Dr. Rebecca Bigoney

Dr. Rebecca Bigoney is Executive Vice President and Chief Medical Officer of Mary Washington Healthcare. Dr. Bigoney is Board Certified from the American Board of Internal Medicine in both Internal Medicine and Hospice and Palliative Care. She received her M.D. and completed her residency at the Medical College of Virginia (MCV), which is now part of Virginia Commonwealth University. Dr. Bigoney began practicing as an internal medicine physician in Fredericksburg in 1983. She was a physician with Pratt Medical Group and Fredericksburg Internal Medicine until she began full time work with MediCorp Health System in 2001. In 1998, she earned a Master’s in Clinical Ethics from the University of Virginia and was instrumental in developing a clinical ethics program at Mary Washington Hospital. Dr. Bigoney became Chief of Medicine at Mary Washington Hospital in 2010, Vice President for Medical Affairs at Mary Washington Hospital in 2012, and Chief Medical Officer in 2013.

Dr. Rebecca Bigoney was interviewed by Jess Rigelhaupt on September 20, 2013, November 8, 2013, and January 29, 2014.

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 – September 20, 2013
00:00-15:00
First experiences at Mary Washington Hospital—Completing residency at MCV (now VCU)—Beginning internal medicine at Pratt Clinic—Mary Washington Hospital (MWH) patients had been transferred to VCU—Choosing a specialty in internal medicine—Relationship between MWH and physicians—Work environment with physicians and nurses—Experiences being the first woman physician to practice actively at MWH—Memories of MWH administration and transition to MWH MediCorp—Working with hospital administration—Importance of medical staff meetings—Smaller organization—Being a part of the hospital really felt like you were part of the community in the early days of practice—Knew the name of everyone on the medical staff and felt like a family among the medical staff—Idea for the Moss Clinic was born from the Medical Society and leaders in the community—Hospital administration supported and funded the Moss Free Clinic from the beginning—Agreement between physicians, hospital administration on the importance of good medical care

15:00-30:00
Looking back, some of the medical care was inefficient—Debates about changes in the practice of medicine—Debates about economic credentialing—Questions of efficiency are a part of contemporary medical practice—Disagreements between the medical staff and the administration—Start of the medical affairs committee, which is made up of board members, physicians, and top administrators—Serving as a physician board member in the late-1990s, early 2000s—Learning about the role of the trustee and serving the health care system—Transformation from MWH to MediCorp was about finances—An important vision—Not all people were in favor of the transformation and there was apprehension—Would the hospital be competing with physicians?—Not a concern about becoming a for-profit hospital, but questions about for-profit subsidiaries aligning with MWH’s mission—Leaving Pratt Medical Group and joining Fredericksburg Internal Medicine—Working with Dr. Wayland Marks at Fredericksburg Internal Medicine—On-call coverage policies at Pratt Medical Group—Internal medicine covered for nephrology, cardiology, pulmonology, gastroenterology—Complex medical cases in the hospital—Rapidly built a large, full practice at Fredericksburg Internal Medicine—Long hours at the hospital and seeing patients in the office—There were no hospitalists at that time—Beginning of hospice practice and some controversy—Development of new clinical practices at the hospital became more strategic, such as geriatrics, cardiac surgery, and neurosurgery—History of hospice practices in the region—Hospice support services versus medical hospice—Deliberate effort to recruit an infectious disease physician—Hospital and private practice recruitment of physicians—Recruitment is now more structured and organized

30:00-45:00
Infectious disease and the early days of the AIDS epidemic—Dr. Bernstein did not begin with the expectation of making money for the hospital; it was a meeting a community need—Atmosphere of fear during the early days of the HIV/AIDS epidemic—Responses to AIDS from the medical community—Education about AIDS in the medical community—Learning from medical literature and patients——“A typical day” and descriptions of her practice—Cases that caused patients to have to travel to Richmond of Northern Virginia—Neonatal intensive care and high risk patients had to go to medical centers—ICU patients in the early days of practice at MWH—Changing medical practices—MediCorp opening facilities in underserved communities

45:00-01:00:00
Hospital worked to recruit physicians and made some investments to set-up practices in underserved communities—These practices did not create controversy—MediCorp has expanded and contracted its vision—Expansion of primary care practices emerged around the time of the Moss Free Clinic and the Community Service Fund—Expansion was community driven and was mission and vision—Now it is a responsibility: the hospital has responsibilities after patients leave—Early discussions of the new hospital—There was a fair amount of opposition to the new hospital—Consultants thought hospitals would be smaller and there would be more emphasis on outpatient treatment—The vision of the board was for the new hospital to become a regional medical center—Skepticism from the medical staff—As the opening of new hospital approached the medical staff was generally more onboard and excited—New ICU rooms, new technology, and private rooms for patients—Making rounds the day that the new hospital opened—Made rounds at 2300 Fall Hill then at the new hospital after patients were transported—The move was well-planned—Spacious, better-designed emergency department at the new hospital

01:00:00-01:08:09
The new hospital was better for physicians and patients—The new hospital space was designed for patient care—Interventional cardiology takes off after the move to the new hospital—Starting cardiac surgery and surgical subspecialties—Expansion of ORs supported growth in surgical subspecialties—Medical specialties expanded and the hospital recruited and hired—Physicians were excited to have cardiac surgery and interventional cardiology—STEMI program—Higher level of nursing and anesthesia care goes along with cardiac surgery

Interview 2 – November 8, 2013
00:00-15:00
Physician-hospital relationship—Questions of “economic credentialing”—Physicians treating patients in the hospital and a part of daily practice—Cohesiveness among the medical staff—Physician-nurse relationships and transition to nurse as team member—Founding of ethics committee—Training through the University of Virginia and headed by John Fletcher—Some concerns about starting an ethics committee—Transitioning from an ethics committee to an ethics program—Ethics program contributions to the organization—Ethics case early in the program’s history—Ethical challenge and patient autonomy in early case—Patient, family, and medical team decisions in medical treatment—Patient-centered focus

15:00-30:00
Evolution of ethics committee practices—Patient-centered decisions—Goal is to come ethically acceptable consensus or list of options—Different ways to approach ethics consults, but always includes patient’s wishes and values—Ethics training, models, and practices—The development of ethics policy guidelines—Most common ethics cases involve end-of-life care—Development of the ethics program over the last the twenty years—Ethics committee includes physicians, nurses, chaplains, mental health, LCSWs, and community members—Dr. Bigoney and Diane Brothers, RN both received master’s degrees in clinical ethics in the late-1990s—Sought out community involvement in ethics program—Clinical ethics committee was initially called bioethics committee—Formed organization ethics committee around 2000—Organizational leadership has emphasized mission and values in day-to-day decision making

30:00-45:00
Fred Rankin has had a special interest in mission and values—Late-1990s board retreat focused on organization ethics—Discussing case studies and scenarios—Organization ethics committee has continued since the late-1990s—Organization ethics committee is a “safe space” and an action-oriented group—Board is committed to organization ethics—Developing policies on discrimination by patients, disturbing scarce resources in a disaster or pandemic—Guidelines for a patient that does not want to be seen by a particular physician or nurse and/or an abusive patient—Early experiences as physician board member—Serving two masters as a physician board member: serving the organization and raising physician concerns—The board is strong, vocal, and serves the community—Some tension between the needs of the community and the needs of the organization, and that is the way it should be—Serving on the board during the managed care era

45:00-01:00:00
First integrated activity between physicians and the hospital was Pinnacle Health—Did not expand as planned; it became a joint contracting tool—Rules for negotiating with insurance companies and anti-trust concerns—Decision to pursue master’s degree in clinical ethics—MWHC paid for Dr. Bigoney and Diane Brothers to purse master’s degree in clinical ethics; MWHC valued clinical ethics—Developing a system ethics program rather than hospital ethics program—Implementing HIPAA—Viewing HIPAA, privacy, and ethics as interrelated—MWHC made HIPAA resources to local physicians at no cost; it was a health care community issue—Internal training on HIPAA and privacy—Safety initiative led by CMS and the Joint Commission—Change in visitor policies—Beginning service as Medical Director in 2001—Ethics, case management, and patient’s rights—Ethics and complex discharge planning

01:00:00-01:15:00
Medicaid and discharge planning—Case management, discharge planning, and access to home-based or nursing home care—An interdisciplinary team of community members, chaplaincy, ethics, the medical care team, someone from a VP level, finance, and legal, to act on complex case management issues and discharge—Ethics, case management, and demands for inappropriate medical treatment—Clinical documentation improvement program—Quality program and patient safety—STEMI—Stroke program—Stereotactic radiosurgery for cancer—Clinical documentation and revenue—Improving obstetrics program—Physicians have traditionally focused on patient care and have not been concerned with finances—Physicians should consider cost and access to health care—Transition from Chief of Medicine to Vice President of Medical Affairs and now to Chief Medical Officer

01:15:00-01:30:00
Work as and role of Vice President of Medical Affairs—Work as and role of Chief Medical Officer—Balancing financial resources and new subspecialties and clinical programs—Goal is to improve care and be more cost effective—Improvement in practicing evidence-based medicine—Computerized physician order entry—Board’s role in clinical practices and new programs—Dramatic change in number of women physicians—Milestones since 2001: palliative care; intensivist model in ICUs; trauma, hospitalists in adult medicine, pediatrics, neonatal ICU, and obstetrics; STEMI and cardiologists available 24/7; Centers of Excellence; women’s care beyond OB/GYN

01:30:00-01:34:41
Transition to regional medical center—MWHC’s work in primary care and public health—Trying to align with primary care physician and integration—Increasing trust between MWHC and physicians—Mary Washington Healthcare Alliance—Population health

Interview 3 – January 29, 2014
01:00-15:00
History of Stafford Hospital—Concerns about becoming a two hospital system—Working with physicians on Stafford Hospital planning and clinical practice—HCA Spotsylvania Regional Medical Center, a competing hospital in the region—Culture at Stafford Hospital—Stafford Hospital has a good relationship with physicians—Importance of the Emergency Department, ICU, and OB at Stafford Hospital—Planning the ICU rooms at Stafford Hospital—Fred Rankin’s working relationship with physicians, emphasis on communication, transparency, and values

15:00-30:00
Fred Rankin’s promotion from President of Mary Washington Hospital to CEO of MediCorp in 1995—A patient’s story and patient care at board meetings—Ethics program, values, and obligation to do what is right for the patient—Balancing high tech medicine, evidence-based medicine, and patient-centered medicine—Complex patients—Communicating with the physician community—History of nursing at MWHC—Nurses are now a vital member of medical care team—History of aligning nursing as part of the medical care team

30:00-45:00
Emphasizing physician-nursing relationships as Chief of Medicine—Nursing at Stafford Hospital—Discussions of new programs between physicians and administration—Balancing physician desires for new programs or services and the financial viability of the program or service—History of the Community Benefit Fund and community benefit practices at MWHC

45:00-58:06
History of the Community Benefit Fund and community benefit practices at MWHC—Vision and commitment from the board—Support from physicians—History of the Moss Free Clinic—Challenge of integrating care with patients at the Moss Free Clinic—Mary Washington Health Alliance, an Integrated Provider Network (IPN)—Rankings and awards—Leading programs at MWHC

Transcript

Interview 1 – September 20, 2013

01-00:00:06
Rigelhaupt:
It is September 20, 2013. I’m in Fredericksburg, Virginia doing an oral history interview with Dr. Rebecca Bigoney. If I could begin by asking you to describe your first interaction with Mary Washington Hospital.

01-00:00:24
Bigoney:
I was finishing up my medical residency at what at that time was MCV, now VCU, in Richmond. My husband was actually a Fredericksburg native. He was born in Fredericksburg. His father was a podiatrist here in practice. While we were living in Richmond, he had started an engineering business here. We had made a decision to settle in Fredericksburg, and I needed to look for an internal medicine private practice. A number of people had told me that Pratt Clinic was known for having excellent physicians, and so I came to interview with Pratt Clinic and some of their physicians. At that time, I was told that those doctors practiced at Mary Washington Hospital. As part of the getting-to-know-them interview process, one of their physicians took me on a tour of Mary Washington. In fact, that physician was Dr. Lloyd Moss, for whom the Moss Clinic is named. He was my mentor when I came to town.

01-00:01:26
Rigelhaupt:
So the tour you had of the hospital on your job interview. It sounds like that was your first experience at the hospital?

01-00:01:36
Bigoney:
It was.

01-00:01:37
Rigelhaupt:
And what was your impression?

01-00:01:40
Bigoney:
I thought it was a hospital. I was used to working at MCV, which had predominantly older hospitals, although we had just built a bright, shiny, new hospital. Mary Washington looked more like the older hospitals to me that I was familiar with, but it felt warm and friendly and welcoming.

01-00:02:06
Rigelhaupt:
Had you heard much about Mary Washington Hospital before you began practicing and before this interview? Or was your first impression really the visit?

01-00:02:18
Bigoney:
I had heard a little bit, because of course my in-laws lived in Fredericksburg and we were up here to visit a lot. We also received a reasonable number of transfers from the Mary Washington Hospital and the Fredericksburg area down to MCV. In fact in my last year as a resident when I was in the intensive care unit, I particularly remember receiving a patient with very severe Staphylococcal pneumonia that Dr. Fuller was taking care of. She was referred down for high-frequency ventilation, which was something that Mary Washington was not able to do, and at that time was felt to be a useful technology. It has not been found to be so useful. [03:00] In an attempt to save this woman’s life, the team from Mary Washington came down with her. Our attitude as an academic medical center was always, “We’re going to get somebody from the backwoods who comes in who has been poorly-managed. We’re really going to have to take over this.” Going through the case with a fine-tooth comb, we actually found superb management. I didn’t find anything I could have done better, and I felt a little embarrassed at my attitude about the physician. It was kind of ironic that when I came back to interview at Pratt, Dr. Fuller was a Pratt Clinic physician, and of course became one of my partners.

01-00:03:43
Rigelhaupt:
Could you talk a little bit about how you chose your specialty in internal medicine?

01-00:03:48
Bigoney:
I always saw myself doing primary care. Originally, I had thought probably family practice or pediatrics. I am basically a very cognitive person, which is to say I’m terrible with my hands and nobody would ever want me doing surgery on them. At one point, I had thought about becoming an ophthalmologist because I find medical eye disease very interesting. But it’s such a surgical specialty, I really didn’t feel like it would be a good fit. I assumed I would do probably family practice, or maybe pediatrics. When I did my inpatient pediatric rotation as a medical student, I realized it was going to be very difficult for me to work with sick children. I love well children. Sick children are challenging. When I did internal medicine, it just felt like I had come home. I really found people reading the medical literature, looking at evidence, taking care of people who were really sick, thoughtfully coming up with a differential diagnosis, thoughtfully working out what were the best medications to use, and what was the evidence for this treatment or that treatment. That just felt like a fit for me. I had gotten married right out of college, and my husband was very long-suffering and patient to put me through medical school. Had I not been married, I might well have done a fellowship in a cognitive internal medicine specialty, probably infectious disease, but at that point was ready to go into private practice and move on with my life.

01-00:05:30
Rigelhaupt:
The time you began practicing here, how would you describe the relationship between Mary Washington Hospital and the physicians in the community?

01-00:05:44
Bigoney:
It was very good. It was an old-style relationship. I remember at one point having one of the older physicians complain to me that he remembered when he came on the floors all the nurses would stand up, and if there weren’t any chairs, a nurse would get up and give him her chair, and that he was really sad that now you just walk on the floor and it’s just like you’re any other person. [06:00] That was an old way that was dying, but there was still a fair amount of that. There was still a lot of vision of the nurse as the handmaid to the physician. The doctor tells the nurse what to do, and the nurse does it. As opposed to the current model, in which the nurse is a professional, a patient advocate, a member of a team, and not someone who just does as she is told without questioning. As the first woman, actually, to be practicing actively in the hospital, I was very anxious about how I would be received. I’m not sure what I expected, but I was certainly anticipating there could be some negativity from both the medical staff and the nursing staff. To my amazement I found absolutely none of that. The physicians went out of their way to welcome me, greet me, send consults to me, really give me a chance to practice, and the nurses were so supportive and solicitous. Now, admittedly, I discovered I was pregnant right after I came to town. When I was working long hours and nights pregnant, they would make a point of bringing me a glass of water or seeing if I needed anything and trying to make it easy for me. It was apparent to me that they were really on my side. They were excited to have me there. I came in with apprehension, and really walked into a system that was so warm and welcoming. I never had a single experience with any medical staff or hospital staff that made me feel that I shouldn’t be doing this job as a woman. There was an occasional patient back then who would indicate they were not comfortable with a woman doctor. There were a lot of patients who would say, “Thank goodness. I’ve always wished I could have a woman doctor.” With the staff, it was a warm, welcoming community to come into.

