 – July 22, 2013
00:00-15:00
Goals and work as president of the medical staff—Interactions with the board of trustees as medical staff president—Communication between staff about expansion due to the new hospital—Techniques and tools shared between the hospital and private practice

15:00-30:00
Techniques and tools shared between the hospital and private practice—Work in hospital leadership and administration—Service as Director of Mary Washington Home Health—Conflicting and complementary goals of the board and physicians—Changes in medical practice and influences on the board—Communication between the board and medical staff

30:00-45:00
Goals as medical staff president: present the perspectives of the medical staff—Dynamics between the business and administration side of hospital-based medicine and the medical staff—Communication between strategic planners and medical staff—Different perspectives among the physicians about the new hospital—Concerns among medical staff about the addition of more specialties in the 1980s and 1990s—Transformational changes to medical practices—Issues of physicians relying on referrals—Physicians that become administrators

45:00-01:00:00
Physicians that become administrators—MediCorp’s influence on physician practices—Tensions between medical staff and administrative staff—Efforts of Mary Washington Hospital to resolve tension—Prominent examples of tension, how it is resolved, and lessons to be learned—Certificates of Public Need (COPN)—COPN’s impact on hospital and health system, especially financial

01:00:00-01:15:00
Economic opportunity versus medical rationale for COPN—Master’s in Healthcare Administration at VCU—Development of MediCorp—Community outreach and development of free medical care

01:15:00-01:30:00
Development of the Moss Free Clinic—Understanding health care and community in larger cultural terms—Community health concerns and preventive care—Financial commitments of the hospital to the community—Community Benefit Fund—Community outreach—Public health

01:30:00-01:41:25
Mary Washington Hospital and physician dedication to providing medical care to all patients—
Dr. Ryan’s move from Pratt Medical Center to Rappahannock Family Physicians—Work in the Moss Free Clinic—Discussion of how Mary Washington Hospital maintains relationship with community

Transcript

Interview 1 and Hospital Tour – June 5, 2013
01-00:00:00
Rigelhaupt:
It’s June 5, 2013. I’m in Fredericksburg, Virginia at Mary Washington Hospital doing an oral history interview with Dr. J. Thomas Ryan. If I could begin by asking you to discuss your first interaction with Mary Washington Hospital and MediCorp. How did you become involved with the organization?

01-00:00:26
Ryan:
I’d be very happy to, Jess. I’d like the record to show that I was not here when Mary Washington Hospital began in 1899. We’ve got a 114 year history now. But I did come up here in 1979. I had been in the Air Force with Dr. Don Bley and Don had wanted me to come to Fredericksburg. And, in fact, in 1979 I did. I came here to join the Pratt Medical Center. I was the third person in the department of family medicine at that time. Family medicine was a relatively new specialty and we were probably three of the earliest board certified family doctors here in Fredericksburg. And I had a nineteen year career with Pratt Medical Center and Don Bley and David Johnson, the two family doctors with whom I practiced. The first day in the hospital David Johnson brought me in to meet the administrator of the hospital, Mr. Harry Bach. Mr. Bach was a very genteel sort of person who was very happy to meet new doctors coming in. There was none of the high pressure of today’s business or big organization sort of thing. It was just kind of laidback, sit down, put your feet up, and tell me about yourself kind of stuff. Back in those days, new doctors were coming in to Fredericksburg, but at a much slower rate than they are right now. That first year I probably met a medical staff of around seventy-five doctors. Not only did we know each of the doctors, but we knew their wives, because most of them were male, and we knew the names of many of their children. That’s how close we were as a medical community back then. We talked a lot amongst ourselves in hallways and on the telephone because there was not the hustle and bustle in our daily lives. As busy as we were, and as long hours as everybody put in, there was still time for that collegiality among the physicians back in those days. We knew most of the nurses and we knew some of the nurse’s children. Nurses and physicians worked very closely, as they do now, but in a more relaxed atmosphere it seems. In my first couple of years of practice here at Mary Washington Hospital, before we had the corporate entity, we began a department of family medicine. That was a new specialty then. [03:00] I have had the opportunity to see the rise of family medicine within Mary Washington Hospital and then the dissipation of the department because it was no longer needed as hospitalists became the deliverers of care, of most of the medical care within the hospital.

01-00:03:16
Rigelhaupt:
Starting that new department, family medicine, could you describe the process of starting a new department at a hospital? And this sounds like the late ‘70s, early ‘80s?

01-00:03:26
Ryan:
David Johnson, Don Bley, and I were a relatively new specialty within the hospital. We were in the department of medicine, just included among them. We appealed to the general internists and the specialists within the department of internal medicine. We said, “Listen, we’re a new specialty. We’re board certified in our specialty. We would really like to have our own department.” They were very happy to allow us to do that. We had to write up a set of bylaws, elect a chairman, and I was the first chairman of the department of family medicine. They were very happy to let us go on our way. We continued to collaborate, but they recognized us a specialty and as the division chair I got a seat on the medical executive committee. It gave family medicine a presence in the governing body of the medical staff. They had not had that previous to that time.

01-00:04:16
Rigelhaupt:
Now, in practicing at this point, a lot of physicians were not Mary Washington Hospital employees at that time. Or am I right in that point?

01-00:04:27
Ryan:
You’re very correct. I’m not sure there were any Mary Washington Hospital employees among the physician staff at that time.

01-00:04:34
Rigelhaupt:
And so were you seeing, in terms of your practice of family medicine within the hospital, were you seeing patients that were largely coming out of your practice or were you also seeing patients that other physicians were, I guess technically, the physicians of record on? What did that practice mean?

01-00:04:56
Ryan:
As a primary care doctor— and in family medicine in general— most of the patients that I brought to the hospital were patients out of our practice, my practice, Dr. Don Bley, and Dr. David Johnson’s. We would bring them to the hospital and hospitalize them there. Even as primary care doctors in those days, in 1979 and the early 1980s, we had large inpatient practices. I would keep six or eight patients in the hospital just on my service, and Dr. Bley and Dr. Johnson did the same. When we came in on a Saturday to make rounds on all of our partners patients, we were here most of the day just making rounds. Today, of course, there are very few primary care doctors in the community that actually admit their own patients. There are still a few, but not many. Most patients are cared for by hospitalists, who the patient may not know and probably doesn’t know prior to coming into the hospital. But in those days we made our own rounds. In fact, in the emergency department—and I’ll mention this as we go by the emergency department—we would come in and see our own emergency patients. [06:00] If Mrs. Jones called me at 11:00 p.m. and said, “I’ve got bronchitis, I’m on my way to the emergency room, you come see me.” We drove in and saw our own patients in the emergency room. There were some doctors in the emergency room, but for the most part patients expected their primary care doctor to be there for them. When we were on call, which was every third night, we were here much of the night. It was a much different experience. We did not have hospitalists to care for our in-patients and we did not always have emergency room doctors that our patients wanted to see. Then we saw our own patients in the emergency department.

01-00:06:38
Rigelhaupt:
That first year, say, when you begin practicing, how would you describe the relationship between the medical community, physicians, and Mary Washington Hospital and MediCorp?

01-00:06:55
Ryan:
There was no MediCorp at that time. It was Mary Washington Hospital and the relationship was a very warm and inviting one. Of course, it was a very different relationship than it began to become even in the mid-1980s. It was a relationship where the hospital administration ran the hospital and it was a place where physicians put their patients. The hospital provided them with the tools to take care of their patients, whether it be x-ray or an emergency room, and the nursing staff to do all of that. It was largely a friendly collegial kind of atmosphere. The reimbursement was basically tied to what you did. When you did things, you were reimbursed for them. When the hospital did things, they were reimbursed for them. All of that, of course, started to change with the onset of DRGs in the 1985 range. But in those early years it was a delightful way to practice medicine because the patients came to our practices. When they needed inpatient care we brought them to the hospital. Most outpatient care was delivered by physicians or physician’s offices, not so much by the hospital. The hospital was largely an inpatient facility. It provided good nursing staff. Mary Washington Hospital has always provided good tools for the doctors, even back in those days. The tools, of course, have matured and technology has increased significantly since those days. It was a very warm inviting relationship.

01-00:08:29
Rigelhaupt:
So you mentioned in the mid-‘80s a change with the diagnostic record group, or the DRGs. How did you experience that? How did it change your practice?

01-00:08:41
Ryan:
Basically what happened is the government began to change reimbursement mechanisms. With DRGs they determined that for a patient who might have congestive heart failure, this is how much money they were going to give the hospital for that congestive heart failure. It impacted the hospital far more than it impacted the physicians. [0 9:00] We pretty much practiced medicine as we always had, but we needed to be mindful that the hospital was going to be reimbursed a set fee. So if Mrs. Jones stayed in the hospital for four days there was one fee. If Mrs. Jones stayed in the hospital thirty days, it might be that same fee with a couple of little add-ons. The DRGs changed the business side of medicine for the hospital greatly, and of course, it has been changing ever since that time, usually in a way of decreasing reimbursement for the same unit of services. Physicians were not impacted so much but we needed to learn about them. As DRG’s came in 1985, they had physician advisors or physicians who would look at the cases in reimbursement and you would go to hospitals other than your own. I signed up to do that because I figured by immersing myself in that new way of reimbursing I could learn more about it. I would go and review cases at other hospitals in our region, not at Mary Washington Hospital. It was a way for us to get a handle on what the government’s expectations were, and soon to be the commercial payers’ expectations, too.

01-00:10:19
Rigelhaupt:
Do you remember conversations about DRGs and questions of reimbursement in the business of medicine, as you described it, between physicians and hospital administrators or the board, as DRGs were being implemented?

01-00:10:34
Ryan:
There were conversations, but the conversations, particularly between the hospital administration and physicians were not plentiful. They were acknowledgements that things had changed. I think at that time there were far more conversations within the hospital leadership and the board of trustees. Physicians were largely immune to the changes and so therefore acknowledged intellectually that they existed, but were still not being paid so much on a DRG system. On the surgical side of things, surgeons were beginning to be paid global fees, which means they would get a set fee for taking out a gallbladder. If that person remained in the hospital an extra day they would not be paid more and the postoperative care in their office was included oftentimes in the global fee, too. This was much more significant for the hospital at the time than it was for the physicians.

01-00:11:30
Rigelhaupt:
Now, DRGs were tied to Medicare. And so this was patients sixty-five and older. Did they begin to have an impact on other practices of medicine? Certainly someone as yourself practicing family medicine wasn’t only seeing Medicare patients.

01-00:11:47
Ryan:
Correct. No, not immediately, the commercial payers didn’t do that. What I have seen in my medical career, which since residency is now thirty-eight years, thirty-four of them here at Mary Washington. As the government goes, so goes a commercial payer. [12:00] They would generally follow behind a year or two in beginning to institute some of the changes that CMS did for Medicare. Of course, it wasn’t called CMS back then—The Centers for Medicaid & Medicare Services. They pretty much lead the charge. If CMS does one thing or another, we can expect the other commercial payers to follow pretty shortly.

01-00:12:30
Rigelhaupt:
One thing I wanted to do early in this process was just if you could go through, and I know it’s hard to work truly chronologically. But if you could describe the different positions and the different times that you’ve had with Mary Washington Hospital over the thirty-four years.

01-00:12:47
Ryan:
My positions?

01-00:12:48
Rigelhaupt:
Yes.

01-00:12:51
Ryan:
I have to say I’ve had two general roles. One is as a medical care provider and it has been an extraordinary career for me. I have thoroughly enjoyed it. I love taking care of patients. I finished my residency in 1975, starting with the United States Air Force. I came here four years out of residency and had a wonderful career here at Mary Washington Hospital, seeing patients, practicing with Dr. Bley, Dr. Johnson, and then later a growing family medicine department as Pratt Medical Center grew. I continued to see patients up until about four or five years ago on a part-time basis. In my leadership side of the career, I was the first chair of the department of family medicine. Then I took increasing numbers of leadership volunteer positions with the committee work. Most physicians volunteered to do work with the hospital back in those days because, frankly, we had the time. We would come over here at lunch or we would come over here towards the end of the day and do work within the hospital, whether it was medical record committee, quality committee, or looking at the bylaws of the medical staff committee. We had the time, the energy, and the willingness to do that. Physicians no longer have the time to volunteer. Most physicians don’t even get lunch, so never mind coming over here for an hour and a half. We had medical staff business meetings in the middle of the day when we would gather lots of physicians and have a very nice meal. Nowadays it’s very hard for physicians to get over here for any sort of a meeting. In 1989, I was elected president of the medical staff and then was the first person to do two successive terms. I was elected again in 1990. That’s very common now, but nobody had done that before, to my knowledge. As the president of the medical staff at Mary Washington Hospital, I sat on the board of trustees. That was an opportunity to learn the whole picture. Sometimes we physicians, when we’re so immersed in our own practice, don’t get to see the big picture of things at a community level. [15:00] On the board of trustees, those individuals are charged with planning a strategic direction and they are advocates for the community. I got an opportunity to see medicine and the hospital at the community level. In the 1990s, I spent increasing amounts of time in part-time positions working in the leadership of the medical staff as we did the strategic planning for moving Mary Washington Hospital from its building on Fall Hill Avenue, where I began to practice, to up on the hill where Mary Washington Hospital is right now. We moved up here in 1993. There was a lot of planning and a lot of medical staff input as to where these suites should be. How many call rooms should we have? What should the ORs look like? The planning involved all sorts of things. My job was to facilitate physicians having input into the new hospital. After that, I did increasing amounts of work in the new hospital. Finally in the mid-1990s, Fred Rankin, our CEO, said, “Tom, you’re going to have to make a decision. You can’t have two full-time jobs.” In 1997 I did make that decision and I came onboard part-time for one year as the senior physician executive. It was the same time when we were embracing a physician leadership model. We had service chiefs in medicine, surgery, and women and children’s medicine. For our in-hospital groups, we would give a stipend to physicians to contribute, to make sure that the quality assurance and quality improvement was happening among the medical staff, and to help physicians have a voice at the leadership level. It wasn’t just my role, but there were other physician leadership roles that began then. Then in 1998 I came onboard full-time, at that time as Vice President of Medical Affairs of Mary Washington Hospital. As we became a system and, of course, developed other entities, both outpatient and inpatient, I eventually became the chief medical officer for the entire system. Then we brought onboard a vice president of medical affairs to help me run Mary Washington Hospital. We have a physician leader at Stafford Hospital. We have numerous other medical directors who provide us expertise in their specialties. I have not returned to the board of trustees after I finished as president of the medical staff because it wouldn’t be appropriate for an officer of the organization to be on the board of trustees. But I have worked very closely with the board of trustees in my executive role and have thoroughly enjoyed that. Working with these committed community leaders who spend enormous amounts of time learning the health care industry and work to provide strategic direction to Mary Washington Healthcare, the system has been one of the more rewarding things that I’ve done. [18:00] I have also seen our medical staff grow from the seventy-five or so that I first met in 1979 to now over 700 credentialed providers, including medical staff, nurse practitioners, PAs (Physician Assistants), and licensed independent practitioners. It has greatly changed in my time. I do not know the names of their children and spouses, but I sometimes see new physicians in the physician areas and I have to go introduce myself to them. They’re coming so quickly now between Stafford Hospital and Mary Washington Hospital. And frankly, we have a lot of outpatient physicians who no longer spend much time in the hospital because they have outpatient practices.

01-00:18:42
Rigelhaupt:
What do you remember just about the initial conversations about a new hospital? Was there a way in which there were informal conversations that started before formal planning? And do you have any recollections of those informal conversations?

01-00:18:56
Ryan:
I do. Unique to Fredericksburg, one of the challenges in my career and the career of the executives here right now, had been to keep up with the growth of our region. We have been modifying, refurbishing, and building new structures since I have been here. That is unique because there are many hospitals across the country that need to figure out how to close down beds as they needed fewer and fewer beds. In the late 1980s we were again reaching the point where we needed to grow. The question at that time, and the question in the boardroom, in the hallways among the executive team, and the board of trustees, was where do we put those new beds? Do we add on to Mary Washington Hospital or do we provide access elsewhere in our primary service area for those same beds? And we labored over this for a couple of years. Where is the best place to do it? Of course, everybody wanted us to put new beds in their particular jurisdiction and we were courted by all of the local jurisdictions. In the end we decided, at that point in history, to keep the new structure within the confines of the city of Fredericksburg and not go to any of the other jurisdictions.
Of course, we’ve altered that decision with the new Stafford hospital and our outpatient facilities in Spotsylvania County. We have decentralized many of our facilities since that time. Back in the late 1980s, we were struggling to determine where the growth should be to best meet the needs of our populace. We decided we were going to go to a new campus where we had the ability to grow for the next twenty, thirty, or forty years; and that’s why we came over here to Snowden. Snowden at that time was a beautiful old home with gorgeous pasture that had horses roaming around in it. It had the room to build the new Mary Washington Hospital and room to grow outpatient office facilities, whether they be physician facilities, the psychiatric hospital, Snowden, Kids’ Station, or anything else that we felt like was going to be needed to be built. [21:10] We built the physician office building in Tompkins-Martin. We have since built the ambulatory surgery center and an imaging center. We have continued to build. We have continued to add on to that original facility since 1993. But those original discussions were, “We need to grow. Where should that growth be?”

01-00:21:36
Rigelhaupt:
So when did it first start being planned and could you describe those initial meetings if you were involved and what you remember about them?

01-00:21:44
Ryan:
The discussions probably started in the mid-1980s. I can’t tell you exactly when we started to hone in on it. But I can tell you that in my terms as president of the medical staff in 1989 and then in 1990, we were thick in the strategic planning. At that point we were having medical staff come down and look at drawings and discuss how they wanted to change suites. Then finding an architect and finding a builder probably happened in the years prior to that, in ’86 and ’87. This is for a hospital that opened in September of 1993. It takes a long time to plan and build a facility of this size.

01-00:22:39
Rigelhaupt:
So it sounds like the central part of building the new hospital was about growth in the region and serving the community?

01-00:22:45
Ryan:
It was. We, as a not-for-profit hospital, have always been about serving the community and we could no longer do that. We were the only hospital in the region. The community was growing very, very rapidly and we could no longer do it with the facilities we had. The question is, do we keep trying to renovate a hospital, which was built in the 1950s, or do we build a new structure and provide in that structure the opportunity for continued growth? That was the choice we made.

01-00:23:16
Rigelhaupt:
Do you remember who were the strongest advocates for a new building?

01-00:23:22
Ryan:
I can’t. There were certainly principal characters back in those days. Bill Jacobs, the CEO, was certainly one of the strong advocates. We had board chairs back in those days, people like Homer Hite and Bill Poole, and other strong advocates that wanted to make sure that whatever we did, we had the ability to serve the needs of the community. There were many other people involved, but I’d have to think about a little more to recall them by name. Those were some of the key individuals. [24:00] The medical staff, of course, wanted to be involved too, at least on the clinical areas and in their specific areas.

01-00:24:10
Rigelhaupt:
Speaking of the medical staff. What other physicians do you recall playing an active role, sitting down with drawings, talking about how their specialties would be represented at the new building?

01-00:24:21
Ryan:
When I came here we had some very, very fine physicians who oftentimes came out of that Marcus Welby mold. Bill Scott was a primary care physician. Jeppy Moss, was a general internist and a superb physician. John Rose, a general practitioner, was also a superb physician. Chris Cimmino, the first radiologist here, to my recollection, helped build the current superb radiology group that we have. Rich Lowe and Bill Hollister, who were just fantastic general surgeons and did great things. We had some ob/gyn doctors, Dr. Lee Earnhardt and Jay Robbins, that were superb. And there’s another that I would love to think about who was just a wonderful, wonderful ob/gyn doctor—Dr. Gordon Jones. John Painter in pediatrics, is kind of the father of pediatrics in this particular area. All of these people, of course, were leaders of the medical staff. In those days they led by modeling the practice of medicine. There were no paid physician leaders in those days. Physicians volunteered their time, again, because they could volunteer their time. The world has changed for physicians just as it has changed for hospitals. Those are some of the people that were leaders by virtue of their practice of medicine and their desire to see that the right things happened at Mary Washington Hospital. Don Kenneweg, another one in the radiology department, was instrumental in the new things that were brought to this community.

01-00:26:01
Rigelhaupt:
Do you recall anyone having any reservations about expansion to a new building? Perhaps thinking that renovating the Fall Hill facility might be sufficient?

01-00:26:14
Ryan:
Absolutely. And many of them were physicians. There are always people who are disturbed or distressed by change and many of our physicians had practiced in the building on Fall Hill Avenue for a long time. Others had built their professional lives around the location of Mary Washington Hospital and they really didn’t want to see the location change. There were people who either didn’t want to see too much growth or they were concerned that the community couldn’t afford new growth or they didn’t want to see the location change. This was not a slam-dunk where we had ninety-nine percent approval rate. [27:00] Any time you have a momentous change in any community, including the medical community, there were voices saying, “No, let’s not do this. Let’s just continue doing better at where we are right now.”

01-00:27:16
Rigelhaupt:
You used the word afford. This was a large financial venture.

01-00:27:23
Ryan:
It was a huge financial venture. There were many people back in the late-1980s who said, “I just don’t see how we can spend that sort of money and still survive. What if the community stops growing or what if government changes their reimbursement and there’s more stringent reimbursement? We’ll go broke and we’ll go bankrupt.” Back in the 1980s people were concerned about that. Of course, it was an immense success and Mary Washington Hospital has continued to build here on the new campus just to meet the needs of the community. But back in the 1980s people didn’t know how it was going to go and there were people who were very concerned.

01-00:28:03
Rigelhaupt:
Do you remember conversations about the questions of finances between the physician community, the board, and administrators? How did those three different groups bring different perspectives to the decision to expand?

01-00:28:19
Ryan:
The administrators were data driven because their job is to do the projections and say, “Okay, this is what growth has been.” And then they would go to the jurisdictions and to the Commonwealth of Virginia and say, “What are the projections for growth in Stafford County, Spotsylvania County, Caroline, King George, the City of Fredericksburg, Westmoreland, and Orange?” They would get all those figures together and they’d say, “Okay, the data shows that we should be able to do this. We can project what reimbursement will be and what the growth is.” The board of trustees ultimately has the fiduciary responsibility for the success or failure of Mary Washington Hospital then and Mary Washington Healthcare now. They wanted to see the data that the administrators put together. The physicians oftentimes were more emotional. They didn’t necessarily have the financial figures or the demographic data or the projections. They were more concerned about how the practice of medicine was going to change, how it might change, and how it might impact not just their reimbursement, but they were concerned about the hospital. They wanted to have a strong Mary Washington Hospital and they were uncertain as to what the future was going to hold. Therefore they were reticent about any major changes; now, this is some medical staff. There were other medical staff who were very enthusiastic about coming up on the hill, as I say, and having an entirely new facility. But there’s never ninety-nine percent approval in everything. Remember, the president of the United States usually gets elected by one percentage point. We did much better than that. We had the majority of physicians who were pleased to have a new facility and participated in the planning. [30:00] But there were others, for reasons of concern about the fiduciary responsibility, who were concerned that it might not be a success.

01-00:30:15
Rigelhaupt:
In 1989, as president of the medical staff, could you describe some of what you brought to that position as a family practice physician versus a surgical specialty and the way you would look at the practice of medicine in a hospital perhaps differently than a very specialized surgeon?

01-00:30:44
Ryan:
From a specialty standpoint there’s one difference between a primary care physician and a specialist physician, and this pertains to when you are trying to make substantial changes. This was an era in our history when we were trying to make substantial changes. And this isn’t just my observation; we were actually told this when we would go around looking at places building new hospitals. They would basically say that if you really need to have transformational change, back in these days—now, this is no longer true, necessarily. Back in those days if you needed to make transformational change you should consider finding your leaders among the primary care physicians. It’s not because the specialist physicians weren’t capable, but the specialist physicians were concerned about losing their referral sources. Back in the 1980s and the early 1990s, if in fact they took unpopular positions, they might find that their referral sources would dry up; they were unwilling in some cases to take unpopular decisions. Primary care doctors got their patients from the community. We did not get referrals from other doctors. Most of our patients came from our patient pool, their families, their neighbors, and their friends. We were not so dependent upon other doctors sending us patients. Therefore if we made a decision that led to transformational change—and so-called moved the cheese of some of the other doctors—we were not subject to having our referral sources cut off. Therefore we could make the decision more independently, more data driven, and less emotionally. As I say, things have changed since those days. But back then, referrals were made largely among physician relationships. You knew who the good specialists were and that you wanted to have see your patients. You built relationships with those doctors and the specialists didn’t want to do anything to jeopardize that relationship. They did not want to make unpopular decisions.

01-00:32:46
Rigelhaupt:
So in these initial conversations, and maybe if we could stay with that first two years you were president of the medical staff. What departments at the new hospital were being prioritized? Were there new specialties you wanted to see implemented? [33:00] Or were there new practices that a new hospital could potentially facilitate that were being prioritized in your discussions?

01-00:33:10
Ryan:
No, there were not departments that we were prioritizing, but we really did want to take the medical staff to another level. We were largely, at that time, generalists. We were family doctors, general internists, or general surgeons. We wanted to bring subspecialties into the community. When we came up to the new hospital in 1993, a couple of things happened. Number one, for the first time in my experience, and I had been here for some time then, doctors began wearing white coats around the halls. It just kind of happened. We had a closet in the medical staff lounge where they could hang their white coat. All of a sudden you saw another level of “professionalism.” Not that a white coat made you a professional, but the physicians were very proud of the new facility and they started wearing their white coat, just as I am today, with their name on it, and oftentimes their specialty on it. That was a distinct change when we came up to the new hospital. We also saw the increasing development of subspecialties. We moved in and shortly thereafter we brought in cardiovascular surgery. We brought in neurosurgeons and thoracic surgery. We had increasing numbers of medical subspecialties with gastroenterology and endocrinology. These are the kinds of specialties that you need to run a tertiary care hospital. Remember, we were still the only hospital in this region and were becoming increasingly a medical center rather than a community hospital. We needed to have subspecialties both in medicine and surgery that we had not had prior to that time. As we go up to some of the floors, I’ll make mention of some of the differences in our specialty selection between those early years and these later years.

01-00:35:05
Rigelhaupt:
Okay. Well, I’d say the last thing I’ll pick up on before we can start going up to the floors and the different departments is actually just what you said about this transition from a hospital to a medical center. Certainly I’m new in the area and I only know this as a medical campus. And certainly I have seen the growth in the five years I’ve been here. But it sounds like from what you’re saying this growth from a community hospital to a medical center is really happening in the mid-1980s, as you’re talking about building this new hospital and beginning it. And was that actually discussed directly? What it would mean to transition from a community hospital to a medical center?

01-00:35:55
Ryan:
We did talk about the changes in going from a community hospital to a medical center. [36:00] It began in its planning stages slowly in the mid to late 1980s. Really it began exponentially to increase in the 1990s. When we brought in cardiovascular surgery it started to require people who could deal well with intensive care medicine among sicker patients. When I first came here and Mary Washington was a community hospital, we saw a lot of the people in Fredericksburg who had the mentality that if you’re really sick you need to go to Richmond or to Fairfax. That’s no longer true. The vast majority of people, even those who are very sick, now stay here at Mary Washington. In this vicinity, people now seek to come from other hospitals in the region to Mary Washington because we have the subspecialists. We have a magnificent intensive care unit. We’ve got a trauma program. Now we can deliver, bring to bear the resources, both the physical resources and the physician and nursing resources, to take care of the sickest of the sick. We couldn’t do that in the early days and people did go to other places. So not only were we building facilities but we were building capabilities within our medical staff and in our nursing staff that we had heretofore not had.

01-00:37:19
Rigelhaupt:
And so if we were to shift the timing, it sounds like the big growth in terms of the medical center is happening after that new hospital?

01-00:37:30
Ryan:
Correct.

01-00:37:32
Rigelhaupt:
Cardiothoracic comes in. Was there coordination between the physicians, the board, and the administration in terms of the growth to a medical center or was that another moment in which there was some trepidation about change?

01-00:37:50
Ryan:
Yes, there was coordination because it couldn’t happen without coordination between the medical staff, the board of trustees, and the administration. It doesn’t mean that it was a slam dunk. There was sometimes heated discussion about how this should happen or that should happen. That was particularly true in the late 1980s as it became evident that we were going to have this metamorphosis from a community hospital to a medical center. Once we built the new hospital and most of the people were onboard and everybody saw what a success it was, there was much more unanimity of opinion among the medical staff, the board of trustees, and administration. Then it was a question of what specialties. Where do we grow? How do we grow? What resources do we need to provide for a new cardiovascular thoracic surgeon? What resources do we need? What equipment in our ORs do we need for our neurosurgeon? What are the latest things going on in ob/gyn and newborn nursery care? The discussions were much more forward looking. [39:00] The tumult was really more in the late 1980s as we were going through the machinations of do we, should we, and if so, where. We didn’t have long hallways like this to walk in when I first came either. You can get pretty good exercise walking the hospital all day long.