01-00:08:09
Rigelhaupt:
Did you have much interaction with hospital administration in the early years you were practicing medicine here?

01-00:08:18
Bigoney:
I did have some. Before I came to town, one of the interviews that I did was with the administration. At that time, it was just on the cusp of going from Mary Washington Hospital to MediCorp Health System. They were just working up the materials and the logo and so forth. I had a meeting with Bill Jacobs, who shared this vision with me. We had some conversation. I think at that point, he was thinking, potentially, MediCorp might start hiring physicians at some point in the future. There was a little bit of that in the conversation, although that wasn’t a direction either they or I were ready to go. I also remember meeting the vice president for nursing and some of the other administrative leadership. [09:00] Once I started work, at that time, our department meetings and our medical staff meetings were meetings you never missed because there was often a lot of excitement and controversy, but also a lot of valuable work and conversation. Leadership was always at those meetings. In fact, it was a small enough place, everybody ate in the cafeteria, and when you went to the cafeteria, you sat down with whoever might be there that you need. It would not be unusual for me to go to the cafeteria and sit down with the chief executive officer of the hospital or one of the members of the executive leadership and have a conversation. It did feel like you knew them; you knew who they were and you were not hesitant about approaching them.

01-00:09:50
Rigelhaupt:
A small community and a lot of interaction. Do you remember any discussions—in these early years—any discussions with hospital administration about new practices they could bring to the hospital or any coordination on patient care?

01-00:10:14
Bigoney:
I don’t think so. Nothing comes to mind. There were certainly new services being developed, but I don’t remember any of those particular conversations.

01-00:10:34
Rigelhaupt:
Mary Washington Hospital has a long place in the community. What do you remember about your sense of community involvement as you began practicing medicine in the area and working at Mary Washington Hospital?

01-00:10:52
Bigoney:
It really felt like being part of the community. At that time, I knew every physician on the medical staff. I think a good many of the people in town knew the names of most of the doctors in town. If you met someone in a social situation, they had usually heard your name or heard of you. There was quite a bit of interaction. For example, going out to give talks to groups in the community, it felt very much like a small town. There were lots of people whose names you had heard, or you knew their family member. Of course, it was compounded with me by the fact that my husband grew up in Fredericksburg. I also had the additional experience of seeing patients who turned out to be old teachers of his, or classmates of his brother or sister. There was also that connection. It really did feel like the hospital, the physicians, and the medical staff were just all part of a family and community. [12:00] It didn’t feel, at that time, like an area that was largely populated by northern Virginia, D.C. commuters in the way that it sometimes does now.

01-00:12:11
Rigelhaupt:
Was there community involvement in the sense of asking for new practices, trying to provide medical care that was new? Did any of those ideas come from the community?

01-00:12:28
Bigoney:
I think certainly the idea of the Moss Clinic was born from a combination of sources. One was our medical society, which was our medical staff and other physicians, retired physicians, other community physicians, who brought the idea to the hospital. But there also were leaders in the community, people involved in various aspects of social services, advocacy, and the mental health community, who were giving voice to this need for care for those who didn’t have a payment source and didn’t necessarily have access to care. I would see that as if you had to say what was the one place the seed was planted, I would probably say the medical society. But then as the project was put together it really was a community initiative. The local government leaderships were involved.

01-00:13:30
Rigelhaupt:
Did you have a sense that there was a lot of support from hospital administration, along with physicians in the medical society?

01-00:13:38
Bigoney:
Absolutely. The major funding from then to now, for the ability of the Moss Clinic to exist and to be the largest free clinic in the state of Virginia, and by far the most beautiful and best-supported free clinic in the state of Virginia, has come through the support from Mary Washington Healthcare.

01-00:14:13
Rigelhaupt:
You said at some of the department meetings and the medical meetings, that they were worth attending. I won’t ask a leading question here. What were some of the places that, in those early years, you found that there was a lot of agreement in terms of the direction between physicians and the community and hospital administration, and some of the places that there might have been disagreements?

01-00:14:45
Bigoney:
There has always been agreement in the importance of good medical care. Even back then, when I think physicians perhaps had less voice in hospital decision-making, there was never a time that anybody in the hospital applied pressure to do anything that was not good medical care. [15:00] When I look back on it, some of the care we provided then was so inefficient. When I was first in practice, I remember having one woman in the hospital for over a year. She was perfectly stable. She was very elderly. She had dementia. Her medical condition was stable. She was part-owner of about four pieces of property with multiple other family members. We had to figure out who owned them. Somebody had to sell them all and liquidate the money to get her eligible for Medicaid before we could get her in a nursing home, and it took that long. Of course, now we would have case managers and social services people who would come up with a different answer. There was never any sense of wasted resources or money. It was just, you practiced the way you wanted to, and nobody ever pressured you otherwise. I think there was some disagreement, or maybe some mistrust, even back then, in the direction medicine was going. It used to be very common for the hospital leadership to say something, and physicians would say, “It sounds like you’re trying to go directly into competition with us.” Or, one of my favorites was, “It sounds like we’re moving toward economic credentialing, where you’re only going to let us be on your medical staff if we bring you a certain amount of money or we bring you certain services.” Of course, ironically, administration would always say, “Oh, no, no, no. You’re misunderstanding. That’s not what we’re doing.” These days, of course, those are very open conversations. With resources such as they are, if you’re going to work in our facility and take care of our patients, we need to partner with you to be efficient because there are not unlimited resources. If that sounds like economic credentialing, then so be it. But back then, that would be a terrible, unethical thing for anyone to question how much money a physician spent for a patient. I think, at that time, there was a different sense of what the role and voice of the medical staff and leadership should be. I remember a conversation with one of our leaders at one point. It was one of those lunch-table conversations in which there was something very controversial going on. I made a comment about the medical staff not being very happy, and this leader’s response was, “Well, the medical staff are sort of like a fly buzzing around you. They get your attention initially, but you’ll smack them out of the way,” or something to that effect. Within a few years, we had a real sea change such that we started the Medical Affairs Committee, which is a combination committee that includes physicians, board members, physician leaders from the medical staff, and top administration to talk about clinical or medical care-related issues. [18:00] Everybody there has a voice. I was a physician board member on the hospital board in the late-1990s to 2000 or so. At that time, I felt like my job was to represent the medical staff. Some of that was my lack of understanding, I think, of the obligations of a trustee. But now, I think it’s very clear: if you’re a physician on the board, yes, you’re obligated to the medical staff and to the medical profession. You’re obviously obligated to patient care, but you’re also obligated to the health care organization, to work with us, to make us better, to make us stronger, and you’re not an adversary who is on our board. I do think those relationships have changed pretty significantly through the years.

01-00:18:56
Rigelhaupt:
So right about the time you started, as you alluded to in your conversation with Mr. Jacobs, the Mary Washington Hospital was transforming into MediCorp. What do you remember about that transition? Why it happened and—well, I’ll stop there and ask follow-ups.

01-00:19:13
Bigoney:
Of course, at the time, I was just out of residency and didn’t understand it. But I think it was very clear to everyone that it was about finance. It was about having the opportunity to branch out into other health care related businesses, some of which would be for-profit. Actually, it’s kind of interesting. At the time, I was sort of puzzled and wondered why a hospital would want to expend some of its energy and resources going that direction. Now it looks like, “Wow, what vision.” To realize that medical care alone was going to be more and more difficult and have a more and more difficult time being self-supporting. Looking at ancillary ways to work in the health care system to provide needed quality services, and use that income to supplement your mission. That is part of what a health care system has to do.

01-00:20:19
Rigelhaupt:
From my understanding, Pratt was a large medical practice in the area at the time. Do you recall any sense from your own medical practice, and being part of Pratt, that there was any apprehension about the transformation at Mary Washington Hospital into MediCorp in a broader health care delivery system?

01-00:20:45
Bigoney:
There were people who were not in favor of the transformation. Not all of them trusted hospital leadership and felt that this might be part of moving toward hiring physicians or competing directly with them. [21:00] In part, it was because there were a lot of physicians who really felt the role of medicine is to take care of patients, and that it is outside the goals of medicine to become a for-profit business.

01-00:21:20
Rigelhaupt:
So there was some perception that this transformation into MediCorp, and aspects of it being for-profit, could potentially change not the culture, but maybe the mission? I’m not sure of the right word—but Mary Washington Hospital’s nonprofit origins.

01-00:21:41
Bigoney:
Right. I don’t think it was so much a concern that we would become a for-profit hospital as it was concern about, “Is this consistent with what the mission of the health care system should be? Is it consistent with what the practice of medicine should be?”

01-00:22:05
Rigelhaupt:
About this time, a couple of years after joining Pratt, did you start Fredericksburg Internal Medicine?

01-00:22:16
Bigoney:
No.

01-00:22:17
Rigelhaupt:
You joined that practice?

01-00:22:18
Bigoney:
Actually, it was a solo practice at that time. I can’t remember—he probably already did have that name. Wayland Marks had come to town. I’d been in town two years. I stayed at Pratt two years. Wayland had been in town two or three years before that, as a solo internist. At that time, when you came on the medical staff, you were assigned a physician to proctor and review your progress notes and your H and Ps (patient history and physical), and so forth. He had been my physician who oversaw my peer review for the first year and made sure the quality of my work was acceptable, and so forth. He had heard that I was not happy at Pratt. I wasn’t practice-building as well as I should be. Their primary care base was really largely family practice, and I was a little bit of a fish out of water there. Dr. Moss and I were the only internists. Dr. Marks approached me to see if I would like to join him. The two of us worked together in Fredericksburg Internal Medicine, and then added additional physicians. We had physicians who came and went, and then one additional long-term partner.

01-00:23:26
Rigelhaupt:
What were some of the upsides of practicing with just one other physician? A smaller practice in terms of structure, but it sounds like also building a practice.

01-00:23:37
Bigoney:
At the Pratt Clinic, because the primary care structure was so heavily family practice-oriented, I didn’t get very many new patients. The staff was accustomed to new patients who need a doctor need a family practice doctor. That was a challenge for me. When I was at Pratt, also, our coverage arrangements were very interesting. [24:00] That is, when you were on call for internal medicine you were on call for internal medicine. It meant I covered not only my patients and Dr. Moss’s, but also then the nephrologist, the cardiologist, the pulmonologist, and the gastroenterologist. I can’t remember if we had any other medical subspecialties. The good news was I didn’t have call very often. The bad news was that when I was on call, I was taking care of respiratory failure, renal failure, GI bleeding, septic shock, and whatever came, which was obviously very challenging. When I was just with one other person, we practiced internal medicine and we could consult the other subspecialties as needed. It was a much more comfortable scope. Wayland Marks was so busy. From the moment I came in, I had a full day and a full panel of patients because he had people waiting to get in with him. I rapidly built a large, full practice.

01-00:25:04
Rigelhaupt:
When you were on call with Pratt, were you here [at Mary Washington Hospital] a lot?

01-00:25:10
Bigoney:
Yes. Of course, in those days, we didn’t have hospitalists. When you were on call, you were on call for twenty-four hours. You might not go home and you might not sleep. Then, of course, the next day, if you had the day off, you would do your hospital rounds, which might take you four hours, and then you would have the rest of the day off. If you didn’t, you’d then go work another twelve-hour day in the office. It was not unusual to work thirty-six hours, nonstop, at that time.

01-00:25:47
Rigelhaupt:
In the first couple years that you were with Fredericksburg Internal Medicine, do you recall any conversations with hospital administration or other medical staff about practices or new services that could be brought to the hospital that would benefit your practice?

01-00:26:11
Bigoney:
I know around that time—I don’t know the exact year, but sometime around that time—the Medicare law was passed that created hospices. Initially, there were for-profit hospices. We had conversations about bringing it to town, and of course ultimately ended up starting our own, not-for-profit hospice internally. That was actually very controversial. There were people who were strongly opposed to bringing hospice to town. As far as other new services we developed, services tended to develop at that time because you had a physician who had a specialty who was interested and came to town. They brought that new service with them, rather than as a strategic plan to bring a new service to town. [27:00] Skipping ahead a few years, there were new services that were more strategically developed, from geriatrics to cardiac surgery to neurosurgery. But at that point in time, for the most part, it felt like something that just happened.

01-00:27:25
Rigelhaupt:
What was the opposition to hospice?

01-00:27:30
Bigoney:
We had, and still have, a wonderful volunteer group in town called Hospice Support Care. It’s made up of volunteers. It doesn’t cost patients anything, but they don’t provide medical care. They provide psychosocial support. They bring people meals. They have volunteers. They take people to doctor’s appointments. That was, and still is, much beloved. It was felt that a group that would come in and charge money to do end-of-life care would marginalize and push that group aside in terms of their fundraising and support, and that we didn’t really need them. We were doing just fine with what we had. Obviously, the medical hospice model is a completely different service, and now the relationship between the two hospice groups is collegial. There’s a lot of back and forth. A lot of patients in Mary Washington Hospice also have Hospice Support Care services, and vice versa. But back then, it was looked upon with suspicion. I will say, now that I think about it, when you talk about bringing services to town, I do remember a deliberate effort was made to bring an infectious disease physician to town, because that was a service we did not have. Dr. Bernstein was deliberately sought out and recruited, and no one has ever been sorry for a day since he came and that happened.

01-00:28:53
Rigelhaupt:
How does that work, when you’re recruiting a physician? Is the hospital involved? Or was he in private practice and then would have a contract with Mary Washington Hospital, or how would that work with infectious disease?

01-00:29:07
Bigoney:
I believe he has been employed by the hospital since the beginning. In those days, the hospital generally did not recruit. The private practice groups recruited. It was unusual for the hospital to recruit. He is currently employed by the hospital. I could be wrong, but I believe he has been employed by the hospital from the beginning. The philosophy has generally been, if there’s a private practice group that wants to bring someone in, we help and support and prefer that. But if there is a specialty that nobody is interested in bringing in or has the resources and ability to bring in, and it is needed in the community, then the hospital will recruit. Of course, back then it was more people would talk about it and come up with an idea. Now, it’s a very organized, structured process that we go through to determine what those needs are. [30:00] I don’t know that we had an actual, formal medical staff development process in those days.

01-00:30:12
Rigelhaupt:
Was this because something like infectious disease might be harder to do in private practice in terms of, I imagine, at this point, a more traditional fee-for-service model? That there might not be as many patients to bring that practice to an area, would require a hospital.

01-00:30:29
Bigoney:
Right. There were a couple of things. One was there are not that many of them, and so it was relatively difficult. Second, none of the internal medicine groups at Pratt, which really was the only multi-specialty group in town, had much interest in bringing them. And third, that was in the early days of AIDS. At that point, management of AIDS was not as complicated as it is now, but it was complicated. Prior to that, a general internist could pretty well know their antibiotics, feel comfortable that you were treating patients appropriately. You might miss a rare, exotic disease that you did not know about or send that patient to a medical center, but basically you could provide good care. Then there was a proliferation of antibiotics, a proliferation of new infections, and the AIDS epidemic made things extraordinarily complicated. Practices were concerned, because, at that time, it was a very expensive, very money-losing kind of practice; many of those patients didn’t have a payment source. Infectious disease doctors were overwhelmed by the needs and burden of that population. While we’ve never had a very large HIV/AIDS population in the Fredericksburg area, we certainly have a significant number of patients, and we really were not comfortable that we were providing the care that was as good as they should get. They were driving to Richmond or Charlottesville. It was not just for the AIDS population, but it certainly was recognized that there were people that we were not serving the way we should serve them.

01-00:32:12
Rigelhaupt:
This sounds like one of the ways that the hospital at the time could provide resources for medical practices that could be hard for private practice.

01-00:32:21
Bigoney:
Right. Dr. Bernstein did not come on with an expectation that he had to make money for the hospital. It was recognized that there would be a large population of patients whose care might be more expensive than the reimbursement. It was a community need and that was something that we needed to do.

01-00:32:46
Rigelhaupt:
What was the initial reaction to AIDS in the medical community in Fredericksburg?

01-00:32:53
Bigoney:
Probably about like it was in the world at large. People were terrified. [33:00] There were rumors that if you sat on the same chair someone had sat on, or if someone spat, or that this was so dreadfully contagious that mosquitoes would be transmitting it. There were doctors who did not want to take care of these patients, although I’m not honestly aware of an instance in which anybody refused. We didn’t have very many of them, so you could talk about it a lot hypothetically. People would say, “I’m going to refuse, because, frankly, I don’t feel like I’m qualified. I’m not adequately trained, and therefore I’m going to decline to take care of those patients.” It was a scary time. When you think about it, it was a death sentence. It was a rapid death sentence. There was poor enough understanding of the degree of transmissibility that people were unduly frightened.

01-00:34:03
Rigelhaupt:
How did the medical community become more educated about the disease, its transmission, that might have been different than the general community in terms of reading the newspaper, watching the evening news? How did that information move through physician networks?

01-00:34:23
Bigoney:
There was a lot of medical information education out there. There were people who did an excellent job conveying information from the evidence-based literature. I think we were helped by the fact that, unlike some hospitals for whom it was just a Hurricane Sandy—they went from doing business as usual, and suddenly they had a quarter of their beds full of these very expensive, young people who were dying horrible deaths. It was a sea change. For us, it was more of a trickle. As a result of it being a trickle, they’re actually individual people. Instead of this hypothetical wave of black death, a contagious disease, and dying—people that want to infect you and are not at all like you—what you are actually seeing is patients one at a time. Good, thoughtful, individual people with sad stories that you are caring about and caring for. I guess it’s kind of like hating a group of people and then starting to get to know them as individuals. I remember one man that I was covering for one of my partners. He was pretty close to the end of his life and had some open, weeping wounds. When I went to round on him on Saturday and I opened the door he said, “Stop. Don’t come one inch closer to me until you’ve got on a gown, gloves, and a mask. I think everything is bandaged, I think everything is covered, but—.” [36:00] When you meet someone like that, then you feel like, how can you really villainize a patient that is that concerned about you and wants to reach out and help other people in that way? Then, of course, at the same time that was happening, treatment was evolving and it was becoming less frightening. It’s still a very tragic disease, but it’s a different disease and we see it differently than we did at that time.

01-00:36:48
Rigelhaupt:
From what you’ve said, covering so many subspecialties when you’re on call, my question about a typical day is probably hard to describe. But if you could describe being at home, you’re on call—being on call, the process of coming in and seeing patients, making rounds, particularly in these early years when you were with Fredericksburg Internal Medicine.

01-00:37:16
Bigoney:
We would come to the hospital to round on our own patients Monday through Friday, and then whoever was on call would round for the weekend. We generally started office hours at ten, depending on how many patients you had in the hospital. You’d try to get to the hospital somewhere between 6:30 and 7:30 or 8:00. I always made a point of trying to get to the office by 9:00, because I always had a stack of phone calls, labs, and prescription refills. I could easily walk in to sixty charts on the desk. I needed to get at least the simple ones signed off so my nurse could start working on them and get those things out in a timely fashion. Sometimes we had morning meetings at the hospital. Then you had to come in even earlier. Then I would go to the office and start seeing my patients for their scheduled appointments. Sometimes if it was my patient, even if I wasn’t on call, and that patient came in through the emergency room, or if one of the patients in the hospital took a turn for the worse, I had to leave the office and come to the hospital. I would do a history and physical on the patient being admitted, or go up to the ICU and stabilize, or do whatever had to be done, while my patients waited in the office waiting room and my nurse explained I’d been called to the hospital. If things got really bad or if I had an ICU patient I had to spend a lot of time with, my nurse would reschedule, although appointments were always booked up weeks in advance. That meant there would be other days that would be very long and hard. If the patients chose to wait, I’d come back, squeeze them in and see them. Then, generally, I made a point, because I had small children, of always trying to get home by 7:30 in the evening, unless I was on call. If I was on call, I would have to go back over to the hospital, round again on anybody who was very sick, pick up any stable admissions that had come in during the afternoon, and then go home and hope I would not get called back in. [39:00] At the same time, I was also receiving phone calls from the hospital, just for any phone orders or any information from nurses. At night when I went home, the calls were not only for my patients, but also my partners’ patients and whatever other physicians we were covering; we’d take the phone calls from the hospital as well as the phone calls from home. The people who didn’t know if they should come to the hospital or the people who had run out of their Valium and insisted their doctor told them all they needed to do was call the doctor on call at any hour of the day or night and he or she would give them a prescription—the people who had any variety of issues to deal with on those phone calls. Sometimes you would get lucky and you could get six hours of sleep with five or six phone calls waking you up. More often than not, you didn’t get that.

01-00:40:08
Rigelhaupt:
What were some of the cases or medical issues in these early years where patients would have to go to northern Virginia or Richmond? It sounds like, from my understanding, in these years, there were cases that Mary Washington Hospital couldn’t cover.

01-00:40:30
Bigoney:
Right. Early on, we didn’t have interventional cardiology. We had wonderful non-invasive cardiologists. Anybody who needed a cardiac cath had to go; if they needed an urgent cardiac cath or urgent cardiac surgery. In fact, I remember one time at the old hospital a young man—I think he was probably late thirties—who came in with a massive heart attack. That was at the time when angioplasty had just been developed. MCV was one of the first places in the country—in fact, I think they did the second angioplasty that was done there. We needed to fly him out by helicopter, but didn’t have a helicopter pad. We had had a huge snow and the rescue squad people, hospital employees, and so forth went over to the old James Monroe field—the yard by James Monroe—with shovels and shoveled out a big enough spot for a helicopter to land so we could bring this man over on a stretcher and fly him. He did well. But I remember that as thinking, one, isn’t it great we have the technology we can get somebody there to do that? But also, what a close call that was. Of course, we didn’t have neurosurgery early on. We didn’t have neonatal intensive care services early on. We didn’t have maternal fetal medicine. Even though we had intensive care, a lot of the sick or higher-risk cases had to go to the medical centers.

01-00:41:56
Rigelhaupt:
So the patients in ICU were either post-surgery or, in general— [42:00]

01-00:42:07
Bigoney:
Certainly early on and when I first started in the practice, people who had heart attacks generally didn’t get cardiac caths or bypasses or stents or angioplasties. They got medical care. People with respiratory failure, people with strokes, people with infections, sepsis—it was probably more medical than surgical people in our ICU at that point in time. We had a lot of GI bleeders. In those days, we did not do emergency endoscopy. If you had a GI bleeder, we had a couple of things that we did. One was we had some drips that we would put them on to try to constrict the blood vessels. For some reason, it was believed, and I spent many hours doing it, that if you ice-water lavage their stomach—pump in ice water, pump out blood and water, pump in ice water—that you might stop bleeding. Subsequently it has been discredited, but you felt like you were doing something. For people who had esophageal bleeding from varices, we actually had something called a Sengstaken-Blakemore tube, which was a tube with two balloons on it. You blew up the balloons and you hooked it to a football helmet, and then cranked it up to tension on the football helmet. Those were the kinds of high-tech interventions we were doing. If they didn’t stop bleeding, a surgeon came in and took them to the OR emergently. Now you call in the endoscopist. They cauterize or band the varices, and cauterize the ulcers. It was a different world of medical practice.

01-00:43:42
Rigelhaupt:
It sounds like, now, much less invasive procedures.

01-00:43:450
Bigoney:
Right. Much more effective, much less invasive, and much more specialized.

01-00:43:54
Rigelhaupt:
So about this time, MediCorp opened primary care practices and urgent care facilities in North Stafford, Bowling Green, Dahlgren, and Ladysmith. What do you remember about those opening, and was this something coordinated with physicians in the area?

01-00:44:13
Bigoney:
Because those were areas nobody wanted to go, and they were, by definition, underserved areas. Because they actually brought in very good, very strong physicians to the community, there really wasn’t much push back or discontent about that. It was pretty well-received.

01-00:44:39
Rigelhaupt:
Not having been part of MediCorp at this point, you may not know, but was this an instance in which physicians were hired by MediCorp to work in these, or was this physicians who were brought in and still in private practice, but a contract was set up to work in these facilities?

01-00:44:56
Bigoney:
I believe they were still private practices. [45:00] They were brought to underserved areas. Of course, there were a number of physicians who got their medical school paid for with an obligation to work in one of those federally-designated underserved areas for each year of educational support they got as payback. Many of those physicians end up staying in those communities long-term. Some serve their time and then move to other communities. Other people may know more about this. I believe what happened was the hospital worked to recruit them, made some investment in setting up their practices, and probably some contractual loans, forgivable loans or subsidies. But they are and were private practices. Fairly early on, I think we had an employed practice in Dawn. There may have been one or two that were actually employed physicians.

01-00:45:58
Rigelhaupt:
Because these were underserved areas, and it sounds like a lot of the physicians practicing in and around Fredericksburg were not as concerned about the areas, this didn’t raise concerns about the hospital increasing competition or—as you said about becoming MediCorp, that it was a change, was there any concern that these became evidence of a change in corporate structure or practice?

01-00:46:31
Bigoney:
You would think there would have been with that atmosphere. It’s possible, but I don’t remember ever hearing that and people were usually pretty vocal. It was a small enough medical staff, you usually knew who thought what. For whatever reason that didn’t create a lot of waves.

01-00:46:52
Rigelhaupt:
In this sense of building facilities, urgent care facilities, in underserved areas—and I’m cautious about asking a leading question and using today’s language. But is this an early instance of MediCorp seeing a need and, as a hospital, thinking about some kind of clinically integrated practice? That they’re providing primary care, urgent care, in underserved areas.

01-00:47:24
Bigoney:
I think, through the years, MediCorp has expanded and contracted its vision several times. I think that was a time in which the vision was about the continuum of care and community needs. That was around the time of starting the Moss Clinic, the Community Services Fund, and the aggressive recruitment to outlying areas. The understanding was there were things that you invested in for the health of the community. In the long run, it would make you a stronger, better organization, but that they weren’t necessarily profitable, directly or indirectly. [48:00] As the years went by and things changed in terms of finances and reimbursement, there were some deliberate decisions made to contract back down to the core mission of acute in-patient care that only we could do, and then through the years some expansion back out. Now I think the expansion in the community is certainly mission-driven, but it’s also financially-driven. At that time, I think it was a conflict between mission and finances. Even though this was going to cost you money you might not get much return on, you did it because it was part of your vision, your mission, and part of who you were in the community. Now I think it’s still part of the mission and the vision, and it feels good to do things the community needs. But now there’s also the recognition that you have to do this to survive because we’re not just responsible for the patients when they walk in our doors now. We now have responsibilities that extend to what happens when they leave our hospital, when they choose where to go, and even the care they get when they’re not within our walls.

01-00:49:22
Rigelhaupt:
Also, soon after you started practicing in the area, there had to have been discussion about building the new hospital. I know it’s only twenty, and I don’t think I’ll ever be able to call it anything but. I don’t know what number it will have to reach. What do you remember about first hearing about the potential for this new hospital and the discussions about it being built?

01-00:49:47
Bigoney:
First of all, it seemed like it was so far off in the future when we first started having the conversations. It seemed like one of those remote things that they might do someday, but it’s kind of like putting people on Mars. “Yeah, yeah, I’ll believe it when I see it.” There was a fair amount of opposition. There were a lot of people who felt what we had was just fine, was big enough, and that we really didn’t need anything else. There was a sense at that time from consultants and from the prevailing opinion of health care around the country, that health care was shifting more and more to the out-patient setting. Hospitals were going to become almost—not irrelevant, because there would always be a small group of very sick people who needed hospitals, but that the requirement for the number of hospital beds would decline dramatically. If you were building a hospital, you needed to build much smaller, not bigger, because you would have less demand. What, of course, that didn’t take into account was the enormous growth of population in this area, as well as the enormous changes in what we can do for people technologically and the medical care that we can provide. It was kind of short-sighted. [51:00] But nonetheless, that was the prevailing view. It was controversial initially, whether it was something we should do.

01-00:51:22
Rigelhaupt:
In the early conversations, did you hear about the bigger plans? Because part of the story was that the facility on 2300 Fall Hill—it’d been thirty, forty years—that simply there was no way to drop the ceilings anymore or get the wires and the infrastructure that you would need for modern ORs, and it might simply be more expensive to renovate that building, to bring it up, than to build something new, or pretty close in cost. So that’s part of the story. Do you remember hearing about the sense that this was going to become a regional medical center more than just a replacement, a physical replacement, for that facility?

01-00:52:14
Bigoney:
That was the vision of our board. There were a number of leaders who said that. The medical staff, I don’t think, necessarily saw that vision. I think there was a little skepticism of that being the direction we would go.

01-00:52:38
Rigelhaupt:
What was some of the skepticism based upon?

01-00:52:42
Bigoney:
Just that we’re a community hospital. We don’t have all those specialties like they do at the other places. We’re just fine being a community hospital. In retrospect, that seems a little odd. The questions that come to mind: “So you don’t think your patients really needed cardiac surgery and neurosurgery and surgical sub-specialists? And you think it was just fine to have them go out of town for that? Or maybe have an internist take care of GI bleeders and heart attacks? You thought that was just fine?” But at the time, it was not everyone. There were some people who were forward-looking and shared that vision, but a lot of the medical staff felt that the status quo was good and didn’t want to see change.

01-00:53:33
Rigelhaupt:
Do you remember, in the interim between the discussions, which I think were happening around 1988, 1989—there was clear talk about a new hospital—and then it actually opening in 1993, do you remember any change in the medical practices at 2300 Fall Hill? Any beginnings of new programs? Almost just an experimentation with new practices in anticipation of this new facility. [54:00]

01-00:54:05
Bigoney:
It’s hard to come up with any specific examples, but the sense of the hospital and the sense of the medical staff changed. By the time the new hospital opened, there were still a few naysayers scattered in the community, writing letters to the newspaper and so forth. But by that time, the medical staff was generally on board, excited, and it really did feel like we were moving to something that was a different era of care. I think during the design of the hospital, there was a chance to kind of blue sky and dream a little bit. For example, that the ICUs would be very different in terms of the capability. Rather than just necessarily having people who were more or less in cubicles, crowded together, you actually had the ability to design something that will let you do whatever level of care you can grow to and be able to do. There was a sense of energy around it.

01-00:55:09
Rigelhaupt:
Was some of it the potential for new technology coming into the hospital?

01-00:55:15
Bigoney:
Probably so. Certainly at that time, really a little bit of computer technology there. The anticipation that, for example, it was designed with a thought to, where will computer terminals need to be? Something that was never a thought of in the design or work at the old Mary Washington.

01-00:55:49
Rigelhaupt:
My understanding is that one of the notable transitions was to private rooms. What was the response from physicians?

01-00:56:00
Bigoney:
Almost all positive. There were some patients who actually liked having a roommate. As a physician, it was very difficult. During our anniversary celebration—I guess it was a week before last—Dr. Rick Lewis, who’s one of our cardiologists, had written a song, reminiscing about the hospital and the move. One of the lyrics in the song reflected how you’re seeing the patient in bed A, and the patient in bed B is answering your questions, which happened pretty frequently. Or the family on one side wouldn’t get along with the family on the other side. Or people would fight over which channel on the TVs they were going to watch. It was challenging to practice. You’d walk past the patient in bed A to the patient in bed B, and the patient in bed A would start asking you to do things for them and get them things. Just from a medical practice point of view, private rooms made things much easier, and in general, made patients much happier. [57:00] Their families could stay with them. They had more privacy with their physician.

01-00:57:12
Rigelhaupt:
What do you remember about your first day making rounds or coming in on call in the new hospital?

01-00:57:17
Bigoney:
I was actually on call the day we moved. It was a Saturday. So I came in, I don’t know, 4:30 or 5:00 in the morning, and rounded. At that time, we probably had about five people in the coverage group and I had probably thirty, thirty-five patients to round on. I went and saw all those patients, put notes on their charts, made sure everybody was stable, and then, of course, the move happened. I went over to the new hospital. Did kind of quick check-back-in rounds on everybody, made sure everybody had gotten moved, everything was stable, and people were tucked-in. That gave me a little bit of a sense to know who was where and what things looked like. Of course, the next day, which was Sunday, I had to come back and round on that group again. And then come in during the night and admit whoever came in through the new ER during the night, which was pretty chaotic when you didn’t know where things were. Initially, there was a bit of a sense of disorientation and difficulty getting processes done, but the staff was the same and that transition and move was so beautifully designed. Really, I would say within a week, you couldn’t imagine you hadn’t been practicing there forever.