01-00:39:14
Rigelhaupt:
But that’s even something that there had to have been discussions about, of how you’re going to get from point A to point B.

01-00:39:17
Ryan:
There were. In the planning of the hospital, the architects bring in their industrial engineers and everything is movement oriented. How many steps do you have to take to do this? How many steps do you have to take to do that? When we were creating the endoscopy suite, our physicians asked, “How many rooms can I have so that I don’t have to wait while one room is being changed over and I can get my next patient in to do that, too?” This is one of our trauma rooms. When I think about the difference between the emergency department in 1979 when I came in and the emergency department today. When I came here we were on Fall Hill Avenue and we were a very small department and many of the community physicians were the emergency department physicians. We didn’t have access to all of the multitude of specialties that we have right now. Now we have fifty-two bays in this emergency department. We have very slick systems to make sure patients don’t have to wait for long periods of time. We’ve struggled with that over the years that we have been up here on the hill. But we’ve brought in industrial engineers to work with our nursing staff and to work with the emergency department doctors. We have specialists in emergency room care. There are emergency doctors who do fellowships or do residencies in emergency medicine. They are all board certified here. That, of course, wasn’t true when I was there. It was mostly those of us in the community that took care of the emergency patients. For the surgical things we would have general surgeons doing a lot of that work. Now we have probably nearly thirty emergency department physicians, as I said, resident trained in emergency medicine and board certified. We have nurses who are specialists in emergency care. At their fingertips they have a multitude of specialists that can help them if they have patients who need it. For instance, if somebody comes in here with major head trauma, we’ve got neurosurgeons. We have five trauma surgeons and those trauma surgeons are trained in the care of people who have undergone significant injury. We have a system built with our EMS community. EMS brings them in, they turn over to the trauma surgeons, and we have rooms such as this that are built and reserved for those sickest of the sick, who come in with trauma. We have all of the imaging capabilities and are able to deliver whatever gases they need. We are able to take care of those patients who may have medical problems in addition to open wounds, major abdominal injury, and major head injury. [42:00] The trauma surgeons have the other specialists that can help them, too. The trauma surgeons have the ability to call in the orthopedic surgeons, the neurosurgeons, or the ophthalmologists if there are eye injuries. The intensive care physicians upstairs who, when they move the patient from here upstairs, can provide that intensivist care also. These are all things that we did not have access to in 1979. It’s a wonderful addition to the community, not just to Mary Washington Healthcare.

01-00:42:34
Rigelhaupt:
So what were some of the first priorities in terms of the emergency department when you built the new hospital and it opened in 1993?

01-00:42:43
Ryan:
The first priority is we wanted to make sure that the workflow in the new emergency department was sufficient and patients would not have to wait. Initially we were very successful in that, despite the fact that we had a pretty good sized emergency department and our community continued to grow. Wait times started to increase again. We read about ourselves in the editorial pages of the newspaper, where people were saying, “We don’t want to wait this long,” and “we’re unhappy with this.” We again had to expand the emergency department and our cadre of emergency department physicians and nurses. Now, in 2013, we have it such that we are providing excellent care in a very timely fashion. But at first the priorities were growth and workflow.

01-00:43:32
Rigelhaupt:
Were there any particular practices—you mentioned cardiothoracic—in terms of some of the specialties. Were they going to play a role in how the emergency department was going to be built and grew over the first years?

01-00:43:45
Ryan:
The cardiovascular docs were not so concerned about the emergency department; thoracic yes, to a certain extent. The general surgeons back in those days were concerned about it. The orthopedic surgeons, of course, spent a lot of their time in the emergency department and, frankly, the medical physicians, too. We would have patients coming in with either cardiology crises or endocrinology problems or just the general medical problems of some of the very sick patients. The key was to get them in the door, get them triaged, get them diagnosed, and then get them upstairs as quickly as possible. To coordinate all of that is a challenge and we get better at it every year and we’ve got it down now so that we do very well. There have been points in our history where we were overwhelmed by people seeking to get their emergency care here.

01-00:44:39
Rigelhaupt:
When the hospital first opened in ’93, was it still a practice that if you as a family practice physician had a patient coming to the emergency room, were you still as likely to come in as when you started or was it already transitioning to hospital based physicians providing care?

01-00:44:59
Ryan:
It was already transitioning to hospital based care. Yes, we could come in and see our own patients here in the hospital, but the community physicians were less likely to do it by 1993. By that time did have a very fine group of emergency physicians who delivered most of that care. And by this time, with the growth of the community, many of the community physicians were so busy in their offices they could not just drop everything and come over to the emergency department.

01-00:45:31
Rigelhaupt:
Were the emergency physicians at Mary Washington—MediCorp at that time—were they MediCorp employees or were they still part of their own practice?

01-00:45:41
Ryan:
The emergency department physicians have never been employed by Mary Washington Healthcare. They are an independent group and they do have a contract with Mary Washington Healthcare. They provide care in both of our acute care hospitals and at the freestanding emergency center now at Lee’s Hill. But we have never employed the emergency department physicians.

01-00:46:03
Rigelhaupt:
And how is that decision made? What are the positives? Are there negatives? How does that work?

01-00:46:10
Ryan:
It goes way back in health systems across the country. We’ve been fortunate enough that we have had a clinical excellence demonstrated continuously by our emergency room group and a collaboration to see that their success is tied directly with Mary Washington Healthcare’s success. We have never felt the need to employ them and we have a wonderful relationship without having that formal employment relationship.

01-00:46:37
Rigelhaupt:
Are there discussions about goals in terms of hospital growth or decisions that board members and the administration have to make? Are the emergency physician groups a part of those discussions?

01-00:46:54
Ryan:
All of our in-hospital groups, most of whom are not employed, very much have a say in the strategic direction of their department within Mary Washington Healthcare and the health system department. For instance, right now on our board of trustees we have an emergency department physician and we have a radiology physician, both of them inpatient groups. We have other physicians, too, but our in-house groups have a say in how this organization goes. Increasingly, with clinical integration in medicine today, the well-being of physicians and health systems are going to be very closely tied to their ability to work together.

01-00:47:40
Rigelhaupt:
The trauma program—is that also a separate group or is that part of Mary Washington Healthcare?

01-00:47:49
Ryan:
The trauma surgeons are employed by Mary Washington Healthcare. We currently have five trauma surgeons. This was a program that was talked about for some years before it started. [48:00] It was, again, a major leap forward in our capabilities in providing this community with good trauma care. Patients no longer have to be flown out to another hospital. They can get that care right here and it has saved enormous number of lives over the period that it’s been up and running. Our trauma doctors also provide surgical intensive care in the intensive care units, so we now have that capability, too.

01-00:48:27
Rigelhaupt:
And what led to the decision about having them become Mary Washington Healthcare employees versus a group contracted like the emergency department physicians?

01-00:48:38
Ryan:
By the time we brought on some of these later specialty groups, increasingly specialist physicians were seeking to be employed by health systems. The vagaries of running a practice and reimbursement system on the outside world for a specialist—it’s so difficult now that many times they seek to be employed. We have our trauma surgeons. We do employ our cardiovascular surgeon. We employ our thoracic surgeon. We employ one of our two neurosurgeons. We employ our plastic surgeon. We employ numerous other medical specialists also because they want to be tied to the health system for security reasons and they just want to practice medicine, and have us be the employer. Mary Washington Healthcare does not have a large cadre of primary care physicians, but we have a large number of primary care physicians in the community. With the few primary care physicians that we employ and those in the community, that foundation is covered. The subspecialists oftentimes in today’s world want to be employed.

01-00:49:49
Rigelhaupt:
Was there a kind of informal clinical integration between hospitals and physicians?

01-00:49:53
Ryan:
Exactly, exactly.

01-00:49:54
Rigelhaupt:
And I’m wondering how you translate that to what is a medical campus. In some ways, it sounds like the push toward clinical integration is taking you back to your roots in some respects.

01-00:50:06
Ryan:
Well, you know, in some respects you’re right. In fact, I hadn’t really thought about it that way. But certain elements of clinical integration weren’t well served when I first came here. When it came to patient collaboration and communication among physicians, it was excellent back then. It was not done technologically, but done face to face or on the telephone. The aims and aspirations of the entire enterprise have changed so much because of the industry in this country today. They weren’t even addressed in those days. Doctors took care of patients, administrators ran hospitals, and nobody much worried about the other because it all took care of itself. When I came here, you’d send people for x-rays and you might get chest x-rays and long bone x-rays if somebody had something going on. A skull x-rays was the way we would image the head. Since that time, of course, we now have CT scans. [51:00] We’ve got MRIs. We’ve got intervention radiology, where our radiologists are able to enter most any area of the body and place things, take biopsies, or do things such as that that obviates the necessity for an operation. Imaging has been one of the greatest advances in medicine in my professional career. I still remember the early radiologists coming and telling us that CT scans are coming, and computerized tomography and the MRIs. They would talk about the physics of the magnet as we were learning about these new technologies. These were people who were already in practice learning new technologies. It has made an enormous difference in how we care for our patients, how we diagnose our patients, and how we follow some of their illnesses. The imaging centers in most health systems, including Mary Washington Healthcare, are some of the most important areas of both the inpatient and outpatient areas. We now do all of these sorts of things as outpatients, too. We have outpatient areas that have this capability, inpatient areas that have this capability, and it’s been a wonderful addition to our armamentarium in my professional care.

01-00:52:17
Rigelhaupt:
And this is something that a hospital and a community health center can provide the physicians? A small physician practice can’t buy a CT machine.

01-00:52:24
Ryan:
A small physician cannot buy a CT machine. Now, there are states where physicians can buy CT machines. There are generally coalitions of physicians that get together or a specialty that uses a lot of CT. For the most part in Virginia they’re held by health systems or outpatient centers. In Fredericksburg there are multiple outpatient centers, as well as our acute care hospitals that have both MRI and CT.

01-00:52:52
Rigelhaupt:
And I didn’t even mean just in terms of being able to buy and own but the cost, right. That this is—

01-00:52:56
Ryan:
Cost is enormous, yes.

01-00:52:59
Rigelhaupt:
That this is something that a small—

01-00:52:59
Ryan:
These are very expensive pieces of equipment.

01-00:53:01
Rigelhaupt:
Right. It’s a place of integration.

01-00:53:07
Ryan:
It’s a place of integration, yes. This is another instance where the health system provides the tools for the physicians to practice. In today’s clinical integration our radiologists and other specialists help us decide which of these are necessary, how best to place them, and how best to use them. The hospital does nothing in isolation anymore, just as the radiologists do nothing in isolation.

01-00:53:33
Rigelhaupt:
And it sounds like this is in some respects technology driven now, but when you started it might have been the informal discussions?

01-00:53:43
Ryan:
Yes.

01-00:53:43
Rigelhaupt:
In terms of patient care and practice.

01-00:53:44
Ryan:
Yes. But as the science started creating this technology, we wanted to be in the forefront of that and our early radiologists said we need to have that sort of technology here. [54:00] I still remember bringing people in who were trained well in that, and they would be added to our radiology group. Neurologists came here because they were, in the early days, big users of the head CTs. It’s been an evolution.

01-00:54:17
Rigelhaupt:
MediCorp at that time was probably making the capital investments for some of this equipment, large pieces of equipment. The radiologists were still their own group or were—

01-00:54:31
Ryan:
Radiologists are still their own group, yes.

01-00:54:33
Rigelhaupt:
Okay. So they are also—

01-00:54:34
Ryan:
They are one of those independent groups who are contracted to the health system and collaborate with the health system, but they are still their own private entity. We also collaborate on some of the outpatient centers and joint ventures, but it is Mary Washington Healthcare collaborating with the independent radiology group.

01-00:54:54
Rigelhaupt:
What were the priorities with labor and delivery when you were building the new hospital?

01-00:55:01
Ryan:
We had some very fine labor and delivery nurses. We had wonderful ob/gyn doctors from the previous era of my career. Most of the babies were taken care of by community pediatricians and family doctors. That has changed significantly in the years that I’ve been here at Mary Washington Healthcare. In those early days, the family doctors and the community pediatricians would come in and make rounds in the morning, and then if it were appropriate we would do the circumcisions on our own babies. Then we would see those babies again three to seven days after they were discharged from the hospital. If there were babies who were ill, anything beyond just the ordinary things one would expect, we would call VCU or Fairfax. We would send them, usually by ground transportation, down to a neonatal intensive care unit where they had the facilities to take care of sick babies. We just did not have those kinds of facilities. That has all changed and we now have a neonatal intensive care unit where babies, some of them very, very small, and some of them with significant illness, are cared for by nurses who are very comfortable taking care of them. The nurses are trained in taking care of sick neonates. The neonatologists, special doctors who are not just pediatricians but they are also trained in taking care of the sickest of the neonatal. We have also developed a collaboration with Children’s National Medical Center so that we have the expertise of that academic medical center, one of the finest children’s hospitals. It’s in Washington, D.C., and is one of the finest children’s hospitals in the country. We have the ties to that academic medical center. We still have access to VCU if we should need them. [57:00] But many of these very small neonates or sick neonates now stay here, close to their mothers, close to their fathers, close to their support structure, and get superb care. It’s one of the major changes that has happened in the Fredericksburg region during my years here at Mary Washington.

01-00:57:23
Rigelhaupt:
Was the discussion about labor and delivery, potentially putting in a neonatal intensive care unit, was that part of those discussions you described in the mid-1980s and then as you were president of the medical staff in 1989 and 1990?

01-00:57:37
Ryan:
We did discuss it in the early strategic planning for this facility but it really happened a little bit later than that. We lived in an area that has a lot of young people. Because of that we’ve had a very, very active OB service and with an active OB service, mothers want to make sure that you have the finest facilities going. Over time we developed the ability to take care of these sick children. We also developed the ability, in a prenatal sense, to provide expertise to our ob/gyn doctors. We developed the specialty of perinatology at Mary Washington Healthcare. We now have three perinatologists who are OB doctors and have been specially trained in taking care of at risk mothers prior to delivery and sometimes at delivery. They consult with the ob/gyn doctor, the attending ob/gyn doctor to collaborate on the care of the mothers that are at risk. We have the perinatology specialty involved before delivery. Then we have, of course, the ob/gyn doctors and now we have the neonatologists, so that the entire continuum is cared for well and with super specialists.

01-00:58:53
Rigelhaupt:
Something like perinatology. Was that something that came out of requests from ob/gyn physicians—

01-00:59:01
Ryan:
Yes.

01-00:59:01
Rigelhaupt:
—in the community and then the larger entity of Mary Washington Healthcare was able to put that into practice—

01-00:59:09
Ryan:
Exactly.