01-00:58:37
Rigelhaupt:
Would you say a little bit more about the process of admitting people who came in through the ER? So those would be patients in your practice that ended up coming to the ER, first being treated by an ER physician, and then you would be called in?

01-00:58:54
Bigoney:
Right. Plus, there also were patients who didn’t have a doctor, and we had a rotation. If you were up on the rotation and the patient didn’t have a physician, you also picked up that patient.

01-00:59:05
Rigelhaupt:
So you, as an internal medicine physician in town, would see patients at the ER?

01-00:59:11
Bigoney:
Right.

01-00:59:16
Rigelhaupt:
Other than the challenges of not knowing where things are, practicing in a new space, which would be challenging at any time, what did you see as the benefits of the new emergency facility at this hospital?

01-00:59:30
Bigoney:
It was great. It’s so much larger. The layout makes so much more sense. The old ER was built and then it kept having to grow. It had to grow into whatever space you had in ways that didn’t really make sense or work well. Plus, it was way too small. You frequently had people on stretchers just kind of wherever you could put them, or lots of people that couldn’t get in to be seen. To have something that felt larger, spacious, and logical, was a very positive change. [01:00:00]

01-01:00:14
Rigelhaupt:
In maybe the first year, the early time of the new facility, do you recall how simply having the space, the growth of MediCorp at the time, influenced medical practices or patient care in health care in the region?

01-01:00:35
Bigoney:
There were a lot of things that were different and better. For the first time, we actually had a doctor’s lounge. Although nothing like what we have now, it was a doctor’s lounge that had some food, some snacks, and some sitting space. Doctors would come in, talk to each other, congregate, and get their computer list. It helped to promote that collegiality. Plus it was right next to our medical support services, who were able to support us better. Radiology was such that it was very easy to go down, find the radiologist, look at the films, and go over them with the physician. The layout on the floors made it easy to find the—at that time, I think they were called unit secretaries—the HUC when you needed something stat or when you needed to make sure an order got put in. It was a thought-out flow. In the old hospital, it kind of started when medical care and process flow was very different, and then you had to adapt to the space. Here, the space was able to be designed based on the way patient care worked. Of course, the patients and families were so happy because everything was so beautiful. It was nice to walk around with happy people rather than grumpy people complaining they found a roach or they didn’t like the roommate or whatever.

01-01:02:03
Rigelhaupt:
What were some of the specialties that followed, not necessarily directly just because of this new facility, but certainly, as you’ve described, that there are specialties that started after this hospital was built?

01-01:02:18
Bigoney:
I believe we were doing some interventional cardiology prior to the move, but certainly interventional cardiology really took off. We were certainly doing diagnostic before the move. I can’t remember if we were doing interventional. But that really took off. It enabled us to also start the cardiac surgery program and to have the ability to support that. It enabled us to start really looking at surgical subspecialties, surgical oncology, neurosurgery, vascular surgery, and, more recently, colorectal surgery; rather than just everything being done by general surgeons. [01:03:00] It was the ability to have enough OR space, enough support for technology, and enough volume in the larger facility to support those surgical subspecialties. In medicine, we recognized that we really could not have any gaps in our medical specialties, so we had to have all the medical specialties adequately represented. In some cases, that meant when the providers in town chose not to come to the hospital, or if there weren’t enough providers in town, the hospital did end up recruiting and hiring those physicians. That’s been a change through the years.

01-01:03:41
Rigelhaupt:
The cardiac surgery program was one where someone not from the area began. What do you remember about physicians responding to the beginnings of cardiac surgery?

01-01:03:57
Bigoney:
Everybody was very excited. It was something that there was a lot of medical staff desire to have. The medical staff was glad that we had moved to that level, particularly with interventional cardiology. It is very frightening to have a patient that you discover has critical lesions on the table, or a patient who goes bad and you have to fly them somewhere for emergent cardiac surgery and hope that they will survive.

01-01:04:27
Rigelhaupt:
Could you say something about the surgeries? The particular kinds of cardiac surgeries or interventions that this new specialty was able to do that would have often been flown or gone to Richmond and Charlottesville or Northern Virginia.

01-01:04:43
Bigoney:
Sure. Certainly bypasses, valves, and some of the aortic aneurysm repairs. It also enabled us to do some of the higher-risk interventional cardiology procedures, knowing that you had cardiac surgery backup. Then, of course, evolving into the STEMI program. A patient who comes in with an acute MI, who is rushed upstairs to get the artery opened in less than ninety minutes by the interventional cardiologist, and most of the time that’s fine. Occasionally, the lesion is so critical, or the patient, for example, may have arrested in the field, been resuscitated with CPR, arrest again on the table. Or the lesions may be so critical and it may be apparent that’s going to happen. That ability to immediately get those people to the OR for cardiac surgery, those were new directions it let us go.

01-01:05:39
Rigelhaupt:
Was this an instance where a cardiac surgeon would always be in the facility or on call? And were they in private practice?

01-01:05:49
Bigoney:
Dr. Armitage worked for the hospital. He was never in private practice. He did not stay in-house twenty-four/seven. [01:06:00] We usually had a PA who was in-house, although I don’t know we necessarily had that twenty-four/seven. Really, with something like cardiac surgery, when you need it, but if it’s off-hours—by the time you get the OR set up, get anesthesia ready, and get the patient prepped, the doctor can be here in twenty minutes. By the time you can get things ready on the table, he can be here.

01-01:06:26
Rigelhaupt:
Actually, that leads into another question I was going to ask about starting a specialty. It’s not simply bringing in a physician. What do you remember about what else was involved? From the nurses, with expertise in cardiac surgery. Did anesthesiologists have to change their practices?

01-01:06:49
Bigoney:
Absolutely. You can imagine, for a cardiac surgery, when you have a patient on a heart-lung machine in full arrest, obviously you can’t use inhalational anesthesia. You are using entirely IV anesthesia. You also have somebody who frequently has a high potassium level. By definition, they are hemodynamically unstable. Their blood pressure, zero. You have to restart their heart. It’s a completely different kind of anesthesia. You also have to work in close coordination with the perfusionist who does the heart-lung machine. The ICU care is very different, because these are people who have had their heart stopped and started, have low blood pressure, have high risk of clots, and a high risk of bleeding. They’ve been on blood thinners. From intensive care nursing, intensive care physician, anesthesia, to equipment needs—our support people have to be able to maintain that equipment. It involves sterilization of those new machines and equipment. It really is a whole program that you have to develop to have the infrastructure to do it well. [knock on door] I think we’re over time.
[End of Interview]

Interview 2 – November 8, 2013

02-00:00:06
Rigelhaupt:
It is November 8, 2013. I’m in Fredericksburg, Virginia doing a second interview with Dr. Rebecca Bigoney. And, I want to pick up partially where we left off the last time. And in our last interview, you said that you became a physician board member at MediCorp the late 1980s. I’m wondering if you could think back to that era and talk a little bit about what you learned about the health care system’s core values as you began your work and have an inside view.

02-00:00:38
Bigoney:
You know actually, my board tenure, when I think about it, was late 1990s. In the late 1980s, I became Chairman of the Department of Medicine and got involved in medical ethics, but it actually was the late ‘90s when I was on the board. I probably got that chronology confused the last time.

02-00:01:03
Rigelhaupt:
Well, in terms of becoming more involved with the medical staff and health care, did you see new things from working on that committee?

02-00:01:15
Bigoney:
I think certainly relationships were changing between physicians and the hospital. Traditionally, the doctor’s practice did their thing and the hospital provided care. There was a bit of a sense of animosity between the two, and very much a sense of, leave me alone and let me do my job. Particularly, I think the physicians saw the hospital as a place that should do whatever they said. It should not ask any questions about the care they were providing, how long patients should be in the hospital, and how much care cost. That was really felt to be forbidden territory. In fact, one of the things I can remember, and I won’t call him by name, was one of our prominent medical staff members frequently saying in that era, “Well the next thing you know, we’re going to have economic credentialing.” The hospital is going to feel like it’s their business how much money we spend on taking care of patients. The thought of that at that time was completely outrageous. Whereas now that’s just part of doing business, and doing it well. I think, and I guess the other thing I would say about that era is, it was also very different in that at that time much of any physician’s practice was in the hospital. While there was a sense of animosity, we all spent a good bit of every day here. Most all the procedures were done here. [03:00] It was an era when, really, the ambulatory surgery center was very new and very limited. We all saw our own patients here. We came in the middle of the night to admit them. We interrupted our office hours in the day to come in and admit them. There also was much more of a sense of cohesiveness among the doctors and the medical staff and much more engagement in the hospital in our daily lives.

02-00:03:25
Rigelhaupt:
So as you began working more with this hospital, what were you most excited about contributing in terms of, as a physician?

02-00:03:34
Bigoney:
I was very interested in the physician-nurse relationship. When I went into practice, we have moved from an era of the nurse as the handmaiden of the physician and the person who did what the physician told her, to the nurse as a patient advocate, who often had to stand between the physician and patient for the patient’s protection and empowerment, and to the nurse as a team member. The physician, the patient, the nurse, and other members of the health care team are all part of the same team. I think that evolution was in progress then and was very interesting to me. That was more during the era between nurse-as-handmaiden and nurse-as-advocate, which could be a bit of a rocky transition. It was also around that time I got interested in medical ethics, and found that exciting and energizing.

02-00:04:41
Rigelhaupt:
So about the same time, MediCorp is going from few urgent care clinics and a community hospital to becoming a regional medical center. So staying with your interest in changing the relationships between physicians and nurses, and what that means, both in terms of practice in the hospital and patient care, did that transition to a bigger regional medical center present challenges or opportunities?

02-00:05:15
Bigoney:
It presented both. There’s something and some appeal in the community hospital model and vision. I do think that sense of a small, cohesive medical staff, where everybody knows everybody, is something that is a loss. On the other hand, I think the goal of really meeting the community’s health needs, of looking forward and being more than what we have been, and doing that in a way that’s strategic and practical—more is gained than was lost from that transition. We did start thinking about specialty services like cardiac surgery and surgical subspecialties that we hadn’t thought about before. [06:00]

02-00:06:09
Rigelhaupt:
Could you talk about the origins of the ethics committee, and when you began serving on it?

02-00:06:17
Bigoney:
Actually, there was no ethics committee until I began serving on it. Right around 1990, the University of Virginia got a grant from a not-for-profit company to do a pilot project around establishing ethics committees in community non-academic hospitals. There were a handful of hospitals that had ethics committees, but they really were non-functional, and generally non-trained. I think there were about twelve hospitals. One from West Virginia and the rest were from around the state of Virginia. We had a two-year program in which two people from each hospital went to Charlottesville one day a week from about noon until about 9:00 p.m., did a series of seminars, some graduate coursework with the medical students or graduate students, and had projects and reports we did back home. The outcome was the hope that each hospital would start an ethics committee; and as John Fletcher, who headed the program said, not only an ethics committee, but actually an ethics program. Initially, Steve Mills, who at the time was our hospital chaplain and later became our director for community programs, and I went to Charlottesville and started the program. We were at first very apprehensive about starting an ethics committee, because it was not frankly like people had been crying out for one. Although I did have one of my partners who said, “You know, these things come up. There must be some way to deal with them. There must be some answers that somebody has figured out. Why don’t you go find it and bring it back to us?” But in general, people were not particularly enthusiastic and sometimes a little worried. In fact, one physician thought it might sort of be like the Senate ethics committee and told me that if he ever got hauled in front of the ethics committee he did not want any administrators there. There was a sense of the ethics committee being perhaps some people who were going to police morality on the medical staff. However, once we got established and got the committee started, it was surprising how quickly people started asking for help with these issues. We became very busy and I think an important part of the organization. We did, and still do, ethics consults. In fact, right before I came down here, I was on the phone with someone about a patient who will likely need an ethics consult. [09:00] We do policy development. I think we have about twenty-two policies that the ethics program owns. We have an organizational ethics committee now, as well as a clinical ethics committee. We do education for our medical staff and nursing staff, orientation, education on various topics that come up, and we serve as a forum for general ethical issues that arise. Then we also support other ethical programs in the organization, like corporate compliance, research, our institutional review board, and so forth. I really do feel like we have filled John’s vision of a program, rather than just a committee. In fact, in one of the books that he wrote he mentioned that there are community hospitals that have been successful in making that transition from a small committee of outsiders to an integral program, and referenced us in the footnotes; we were flattered by that. It really is a labor of love, and a different way of thinking about problems and problem-solving. I think it’s useful to the people involved, both the health care professionals and the patients and families, but also really a fascinating dynamic. It is a fascinating field of study because it is not just mediating communication. There actually is a body of knowledge, a body of consensus, accumulated cases, and ethical thought that goes into it.

02-00:11:00
Rigelhaupt:
What were some of the first cases that you brought to seminars at UVA, or when you came back here?

02-00:11:11
Bigoney:
One of the first cases I remember that was particularly challenging—and actually, we dealt with the case after the fact, but after the fact was what should have been done—was a woman who presented with no prenatal care in labor. At that time, we had a very small medical staff, and the only obstetricians available in town were men. Her religion forbade that any man touch her. She arrived ready to have a baby screaming, “No man, no man!” So the question was, should the nurses deliver the baby? Nurses do deliver babies. [12:00] Now with our OB hospitalists program it doesn’t happen, but prior to that there would be times nurses did deliver babies, just like people in rescue squads and police officers deliver babies. Sometimes babies come and whoever is there catches them. OB nurses in the course of their career certainly end up doing a fair number of deliveries. Their licensure is that they can only do that if there’s no physician present or available. In this situation, there were physicians present and available, but she was just refusing to have them assist with the delivery. The ethical analysis was of what should have happened. What did happen, which didn’t feel particularly ethically comfortable was that her husband arrived and overruled her, and said that, “No, a man could touch her.” And so her autonomy was violated by her husband, as well as by the doctor who delivered the baby. That was an interesting ethical challenge as to what your options were, what you could do, and what you should do. Early on, we had a number, and we have continued to have a number of cases in which families want more aggressive care than the medical team feels is appropriate. Of course it sometimes goes the other way too. The medical team doesn’t feel like it’s time to quit, and the family says the patient wouldn’t want this and wants to quit. Those two dynamics are probably our most frequent case consults. Early on, and again, some things you start with appearing to be problems, and then when time goes on, you get a settled consensus, and they’re no longer problems. For example, one of the ones we dealt with early on was the family who says, “Don’t tell Mom that she has cancer because she couldn’t stand hearing it. She would just give up. So we don’t want you to tell her.” That really is not an ethical problem. What you do is you ask mama. If mama has severe dementia and won’t remember or understand anyway, then obviously you’re not obligated to tell her, but if mama has a reasonable ability to understand, then you say, “You know, Mrs. Smith, we were doing a lot of tests, and we are getting and are going to be getting a lot of results back. Some people like to know exactly what’s going on with their body. And some people prefer that we work with their family, and just have their family let them know whatever they feel like they need to know. Which kind of person are you?” And about ninety-five percent of people want to know, and about five percent of people have a family dynamic where everybody wants to pretend that mama doesn’t know. That was the sort of the thing that when you first face it felt like a serious ethical dilemma. And then when you unpack it, actually it’s pretty easy to advise people what to do in that circumstance. [15:00]

02-00:15:05
Rigelhaupt:
So I imagine in a seminar setting, it’s a little easier to talk about these things. Could you walk me through how it played out after the ethics committee is functioning at the hospital, and really are confronted with this and families? Who gets involved? Is it certain members? Is it chief medical officers?

02-00:15:31
Bigoney:
We have evolved through some different models. Very early on, we actually tried having the whole ethics committee do an ethics consult. We might have the patient, two or three family members, and all the members of the ethics committee who are available on short notice, which might be ten or twelve, all in a room together talking it out. That clearly was not a good model. For one thing, it overwhelmed patients and families and it was too many people. We then went to a model where we had a primary ethics consultant, which was generally one of us who had particular training, and one or two other committee members. We would select those based on the case. Usually, we would try to get one of our chaplains who was on the committee come. If it was a pediatric case, either a pediatrician or pediatric nurse—somebody that might have some expertise in the field that was relevant to the case. We would try to have two to four ethics committee members there, along with the patient family and the health care team. The physicians and nurses involved with the patient’s care would all sit down together in a room and establish the issue at hand. What we would usually do would be start off by having the medical people give a synopsis of the medical condition in lay terms. Then turn to the patient or the family, and most often the family because they usually are very sick patients, but sometimes it’s the patient, if they’re refusing treatment, or demanding treatment. We would say, “Tell me about yourself.” Or to the family we would say, “Tell me about your loved one. Tell me about what kind of person he or she was. Tell me about what happened to get him into this illness and this situation. And then from there, talk about what do you think he would want? ” To frame it around the patient and the patient’s wishes and desires, which can be very interesting. Sometimes the family will say, “Well, I know good and well he wouldn’t want to be kept alive like this, but you know what, I’m not ready to let him go yet.” Which brings you to a conversation about, “Well, you know, your moral duty as his decision-maker is to put himself in his shoes. It’s not what you would want and it’s not what you want for him. It’s what you believe he would want. And if you can answer that question, that you know, that really is what you’re morally obligated to do.” [18:10] To follow through, and then the goal is to come to an ethically-acceptable consensus. Sometimes in doing that you come to a list of ethically-acceptable options, and then you try to build a consensus around one. It might be, if the family wants to keep going and the doctor feels this is hopeless, and the patient is dying, and the patient is on the ventilator and dialysis and six antibiotics, the ethically-acceptable consensus might be, “We’ll go ahead and keep him comfortable and withdraw.” Or it might be, “We’ll continue what we’re doing, and we’ll meet again in a week. If there’s no improvement, then it really is looking more and more like your hopes are false hopes and he’s not getting better.” Or it might be, “We’ll continue what we’re doing, but we don’t escalate and add anything new.” Or it might be, “We’ll continue what we’re doing, but if his heart stops, we won’t do CPR.” It wouldn’t be, “Well, we don’t really care what the family thinks, we’re going to go on and do what we want.” It wouldn’t be, “Well, we’ll go ahead, give him a lethal injection and kill him.” I mean, there are some options that are not ethically-acceptable, and they’re not on the table. You try to define those options, and then see which one you can build a sense of agreement around.

02-00:19:33
Rigelhaupt:
And how quickly can you put this together when you’re confronted with this in terms of bringing in an ethic committee?

02-00:19:39
Bigoney:
Now, because of the dynamics and the busyness of the roles, we often end up as a solo consultant. Diane Brothers, who’s our nurse ethicist, and I often end up doing the consults as a solo consultant. That is often spur of the moment—a call that we have a problem in the ICU. The family is up here now, can you come up and sit down with us and with them? Or sometimes it’s scheduling a meeting for the next day, or two days later. It is usually within twenty-four to forty-eight hours, even if we had to get several people together, we can do it.

02-00:20:14
Rigelhaupt:
I can’t be help but be struck by where you say that you start these in terms of asking the family often if someone’s sick to almost tell a brief life story of the person. If nothing else because we’re doing an interview right now. Where does that practice come from? And is that standard across ethics committees?

02-00:20:38
Bigoney:
There are different ways to approach ethics consults, or different ways to think about them. But certainly all of what you think about always includes the patient’s wishes and values. The method that I was initially taught in is, what are the objective facts? [21:00] What are the human facts in terms of preferences and social issues? And how you frame the ethical questions, and then what are the options? Another model is to divide it into four quadrants—the medical issues, the psychosocial and spiritual issues, the ethical questions, and the resolution—so you can think about it different ways. I have done consults in which actually we started with the conversation about who the person is, and then moved to the medical information second. Some people do it that way. Although it seems to me that first of all the family is usually a little shy and inhibited when they come in, or they don’t quite know what this is, and they’re worried and suspicious; it sometimes works better for them if somebody else has talked first. Also sometimes, they may say things, and then if they’re contradicted by the physician, that embarrasses them. “You know, it’s obvious to us that she’s getting better, and that she knows us, and that she”—and then you have the neurologist who might say, “Well actually, she’s in an eyes-open coma. She doesn’t know you.” To me, that seems to work better, but it’s not a hard-and-fast standard.

02-00:22:37
Rigelhaupt:
Did the ethics committee here try to develop common practices, or is it truly case-by-case?

02-00:22:48
Bigoney:
We have developed guidelines, and some of that is in our policies. For example, a policy on withdrawing and withholding medical care and when it may be reasonable to consider what kinds of treatment you may provide to keep people comfortable: if you’re stopping dialysis for a renal failure patient; if you’re stopping a ventilator for a respiratory failure patient. What kinds of thoughts you need to have to make sure you have all the pertinent stakeholders on board so there’s nobody on the medical team that has any grave reservations. The key family members are aware if they want spiritual support from our internal chaplains or their own people, we can do that. There is a checklist to make sure you’ve thought of everything you need to think of to be able to do this right.

02-00:23:50
Rigelhaupt:
Are the majority of the cases that come up end-of-life issues?

02-00:23:57
Bigoney:
Yes, that’s the most common kind of issue that we see. [24:00]

02-00:24:11
Rigelhaupt:
So the practices, have they become more consistent over the years? I mean it sounds like it’s almost over twenty years that it’s been running here at Mary Washington.

02-00:24:22
Bigoney:
Every person’s journey is unique. On the one hand, it almost feels like there’s nothing we haven’t seen. On the other hand, each one is different. Each family and each medical care team’s suffering and moral distress and concern is different. Each patient’s story is different, and family story is different. I think there’s more of a sense of an internal case base to work from. When you first start in ethics, one of the things that you do is what’s called, “casuistry.” That is looking back at other cases, and then saying how is it the same or different: “Well this is a lot like the Terri Schiavo case, but it’s different in this way, that this patient actually did have an advanced directive. Or that this patient isn’t really completely vegetative, but has a little function, and this was the moral resolution in that case. How is this one different?” I think we’re at the point now that we really have enough of our own cases that we hark back to, and sort of intuitively compare the outcomes and the issues.

02-00:25:47
Rigelhaupt:
Is this something then, there’s a practice where the ethics team committee gets together, shares new information on cases, and that’s part of the practice?

02-00:25:57
Bigoney:
Right. We have an ethics committee meeting every month, and one of the standing agenda items is current cases.

02-00:26:08
Rigelhaupt:
And now that it’s become a core component of the hospital, who serves on the ethics committee?

02-00:26:16
Bigoney:
We have always wished we had more physician involvement than we do, but we always have some physicians on the ethics committee. We have nurses, and in fact, I mentioned Diane Brothers. Diane and I both got masters degrees in clinical ethics in the late 1990s. We always have someone from chaplaincy. We try to have representatives from all the major care centers: so from our mental health department and those are usually our licensed clinical social workers, our emergency department, our medicine surgery, and women’s and children’s areas. [27:00] We also have community members who sort of serve as the voice of the community, and they are very valuable and interesting participants.

02-00:27:12
Rigelhaupt:
Could you say more about how people from the community have become involved? Did you seek them out, or was that a conscious part of the ethics committee?

02-00:27:23
Bigoney:
It was. And we, in general, have sought them out. Sometimes, we’ve occasionally had people who have expressed an interest. For example, we’ve always had at least one University of Mary Washington professor who teaches, or taught ethics on the committee, which is a very interesting perspective. Right now, we have one current and one retired ethics professor from the University of Mary Washington. We frequently had community clergy. We had a local rabbi who, sadly for us, just moved out of the area, who was a wonderful contributor. We currently have someone who works with the elderly in the community, is an advocate for the elderly, and has an interest in medical ethics from the community. It is a variety of people who may have particular interests or knowledge. Most of the time, we reach out and start thinking about, who do we sort of need to round out the diversity or the knowledge base on our committee?

02-00:28:45
Rigelhaupt:
Was there a direct connection between this ethics committee, and then the formation of a clinical ethics committee, which sounds like happened soon thereafter?

02-00:28:53
Bigoney:
The clinical ethics committee was the first committee that we formed. I think we called it the bioethics committee initially, but it’s really always been a clinical ethics committee. And then, some years later, around 2000, we formed our organization ethics committee that focuses on ethics and mission and values-driven decision making for the company, for the health care system. We also now have a clinical ethics committee at Stafford that started within the last two years.

02-00:29:31
Rigelhaupt:
The clinical ethics committee at Stafford does very similar work in terms of cases with patients.

02-00:29:35
Bigoney:
Right.

02-00:29:38
Rigelhaupt:
Could you discuss the formation of the organizational ethics committee?

02-00:29:35
Bigoney:
We have leadership that has always been very interested in how you live your mission and how you use your values in your day-to-day decision-making at every level in the organization. [30:00] Fred [Rankin] in particular has always had a special interest in that. In the late 1990s for our annual board retreat, we decided that organization ethics would be our topic. We brought in some nationally known speakers, did kind of a number of didactic sessions with Myra Christopher from the Midwest Bioethics Center to talk about organization ethics, what it was, how it would help you, and so forth. We spent a large part of the time doing case studies in small groups that we had come up with. They were scenarios like, you have a limited amount of money in your budget. Your community programs group has come to you to request a van to provide free care to underserved in your area, and your surgery department has requested the replacement of a piece of equipment that is still working, but is no longer state-of-the-art. How do you decide which of these to choose? Another case I remember that we discussed was our Home Care America business; the fact that we’re an organization that has both for-profit and not-for-profit businesses. We have a for-profit subsidiary of a not-for-profit business that’s competing with entrepreneurs with for-profit companies in our market. Is that really fair? And is that a business that we should be in? And the conclusion that we came to was, if we have an identified need that those other businesses aren’t meeting, then it’s reasonable for us to be in that business. But if the need is met by other organizations in the community, then we need to be prepared to get out of that business. That kind of ethical scenarios and then when we came back. There was a fair amount of enthusiasm for starting an organization ethics committee, which we did and continues since that time. We only meet quarterly now, but it’s always a fun meeting that always goes way over with time; it’s very lively. In fact I went—it’s probably been maybe four years ago now—by invitation to conference University of Virginia had on ethical leadership in organizations. They primarily had internal people from UVA, but they had people from maybe a half-dozen other hospitals. We were the only ones, including UVA, who had an active, functioning organization ethics committee. [33:00] The entire group was very interested and a lot of people started those committees in the early 2000s, but sort of didn’t know what to do with them. We are very pleased that it has remained a useful and functional piece of our organization.

02-00:33:20
Rigelhaupt:
Why do think it’s become something that is consistently regenerated, and has been self-sustaining within the organization?

02-00:33:29
Bigoney:
One of the things that Fred Rankin said early on was, “This needs to be a safe place where we can talk about whatever we need to talk about.” And I think it has been an action-oriented group. The actions that the organization ethics committee takes are generally in the form of recommendations to the board. It is a board committee and the board members are very committed to its success. I think the fact that it’s actually done things, it’s actually come up with recommendation to solve problems, and that we’ve had board members that are engaged, have contributed to its success. I mean an example of the sort of issue organization ethics—and I hope I’m not going on too long here—tackled was that we had a series, and probably shortly after we initially started, with hospitalists. And also after 9/11, we had in rapid succession about three patients who threw doctors out of their rooms or refused to be seen because they perceived those doctors to have Arabic names or presumed that they were Muslims. We had basically qualified physicians on our staff who were being victims of discrimination by patients. Now we wouldn’t let our staff discriminate against patients. But what’s our ability to protect our staff, and at the same time not condone that sort of behavior? Or if you have a patient who says, “I don’t want any African-American nurses,” or “I don’t want any white nurses.” Clearly, they’re our patients; they have rights. But also clearly, we don’t want to condone what we consider immoral prejudiced behavior. We actually came up with a guidance document and a policy for dealing with those situations through organization ethics. More recently, we’ve been dealing with issues having to do with how we would distribute scarce resources in a disaster or a pandemic; what the ethical principles and process would be if you didn’t have enough ventilators, or enough blood, or enough something. [36:00] These kind of larger issues are what we deal with.

02-00:36:08
Rigelhaupt:
I’d like to think the pandemic is of lower odds. But tell me what your organization came to a conclusion about a patient who doesn’t want to be seen by a particular doctor, or particular nurse. What are the guidelines you developed?

02-00:36:25
Bigoney:
That we make sure all the care providers that we offer to a patient are well-trained and well-qualified. For physicians, you’ve got to have a physician. You can’t fire your doctor and be here without a doctor. Whether you don’t like that doctor because of what you perceive to be their cultural background, or because they won’t give you all the narcotics you want, or you just don’t like them, you certainly have the right to change physicians, but only if you can find another physician who’s willing to assume your care. In some cases, it may be easier, particularly for a hospitalist, to just ask one of his or her colleagues to go ahead and take over the care and to make it easier for everybody, but they’re not obligated to do that. And sometimes there may not be another doctor available to do that or willing to do that for a really difficult, abusive patient. The patient, again, if they can find a hospital that will accept them in transfer, or a doctor that will take over their care, we’d be glad to facilitate that. We request that the physician attempt to talk to the patient and resolve it. If that’s unsuccessful, then our medical leadership will talk to the patient and explain the system and the rules. It’s a little bit different for nursing in that most of the time we do have other nurses available. Because of our obligation to protect our associates from abuse to the extent that we can without compromising the care of others, we will try to excuse our nurse from that assignment. We make it clear to the patient that we’re not doing that because we honor the request, but rather because we really feel that we should not subject our associates to abuse.

02-00:38:29
Rigelhaupt:
Let’s jump back to when you came on as a physician board member. What were you most excited about contributing to the board?

02-00:38:39
Bigoney:
At that time, we had two physicians on the board. One was the representative of the medical society, which is separate from the hospital, and one was the representative of the medical staff. I was the representative of the medical staff. It was kind of a serving two masters sort of position. [39:00] Certainly when you are a trustee on the board of trustees, you do have that fiduciary obligation to the organization, and to represent the needs of the organization. But at the same time, it’s an opportunity to give voice to the concerns of the medical staff and to make sure if there is something the physicians are concerned about or need to know that it gives you a chance to do that. I think that it was an opportunity to be that voice in-between and make sure everybody knew what they needed to know, obviously within the bounds of fairness and reasonable strategic confidentiality. It was an opportunity to be able to express the fears, concerns, and needs of the physicians.

02-00:39:54
Rigelhaupt:
As you hinted about, in terms of the multiple perspectives around the corporate ethics, one of the things that is clear about hospital administration and the board, is that there’s a range of backgrounds from MBAs to MPHs, physicians, attorneys, people in business. What did you observe, some of this initially, when you first came on the board as a physician about different ways the board and the administration sought to solve problems?

02-00:40:39
Bigoney:
The board—we have always had a very strong, very vocal board that speaks for the community. I’m not sure people who have never sat in on one of our board meetings know what happens. Particularly medical staff members, I think would be astounded. They often think the board sort of rubber stamps whatever leadership tells them, doesn’t ask too many questions, and so forth. That is so far from the truth. It’s a very exciting dynamic. I do think the citizen board members think on behalf of community, whereas the health system leadership are thinking about the needs and the future of the health care system. And that is as it should be. That’s how those roles should be, and sometimes those roles should be in some tension with each other. I do think people with no clinical background, whether they are board members or whether they are executives, sometimes are a little bit naïve about medical care and the complexity of medical care. [42:00] I think that’s something that they may have in common. But most of them know what they don’t know, and will ask questions. Something may seem perfectly logical to them that actually is not, but they’re generally very open to asking those questions and having that conversation.

02-00:42:22
Rigelhaupt:
Can you think of an instance early on in your time working with the board where you felt that, with your medical authority, or the voice you were bringing from the medical staff and you were vocalizing, was being challenged, or you were facing hard questions?

02-00:42:44
Bigoney:
Gosh, it has been a number of years ago. Certainly, around the time I was on the board was also around the managed care era. There was a lot of concern on behalf of physicians that the system might sell them down the river and make deals with insurance companies that were favorable to the hospital, but unfavorable to the physicians who don’t have as much voice because they don’t speak with as large a single voice. Physicians don’t have as much money on the table for any one group or any one contract. There were some conversations around that, although I don’t honestly ever remember anything that I felt disappointed about, felt the board had not heard, or had made the wrong decision.

02-00:44:01
Rigelhaupt:
When you say the “era of managed care,” was this when—in some ways, the push for cost containment will still limit access.

02-00:44:12
Bigoney:
Right, right. Pay for what you don’t do.

02-00:44:17
Rigelhaupt:
And there was concern from the physician community that the hospital was more likely to line up with the insurance companies, and that might interfere with the patient-doctor relationship.

02-00:44:32
Bigoney:
Right.

02-00:44:38
Rigelhaupt:
Did that lead to any discussions, specifically between the physicians, the senior-level, and the administration itself?