01-00:59:09
Rigelhaupt:
—and provide it?

01-00:59:10
Ryan:
Exactly. Our ob/gyn doctors said, “Listen, we have a very, very active ob/gyn service here. We increasingly, because of the volume of our service, have babies or mothers that are at risk and babies that need help afterwards. We want to have more support, more specialization at our fingertips to help us take care of our patients.” The health system said, “Okay, we will do that.” We began to provide, at first, one perinatologist, who quickly got very, very busy. And then we had two perinatologists, and for the last year we brought in our third perinatologist here at Mary Washington Healthcare. They are collaborating with our attending ob/gyn doctors.

01-00:59:51
Rigelhaupt:
And when you’re describing the perinatologists, are they Mary Washington Healthcare employees?

01-00:59:55
Ryan:
All three of our current perinatologists are Mary Washington Healthcare employees. [01:00:00] Again, what a health system needs to do to provide that tertiary care medical center.

01-01:00:05
Rigelhaupt:
And so even if ob/gyns in some ways could have done residencies, fellowships to have that expertise, it sounds like this is another one of those instances where a physicians group can’t create this kind of a specialization without a larger health care organization. Or it might be very challenging.

01-01:00:25
Ryan:
It might be challenging. There are perinatology groups who are independent groups. Some of them are large groups and they serve entire cities going to multiple hospitals. But it is a specialty. They need to have an anchor of a place where they obviously had lots of deliveries and lots of at risk mothers that they can provide their expertise for. Being here with a health system is certainly beneficial in this area. In an area such as Richmond, they might be able to have independent groups because they have so many hospitals.

01-01:00:58
Rigelhaupt:
What were the biggest changes with the ICU when the new hospital—

01-01:01:03
Ryan:
When I came in 1979 we had an intensive care unit and it was very small, just a few beds. We had our nurses there who were not necessarily trained in intensive care medicine, but were experienced in intensive care medicine. It was a good place to take care of sick people. Since that time the technology, what is able to be done for intensive care patients, and the specialization among those physicians and nurses taking care of the sickest of the sick has greatly increased. We now have two intensive care units on this floor, not counting, of course, the neonatal intensive care. We have a surgical intensive care unit and a medical intensive care unit. Our nurses are trained in taking care of the sickest of the sick. They have certifications in that kind of a specialty for our nursing staff. The technology that assists them, whether it be in monitoring and doing procedures within the intensive care unit, is there. We have both medical and surgical physicians who spend much of their career staying on top of how to take care of the sickest of the sick. We call them intensivists. In many situations, and in our particular facility, in the medical ICU, it is pulmonologists and critical care specialists—generally that’s one training program—who deliver that care. On the surgical side of things our trauma surgeons, who are also critical care specialists, take care of the surgical intensive care patients. Attending physicians can still participate in the care of their own patients, but they know that when they are not there they have the expertise of an intensivist, whether medical or surgical, that can bring to bear all of their armamentarium for their patients. [01:03:00] It is a huge change across the country in delivery of both medical and surgical care and a wonderful opportunity for us to take ourselves from a community hospital to a medical center. This is something that we’re very proud of, across the country now. The Leapfrog Group, which is an industry group, is setting the expectation that hospitals have intensivists in their intensive care unit and we do.

01-01:03:23
Rigelhaupt:
Were intensivists, and having them be part of Mary Washington Healthcare—well, MediCorp at the time—but were they part of the plans as you were president of the medical staff in 1989, 1990? Was that still—

01-01:03:38
Ryan:
It was later. When we were developing the strategic plan for this hospital we had physicians who were specialists in both medical and surgical who would do a lot of the intensive care. But they were not intensivists and they also had practices outside the hospital. Or they had to be in the OR or they had to be elsewhere within the hospital. The intensive care specialty, both on the surgical side and medical side of critical care, developed as a specialization. As we learned more, had more technology, had sicker patients in the hospitals, and the ability to both take care of them and keep them alive, it allowed us to develop that specialty and utilize that specialty as best we could.

01-01:04:31
Rigelhaupt:
What were some of the earliest discussions you recall about hiring intensivists and planning that specialty within Mary Washington Healthcare?

01-01:04:42
Ryan:
It was really driven by two things. Number one was the expectation of our community that they would have access to the best care that was available, and across the country that expectation was being set. There are still hospitals that don’t have intensivists or they’re so small they cannot afford to have intensivists, and that’s not unusual. But for a tertiary care center like Mary Washington Hospital, the expectation is that we do have twenty-four hour intensivists available. That was one expectation. The other expectation is that our physicians, our attending physicians who are so busy, have aid and assistance to complement their care in the intensive care unit. That is a tremendous boon also. If a surgeon does surgery on a patient and that patient has difficulties either off hours or while the surgeon is in the OR with another case, there is somebody in the intensive care unit who has the expertise to be able to take care of their patient. Intensivists are both a community expectation and an attending physician expectation.

01-01:05:44
Rigelhaupt:
As the intensivists were being hired, and surgical ICU and medical ICU are being planned, do you recall that all the major players in terms of Mary Washington Healthcare, the board, administrators and physicians were onboard? [01:06:00] They all wanted to see this develop?

01-01:06:05
Ryan:
As with any change within the medical enterprise, nothing is ever 100 percent agreed to. Yes, most people intellectually knew that this was a good thing to do. There was concern amongst some of our attending physicians, and rightfully so. They did not want to lose control of their patient or they did not want to lose the ability to care for their patient in the intensive care unit. This is what comes up across the country when such a specialty is introduced. We worked it so that our attending physicians who want to can still actively participate in the care of their patients. The ultimate authority and go to person in a crisis is generally the intensivist because they’re there all of the time. But we continue to allow our attending physician to care for their patients or participate in the care of their patients in the ICU. In other words, our ICU is still an open ICU. Many tertiary care centers have gone to closed ICUs, where when your patient enters the ICU, you can go in and say hi but you’re not participating in their care. That is not the way it happens here at Mary Washington Healthcare. We believe that allowing the attending physician, if they choose, to participate in the care is a good thing, but we provide the expertise and full-time presence of the intensivist there, too.

01-01:07:32
Rigelhaupt:
Who are the attending physicians and what are their roles within medical care in the region?

01-01:07:36
Ryan:
The attending physician in a surgical ICU might be your surgeon. You may say, “Well, I just had a lung operation and Dr. Tim Sherwood is my thoracic surgeon. Dr. Sherwood is going to do my surgery and he is going to follow me post-operatively.” But he will have the assistance of the surgical intensivist also or, if need be, he will have the assistance of the medical intensivist. On the medical side, the attending physician might be one of our hospitalists who take care of the vast majority of the general medical patients here in the inpatient setting. They may find that they have somebody who has both heart failure or respiratory failure and they need the expertise of having somebody who’s trained in critical care and medicine; they want the twenty-four hour presence of somebody there who has that expertise, too. And so it benefits the patient and it benefits the attending physician.

01-01:08:34
Rigelhaupt:
So it sounds as though within Mary Washington Healthcare the attending physicians are the physicians of record?

01-01:08:43
Ryan:
Correct.

01-01:08:43
Rigelhaupt:
They have the responsibility, but not the same as at a teaching hospital. They are not supervising residents?

01-01:08:51
Ryan:
They’re not supervising residents, correct. They are attending to the patients on the floors or in the units, and the attending physician is generally the physician of record or part of that group. You’re correct.

01-01:09:02
Rigelhaupt:
Okay.
[End of Interview]

Interview 2 – July 22, 2013

02-00:00:05
Rigelhaupt:
It’s July 22, 2013, in Fredericksburg, Virginia, I am doing a second interview with Dr. J. Thomas Ryan. To start today, I was wondering if you could think back to 1989 and if you could talk a little bit about your top priorities and goals when you became president of Mary Washington medical staff?

02-00:00:29
Ryan:
As I look back to 1989, prior to that time, the president of the medical staff had been largely, number one, a volunteer, meaning unpaid. And number two, it was something people did out of service to the organization, to the medical staff organization, and it was, at times, an imposition on your practice. As we came to the late ‘80s, we recognized the need to have somebody in that presidency who had the time to dedicate themselves to the medical staff. Therefore, the medical staff chose to provide a stipend for the medical staff president, and the health system matched it. [Half of the stipend was from the medical staff and half was from Mary Washington Hospital] That allowed you to take time from your practice. There was recognition that there was a need to have people in that position who, number one, wanted to be there, and number two, had the desire to not just provide service to the medical staff, but to try to organize in a fashion they had not been able to do before that. When I took over as the medical staff president, I was probably the second president to be able to receive a stipend. Therefore I was able to take some time from my practice and work at being the medical staff president. Number two, I wanted to organize it more in what today we would talk about as a highly-reliable organization. Back then, it simply meant trying to put people together that would work towards the benefit of the medical staff and make a difference with administration. That meant providing a cabinet of sorts, and there were people, such as Dr. Paul Hine—he is still working, of course, as a pathologist, but was relatively young in his career at the time. He was very much involved in medical staff matters. Vickie Pittman, who was the medical support services director, basically ran the office that supported the medical staff. We would meet as a cabinet of sorts, and bring in other people if we needed. We met before each medical staff meeting, both the business meetings and the medical staff executive committee meetings. We developed agendas, priorities for each year, and said, “What do we need to do? What is going to go over easily? What do we need to do that may be more controversial, and how do we need to present that to our medical staff leaders and those on the executive committee?” [03:09] We spent more time in the leadership of the medical staff, and I put more organization into it because I had the time. The medical staff was supportive of that because they were now providing one half of the stipend that went to our medical staff president. The medical staff business meetings, therefore, were a little bit more organized. The medical staff executive committee meetings were a little bit more organized. I think that we began to see that it was easier to accomplish things when we were more organized. The general medical staff was generally appreciative of the fact that they had people looking out for their best interests and they didn’t have to do quite so much. It was about that time that we began talking about the development of a new hospital somewhere, and we were here in what is now the 2300 Building. We knew we had to grow: the question was, do we grow here and stay within the city of Fredericksburg or do we go somewhere else? Most particularly and most frequently discussed was Stafford County. There were voices on both sides of that. The more far-seeing people felt like, well, we should really go out to Stafford County because that’s where the growth is going to be. But there were many physicians and certainly many people within the leadership of Fredericksburg City who very much wanted Mary Washington Hospital to stay within the city. In the end, our board of trustees chose to remain within the city, and chose not, at that time, to go to Stafford County, which, of course, we did later. We began the strategic planning and development of the new Mary Washington Hospital, which is up here on the hill. There was a lot of strategic planning going on, and these are things that the medical staff had not been heavily involved in, in the past. We had to be involved. We had to know what our expectations were, as far as what the medical staff needed out of a new hospital. What sort of call rooms? How many call rooms? What sort of an emergency department did we need? What sort of an endoscopy suite did we need? Things that in old hospitals just kind of got jury-rigged. We had the opportunity now to create de nouveau. We spent a lot more time with our department heads, our division chairs, and as a medical staff, saying, “What is it we want? How do we want this to look?” Then, melding that with the board of trustees and their strategic planning. And then when the architects came in, we would sit down with them and say, “Before you start designing rooms, from a functional standpoint, this is what we want to see as a medical staff.” It was great fun doing that. This was an era where physician leaders began to recognize that they did have a major role in leadership of hospitals and health systems, and medical staffs were beginning to see that there was benefit to having physician leaders who would take the time and develop the expertise to sit at the board table. [06:14] As the medical staff president, at that time and now, you sit on the board of trustees as a voting member of the full board of trustees and on the executive committee of the board of trustees. It was a tremendous learning experience for me, sitting with those people charged with the strategic planning for the health system—most particularly, the development of the new Mary Washington Hospital.

02-00:06:42
Rigelhaupt:
Thinking about the kind of integration that you were applying to physicians, now it’s almost working with the administration and being a board member, what were some of the things that you particularly advocated for, in terms of strategic planning, coming from the perspective of a physician? What did you suggest and prioritize at meetings of the board of trustees?

02-00:07:08
Ryan:
Prior to this time, hospital administrators built hospitals and they ran hospitals, and the medical staff kind of used it as a hotel to put their patients. The medical staff did not have a lot of say in either the physical plan, or sometimes even in the programming. There was an informal dialogue, and back in those days things were much more informal. What we wanted to do and what I advocated for at the board level was the fact that the medical staff needed to have a real say in what went on, not just a rubber stamp. Recognizing that things were more formal and the stakes were higher—both on the administrative side and the medical staff side—we needed to work together. The term “clinical integration” was not yet born and the function of clinical integration was there occasionally and not there a lot. It depended on the personalities of the hospital administrator, the department chair, maybe, of the medical staff, or that physician’s worth to the health system. If they were a high-producing surgeon, then they may have a little bit more say in what went on in the OR than the general medical staff did. The transition was a point where the medical staff needed to have a very real voice in the planning of programming of the medical staff, and, frankly, in some of the physical planning of the hospital. While I was the medical staff president, we tried to make sure that that became institutionalized and systematic; where board of trustee members would look to the medical staff president and say, “What does the medical staff think?” You would speak, as the president, for the medical staff in that particular area. It’s a little bit different than some of the other physician leadership roles that have developed since. You were representing the medical staff. [09:00] Back in those days, of course, we maybe had— when I came in 1979, seventy-five active medical staff members. By this time, we maybe had 150 or 200 active medical staff members. You had to speak for them, make sure that each of those departments had a role and had a say. If nothing else, it was my role, when the strategic planning people sat down with the architects, to say, “Let me bring our gastroenterology division because they need to have a say in what endoscopy’s going to look like.” They had really never had that opportunity before, in the previous era. The personnel issues that would happen at the medical staff had been handled behind closed doors in past eras. We became much more transparent, as we finished the ‘80s and we’re going into the ‘90s, when we had physicians that had personnel issues. We dealt with them more on a systemic level. The board of trustees both had a duty to know what was going on and had a desire to know what was going on. Those discussions were held more with myself, as the medical staff president, talking about what was going on among the medical staff, in both leadership and development. I talked problems that might arise, either behaviorally, substance abuse, or any of those other such things that happen in any population of professionals.

02-00:10:34
Rigelhaupt:
Would it be fair to say—you mentioned, in terms of clinical integration, that the term hadn’t yet been developed—that some of the initial steps of institutionalizing that came about because the new hospital was being built? That for the first time, you had the opportunity to discuss what endoscopy suites would look like, how many there might be? That in some ways, the building itself increased the level of conversation between medical staff and hospital administration and the board of trustees?