02-00:44:51
Bigoney:
It was also around that time that we started our first integrated activity between physicians and the hospital, what’s now Pinnacle Health. [45:06] Although it’s gone through several different names through the years and it is certainly not the robust sort of physician-hospital alignment organization we’re putting together now, we thought that vision-wise it would grow into that. That didn’t really happen, but what it did become was a joint contracting tool. Because of anti-trust issues, physicians can’t tell each other what they’re charging or tell each other what kind of deal they got with an insurance company so that somebody else can go to the same insurance company and demand the same thing. But there are some legal ways you can, as a group, sort of have a messenger model where you have somebody who’s negotiating on behalf of multiple groups of physicians. Of course now the rules have changed again since then. But at that time those rules weren’t in effect. The hospital helped the group of physicians put something together, and then also brought its own negotiating skills and power to the table to work with those physician members to make sure there were contracts. Then of course the physicians who were in the group could take it or leave. You weren’t forced to sign those contracts, but you had the opportunity to. I think that was a constructive way to try to work together and align that power to everybody’s benefit. Obviously as a hospital, if you have a whole group of physicians in different specialties you’re bringing to the table to, you have something stronger to offer.

02-00:47:01
Rigelhaupt:
Could you talk a little bit about your decision to pursue a degree in clinical ethics in the late 1990s?

02-00:47:14
Bigoney:
It was just something I loved doing. I was reading about it, going to national meetings, subscribing to all the journals, and participating—in fact, we had a Virginia Ethics Network for a number of years, and I was the president. I was always on the board and president for several years. The University of Virginia actually only ended up doing the two-year program once, sadly, because it was logistically difficult for people working jobs and in practice to do. But they developed a two-year master’s program at their auxiliary site in northern Virginia that they share with Virginia Tech. Diane Brothers and I commuted back and forth for that program. [48:00] Then of course we worked on research projects and papers and so forth here as part of that. It was an opportunity that came along. The health care system paid for it, for the two of us; and actually I believe we were the only participants in the program whose health care system paid all the expenses for the program. Some people had to pay out of pocket. Some people said their health care system would help them a little bit, but ours was very generous in training us to be able to have that expertise in-house.

02-00:48:36
Rigelhaupt:
Was this part of building a stronger foundation, in terms of that commitment to pay for it, to become a regional medical center?

02-00:48:45
Bigoney:
It was. It was considered a valuable program, a valuable asset for our health care system, and supporting and training people to be sure they do it right. If they have the knowledge base to bring back, that was an important part of the organization’s commitment.

02-00:49:07
Rigelhaupt:
Was there a sense that the organization wanted you and Diane Brothers to come back and use the problem solving skills that you learned with further training ethics to go throughout the organization?

02-00:49:25
Bigoney:
Yes.

02-00:49:27
Rigelhaupt:
Could you think of ways that that played out? They asked you to meet with this committee, or that committee, some of the ways in which you really saw that play out on a day-to-day basis?

02-00:49:37
Bigoney:
We’ve actually done ethics consults for patients, for example, in home health and hospice. Actually, I’ve gone to patients’ home before as part of that process to meet with families and patients for ethics problems. Certainly, we have done a lot of outreach in teaching in the community, to churches, to citizen’s groups, to college students, and various other groups who’ve wanted that input. We’ve talked; we’ve done presentations to the board. I mean, I think we really do see it as a system ethics program, rather than just a hospital ethics program. One way to think about the way this health care system sees ethics that is different than most health care systems is when we got ready to implement HIPAA privacy, which if you know anything about HIPAA was a huge, unfunded bolus of work that the government dumped onto hospitals. Jina Haikey headed up the effort, and I co-chaired it with her. I will be very surprised if there were very many other people who thought about privacy and ethics as interrelated. [51:00] But that was the vision this health care system had.

02-00:51:11
Rigelhaupt:
What were some of the ways that you and Jina tried to integrate questions of privacy and ethics?

02-00:51:18
Bigoney:
HIPAA was very prescriptive in terms of the paperwork you had to give patients when they came in, the questions you had to ask, the policies you had to put in place, the resources, the hotlines, and the teaching you had to do. We put those programs in place throughout the organization. We also made a decision to provide all the resources needed for HIPAA implementation to the physicians in private practice at no cost to them. Because we had to develop all this internally, we shared the letter to a patient who wants to change their medical record. HIPAA gives patients information about how they can do that and what our response has to be. The specific information you have to give a patient the first time you see them has to include all these things, and these examples, and so forth. We came up with a template they could customize. At that time it was a big deal to give people floppy disks. Everybody got a notebook with all the documents and the disks so they could do it themselves because, you know, it certainly cost thousands of dollars to get consultants to come in and do this. The decision was that this was a health care community issue and we would reach out and take care of. And then of course, internally we did a big privacy campaign, teaching campaign, called “Mum’s the Word.” We had Mums, and sticky notes with mums on them, and various kinds of visuals.

02-00:53:16
Rigelhaupt:
I mean it sounds like the organization made a concerted effort to look at a change in regulation not necessarily as a burden, but an opportunity.

02-00:53:26
Bigoney:
It was a burden, but it was also an opportunity. [laughter] And don’t let anyone tell you HIPAA wasn’t a burden. The original intent was good. It’s just the government has a hard time not going overboard in how prescriptive they are. I do think that we are a better place for it, in terms of our honoring of patient privacy and confidentiality.

02-00:53:56
Rigelhaupt:
Along those same lines, [54:00] are there other instances you can think of, in the roughly dozen years that you’ve been a full-time employee at Mary Washington Healthcare, where you’ve seen a change in regulation end up being an opportunity to spark a larger conversation, either about ethics, or about patient care, that the organization has run with?

02-00:54:24
Bigoney:
Certainly, I think the quality and safety initiatives that are out there, largely led by CMS and by the joint commission have made us better health care providers because they have made us accountable, they have made us measure, and they have made us come up with problem-solving plans.
Another example is when the Obama administration changed the CMS conditions of participation around visitors in hospitals. We used to have visiting hours. In many of our units, such as our intensive care units, you could only have two visitors at a time. We had an announcement at 8:00 in the evening that said, “We need all visitors to leave so our patients can sleep.” The new way of looking at it was actually, they’re not your patients, they’re actually people. Their visitors and loved ones are just as important to them as you are and they can stay if the patient wants them to stay, unless it interferes with your ability to take care of patients. It became a patient right issue, rather than as a hospital, “We’re being so generous. We’re letting you come and visit this person for a little while, and then we’re going to make you leave.” It actually is, patients have a right to have the people they trust and love with them, as long as those people aren’t disruptive, don’t interfere with care, and as long as there aren’t infection control issues or that sort of thing. We just need to figure out how to make that happen for them. A lot of pushback, but I think it made us better people.

02-00:556:08
Rigelhaupt:
When you say “pushback” on something like that, where would the pushback come from?

02-00:56:13
Bigoney:
Our staff. “If we have visitors there all night, how were we going to get anything done. I don’t want six people in the room. This works just fine the way it is. Why should we have to change?”

02-00:56:40
Rigelhaupt:
What year did you become medical director, when you came on full-time?

02-00:56:46
Bigoney:
That was in 2001.

02-00:56:50
Rigelhaupt:
What were you most excited about working on, when you became medical director and started working in 2001?

02-00:56:56
Bigoney:
It was a complete career change for me from private practice. [57:00] At that time, I was doing geriatric work primarily in the nursing homes. I was doing my medical ethics work. I was providing support for case management and for a clinical documentation improvement program. I was doing a variety of different things. Honestly, the thing that excited me the most, at that point, was to really have the time to devote to the ethics program I felt I had not had before. Early on, the rest of it was kind of was, I didn’t mind doing it. It was sort of the day job you have to do, to do what you’re really passionate about better than you have been able to do it before. I will say that with time, I really became energized around the case management support work. I found that to be a lot of fun. It was a new body of knowledge that I enjoyed learning and I had a great group of people to work with.

02-00:58:04
Rigelhaupt:
So having more time to work on ethics in this new position as medical director, what are some of the ways that you saw yourself, in the first couple of years, really applying the questions that an ethics approach would demand to your day-to-day job?

02-00:58:26
Bigoney:
It’s always part of the day-to-day job. The interface, the combination of jobs I was doing was very interesting in that in geriatrics, and certainly in doing a lot of nursing home work, and then taking care of the nursing home patients in the hospital; the connection is obvious. Patient rights, supporting patient decision-making, and exploring goals of care and wishes with patients and families is really part of the core of what you do in ethics. With case management it was very interesting, more from the perspective of organization ethics than in terms of resource utilization, patient demands and refusals, and complex discharge planning, which actually has a lot of ethical implications. And then dealing with the demanding, difficult, or disgruntled patient.
For example, we are a no-smoking campus, but you’ve got patients that you know are leaving the unit and going outside to smoke. If they’re people who are in for decompensated chronic lung disease, and you know they’re going outside to smoke, and that is prolonging their stay and interfering with their care, how do patient rights, patient care, and organizational policy interface? Or you have someone who owns their home, but the family is living in the home. [01:00:00] The patient can’t go home, but can’t go to a nursing home long-term, unless the family reveals what assets there are so we can get Medicaid eligibility, the family potentially sells the home, liquidates the assets, and uses them for the patient’s purposes, and that in no way is what the family wants to do. So how you deal with a family who are not acting in the interests of their loved one, and that we’re now the residential facility for their loved one. We don’t have a payment source for them to leave, they can’t safely go home, or the patient who wants to go home but isn’t safe to go home alone, or is homeless and doesn’t need to be in the hospital anymore. So those issues are classic case management issues, and yet at the same time, are ethical issues. I actually found that to be a more robust interface than I would have guessed.

02-001:01:10
Rigelhaupt:
With your interest in case management, what are some of the ways that you’ve seen the health care organization make a concerted effort to deal with, as you said, complex discharge? They’re not medical problems per se, but they have a direct impact on care. How do you see that being implemented?

02-01:01:37
Bigoney:
I think philosophically, seeing that we have an obligation to patients to at least offer a safe discharge plan. Patients and families have a moral obligation to cooperate with us with that. We are a community-owned hospital and our moral obligation of stewardship means we have to use the resources of the community in a way that is wise and fair. Having a difficult family and having somebody stay here six months because they don’t want to sell the house violates the stewardship obligations, as well as kind of not being appropriate on the patient’s behalf. Some of it was coming to a moral position. We also from a practical point of view came up with some tools. We are not currently doing it, although we’ve talked some about revising it. It is having an opportunity once a week to present one or two really complex or problematic patients with a group of people from all different specialties, such as psychiatry, physical therapy, pharmacy, ethics, chaplaincy, as well as the people taking care of the patient. We sit down and talk about a patient who is going off the unit to smoke and missing their antibiotics. [01:03:00] We believe, probably getting drugs from their drug dealer and taking them when they’re out, and then coming in and wanting pain medicine from us—we may overdose them. Being abusive to the nurses and refusing the antibiotics that they need for their infection—so that kind of situation. We also came up with a policy that we have only occasionally used, but it has been very effective for that absolutely intractable situation. We have a group that includes community members, chaplaincy, case management, ethics, the care team, at least someone from a VP level finance and legal. We all get together and discuss the case, and then we give the patient or the family a ten-minute opportunity to come in. They get introduced to everybody in the room, just to state their case. They don’t have to, but they’re just given the option to do that. Then we come up with a recommendation. That is the sort of situation in which you may have, for example, a family that either absolutely refuses to cooperate with a discharge plan, or demands ongoing inappropriate treatment. Someone who, for example, has widely metastatic cancer with brain metastases who has clearly had made it apparent they did not want to kept alive on machines. That patient is now in our intensive care unit on a ventilator on dialysis or on antibiotics having repeated CPR, and the family is continuing to demand this treatment. What often comes out of those cases is that if the family doesn’t yield, we may have to go to court and get a guardian appointed for that patient because their family member is not acting in their interests. And most of the time, just hearing from us is enough to make the family change their behavior. We had two families we went through this with who said they were going to leave their loved one in the hospital. One of them said three more months, and the other one said six more months. The one that said six months said they would be unavailable for contact, but they were going to come back in six months to see how the person was doing, and then they would consider a disposition plan. That’s not okay. You know, we need to have an ultimate big gun that you can do to make sure you’re being fair before you take that kind of action going to court.

02-01:05:44
Rigelhaupt:
In terms of building programs, or I mean certainly since you became medical director in 2001, there’s been new programs. What are some of the programs that you think have been the greatest benefit to the health care system?

02-01:05:58
Bigoney:
I think our clinical documentation improvement program, which helps us document in a way that optimizes our reimbursement. [01:06:10] In other words, we actually get paid for what we do. I think our medical management program, where we look at various diagnoses and DRGs, look for opportunities, benchmark with other organizations, and say, “Who does it better, and what do they do that we could improve on?” Certainly our quality program, which now has a robust dashboard and a set of goals every year that we measure every month. Then have targeted processes to improve patient safety, hospital-acquired conditions, and appropriate care for myocardial infarction. Our STEMI program, where we get people who come in with a heart attack to the cath lab and get the artery opened. We are at essentially one hundred percent for the timeframe that is allowed. Our stroke program—where we similarly call a “Code Neuro.” If somebody looks like they have a stroke, we evaluate them, have time to get the clot buster drugs in, if they’re appropriate for it, and essentially stop a stroke midstream. Our “Code Ice” program is for patients who suffer cardiac arrest. If you cool the patient’s core body temperature, you have a significantly increased chance that they will wake up and make neurological recovery. I think there are a lot of exciting programs we’ve added, including stereotactic radiosurgery for cancer. We just have so many programs we have added through the years.

02-01:07:44
Rigelhaupt:
From your perspective as medical director, you maybe just pick one of the programs. If you could talk about your involvement from the beginning conversation, even kind of a water cooler talk about, wouldn’t it be great if we had this, to it being up and running?

02-01:08:01
Bigoney:
Probably, the clinical documentation patient program is one example of it. I will say that Dr. Ryan had started those conversations before I came on board and we were at the point of working with consultants, hiring nurses, putting a program together, educating physicians, and thinking about how it could work. Certainly within the first year, we were in the millions of dollars that we had recovered from the program. Of course, money’s not why we do what we do, but we have to have it to do what we do. We do feel like it’s important. Another example was on our obstetrics unit. Our finances did not look the way they should. [01:09:00] The solution that had been implemented was cutting costs by cutting services. Of course in an obstetrics unit, you compete on the basis of good service and happy patients. If you start cutting on all the amenities, you go on a downward spiral. One of the people who was in a leadership role on that unit expressed frustration to me. She felt that there were lots of missed opportunities and that this organization just didn’t see things they way they should be seen. I put together a meeting with a group of people. She was effective in recognizing that there were problems. She was not effective in trying to solve them. What we were missing is we had lots of patients that we actually weren’t even getting into our system for billing. We had patients who would come into the hospital several weeks before their delivery with complications and because of the way we were coding we weren’t capturing that time at all. We were billing them like a normal delivery. We really had what turned out to be, once again, millions of dollars just because of inefficiencies we were leaving on the table. Cleaning up that process quickly turned that around. I think to be able to pull the right people together and do the right thing without—rather than cutting back on service and patient care, enable yourself to provide what patients really need.

02-01:10:49
Rigelhaupt:
You brought up a question of finances. And in one of the interviews, a former board member very succinctly said, “If there is no margin, there is no mission.” And it’s a fine line.

02-01:11:02
Bigoney:
It is.

02-01:11:04
Rigelhaupt:
And where I asked earlier about different approaches, from MBAs to public health officials. People with backgrounds in public health, to the nurses, to physicians, to someone who’s an expert in ethics. I don’t know if you could talk about a specific example, but some of the ways in which the different backgrounds shape the conversation about the necessity for there to be margins, for the finances to work out.

02-01:11:35
Bigoney:
Physicians have traditionally said, “I just do what’s right for my patient, and somebody else is going to have to worry about the money part of it.” I think the days that physicians could say that, if they ever could reasonably say it, are gone. It always struck me as wrong. [01:12:00] Because if you’re a doctor who says, “I believe this is the best medicine for my patient. I’m going to prescribe it. How they figure out how to pay for it is up to them. But I’m not going to prescribe something that I think is okay but not quite as good, even though it costs a lot less. The system needs to work it out.” To feel like, I’m going to do the best thing for my patient because that is who I am. On the other hand, if your patient doesn’t get that medication, and gets no medication, gets worse, comes back in the hospital, or dies, or their condition worsens, you really haven’t served your patient well. The language of, “It’s not my place to worry about money, it’s my place to recommend the best possible thing to do as a physician.” We have to work together and recognize doing the best possible thing as a physician does not just mean prescribing what you think in an ideal world it would be. I think that they need to live together in a practical world. I think people with no medical background often believe there ought to be a right answer. They, on the other hand, often believe, they’ll often say things like, “Generic drugs are just as good as brand names. And what we need to do is not be using all these expensive chemotherapy drugs. We need to be using the old inexpensive chemotherapy drugs.” Well, yes and no. Some of the drugs and some of the patients know that’s not the right answer—I think on either side we can tend to oversimplify what’s very complex.

02-01:14:02
Rigelhaupt:
A recent change for you, from Chief of Medicine to Vice-President of Medical Affairs. What have you seen in the differences in that position, three, four months?

02-01:14:14
Bigoney:
Actually now I’m Chief Medical Officer. I was Chief of Medicine, then I was VP MA (Medical Affairs) for a year. And now I guess I’m four months into CMO. Changes in the role? Chief of Medicine is very much a clinical role, and a medical staff, supportive, and advocacy role. Certainly you are also working for the health care system, but basically, you are a buddy with the docs. You’re a person that helps them problem solve, that helps them get new programs up and running, helps them make their order sets work better, or helps them figure out what medications they need on formulary. [01:15:00] VP MA requires a much stronger organizational alignment. I don’t think it makes you stop being a doctor, or stop being an advocate for the physicians. I really do see that as still part of the role, as is the Chief Medical Officer. Chief Medical Officer, I see it as part of the role to be an advocate for all medical care providers. But it is less hands-on and it is more accountable. As Chief of Medicine, I might argue for a new medical directorship, or paying a lot more to a current medical director because what they do is so valuable. As VP MA, I have to figure out how that is going to fit into the budget, and what else we are going to take money away from to make that happen. Again at CMO, it really has to put that into the larger context, “Well if everybody who thinks they need a medical director for everything comes forward and gets more money and does it, how does that work? Systematically, what kind of criteria do we need to have in place? What kind of process do we need to have in place to make sure we’re really being thoughtful?” So it’s a different mix of accountability, both who you are accountable to, and how accountable you are. Certainly CMO requires a lot of delegation. I’m a person who’s used to developing a project and pulling together a team. There are always people on the team who have to do a lot of the work, sometimes most of the work. But to actually just come up with a project and hand it to somebody is very different, for me. I think the financial, regulatory, and contractual complexities in a leadership role are much more real, rather than just things that you know about or decry; they’re actually things you have to work with.

02-01:17:31
Rigelhaupt:
So you mentioned the directors of services. Would those often be physicians that are still in private practice as well, and then they put in some time, and some salary with the hospital?

02-01:17:45
Bigoney:
Right.

02-01:17:51
Rigelhaupt:
Did the need for more medical directors come along with, as you described in the last interview, more and more subspecialties? [01:18:00] And what I’m trying to ask is, how does that come into tension with increased costs in terms of the salaries, but also the traditional way of reimbursement for hospitals has been on services, and what you do, those physicians who are now drawing a salary are not necessarily doing something that is reimbursable.

02-01:18:27
Bigoney:
One part of the answer to that question is that we have to be wise and thoughtful, and we have to only pay for work actually done. It can’t be just a chunk of money and if we need you, we’ll call on you, or maybe you’ll do a little bit of work. It genuinely is for what you do. But if those roles work well, we will all come out ahead. So for example, in our Human Motion Institute orthopedic service line, one of the key roles of the medical directors is working alongside our supply chain people to negotiate the best possible prices on hip and knee replacements. At the same time they are making sure we have quality products and we have an adequate range of products that meets the needs of the surgeons. We can’t just go with whatever the cheapest thing is out there. We have got to have a low-impact and a high-impact knee. We have got to have doctors at the table. It is the same thing with pacemakers or stents. Another example, also from the Human Motion Institute is our trauma medical director for orthopedics devised a pathway for patients who come in with hip fractures to make sure they are stable for surgery quickly, because we know the more quickly people with fractured hips get to the OR, the better they do. If they are not stable for surgery, then make sure we get their medical conditions corrected. But if they are stable for surgery, we try to get them to the OR within 24 hours. That involves coordination between hospitalists, potentially cardiologists, orthopedic surgeons, and the OR. That is the sort of thing that not only improves our quality, but also helps our bottom line. If those patients don’t get complications and if they don’t stay in the hospital as long then that is better for everybody because we get a lump sum for the hip fracture. The goal is what they do will help us provide better care, but also may help us be more cost effective.

02-01:20:26
Rigelhaupt:
That actually leads into my next question, in terms of thinking of how having a physician with an expertise as a medical director of one these programs. In our last interview, you mentioned the importance of evidence-based medicine. And that was part of your interest in internal medicine. How have you seen, particularly in the years that you’ve been a full-time employee with Mary Washington Healthcare, evidence-based medicine be practiced?

02-01:20:57
Bigoney:
We do a much better job at practicing evidence-based medicine than we did when I first went into practice. [01:21:06] That actually is one of the ways that the computerized physician order entry has helped us. As we developed our order sets there are best practice guidelines for each diagnosis. For example, for the treatment of pneumonia, which antibiotics you use, what the duration of those antibiotics is, when you change from IV to PO, who needs oxygen therapy, when do you need to do a repeat chest x-ray—all those things that affect outcome, affect cost, and are supported one way or another, in the literature. I think we really have moved. It used to be everybody argued for the way they did things. Now you have a real uphill battle, if you argue that you like doing things a different way than what the literature supports. We are getting a much more robust literature on what is the best way to do something.

02-01:22:13
Rigelhaupt:
Are there ways that you, with a long interest in evidence-based medicine, I mean, you said it was almost in medical school, or what specialty you were going into. Are there ways that you saw yourself bringing that to the board, when you were a physician board member, and really trying to interject that into the culture of the health care system?

02-01:22:36
Bigoney:
Now, the board as a whole rarely got involved in clinical issues, although the medical affairs committee of the board often gets engaged in clinical issues. I think in terms of advocacy for new programs, one example would be, which physician should be allowed to do which procedures. The consensus of the medical profession, or a particular medical specialty around a certain area, or guidelines—these are of interest to the board. They don’t really want to be educated such that they could practice medicine, but they do want to be assured that somebody is educated and that they can practice medicine in an appropriate way.

02-01:23:37
Rigelhaupt:
In our last interview you also mentioned that you were the first woman to regularly practice at Mary Washington Hospital. And in the latest statistics I found, which I think were from 2011, nearly half of MDs [awarded] now, are women. I mean, near-parity. That’s a significant change in the time span of your career.

02-01:23:58
Bigoney:
It’s a dramatic change. [01:24:00]

02-01:24:02
Rigelhaupt:
What are some of the ways that Mary Washington Healthcare in your time, both private practice and working around the hospital, and perhaps now a full-time employee, seem to make concerted effort to support women physicians?

02-01:24:15
Bigoney:
Certainly the provision of on-site daycare, which is not just for women physicians, but I think to support all women associates. I think we have had policies and practices that have supported women who want to work part-time; some more flexible professional work schedules. When I went into practice people didn’t care if I worked less, but I had to do my full share of call, pay my full share of overhead, and just take home a lot less money. Now, people would say, “Why in the world, that’s not fair. Why would you do that?” And the answer is, that was what you did. There wasn’t any choice. Now there are a lot more opportunities for women. I think in our health care system, we do look at, for example, if we have someone in the community we know is a valuable practitioner, but who wants to practice part time because of family obligations. Are there ways that we can use that person’s expertise or work with that person and help make it work? There are things like some of our office space. We have time shares; if you only want or if you only need two days a week of office space, you can just get two days a week of office space. Of course, I think the move to hospitalists: a lot of hospitalists are women and with the flexibility of a hospitalist’s schedule, they can make that work for them. But also, physicians in the community don’t have to come to the hospital. They can do a strictly daytime practice, which is much more compatible with family life. I think the system as a whole has changed because of women being a larger force; it has necessitated changing. I mean I always said, “You know when I was in medical school and residency, taking time-out to have a baby was very problematic. The system just wasn’t designed for that.” Yet who takes time out from work all the time to have babies? Teachers. What could possibly feel more disruptive than a teacher who’s committed one-on-one to a roomful of students for nine months taking time-out to have a baby. Yet because young women are the people who have traditionally been teachers, and they get pregnant and have babies, it’s a system that’s just evolved to support it and make it work. I think medicine has moved from a profession that didn’t quite know how to do that, to one that now can do it. I’ve got a 2:30 meeting, so we need to—and I feel like we’ve talked about everything but history. [01:27:00]

02-01:27:18
Rigelhaupt:
So switching, going to the history itself, what are some of the milestones, practices, achievements since you became a full-time employee in 2001, that you would point to as really key areas for the organization’s expansion?

02-01:27:42
Bigoney:
I think the opening of our palliative care unit. Of course, that’s also very close to my heart. Our move to a 24/7 staffed intensivist model in our ICUs. Our development of a level-2 trauma center with designation and recognition. Our embracing of a hospitalist model, not only in adult medicine, but also in pediatrics, neonatal ICU, and obstetrics. Our STEMI program, with cardiologists 24/7 who have made a commitment to get here quickly. Our centers of excellence, although I think there’s been some evolution and changes in those; and there will continue to be evolution and changes. I am thinking about cancer, about neurosciences, about orthopedics, and heart and vascular disease. Women’s care as areas of focus in themselves that go beyond, for example, OB/GYN doctors; taking care of women is a lot more than the practice of OB/GYN, even though they are obviously key. Taking care of heart and vascular disease is a lot more than cardiologists—it is their whole programs, their physicians that cross specialties, their outpatient/inpatient, and their trained hospital staff. That vision of excellent provision, of medical care to patient groups and disease groups. It is a different way of thinking about the practice of medicine.

02-01:29:48
Rigelhaupt:
You just mentioned, in terms of thinking about more than specific medical care, something that, in terms of obstetrics, nutrition, to prenatal care, [01:30:00] versus complicated labor and pregnancy, you know vascular disease, high blood pressure—

02-01:30:11
Bigoney:
Education in the schools, cholesterol management, peripheral vascular interventions by interventional radiologists, appropriate screening for vascular disease. There are a lot of different components for optimal care. It is not just having a good cardiologist when you come in the hospital with your heart attack.

02-01:30:39
Rigelhaupt:
And is this one of the benefits of a health care center in a regional medical center—

02-01:30:45
Bigoney:
Yes, absolutely.

02-01:30:47
Rigelhaupt:
— in a sense, being distinctly different from when it was a community hospital, and a hospital, that it’s acute care, and physicians doing fee-for-service and treating their patients. So what are some of the ways you’ve seen the organization make a concerted effort to really broaden out into questions of primary care and public health?

02-01:31:07
Bigoney:
We’ve been very thoughtful about making sure that all the key specialty areas are covered. In the old days, if there was a specialty you didn’t have, you just sent it out. I think we’ve been thoughtful about the specialties that we have. I think we have made efforts to align with primary care physicians through recruitment, through integration earlier on with Pinnacle Health, and now with the Healthcare Alliance through bringing community physicians, even those who don’t actually see their own patients in the hospital, into some our key initiatives. For example, our Physicians Informatics Council with our information system, or our Primary Care Advisory Board, which is a group of primary care physicians in the community who come in and meet with hospital leadership to talk about interface and needs. I think we have really tried to keep that conversation and that relationship going.

02-01:32:13
Rigelhaupt:
And as you hinted at, both earlier in the other interview, there have been moments of distrust between the hospital and physicians in the community. But that’s true of nationwide, I mean hospitals, and physicians don’t always see eye-to-eye. What are some of the ways that you’ve seen the health care system really reach out to physicians, to build up trust, to make some of these programs, and to bring in physicians into some of these, in a way that they might have otherwise kept the health care organization at arms length?

02-01:32:52
Bigoney:
I think some of the joint venture opportunities that we’ve given physicians, which are win-wins. [01:33:00] Everybody can win financially, as well as by being committed together to the same goals for good patient care. I think some of the education, some of the forums we’ve offered to the community, and most recently, again, the Healthcare Alliance, which clearly has been a transparent conversation about we can’t do what we need to do from within the walls of the hospital. We’re really talking about taking care of populations, and that requires inpatient care and outpatient care. It requires aligned providers in the medical care system. We have also had the medical services organization, which has reached out to physicians to offer services that physician’s offices may want to purchase from us. For example, if they need help with office staffing, insurance credentialing for payers, or electronic medical record purchase and support. We have a large pool of employees and applicants and because of the resources that we have, we may be able to do that in a way that is more economical. If they trust us and we are aligned with them, it may help them run their practices better.
[End of Interview]

Interview 3 – January 29, 2014

03-00:00:00
Rigelhaupt:
It is January 29, 2014. I’m in Fredericksburg, Virginia at Mary Washington Hospital, doing another interview with Dr. Bigoney, and I’m wondering, to start, if you could think back on the first conversations you can remember, perhaps even kind of water cooler talk, about the possibility of Stafford Hospital.

03-00:00:35
Bigoney:
We had had conversations for quite some time about what we needed to do to increase our bed capacity. The first conversations were prior to the building of the additional wing that added the beds that are currently the wing that we refer to as the west wing. Although I don’t think it actually is, interestingly, to the west, but we call it the west wing. At that time, we decided to add more beds on this campus rather than going to another campus. It didn’t take very long for those beds to fill up. It was clear as rapidly as the population in our service area was growing that we were going to have to do something different. We were getting long wait times in the emergency room because we didn’t have beds to move patients up to. We really had maxed out our ability to expand on this campus. If we expanded any more, then we didn’t have enough parking, we didn’t have enough food services, and we didn’t have enough HVAC services. We needed to either make a decision to stay this size and let someone else come in and serve the community or to expand. Once the decision was made that we needed to expand, then the conversation started about what that would look like and where that would be.

03-00:02:02
Rigelhaupt:
And what do you remember about the decision to choose Stafford over other locations?

03-00:02:08
Bigoney:
There were a lot of conversations. Spotsylvania locations were considered. We had some consultants who told us the area for growth would be out Route 17 toward the Warrenton, Hartwood area. But eventually, looking at the demographics population growth and times to get to hospitals, we settled on Stafford. A lot of conversation about the river—because rush hours, the bridges over the river become bottlenecks that are not easily remediated. For patients with acute illnesses and for EMS providers, there would be a lot of advantage to having a site to the north of the river. [03:00]

03-00:03:06
Rigelhaupt:
So at the time that you’re talking about and deciding on Stafford, how much input was there from you as a physician leader of the organization, and your working with the board and the administration about what the new Stafford Hospital would look like?

03-00:03:26
Bigoney:
At that time, I was not actually on the board. I really was engaged in some general conversations, but was not very involved in specifics in terms of definition of services, what kinds of beds we would have, or how many beds we would have.

03-00:03:51
Rigelhaupt:
Well, thinking about the physician community, what was the response to the possibility of building Stafford Hospital? And I’m wondering if you could perhaps compare and contrast to the building of this hospital, where there was some reservation about the expansion and the growth of the new facility here.

03-00:04:14
Bigoney:
There were a lot of medical staff members who had reservations. There were people who had reservations about the location. I think the biggest issue for the medical staff, though, was that we had always been a one hospital community, and that makes life much easier as a doctor. All your patients go into that hospital. You only have to round on one hospital. When you’re on call, you only have one emergency room to worry about having to come into. Now having to split up rounds to two sites, spend time on the road, and potentially get consults at both places—so from a quality of life medical practice point of view, there was a lot of concern.

03-00:05:00
Rigelhaupt:
Was there anything that you can remember MediCorp, at the time, doing to try and alleviate some of the concerns from physicians in the community?

03-00:05:10
Bigoney:
There were a lot of efforts to align with physicians. For example, talking to physicians about how might it work for your practice to have a satellite office location up there. If you may be interested in doing that, how can we work with you to see what the financials would look like and to see what space you would need? I think one good example is the development of the timeshare concept in the office building there. It may only work for you to have someone in an office two days a week, or three half days a week. We can make that happen without having you have to rent full-time space.

03-00:05:55
Rigelhaupt:
At the time that the COPN was approved, [06:00] HCA Spotsylvania Regional Medical Center was also approved. Well, how did the physician community respond to two new hospitals being approved in the area?