02-00:11:12
Ryan:
The building of the building did stimulate that conversation. It wasn’t the building itself, but it was the building of the building. It wasn’t business as usual anymore. Mary Washington Hospital had been a very successful hospital, in many respects, as a community hospital in a relatively small town. In fact, the Fredericksburg region was blessed with having such a good hospital for a relatively small population in this region at the time. As they were growing and as they were beginning to set the foundation as a medical center for a much larger region, those conversations were very necessary. It was a time when across the country, people were recognizing that physicians need to be heard about what health systems should look like. Physicians should not just have administrators tell the physicians, “This is what it looks like. You can admit your patients here now.” [12:00] It was necessary from a business sense, it was necessary from a medical sense, and physicians were, at that point in time, desirous of having a voice in what was happening. The building of a brand-new facility gave us the opportunity to sit down at the same table. You had medical staff leaders, rank-and-file medical staff oftentimes, boards of trustees, and then the architects, who were kind of the focus, and the strategic planning consultants, who were kind of the nidus for all of the people giving input from all around. It forced us to have discussions that weren’t necessary before that time. This was a time, too, when many of the administrators recognized that they wanted to know what the medical staff thought. There was still some angst on their part, of giving medical staff leaders more of a say, but recognition that it probably was important. The board of trustees was very happy to hear more of what the medical staff had to say. The recognition that health care was a huge business, both in this region and increasingly a huge business across the country—we needed to run it more like a very big business. Now, physicians hate to hear that sometimes. But the recognition is that maybe at that time we were twelve percent of the gross domestic product of the country—that’s still a huge amount. That’s more than the Defense Department. We needed even then to begin to institutionalize some of the decision-making processes so that they made more sense and things didn’t just happen because it just happened for that month. We had plans for years ahead, and all of the constituencies had input into those plans. So, to go back to your original premise: yes, the building of the new Mary Washington Hospital that we moved into in September of 1993 stimulated the functional area of clinical integration here in Fredericksburg. Even though we didn’t call it “clinical integration.”

02-00:14:08
Rigelhaupt:
Thinking about that first year and your second—because as I recall, you said that that was a unique thing, that you were re-elected to serve in 1990—those first couple of years, were there things you learned from the hospital and serving in that role that you brought back to your medical practice?

02-00:14:32
Ryan:
Almost certainly. Some of the organizational skills that you learn when you’re organizing anything, you bring back to your practice. I was in a multi-specialty group practice at the time, Pratt Medical Center, and I had actually served as president of that in 1983, prior to coming into the hospital. Although I did serve after that, occasionally, on the executive committee of my group practice, most of the skills that I learned in the organization probably stayed within the health system and not so much my medical group practice. [15:06] They had other good leaders follow me in the medical group practice itself at Pratt Medical Center. Back in those early days, there was recognition that physician leaders were increasingly important in any sort of a medical practice or health system was coming of age. There were people such as David Ottensmeyer, who was a neurosurgeon down at the Lovelace Clinic in Albuquerque and one of the early physician leaders in this country. As you saw people like that begin to have that voice within their health system, and then increasingly speak out for physician leaders across the country, it became apparent that we needed physician leaders who were going to make leadership of health systems actually part of their professional life.
That’s when I began to think about doing that. I enjoyed the experience of representing my fellow medical staff members. Although now it is typical for medical staff presidents to serve at least two years, I was the first one to serve two successive terms. That was probably due to a variety of reasons. Number one, I enjoyed it, and therefore, I wasn’t looking to get out and get back to my medical practice full-time, as had been so much the case. Number two, there was a stipend that was now provided and so it didn’t hurt you financially as much being a medical staff president. Prior to that time, it was a sacrifice from your medical staff, purely out of service. You still, even in my era, did not make up for what you lost in production within your practice, but if you wanted to serve in that capacity, the stipend that was provided took the sting out a little bit. It really allowed me to see that, number one, there was a need across the country for medical staff leaders, physician leaders, and all sorts of health care practices to begin to dedicate more of their time to leadership of their systems. I began to look around see whether I wanted to get more into that, in addition to continuing practice. Of course, I continued to practice full-time up until 1998, and practiced part-time even after that, until probably about 2009 or 2010. Actually, I thought about going back to get my graduate management degree when I finished my presidency of the medical staff after the 1990 term. In early 1991, I considered that, but frankly, there were no jobs back then for physicians who were going to spend the majority, or even half, of their medical staff practice time in leadership. They just didn’t exist. I could have gone to school and gotten that graduate management degree and have come out, and there would not have been a job available. [18:05] I stayed in full-time practice, continuing to do a lot of leadership work. As managed care came in the 1990s, there was again need for physicians to work with the administration of the health system and to start developing our approach to managed care here in the Fredericksburg region. Increasingly, I began working with administration and the medical staff. This is how we’re practicing medicine and this is what is coming to us from other areas of the country in managed care, HMOs, and things such as that. How are we going to respond to that? Increasingly through the ‘90s, I again got back into working through those systems and worked with the administration of the health care system. Bob Lively was instrumental then in the managed care arena. Of course, Fred Rankin was here at the time and was increasingly asserting his leadership in the health system. Bill Jacobs went on to another job and Fred Rankin left as the chief operating officer of Mary Washington Hospital; he became the CEO and president of Mary Washington Healthcare System.

02-00:19:28
Rigelhaupt:
Now, you served with Mary Washington Home Health, is that right, before—

02-00:19:34
Ryan:
I served as the medical director of Mary Washington Home Health, yes.

02-00:19:37
Rigelhaupt:
Could you describe your role, what you did, and how Mary Washington Home Health fit in with the health care system?

02-00:19:44
Ryan:
There was obviously a need for what used to be called, prior to this time, visiting nurses. The public health system across the country and the health department in the Commonwealth of Virginia had visiting nurses, so to speak; they were sort of home health nurses. Increasingly, there was a need to provide care outside of the hospital setting. Mary Washington Health Care, or probably MediCorp, as it was called at the time, decided it needed to have their own home health agency. Dorsye Russell, who I believe was director of nurses at the time, called me. I was a young physician at the time. She said, “Dr. Ryan, would you serve as our medical director?” I said, “Ms. Russell, I’d be very happy to do that. How much is this paying?” She said, “It doesn’t pay anything, but we’d love to have you as our medical director.” I did that, and I got a very nice lunch every month during our business meetings. I served as their medical director for twenty-five or twenty-six years. It was a wonderful group of nurses. They did wonderful work out in the community, and Diane Tracy was the nurse director or the executive director at the time. [21:00] They did tremendous work out in the community for people who either had left the hospital and needed continuing care or were not in the hospital but their physicians said, “I need somebody checking in on Mrs. Jones with her congestive heart failure more often than she needs to come to my office. Will you please go out and check on her?” Or, “She has a diabetic ulcer on her lower extremity; would you please go out and help dress this because she really doesn’t need to be in my office and certainly doesn’t need to be in the hospital.” This was the forerunner of what has become so important now. Home health is a critical part of delivering health care to patients. We see, increasingly, that patients can be cared for outside of the hospital very well by dedicated professionals, and these home health nurses were the forerunner of this movement. It’s much more important to the system now than it was even then; it has always been important to the patient.

02-00:22:13
Rigelhaupt:
This question is about the culture of Mary Washington Hospital and MediCorp, as you came on in ’89 and ’90. How would you characterize the dynamics of the relationship between the administration, the board, and the medical staff? Did they ultimately share the common goal of patient care, share a common goal of success in terms of delivering health care in the region, but bring different perspectives and different responsibilities to that?

02-00:22:48
Ryan:
The culture was different. This was a growing time. When I first came here in 1979, the administration provided us physicians with a hospital. They provided us with all the tools that we needed. For the most part, they were reimbursed for everything that they did because insurance reimbursed the hospital for what they said they needed to provide care. We provided care within the hospital, and it was a very relaxed and collegial relationship. The administrators did their thing, we did our thing, and sometimes, ne’er the twain were to meet. As we got to the late [‘80s], DRGs came in—Diagnostic-Related Groups came in—and when we started getting paid differently within the hospital in 1985; things were changing. Managed care was coming in. Physicians increasingly wanted to have a say in the programmatic direction of the health system. Administrators increasingly knew that things had to change, but were still uncomfortable with physicians having so much of a formal role. The board of trustees, which was very willing to hear what physicians had to say, still weren’t sure what to do with all of that. Particularly in light of the fact that the administration had typically led the hospital the way they chose to lead the hospital. [24:05] In the late-‘80s and the early-‘90s and the mid-‘90s, it was kind of like the metamorphosis of a butterfly, or a pre-adolescent becoming a teenager and growing into adulthood. There was some pain there. There was some friction there, as physicians increasingly wanted to be more assertive. Administrators intellectually wanted to hear what they had to say, but really didn’t want to share in the formal leadership up at that time. At least, they said they did, but they were still uncomfortable in doing so. There was some pain through those years. I still will say that the most challenging time in my professional leadership career was probably my second year as president of the medical staff at Mary Washington Hospital. Even after sixteen years as the chief medical officer, this second year of my medical staff presidency was probably my most challenging time. At that point, the growing pains came to a head. The growing pains became very evident, and there was a movement within the medical staff to say that we’re not happy with the current CEO of Mary Washington Hospital. This was a small group of people, but a very vocal group of people. In large part, there were very fine physicians who just did not see eye to eye with the current leadership at that time. The CEO was Bill Jacobs, who was a visionary leader. He did much to bring Mary Washington Hospital up to the speed that it needed to be to become a medical center. This was all quite new. To have a strong leader like Bill Jacobs as an administrator was quite new to the medical staff. By this time, he had been here not quite ten years, and some elements of the medical staff felt very uncomfortable. They felt like they didn’t have enough of a say and they were just doing what the CEO wanted to do. There was a movement to get a no confidence vote among the board of trustees from the medical staff. As I say, this was not the general medical staff by any means, but there was a group of people, good physicians, who felt very strongly about it. They tried to rally the troops, so to speak. They were informal leaders; they were not the formal leaders of the medical staff. At that time, the medical society got involved with the formal medical staff process, with me as the medical staff president. [27:00] We tried to direct this frustration, maybe some distrust and maybe even some anger among some members of the medical staff, in a more constructive way. It was so that we did not go, as a medical staff, to the board of trustees with a no confidence vote. We found other venues so that medical staff, administration, and the board of trustees could meet in an area where the medical staff could be sure that their voices were being heard. That was the beginning of the board medical affairs committee, which is now the board’s quality and medical affairs committee. That’s a critical committee among the board. It is where our board members, probably a half a dozen board of trustees, senior physician leaders, our chief of service for both of our acute care hospitals now, our physician leadership, and administrative leadership all meet once a month. We talk about the quality issues, we talk about patient safety issues, and we talk about medical staff issues. This didn’t exist before this time. That cauldron, so to speak, was during my second year as medical staff president. We had meetings in the basement of Phil Fuller’s home, who was, I believe, at the time, president of the medical society. We put medical society, medical staff, and then some of the rank-and-file leaders who were very unhappy with the status quo together and created the medical affairs committee. Difficult time. Good things came from it with the formation of the medical affairs committee on the board, but it was probably a period of four to six months that it was very, very difficult.

02-00:28:53
Rigelhaupt:
Do you recall anything specific about where this smaller group of physicians in the community and Bill Jacobs, who was CEO at the time, didn’t see eye to eye?

02-00:29:04
Ryan:
I don’t know that there was anything specific. I think it was, as you say, culture. Bill is a very strong leader. He was a visionary. He knew where Mary Washington Hospital needed to go. Some of the physicians did not necessarily want to go in that direction, or if they were going to go in that direction, they didn’t want to go that rapidly. I think it was just a series of decisions that had to be made over a period of years, and some of them felt like, “We’re not happy with the direction of the health system. We’re not happy. We don’t feel that we have enough say in the direction because we have a very strong leader there, and we can’t be heard by the board of trustees because we may not be able to get to them.” That’s how we were able to craft this solution, by creating the medical affairs committee.

01-00:29:57
Rigelhaupt:
You said that the medical staff that was more involved in Mary Washington Hospital at the time didn’t feel this way. Were there things you saw or participated in, or from your perspective as a physician, that you felt more comfortable with the directions that Bill Jacobs was trying to take Mary Washington Hospital and MediCorp?

02-00:30:24
Ryan:
At the time, as medical staff president, I saw that it was my duty, really, to see where we needed to go as a medical staff. I spent time going to meetings such as the American College of Physician Executive meetings. I was finding out what was going on out there around the country and what some of the health systems that we all admired were doing with their medical staffs and with their strategic planning. In fact, many of these other health systems outside Fredericksburg were already doing these things, doing the kinds of things that Bill Jacobs wanted us to do here. Our medical staff at the time, was still very comfortable in small town Virginia, growing and setting the foundation for a medical center, but still very comfortable in the way things were and were not necessarily rushing into the way things were to become any faster than they had to. As I say, Mary Washington Hospital was doing well, our physicians were doing well, and the patients were being well cared for, but there were services, programs, and systems being developed around the country that we needed to develop if we were going to become a medical center. Those are the kinds of things that Bill Jacobs saw, those were the kinds of things that many on the board of trustees saw, and they were the kinds of things that I made it my business to learn about since I was in that leadership role. There were other medical staff leaders who made it their business to see that, too. I think maybe that’s why I was more comfortable with the strategic direction of the health system: I saw growth as important, I saw the development of new systems as important, and I saw the importance also of making sure that the medical staff and physicians did have a voice at the highest levels of the leadership of the medical system, within the health care system. Therefore I wanted to be able to have that dialogue with both the board of trustees and the CEO.

02-00:32:31
Rigelhaupt:
During this time of change, the building of the new hospital, do you, as a physician, remember either physicians reaching out, or as president of the medical staff, reaching out to the community, with the administration reaching out to the community to get input about this transition from a community hospital to a regional medical center? [33:00]

02-00:33:04
Ryan:
Yes. The administration of the hospital, the strategic planning consultants that we brought in, actually had focus groups where they talked about that. The board of trustees saw to it that the community as such had a voice. We also had opportunities for the medical staff to have their say in the development of the new hospital, which was the physical plan that allowed us to have a medical center here. For instance, we would bring the gastroenterologists in and say, “Okay, endoscopy is a growing practice, it’s a very important part of the health care and delivering health care to the patients here: what should the endoscopy center of the future look like?” Now, it’s been changed a couple of times since that time, as it has grown, but the gastroenterologists had the opportunity to come in. We would provide evening meetings so that they didn’t have to leave their medical practice during the daytime. We would say, “What should this look like?” We did the same thing as we were developing our cardiologic and cardiac surgery program that was beginning as we came into the new hospital. People had an opportunity to say, “Well, what does the catheterization lab look like, and what sorts of needs are we going to have?” The vast majority of physicians were delighted to be able to give their input and try to help develop the new hospital. They were excited about the new hospital. Many of them were worried that the hospital was going to leave the Fredericksburg region, and many of them had their offices around here. Once we settled on yes, we’re going to stay here in Fredericksburg, they were excited about having a role in the development of the hospital. I think many of them were excited about being in a place that could provide more services. Was it upsetting, in some respects, that things were changing? Yes. Physicians, as a professional group, have always been a little bit upset when their cheese was being moved, so to speak. There were some physicians that were upset that they were going to have a new hospital. Or they were concerned we were not going to be able to support a new hospital; that it would be the death knell to Mary Washington and Fredericksburg’s health system because we’d never be able to buy a new hospital up on the hill back in the early ‘90s. In fact, of course, it was immensely successful, but there were physicians who were very concerned about that. They said we should just stay where we are in the old hospital and just tweak it, as we’d been doing since the 1950s. It was mixed opinion, but most physicians wanted to have new programs, particularly as we had such a growing community—we brought newer and newer young physicians in and young physicians wanted to have new programs. They wanted to have access to the kinds of services that they had in their training programs, and they really didn’t care what had gone on at Mary Washington Hospital ten years before. They wanted to have the best and the newest of systems. [36:00] The majority of them were happy, but there was always some level of discomfort at the newness. One of the interesting things happened when we first opened Mary Washington Hospital. Just to talk about culture: all of a sudden, most physicians in the new Mary Washington Hospital started wearing white coats around on their rounds. It became a much more professional-looking atmosphere. The care provided was still excellent care, but the appearance changed when we moved up to the new hospital. We had a new hospital, new systems, and physicians dressed differently. Even those who had been in Fredericksburg for a long time, you saw them wearing very professional lab coats with their names on it and sometimes their specialty on it. That had never been done—not universally done, anyway—prior to that time.

02-00:36:56
Rigelhaupt:
In our last interview, you used the term “transformational change” to describe this event. Part of what I had asked about was what you brought, as a family physician, to this perspective, and you said it was very important that a family physician lead transformational change because a highly-specialized surgeon might be concerned about referrals. What was the transformational change you were leading? How did you define it? That’ll be enough questions for right now.

02-00:37:53
Ryan:
Transformational change, generally speaking, is when you’re doing things substantially different than you did before. You’re not just altering or slightly modifying what you’ve been doing. As we developed this medical center, we had a brand-new physical plant, we were bringing in CAT scanners and MRIs that we hadn’t had before, and we had full-time emergency room doctors who delivered superb care. We had a university-level radiology department. We developed cardiac surgery. We practiced medicine tremendously differently than we did when I first came in. There was transformational change going on. In helping to lead that transformational change, it wasn’t necessarily about me. It was about the fact that primary care is often seen to be the better leaders of transformational change within systems. The reason being that they are less dependent on the referrals of their colleagues within the health system if, in fact, they make some transformational change, which is upsetting to others. As we were thinking about building our new hospital, we went around and looked at other hospitals. There was a new hospital in Winchester, at the time, we looked at. There’s a new hospital down in High Point, North Carolina. The point was made in some of these other places, and among our strategic planning people, if you really want substantial change to happen, you should ask primary care physicians to lead it because they are not dependent on those referrals. [39:00] That was brought home to me when there was a very well-established surgical sub-specialist here in the community and we wanted to get something done. We asked him to raise that at the medical staff level because we said, “You’re so respected and you’re so well-developed in your specialty, that if you bring this up, people will seriously consider it.” Initially, he said yes. Then he came back a couple of days later and he said, “I can’t do that. I understand what you want to do. I support what you want to do, but if I bring this up, others will cut off my referrals. I can’t afford to do that.” What struck me was this is one of the most established, well-established physicians, most respected physicians in the community: they did not feel comfortable doing something that was going to upset others within the medical staff because they were dependent upon their referrals for their livelihood. For that reason, primary care physicians were seen across the country as being those who, when at a system level you’re trying to make some substantial change, they were good leaders to do that. As you look now, most of your physician leaders—not all of them—come out of the ranks of generalists. Family practice, general internal medicine probably have more of them than any of the others. You see some other specialties represented too, but probably family practice and general internal medicine have more of them. Another reason why they are good about leading change is that as a family physician, I was never an expert in anything. I was a generalist. When I needed expertise above and beyond what I had, I felt very comfortable in seeking that expertise among my colleagues. If you need to involve and integrate the thoughts and desires of a wide variety of specialties, to have a generalist do that; it comes as second nature to them. Whereas if I am in a specialty where I am pretty much the captain of the ship, totally, and nobody else is going to question my word, then I may have a more difficult time building consensus among my colleagues because I haven’t had to do that so much in the past.

02-00:41:27
Rigelhaupt:
I wondered if you could say a little bit more about that, in the sense that in another interview I’ve done, it’s come up that some of the relationship, in terms of between physicians and the administration, has to do with training. I was going to get to this later, when I was going to ask about going back to graduate school, but since you just touched on it, I want to go with it now. Generally speaking, physicians are trained to be highly independent. [42:00] And this administrator spoke quite highly of that, in the sense that if you’re in a surgery, you don’t have time to build consensus; you have to trust your knowledge, your skill, make a decision and be very, very independent. While hospital administrators are trained to work on a team, to build consensus, and to make decisions. I’m wondering if you felt like that was something you developed more, as you became president of the medical staff, or that already, as a family physician and as a generalist, you were used to building that consensus, and how you bridged those two cultures? That was a long question.

02-00:42:46
Ryan:
Long question, but it’s talked about in most graduate management studies. Yes, physicians are trained differently than administrators—at least, they have been in the past. I remember—I finished my residency in 1975. That was back in an era where as the physician, it was all about you. We were the captains of the ship and everybody was there to serve us, so to speak. Although from a functional standpoint, in a highly-functioning team, you did work as a team, it was really about the physician and those who worked for the physician. In today’s health care, newer physicians are being taught that it is about the team-based care. Although the captain of the ship may still be the physician and should still be the physician in many cases, the hierarchy is not nearly so well defined because everybody on the team is seen to provide very valuable expertise. Whether you’re a nurse practitioner, a physician’s assistant, a scrub tech, the EKG technician, or whomever you may be, you are somebody taking care of the patient; everybody has a say and everybody’s say is valuable. We recognize that and the physicians recognize that they are an integral part of a team. That team isn’t there necessarily just to serve them. Now, when you’re in the middle of heart surgery, you don’t want to say, “Okay, let’s have a consensus decision on what I should do next.” If you’re the heart surgeon, that is still true—particularly in surgery. But yes, as a family doctor, I involved whatever expertise I needed to have for the care of my family. I took care of children, adolescents, young adults, and I took care of the elderly. There might be a need for a variety of different specialists at any point in a family’s evolution, and I felt very comfortable melding that evolution. There were others in some of the surgical sub-specialties, particularly, who very much felt they needed to be captain of a ship. They developed highly-functioning OR teams, but were noted by reputation in those days as truly being the captain, and don’t question the captain. In today’s world, questioning the captain is actually very important to do. [45:00] Not in the middle of a heart surgery and not in the middle of some critical juncture, but you need to be able to debrief. Everybody needs to be able to debrief the way something is done so that it can be learned about. If you’re the lowliest person, you’re brand new, you’re in a support role, and you say, “Gee, how can I question what this nurse practitioner or what this physician is going to do?” Actually, after the fact, you need to be able to bring that up in a very professional way so that the entire team can learn from it. Administrators have had that team-based mentality forever. They develop consensus, they work in executive teams, and then they would go and try to implement what their consensus decision was. Physicians have largely, in the past, been accustomed to saying, “This is my decision. Now this is how I expect you to implement it.” That sort of team-based mentality is melding together now. From a leadership of a health system level, it’s melding together because we see physician leaders, administrative leaders, and boards of trustees needing to work together for the benefit of the health care system and the benefit of the community. From the individual patient standpoint, we need to bring all the forces to bear. Not just a physician, but the physician, the nurse practitioner, the PA, the home health nurse, the hospice nurse—all of these folks need to be contributing to the welfare of that patient, and everybody recognizes that, now. The world has changed.

02-00:46:35
Rigelhaupt:
It sounds like part of this transformational change was MediCorp, at the time, Mary Washington Healthcare pushing more in this direction, building a consensus with the physician community, administration, and the board. Can you think of instances in which you saw relationships with other physicians who were working with Mary Washington Healthcare that began to be influenced by some of the ideas of integration that were coming about as it had developed into a regional medical center?

02-00:47:13
Ryan:
Absolutely. Back in 1995 and moving on through 1997, we actually saw the need to have physicians have more of a voice in the workings of the health system, and have more of a formal voice. By this time, physicians did have a voice, but they needed to be able to funnel that up so that it reached the highest levels of strategic planning and implementation. We developed the chiefs of service program, which, of our size hospital and for our community focus, was unique. Fred Rankin was very forward-seeing in supporting this maneuver because he embraced physician leaders, and we (MWH MediCorp/MediCorp Health System) actually paid for between one quarter and one half of their time, depending on their particular department. [48:03] We developed chiefs of medicine, chiefs of surgery, chiefs of ob/gyn, chiefs of pediatrics—at first, it was women and children—and chiefs of support and diagnostic services. These people were paid part of their salary to work, formally, within the development of planning for programs within the hospital, working with their medical staff members, and in the implementation of some of these programs. This is really the beginning of clinical integration at Mary Washington Healthcare. This was the same time that I was coming onboard as the vice president of medical affairs for Mary Washington Hospital, first assuming that role on a part-time basis in 1997, and then full-time in 1998. We educated our chiefs of service—at that time, it was only Mary Washington Hospital, this was prior to Stafford Hospital—got them off to meetings, taught them how to deal with difficult situations involving medical staff members, taught them how to interact with the administrative people, and tried to develop dyads, so to speak. It was more successful in some services than it was in others. It was important to have the physician leader, which was the chief of service, work with the administrative leader as a dyad in leading that service. At the very least, they had frequent meetings to talk about the plans. What did we need to do next? This is what our budget looks like, what can we do here? How can we improve the quality, improve the efficiency, and get more medical staff members at the rank and file level involved in what we’re doing? That was really the beginning, in the mid-’90s as we developed the chiefs of service program, of a development of clinical integration.

02-00:49:53
Rigelhaupt:
Was this an era in which physicians were pushing the administration for new practices, new specialties, new technology? What do you remember about what physicians prioritized, and if there was any—I don’t know if “tension” is the right word—tension between physicians and the administration?

02-00:50:23
Ryan:
There was always a dynamic tension between medical staffs and administrative staffs. That’s not unique to health care. It similarly could be seen between the faculty of a university and the administration of a university. Yes, since I’ve been in medicine, there has been a dynamic tension between medical staffs and the administration. Although we now have formal ways to deal with that and to channel it, it still exists and I think it will always exist. Physicians are trained to care for the patients; they are not necessarily trained in developing the systems with which they are going to deliver that care. [51:05] Administrators are trained in developing those systems, and physician leaders have a foot in both camps. But many of your rank and file physicians are going to say, “I think we need to do this in the OR, and please do that.” That may be developing a new program that may or may not be financially viable for the health system. For instance, let’s say we’ve got a system that’s got fifteen ORs, and you say, “I like to do my surgery this way. I think we need to have at least half those ORs that are substantially bigger than they are right now.” That might well be correct, but it doesn’t just happen overnight. You have to say, “Well, what does that mean? Do we have to take some ORs out of production? If we have to take some ORs out of production, how do we provide our surgeons areas to operate in the mean time? If, in fact, we’re going to develop more space for the ORs, what are we going to do with this sort of equipment? Do we have to get a Certificate of Public Need to build bigger ORs? Do we need to get a Certificate of Public Need to build something onto the ORs that is going to require the public saying so in Virginia, as we are a COPN state?” At least, we are right now—by the time people are viewing this tape, we may not be, but we are right now. That requires sometimes a couple of years of work. It requires doing the research necessary to make your case, making your case at the medical staff level, then at the local community level, then at the state level, and then having the appeals process. It’s a long time to get that sort of thing done. The medical staff is saying, “Listen, I need a bigger OR. Why isn’t it happening?” So, there’s always that dynamic tension. If the medical staff says, “We need the latest generation of MRI.” The administration is saying, “Well, can we still use the one we bought two years ago?” There’s a new generation out. It’s like computers: there’s always new technology and in the United States today technology is a huge part of what we do in caring for patients. There is a feeling among our physicians that if there’s an MRI that’s going to show these sorts of things, I’d really like to have access to that for the benefit of my patients. As the administrative leader, you’ve got to say, “How many of those patients that we see each year are going to need this special kind of MRI? Can we still use this and refer out to one of the universities those few patients that may need this?” Again, the point is, the dynamic tension has always been there and will always be there. I will use a specific example. In the development of our cardiac surgery program, which was a new thing for us, the question was, what are we going to do? We brought a new physician in, Dr. John Armitage, back in 1993. He brought a lot of his team down from Pittsburgh, when he came. [54:00] We had to develop the idea that cardiologists and family doctors and internists did not need to refer their patients to Richmond, Charlottesville, or Washington for surgery anymore. We needed to develop trust in the new program, and in the new surgeon. Cardiologists had to develop the cath lab skills, and there was a time where cardiologists would have to actually go down to Richmond to do their catheterizations. There was a dynamic tension there. We’ve got a new program, a new surgeon, and a new surgical team. What does this mean for the health system, what does it mean for the community, and do we trust this? If we’re going to send patients still to Washington, Richmond, or Charlottesville, what does it say about our program? What does it say to our community? With the evolution of that, over the various surgeons that we’ve had, and the new techniques of where are now in 2013—we’re doing very significant valve surgery and doing bypasses, which have become almost commonplace. We’re doing coronary artery bypass surgery on patients we never would have done it on years ago because we have better surgical techniques, we have a better intensive care unit for post-operative care, and we’re constantly learning. Whenever there’s evolution of a program or a service, there’s always that dynamic tension between the oldness and the newness, and the vast question of trust of the program in the meantime. What do you say we do a short break?

02-00:55:37
Rigelhaupt:
Absolutely. [Short break]

02-00:55:46
Rigelhaupt:
You mentioned the COPNs, Certificate of Public Need, and I’m curious, I was going to get to this a little bit later in terms of governmental relations, but since you mentioned it, what do you see as some of the positives of having to do COPNs and some of the hardships that the COPN system creates?

02-00:56:08
Ryan:
It’s a constant conflict and source of discussion across the country, as to whether COPN is a good thing or a bad thing. Some states don’t have them. I’ve grown up in Virginia with COPN, so I have become accustomed to the bureaucracy that it requires to get something done. At the same time, the good that it does, at least in Virginia, is when there is something in health care that makes money, they can pop up on every corner if you don’t have a certificate of public need. In Fredericksburg, we could have a CT and an MRI out in Central Park. We could have one down on Williams Street. We could have one in South Stafford County. We could have one at the Spotsylvania Courthouse. Before you know it, you’ve got individuals—whether they be investors or physician investors—who are putting up things on street corners because they make money at that time. [57:05] Those sorts of things allow the hospital, or the health system—it’s not so much the hospital anymore because the health system has many of these outpatient centers—to have the franchise, so to speak, and those things that are important to the health care to the community and do provide some income. The health system does so many things that provide no income or, actually, they lose money doing it. If you allow investors to skim off the cream and just do the stuff that makes money and give everything else to the health system, your health system is not going to be financially viable for very long. There are communities in other states across the country where that has happened with surgery centers and putting up ORs so that surgeons can have their own little OR on a street corner. They may deliver good care there; they get not just their professional fee, but they will get a facility fee, too. They make more money off it, at least for a while. They feel like they have an investment. If it starts to go bad or go south, oftentimes, they want to sell it to the health system and say, “I may have skimmed all of this money for a while, but now I want to sell it back to you because I can’t do it anymore.” In Virginia, we’ve not had to deal with that. The bad thing about COPN is it can take a couple of years to get something that you feel that you need. You have to build a case. Sometimes, you have to involve consultants in the strategic planning. If it’s a big deal, and then you have to start going at the local level, the regional level, and the state level, and wait for all of those hearings to go on. I’ve been involved with COPN in several different times. The greatest amount of my COPN experience was in the building, the planning, and the implementation of the Stafford Hospital site and building. It was years of work that went into the building of Stafford Hospital. In the general scheme of things, it went very well, but it was a very expensive process and a very time-consuming process.

02-00:59:27
Rigelhaupt:
In the process, you described going through having to get approval and do research. I’m not sure my dates here are exactly right, it wasn’t universal across the country, but this is also an era in which evidence-based medicine is making broader entry into health care systems. Is there a way in which the COPN system reinforced the use of evidence-based medicine, and what was going to approve was really good for patient care? [01:00:00] Or, was it more of the financial viability of whatever might have needed it?

02-01:00:12
Ryan:
Proponents of COPN would say that yes: evidence-based medicine was an important part of this and we need to do this so that we make sure we are thinking about medicine. Practically-speaking, I believe that economics is the largest reason and largest stimulus for COPN. The COPN laws being struck down in some states is largely financially-driven. COPN laws being upheld in other states is largely financially-driven. Health systems can learn to work within whatever system; you just can’t have a hybrid system. You’ve got to either say, “Yes, we can build anything on a street corner that we want, and we know we’re going to have to compete at that level,” or, “We are going to have to apply for and justify anything that we want to do.” We can function within that system, but you can’t have it both ways. I believe that economics is the stimulus.

02-01:01:23
Rigelhaupt:
The first couple years you’re vice president, I can’t remember the exact title—

02-01:01:30
Ryan:
Vice president of Medical Affairs was my first title at Mary Washington Hospital.

02-01:01:34
Rigelhaupt:
It’s also when you went back to get a master’s of science in hospital administration.

02-01:01:40
Ryan:
Health care administration, yes.

02-01:01:41
Rigelhaupt:
Sorry, healthcare administration. What were some of the things you learned in that program that you began to apply to your position?

02-01:01:49
Ryan:
It was a tremendous experience. Before I went down there, Fred Rankin said to me, “Tom, you are our vice president of medical affairs. You don’t have to go back to get this degree.” I said, “Fred, I want to.” I said, “If I’m going to do this job, I want to do it well.” At that time there were not many physicians that had graduate management degrees, but it was becoming more common and I knew that it was going to be the expectation down the road. I wanted to do a good job. In 1997, I still had a full-time practice; I was working half-time as the physician leader of Mary Washington Hospital, not yet full-time, and went back to school full-time. Earlier that year, I had done a management certificate at the Kenan-Flagler business school at the University of North Carolina, Chapel Hill. I was in a class with twenty-six physicians, where we were taught by the graduate business school faculty. It was a very good experience, and I recognized that there was so much to learn out there about the running of larger organizations. I had run a practice and I had had a hand in the leadership of a multi-specialty group practice, but it was still very small compared to a health system. [01:03:03] I started the two-year program. It was an executive program. I would spend two weeks on campus at Virginia Commonwealth University, where I went to medical school, the MCV (Medical College of Virginia)—they had the number five ranked program in the country at the time. It usually runs between number four and number five in the country and it’s a very well-respected program; it was fifty miles from me and was already one of my alma maters. I began the program there. I was in a class of about twenty people. In those twenty people, we probably had four or five physicians; the others were nurses, nursing leaders, and insurance leaders. We had one CFO who was getting his graduate management degree. There was a wide variety of experience. The oldest member of the class was fifty-three years old. He was a retired bird colonel from the Air Force who had been a hospital commander in the Philippines. I was the second-oldest in the class. I was fifty years old entering the program. I was quite anxious because I knew I was going to have to take finance and accounting; I had never had those things in undergraduate school, and certainly not in medical school. The program was very vigorous: we spent two weeks on campus each semester, and then the rest of the time, you’re on what we would call the boards. You’re on the computer, and I had to become computer-literate very rapidly; I did. We were using Excel spreadsheets, Word documents, and all those sorts of things. We would communicate by a special board set up by the university. We would talk to each other on the computer like young people do IM right now. It’s rather commonplace now, to have these executive programs like this, but VCU was one of the pioneers in graduate management education like this. You would do that. It was actually very good because everybody in the class got to participate, rather than having just two or three vocal members of the class participate. The professor would be on the boards, too. I gained an appreciation for finance. Before you took finance, you had to take accounting. I had the wisdom the very first week, knowing that I had no accounting background, to get a tutor that would stay with me the entire time here. My tutor was a young woman named Linda Blakemore, whose husband is a history professor at the University of Mary Washington. Linda had just gotten her MBA from Virginia Tech. She was a patient of mine. I said, “Linda, would you work with me on accounting because this is entirely new to me and I don’t want to get behind the eight-ball.” She did, and she was a large part of my success in getting through this. We would spend Saturday afternoons in my office at the hospital doing accounting, and then during the week I would do more. [01:06:03] Sometimes, in the evening after work, she would come over and we would do homework assignments in accounting. It was a tremendous help, and I actually got through accounting okay. I will never forget the final exam, and sitting there thinking, “I’m in here with thirty-five year olds who oftentimes have had, five years ago, an accounting course.” But I got through it. Finance, I loved. Finance is very important in leadership of large organizations. It’s one thing to know a balance sheet and how to read a balance sheet, but it’s even more important to understand the priorities in financing organizations, net present value of money and how to know what the pot of your resources are, and then how you’re going to allocate that out. Finance was exciting; it was strategic and I thoroughly enjoyed it. The dynamics of organizations, I enjoyed, and what goes on in a large organization. It’s like a community, on the larger scale, and yet, it’s like a human organism on a smaller scale. It has moving parts, emotions, politics, and it’s always moving and ever-changing; we studied the science of that. Studying some of the basic tenets of industrial engineering, just-in-time inventory, queuing technique, those sorts of things, and probably very importantly, studying the science of leadership. Understanding the different kinds of leadership—do you want to be a John Wayne kind of leader or service leadership, is that going to be your style? What it is that fits both your personality and the organization you’re in? And even more importantly, the time that you’re in, in history. For instance, in health care organizations there was a time when those physician leaders that rose to the top of health systems were John Wayne leaders. They would go in with their whip and they would say, “This is the way it’s going to be done.” They would bang heads. In today’s world, that doesn’t get very far at all. Today, you need to find ways to make people want to do things, to let them recognize the wisdom in doing it a certain way, and if, in fact, they have a better way to do it, then you as a leader need to understand that better way and rethink your implementation plan. That was another good thing that I got out of those years. The two years working with an interdisciplinary class—they weren’t all physicians. I was glad that I did that. There are MBA programs that have a health care concentration and are all physicians. Although that’s good, I think growing up where I was working with the nursing leaders, business leaders, insurance leaders, was a better way for me to do that. We had lots of class joint presentations. I had to learn to work with all of those people and see things from their perspective. Whereas if I were in a class of physicians, I would have had my physician perspective just reinforced. [01:09:07] It was a great two years. It consumed my life. My wife had just finished a master’s degree and she was hoping that we could begin having some free time again just as I went back and said, “No, I want to get this degree.” It was all time-consuming. When we would go to beach vacations, I would spend most of the time on my computer, doing work, writing papers, reading, being on the boards talking to my classmates, and doing all the sorts of things you have to do. At the end of two years, I was very delighted—it took me three months to be able to come down and realize I was not in school anymore and had free time. I hope that it made me a better leader. I hope it made me a better chief medical officer, but it certainly made me feel more comfortable in the board room and in the executive rooms when I had to talk to the CFO, the COO, and the CEO. I understood organizations, leadership, and the finances of what we had to do, and strategic planning. I understood all of those sorts of things. I’d had the same formal training that they had had.

02-01:10:22
Rigelhaupt:
Are there ways you could describe what you learned in that program that you saw as beneficial to patient care and medical practice? I don’t think you ever gave up.

02-01:10:41
Ryan:
I was still seeing patients. Of course, the first year I was seeing patients still, I had a full practice. The second year, when I came on board Mary Washington full-time, I went down to two-days, two afternoons a week in a clinical office. I saw patients up until several years ago. My training in the business of health care didn’t directly influence my delivery of care to patients, but indirectly it did because my job then wasn’t necessarily to care for one patient at a time. It was to develop systems with the medical staff and with the administrative leaders to provide health care to an entire community. Yes, it helped me in that regard. It helped me understand the resources that were necessary to go through the process of strategic planning, getting consensus, communicating between the administration and the rank-and-file medical staff. It helped me to lead the other physician leaders, chiefs of service, the division chairs, and those sorts of people who were delivering that direct care. It helped me in that regard. It helped me on a more global scale, not at the individual patient, one patient at a time. [01:11:55] One of the reasons I went in and chose to direct much of my professional life to health care system leadership was that I wanted to try to make a difference to an entire community, rather than just one patient at a time, as I had done for the first twenty-three years of my practice.

02-01:12:13
Rigelhaupt:
That’s a great transition to where I wanted to go next. Could you describe what you wrote about the origin of the Community Service and the Community Benefit Fund at Mary Washington Hospital, MediCorp? MediCorp at the time. How you were hearing about it, and the role that it was going to come to play.

02-01:12:35
Ryan:
There are others who could probably give you a more blow-by-blow description of all that happened. Mary Washington Hospital going to MediCorp Health System and becoming Mary Washington Healthcare, in modern day, has always been community-focused. Since I’ve been here in 1979, it’s had very much a community focus. It is a community-led hospital. Even now that it’s a medical center, our board of trustees is an unpaid group of community leaders; they’ve always had that community focus. It became more formalized back in the days of MediCorp. Joe Wilson, I know, was instrumental in being a person who said—and I don’t remember all of those early conversations—“We essentially need to tithe.” Back then, hospitals were able to make money and health systems were able to make money. With reasonably healthy profits in an area where the economics were very good, we said, “We want to take some of these profits and turn them back to the community and work towards beneficial health care in a wider sense than just delivering it within the hospital and delivering it from a physician. Are there programs out there that are already functioning that need more support? Are there programs that could begin if they had our support? If so, can we develop a group of people who can vet those programs?” They can formally apply, we can vet them, and we can say, “Yes, we don’t want to provide operational expenses, but we’ll give you start-up money so that you can maybe start a parish nurse program within your church. Or you can develop something for the aging, in this need.” It will supplement what our home health people can do and it will supplement what our health system can do. We will provide you the seed money to make that happen. We formally developed that system, and it has matured since then, with our foundation and all of our community input into what they feel should be done for the Community Services Fund. Physicians had a large hand in that same benefit by working through the medical society with the health system to develop the first beginnings of the Moss Free Clinic. [01:15:00] Physicians were very instrumental in that. Again, in the early days, through the health system and then wider through the medical staff, working with the health system—the health system has been extremely important for all of those years of the Moss Free Clinic. Physicians continue to be the providers of most of that care, although nurse practitioners are also providing a bunch of the care directly. That care is facilitated by large numbers of nurses who work long shifts and then come over to the Moss Free Clinic and work. Pharmacists from both the health system and their private drugstores come over and help deliver care to the Moss Free Clinic. PAs and nurse practitioners— so everybody’s in. They have other people, such as community members who don’t have necessarily formal medical training but are coming in to help program and make sure that people get in the system; they make sure the right people get into the system and do all the work that’s necessary at the Moss Free Clinic. That, again, is a continuing community benefit that physicians have been involved in, as well as so many other people in the community.

02-01:16:11
Rigelhaupt:
I was going to get to the Moss Free Clinic, but since we’re there, do you remember its origins, coming from the physician community and trying to work with MediCorp at the time, but Mary Washington Healthcare to bring it into being?

02-01:16:30
Ryan:
Yes. The medical society was instrumental in that, back in those days. There were other free clinics elsewhere—I think Richmond had a very well-developed free clinic at the time—and there was a need. There was a need for providing care for those people who couldn’t afford a private physician, and may not have been on one of the government programs, such as Medicaid. The medical society could not, of course, have done that alone. It worked with the health system to provide that care, but the physicians were very instrumental. Back in those days, basically, you had a community member screening people, you had a nurse helping to deliver the care, and you had a physician there at night, from 6:30 until 9:30 or ten o’clock at night, trying to see some of those patients. From the very beginning, we had to limit the number of patients we could see because the demand was pretty significant. That’s still there: the demand is greater than the number of providers that we have to offer. The physicians, through the medical society in those early days, were instrumental in doing that. Then, of course, as they needed more and more providers, usually primary care providers in the clinic itself, the specialists would see the Moss Free Clinic patients in their offices but would do so gratis if they came through the Moss Free Clinic. All of our specialties had a hand in providing that care, and the health system would provide lab and x-ray, often at no reimbursement whatsoever for those patients. [01:18:00]

02-01:18:06
Rigelhaupt:
It sounds like the Community Benefit Fund is really one instance in which MediCorp, Mary Washington Hospital, and Mary Washington Healthcare has understood that health care goes beyond the hospital and beyond direct patient care provided by physicians. Is there a way in which you’ve seen that recognition come through the broader culture within Mary Washington Healthcare?

02-01:18:42
Ryan:
I think that Mary Washington Healthcare is the best practice, as far as community benefit is concerned. There are people—actually, I don’t think I’d be embellishing this to say nationally—that look to Mary Washington Healthcare as a leader in this particular area. People that can tell you more about that would be Fred Rankin and Xavier Richardson. We had been recognized in various areas and we deliver that care to the community. I think the community itself looks to Mary Washington Healthcare for that seed money; when they have health care needs that they see need to be met, but they don’t have the start-up money to get it going. Again, we try to avoid ongoing operational funds, but there are situations where the health system, through our foundation, will provide care to some of the safety net providers, so that they can provide care that our private physicians cannot do. That benefits the health system, but most particularly benefits the patients—patients who might not otherwise have access to care. I think, as I say, we are best practice in that regard, and Xavier Richardson could give you the details on that. The physicians on our medical staff, and some of our physicians who are no longer on our medical staff but just in the community, will work in the various capacities that are made possible through this. Whether it be the formal programs where we provide seed money, through the Moss Free Clinic, or any of the other things that go on through the foundation.

02-01:20:27
Rigelhaupt:
So, this will be a long question.

02-01:20:30
Ryan:
Do you want a long answer?

02-01:20:32
Rigelhaupt:
Certainly. What I’m trying to get at is why this happened, and if you could speak to it. Part of what is clear in the Community Benefit fund is, again, that health care is not only happening at a hospital level. So, as acute care centers, hospitals, generally speaking, have not made public health a top priority. [01:21:00] Hospitals provided high technology, acute care centers, have not necessarily been the best place to treat chronic conditions—obesity, diabetes, cardiovascular disease, tobacco/substance abuse—I pulled those from community needs that are identified in the Community Benefit Fund. It’s not that hospitals don’t treat these conditions highly effectively because of course they do, but hospital-based care is not necessarily the best place for them, and at the very least, a very expensive place to treat chronic conditions. Yet, the Community Benefit Fund runs contrary to long-term trends in terms of non-profit community hospitals in the twentieth-century U.S., in prioritizing public health, in prioritizing the treatment of chronic conditions. How is this received? Could you speak to how and why? Also, if you think I’m accurate in what I’m saying, and how you think that came to be?

02-01:22:09
Ryan:
I’m going to give you a short answer to a long question. Across the country, it’s recognized now that the community benefit is critically important. We recognize that the high technology, for the critically-ill patients within the hospital, is very, very important, but that most health care can be and probably should be practiced outside of hospitals. The health care will still be within systems, oftentimes, because you’re dealing with physicians and all of the other auxiliary services of health systems. Mary Washington Healthcare has provided community service and community health for a long time simply because of its community roots. We were formed in 1899 by a group of women in the community who said, “We need to have a hospital in Fredericksburg.” We’ve never left those roots, and even the fact that we are now a tertiary care medical center, we still have those community roots. Our leaders, our ultimate leaders, our strategic leaders, the board of trustees, are still unpaid community members who live and work here. They are still men and women who offer their services on behalf of the rest of the community. They come from the community and they worked for the community. We’ve never left those roots. Even in the beginning of time, before it became the norm for health systems to expand beyond the walls of the hospital, Mary Washington Healthcare or its predecessors had that community focus. Again, it’s because we never left our community-based roots.

02-01:23:42
Rigelhaupt:
I want to push you a little bit more on that, in the sense that certainly part of what has come up in our discussion is that there are very real financial questions. Through COPNs and some of the ventures that health care systems and hospitals undertake, have large financial issues associated with them. [1:24:10] Yet, part of what you’re describing, in terms of the commitment to community benefit, would seem to run contrary to the economic incentives, that hospitals are reimbursed based on procedures. The reimbursement structure would not necessarily reinforce this commitment to community care, commitment to treating chronic conditions outside the hospital, and yet, Mary Washington Healthcare seems to have done that, over the last ten years.

02-01:24:47
Ryan:
We have. People are going to be able to hear your question as well as my answer, right? Good, so I won’t repeat your question. But you’re correct: much of what we’ve done in the past, in the community service areas and through our foundation have not been to the financial benefit, directly, of the health system. We’ve done it because it’s the right thing to do and because we are community-focused and always have been community-focused. Today, health systems across the country are recognizing that having that focus on the community and doing things outside of the hospital is to their financial benefit. As accountable care organizations come into play, and we generally, in a functional sense, are more accountable for the care of an entire population of patients, we will see that the kind of community outreach that Mary Washington Healthcare has had for many years is now viable, is now beneficial to the health system because you really want to keep people from needing that critical care. You want to keep people out of the highest reaches of the health system and deliver health and wellness to them at the community level. We did not get a financial benefit directly in the early years; we did it because we were community-focused and it was the right thing to do.

02-01:26:01
Rigelhaupt:
Did you have any sense, at the time, in your position, being involved with the board but not on the board once you were vice president, that what you were creating with the Community Benefit Fund, in some ways, was extremely bold? Was where, in some respects, the future of medicine was going to be?

02-01:26:24
Ryan:
I don’t think we fully appreciated that. I think we did it because we thought there was a need. We had the ability to do it from a financial sense. There were so many organizations or people out there that needed help from our resources, and we were willing to share those resources. We did not fully understand the strategic implications of it when we started doing it.

02-01:26:52
Rigelhaupt:
Have there been discussions in kind of the accountable care organizations and the expansion of clinically integrated medicine, that Mary Washington Healthcare is going to build on the foundation that was built through the Community Benefit Fund?

02-01:27:10
Ryan:
Absolutely. We understand that the outreach, so to speak, is very, very important in our clinical and integrated products. As we move forward in developing organizations that are going to be able to deliver that care and develop an integrated provider organization, they will then carry that torch. Maybe with a little bit of different programs, but very much the torch of community outreach, patient outreach, and organization outreach. If our integrated provider network has responsibility for a population of patients, say, at the Stafford County Schools, we are not going to wait for those people to get advanced diabetes and have all the complications of diabetes and take care of them in a hospital. We’re going to be in the workplace. We’ll be in their homes. We’ll be teaching them about diabetes, teaching them how to care for themselves, how to remain well, and teaching about exercise, diet, and prevention. These are things that our Community Service Fund and our foundation have been doing for some years through other organizations. We will be doing that ourselves in the future; we will be expanding upon the principles, even if not necessarily through the same organizations.

02-01:28:22
Rigelhaupt:
Were there discussions as this was developing and expanding through the 1990s, through the mid-1990s and up until today, in terms of public health? That there was an understanding that Mary Washington Healthcare as a system was going to be committed to public health?

02-01:28:43
Ryan:
Actually, with the beginning of the Community Services Fund and the foundation, that is community health and it is the public health. In addition to that, we’ve always had a very close relationship with the Virginia Department of Health, which is our public health system here in Fredericksburg. We have even had times when our resources have helped fund a nurse practitioner for them, so that they could see more people in their OB clinics. We have gone that far with helping the state because the state didn’t have the funds to do it. So, for at least our population here, we want to do it. It’s in the best interest of our patients and, frankly, it helped our patients once they got to the hospital to have that pre-natal care. We helped the public health back in the 1990s when managed care was coming in; that was the fits and starts of where we’re going now with accountability for a population of patients. We developed some of these systems, recognizing that for managed care, we’re going to need to have such systems anyway. Now, managed care did not pan out very well here. The HMO movement, at least, died out, outside of Washington, D.C. We still had a very small population of people that were in HMOs compared to our general population. [01:30:00] Washington, D.C. still had a fairly large percentage of HMO patients. But outside of Washington, in the East, and outside some of the major cities, you didn’t see much of it. It didn’t pan out then, but all of those same systems of keeping people well—we may have new systems in doing it. But it is the same premise of keep people well, don’t wait until they need the tertiary care center to care for them. That’s going to be the focus of medicine as we move forward in the twenty-first century.

02-01:30:33
Rigelhaupt:
This commitment to public health, to being forward-looking with patient care, is a large part of the Community Benefit Fund. Can you think of instances in which you remember influencing physician practices and physical campuses in the community, perhaps with physicians who are not directly involved with the Moss Clinic but that the ideas behind it, the premises, as you described, influenced the medical community in the region?

02-01:31:10
Ryan:
Xavier [Richardson] would probably be able to give you better instances. I can speak more generally, where our physicians, indirectly at least, and their patients benefit from some of the services of some of these organizations. There are other physicians through our foundation, such as our safety-net providers. There is one of our clinics run by a physician who sees a large percentage of his patients that cannot pay. He is dedicated to doing that, and frankly, is a big help to us in discharged patients from our hospital being able to get in some place for their follow-up care if they have no insurance. We have actually tried to help provide or partially-fund a nurse practitioner for that safety-net provider. In that regard, it is directly responsible. This is a physician who does not come to Mary Washington Hospital anymore and doesn’t come to Stafford Hospital anymore, but is a very important part of the medical community; we help fund some help for that safety-net provider.

02-01:32:11
Rigelhaupt:
Could you say the physician’s name?

02-01:32:12
Ryan:
Dr. Tim Powell.

02-01:32:24
Rigelhaupt:
Were there ideas that you became aware of through the Community Benefit Fund and this commitment to public health and community health that, because you still worked at Pratt Medical Center, that you brought back to meetings, or ideas that you learned that you brought to that medical practice?

02-01:32:42
Ryan:
I left Pratt Medical Center in 1998 when I became the full-time vice president of medical affairs at Mary Washington Healthcare. Pratt Medical Center, at that time, was bought out by a private venture group out of Nashville. [01:33:00] It just didn’t seem appropriate for the community’s chief physician leader to be employed by a venture capital firm from Nashville. I left there and saw my patients with the Rappahannock Family Physicians group, currently led by Dr. Tom Janus. At that time, it was led by Dr. Janus, too. For the rest of my clinical years, I saw of my patients in the Snowden Pond office of Rappahannock Family Physicians. My nurse practitioner, Piper Schlesser, also came over to Rappahannock Family Physicians and helped me see patients over there. Those physicians were kind enough to see my practice when I was not in the office and in the hospital. So, your original question was asking me about if I saw that in my clinical life. By then, my clinical life had narrowed so much that I was seeing primarily patients I had seen for many, many years, and I was not taking on new patients. From a practical standpoint, in my particular practice, I did not see that. Where I saw most of the benefit of our foundation was in my work at the Moss Free Clinic. I did work as a provider at the Moss Free Clinic and would do my times there. Of course, the Moss Free Clinic couldn’t have existed without the help each year from the health system, and it couldn’t have existed without the help each year of the individual physicians, nurses, PAs, and nurse practitioners that dedicated their time after they’d already done a full day’s work. That’s where I saw most of the benefit. There were so many people that we saw there who were often working at jobs, but did not have insurance and had no other access to health care. As a private practitioner and physician, that’s where I saw it, mostly. Most of the time, by that time, I was on the side of the health system, and I was watching us put aside monies each year to be distributed to those places that would apply, write up grants, and seek money from the foundation.

02-01:35:16
Rigelhaupt:
This is another long question. So, what’s become clear to me in the interviews is that Mary Washington Healthcare is community-centered, and that has been sustained for 114 years, now. I appreciated the way you opened the other interview, that you weren’t here, then. It’s evident in the way people have talked about the organization’s culture, day-to-day practices, and yet, since the 1970s and increasingly since the 1990s, Mary Washington Healthcare and not-for-profit hospitals in general interact with incredibly powerful external forces, [01:36:00] financial and bond markets, Centers for Medicare & Medicaid studies, insurance companies, and the cost of new technology, and the associated high cost of technology, market forces, and competition. How has Mary Washington Healthcare maintained its focus on the community and stay attuned to community needs when simultaneously having to negotiate with powerful actors and organizations outside the community?

02-01:36:35
Ryan:
It’s an excellent question. We work each year, each month, and bring it up in most of our common rooms and board rooms. For instance, you will see often our mission put up: we care for the health of the people in the communities that we serve. We have to keep continuing to follow that mission because it is a challenge. We do things at Mary Washington Healthcare that we wouldn’t do if we only had a profit motive because they cost us money. We care for people who cannot pay for that care. We provide services that are not financially profitable, but we do them because the community needs them. If we had shareholders that we had to provide dividends for, we couldn’t afford to do these sorts of things. At times, it puts us at a disadvantage because there are for-profit competitors that, frankly, don’t do those sorts of things if people can’t pay, for the most part. They don’t tithe a portion of their profits to a Community Services Fund to help start up organizations. They say, “Well, as for-profit organizations, we pay taxes.” If you were to add all things up, I think if the not-for-profit world comes out ahead. The people in this community would be in dire straits if Mary Washington Healthcare were not here to provide them those services that, frankly, don’t make money. It is a challenge. Continually, it’s a challenge that all not-for-profit systems across this country feel today. We are providing the same care that for-profit systems provide, that can do whatever they choose to do. We have to buy new MRIs, we have to buy new CT scanners, we have to provide new beds and new emergency departments to grow, and we have to do that out of the excess revenues over the expenses we have. There are no profits that go to shareholders at Mary Washington Healthcare. It all goes back into the system. It’s a very great challenge every year for us to be able to provide these services because the community needs these services. Have we had to become more business-like in our thinking in the last twenty or thirty years? [01:39:00] The answer to that is yes. We have had to make sure that we are evidence-based, to use the term that you’ve used already. We have had to make sure that what we are doing is necessary, and number two, it is necessary for us to provide it. For instance, we, for a short stint, did bariatric surgery, weight loss surgery. We saw that, number one, it was absolutely not financially viable for us. It cost us money every time we did it. Number two, there were bariatric centers close to us that were doing large numbers of these so they could make it financially viable. We had very poor contracts from insurance companies on this because we couldn’t do enough cases just in our small community. We made the conscious decision to get out of the bariatric surgery business and say, “We will refer those patients to centers where that surgery is done, it is done well, it’s easy for our patients to get to, and most of the time you don’t have emergency bariatric surgery.” It’s elective surgery, and so it’s very easy for us to get those people there. But for cardiac surgery, that was a service that we felt like we needed to provide so that patients did not have to leave for that very common and very important service in our community. Now, fortunately, although the practice side of cardiac surgery and all that we do outside of the hospital may not be financially viable, the surgery itself is. Therefore, it’s a service that we have said, it’s important to our community and we are going to do this. There are so many things that actually cost us money to provide that care in our community and we do it anyway because we feel it’s the right thing to do. We’re a not-for-profit hospital; it’s part of our mission and we continually revisit it. What is our mission? Why do we exist? We exist to provide the health care to the people in the communities that we serve. We’re going to continue to do that.
[End of Interview]

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