03-00:06:15
Bigoney:
What I said about their concerns about Stafford multiplied because they were looking at a potential of three hospitals. There was some division in the medical community. There were people who had a sense of excitement about a competitor coming in. And frankly, HCA did a good job targeting and reaching out to certain key physicians to persuade them and to share their vision of why they thought this would be a good thing for the community. There were other physicians who were strongly aligned with Mary Washington who were concerned, and didn’t particularly want to practice at the HCA hospital. Although in some cases they knew if they didn’t, then HCA would be compelled to bring in physicians in their specialties who competed. For many doctors, I think there was a sense that they would be forced to practice there, thereby meaning that they had to be in at least two and potentially three hospitals.

03-00:07:21
Rigelhaupt:
Did the approval of HCA’s hospital change the discussion about the possibility of the Stafford Hospital thriving, that the sense that it would have competition, in some respects, both from this facility, but also from HCA?

03-00:07:41
Bigoney:
It was a concern. I don’t think it was ever a big enough concern that there was ever any talk about turning back from the decision to build Stafford, or about scaling back the number of beds we built at Stafford. There was a feeling that Stafford Hospital would expand our service area, whereas Spotsylvania was building in our existing service area. Spotsylvania would be more competition for our existing patients. Stafford would ideally add a new group of patients.

03-00:08:26
Rigelhaupt:
So one of the things that’s come up in the interviews is the sense that despite the growth over the past twenty-five years, that there were no hospitalists, that there are hundreds of physicians on staff now, versus under 100, that there’s still been a good relationship between the hospital and organization, and the physician community, despite the growth. [09:00] As a physician and a physician leader within the organization, what were some of the ways that you wanted to see that culture be reproduced at the new Stafford Hospital?

03-00:09:10
Bigoney:
Stafford is certainly a different culture and a different medical community. The idea of physician leadership and physician engagement is the idea that physicians are some of the most valuable customers for a hospital. We want to make it a place they wanted to come and see patients, with amenities like providing them with free food, a nice physician’s lounge, and having medical support services to try to make their lives easier. We want to have organizational closeness with their physician leaders, have their physician leaders on the health system board, and have their physician chiefs attend our medical affairs board committee so they could both have a voice and listening ear.

03-00:10:07
Rigelhaupt:
And that’s been able to be implemented and sustained since Stafford opened.

03-00:10:12
Bigoney:
Stafford has a very good relationship with its physicians. That’s one of Cathy Yablonski’s strengths: she is very mindful of the importance of reaching out to, aligning with, and supporting her physician community.

03-00:10:35
Rigelhaupt:
Were there any programs or practices within the new Stafford Hospital that you thought were really important to begin with? And trying to compare and contrast how much the services offered within Mary Washington Healthcare has expanded in the time that you’ve been here.

03-00:10:55
Bigoney:
Certainly a vital, well-staffed emergency department; to build it not just as an elective procedure hospital, but to have full-service emergency services. To have an ICU that could take care of all but the very most severe cases. I think to have a strong OB program. As a beautiful new hospital we had the opportunity to build really appealing obstetrics patient rooms and be patient-friendly, a little more contemporary than what we have here. That seemed like an important market share to be prepared to reach out to.

03-00:11:48
Rigelhaupt:
Was there anything you can remember the physicians wanting to see in terms of how rooms were designed, operating rooms, the emergency department, as the new Stafford Hospital was being designed and built? [12:00]

03-00:12:03
Bigoney:
I particularly remember being involved in conversations around the ICUs. What those rooms would look like and what the layout of the equipment would be. We had done that when we built this hospital too, and you live and learn. Some things you learn are great. We’re so glad we did that and we want to be sure we replicate that. Some things are, “That didn’t quite work the way we thought it would. We wish we had, for example, a little more room for equipment or for people to be in the rooms.” That really probably is the main area that I can remember being involved in. I know there were physicians involved, for example, in the design of the obstetrics suite and the emergency department.

03-00:12:56
Rigelhaupt:
So going backward in time, to try and think a little bit about values within the organization, one thing that is probably relatively common in any organization is that when there’s new leadership, there’s a new discussion of values. What do you remember about discussion of values when Mr. Rankin was hired as president of the hospital in 1992?

03-00:13:26
Bigoney:
The values of the health care system, or the values of the medical community?

03-00:13:34
Rigelhaupt:
Well, was there new emphasis on it? Was there anything that changed or that he tried to bring to the conversation that you can remember that, as a physician, that you noticed as new?

03-00:13:48
Bigoney:
Certainly the way of relating to physicians on behalf of the health care system was different. Mr. Rankin has always valued relationships with physicians, and always valued open conversation and communication. He made a lot of effort to reach out to get to know the members of the medical staff, the medical leaders, and to hear their concerns. I think there was a sense of transparency and communication. I think there had always been mutual respect, but making that more explicit. That was new. We also, during that time, were moving in our journey toward our organization ethics program. I think Mr. Rankin has long been a visionary leader in terms of seeing the importance of really talking about your values, defining your values, revisiting them from time to time, and truly using them in conversations with decision-making.

03-00:15:00
Rigelhaupt:
Did that change or continue in a similar way when he became president of MediCorp in 1995? Did that change his responsibility and his relationship with the physicians?

03-00:15:16
Bigoney:
Initially it did not. Over time, I think his relationship with the medical staff has remained good. The milieu of the practice of medicine has changed so dramatically in that time. The hospital is no longer the center of the universe for many physicians. In fact, many physicians don’t ever even come to the hospital. The growth of his administrative responsibilities means that he no longer lives in the hospital; his office is no longer here. The demands on his time are such that although he would love to be at each hospital more than he is—and he loves going out on the floors and being visible, talking to doctors, talking to nurses, and so forth—he just can’t do as much of that as he used to and as he would like to. And then the broader physician community is less aligned with and engaged with the hospital in their day-to-day lives than they were at that time.

03-00:16:38
Rigelhaupt:
So one of the things he mentioned in a recent interview was a patient story at board meetings, and I’m not sure if he meant at perhaps a medical affairs committee, or the full board meeting. I didn’t clarify that in the interview. But it seemed to ring a bell. So I’m wondering if you could tell me about when you remember this starting, and as a physician, what you thought about patient stories being told at the beginning of board meetings.

03-00:17:13
Bigoney:
I was probably not on the board at the time that that started. That has evolved now. Instead of a patient story, what we have is more a story of something that we’re doing well, that’s new, or a chance to get to know a person or a process. But the idea of reminding the board that this is about taking care of patients, and that this is about the people who are our patients, is certainly something that has been important for many years.

03-00:18:00
Rigelhaupt:
Do you see any connections to what you described in the ethics process? Because I was struck as he told me that you had said, in terms of when an ethics committee meets, often the first thing that happens is tell us about the patient, tell us the patient’s story. Is there a way in which that, perhaps going to the board, came out of the ethics committee process, or do you see a connection between those?

03-00:18:26
Bigoney:
I don’t know. I think there could be a connection. I think that way of thinking about things around values and around people as individuals. While you have to think as a system, you don’t make rules and make processes for the individual. You create those to serve everybody’s needs. But when you see something that’s either gone well and you feel good about doing the right thing, or something that you should have done better and have a conversation about how, from now on, you need to do the right thing. I think that whole concept of we do have an obligation to do the right thing for people, and an obligation to talk about it and take seriously how we do it. I think there’s a close connection there.

03-00:19:22
Rigelhaupt:
I’m trying to think this question out. At the same time that this has been continued to be implemented, of really thinking about patients and stories about them, medicine has gotten increasingly high-tech, and as you’ve talked about, there’s been a concerted effort to bring in evidence-based medicine, and that would involve data. Is there a tension between the stories and the narrative and the technology and the data, or how do they fit together in terms of building a successful health care organization?

03-00:20:05
Bigoney:
There have been tensions through the years. I think we’re coming to a place of peace between those tensions now. I mean, many years ago doctors used to talk about cookbook medicine, and nobody’s going to tell me how to practice medicine; I do it my way. We didn’t really question. Surely if your way and my way are completely different, it’s not a given they’re both right. One of them may actually be better than the other one, in which case we ought to both be doing what’s better. I think physicians have gotten past that. Clearly we recognize the importance of the evidence. We also, however, have moved to a place that the evidence is not the gospel. It’s not black and white because you are dealing with individuals. What the evidence says may be great overall. [21:00] Sometimes for some people it’s not. One classic example is the person who has multiple medical problems, and you have conflicting guidelines about what to do to manage this problem while you’re managing that problem. Another is people who are quite elderly, and their life expectancy is limited. We really have to wonder sometimes, really, how many finger sticks a day do we need to put them through for their blood sugar? How many colonoscopies do we need to put this poor, frail, elderly, confused person through? I think we are doing better balancing the goals of the individual with the objective medical guidance. That is also really a timely, common sense way to practice that we have to do now because money is not unlimited either. If we’re going to spend the money we spend on health care wisely, we also have to make sure we’re not doing things that don’t do any good or that don’t align with people’s goals.

03-00:22:12
Rigelhaupt:
Some of these changes you just described in terms of being very conscious of the number of sticks and procedures that someone will go through, and using the evidence in nuanced ways. How do you distribute those ideas through a medical community, which you described as more dispersed? For example, when you started you might see each other at meetings, in the lunchroom, and it would be easy to disperse new ideas. How does Mary Washington Healthcare get these ideas out to the physician community?

03-00:22:52
Bigoney:
It really is challenging because doctors don’t attend meetings the way they used to. They don’t always come to the hospital. We do a variety of things, some of which work very well and some of which we wish worked better. We have a nice physician newsletter that we send electronically to everybody. We have internal educational programs that are open to all the physicians in the community, whether they are on our staff or whether they come here or not. We do outreach presentations in the community, like our center of excellence conferences. We have our VHVI heart conference in a couple of weeks, and we make a point of inviting all the community physicians to that. If it’s something that is not so much medical care as, perhaps, new legal guidelines or new policy and procedure guidelines, we use our physician liaisons to go out to the practices and share that information. [24:00]

03-00:24:10
Rigelhaupt:
Nursing is a huge part of a hospital. You’ve been on the medical staff for twenty-five years, roughly.

03-00:24:18
Bigoney:
Thirty.

03-00:24:19
Rigelhaupt:
Thirty. Okay. Well then, starting in a big general way, what are some of the ways that you’ve seen nursing practices at the hospital change over the thirty years that you’ve been on the medical staff?

03-00:24:36
Bigoney:
I may have already told you this story. When I hadn’t been in town very long, an older physician was complaining about the nurses and told me that it used to be when he came on the floor, they would all stand up; now they don’t all stand up anymore, which he was very frustrated by. I think you might get a chuckle, and you’d probably just get a look as if you were speaking a foreign language if you said something like that to a nurse now. I think nurses have gone from being the handmaidens of physicians and being people who obeyed physician orders, to being people who are professionals in their own right and patient advocates. But even more importantly, being members of the team. Even though the team may have a captain and somebody who feels ultimately accountable, in some areas, they are really the captains of the team. I think more and more nurses realize and see that. For a number of years, nurses saw themselves as patient advocates, but saw that as frustrating because they didn’t necessarily have a voice. They were fighting for the patient, but nobody was necessarily hearing it. Now I think there may still be a little bit of that, but I think most nurses now certainly feel empowered. I don’t know if I told you about the doctor-nurse game. There was a New England Journal of Medicine article a few years back. The doctor-nurse game is the old game where the nurse knew what needed to happen, but she couldn’t say it. She had to help the doctor get there. “So doctor, did you look at his legs?” “Oh, no.” “Well, let’s take a look.” “We’ll look.” “Look, he’s got swelling.” “Oh, yeah, I’ll order a diuretic.” “Well, look, the swelling is more on one leg than the other. Do you think that one is—?” “Well, yes. We’ll order an ultrasound. Maybe the patient has DVT.” But the nurse couldn’t say, “Doctor, I think this patient may have a DVT. Would you take a look at the leg? You need to order an ultrasound.” She had to play a game where she pretended that she didn’t know. Basically the article was nurses are tired of playing. [27:00] Now they are, in fact, empowered. They don’t have to hide what they know and what they do. They really are members of the team.

03-00:27:16
Rigelhaupt:
Are there ways that the hospital and the health care system has tried to facilitate nurses being more active in patient care and trying to skip the game, so to say?

03-00:27:30
Bigoney:
Nursing certainly has a governance model. I bet if you’ve talked to Marianna [Bedway], I’m sure she has shared it with you. Probably the biggest way we currently try to align medical care and nursing care is through our center of excellence process because those are groups that are not hierarchical groups. They are groups that everybody who needs to be at the table for this specialty patient care is at the table having an equally empowered conversation. For example, if it’s an orthopedic surgery center of excellence, then physical therapy is there, nursing is there, orthopedic surgeons are there, anesthesiologists are there, internists who do medical clearance are there—nursing really is part of that whole provision of care team.

03-00:28:38
Rigelhaupt:
Is this one of the unexpected but beneficial byproducts of starting subspecialty care? That to start some of the programs and develop them as you have, requires a team as you described it, and not just a physician leader. Is that one of the benefits of some of the subspecialties that that culture of teamwork has become more prevalent in the organization?

03-00:29:05
Bigoney:
I think so. I think many of those nursing leaders are seen by the physicians as absolutely key people for their ability to take good care of patients. That has bred better communication and mutual respect, and an understanding of what one another do.

03-00:29:28
Rigelhaupt:
Can you think of one of the subspecialties where it’s been most successful?

03-00:29:33
Bigoney:
A couple of them. One is surgery. Surgeons depend on how the OR runs, the post-op care their patients get, their wound care, and their ambulation. The national quality measures that we have are both physician- and nursing-dependent. If either one of them doesn’t hold up their end—if the doctor doesn’t write the order or the nurse doesn’t carry the order through in a timely fashion or notice the doctor forgot to write it and remind him or her—then it doesn’t happen. [30:00] That’s been a collaboration in which the surgeons will really go to the wire for their nursing leaders. OB is another good example, and one example I would give of that is the elective delivery prior to thirty-nine week process. National literature shows forty weeks is term for a baby. Traditionally, a lot of women get really big and really tired of being pregnant and want to deliver their babies a little bit early. Or maybe the doctor is going out of town and it works better to go on and induce labor at thirty-seven or thirty-eight weeks. The medical literature shows that a lot of the baby’s brain growth is in those last few weeks. And in fact, delivery prior to thirty-nine weeks—although most babies who are delivered prior to thirty-nine weeks do just fine—if there’s no medical reason to deliver a baby early, they are better to wait. It really is something that has required collaboration between the medical leaders saying to the obstetricians, “I don’t care how much you want to keep your patient happy. I don’t care how tired your patient is of being this big. It really is the right thing for quality care to do to wait. If you try to schedule, we’re not going to let you schedule without a medical indication.” Then the nursing following through on that and saying, “No.” We went from actually one of the worst rates in the state to, in fact, tomorrow we’re receiving an award from the Virginia Hospital and Healthcare Association, for our low elective delivery prior to thirty-nine weeks rate. That really is, again, medical leadership and nursing leadership; neither one could have done that alone.

03-00:32:05
Rigelhaupt:
So in the years that you were chief medical officer, were there things that you tried to implement or emphasize in terms of enhancing physician-nurse relationships in terms of patient care?

03-00:32:19
Bigoney:
This is actually my first year as chief medical officer, although I’ve been in a variety of roles through the years. Back when I was chairman of the department of medicine—and I guess that was around 1990, 1991. I was chair for a couple of years. We had physician-nurse collaborative practice committees in which a group of the nurse managers from the various nursing units and physician leaders sat down and talked about what issues we can work on together to do better. That process kind of went by the wayside. [33:00] Then for years we had a committee, a physician-nurse committee, that had other representatives like informatics—and I can’t remember, I think we called it the clinical practice committee, maybe—that looked at ways to problem-solve and work together better. Right now, we don’t actually have any of those forums. Although again, we tend to do our work through the quality councils, the centers of excellence, and having nursing at the department meetings. I think rather than a separate doctor-nurse process, there is more a sense of problem-solving and working together through specific teams.

03-00:33:52
Rigelhaupt:
Was this something that was relatively easy to transfer and build into Stafford Hospital as it developed and grew in the last four years?

03-00:34:03
Bigoney:
I think Stafford’s culture is different and was different from the get-go. But I think starting with a new hospital, a small staff, and a small number of patients, made it natural and easy to establish those relationships. There was quite a bit of turnover in nursing leadership early on at Stafford, which was something of a barrier to trust and to the kind of nursing-physician collegiality and teamwork that we hoped for. The leader that we have there, Deb Marinari, is excellent, very physician-friendly, as well as a nurse advocate. We’re thinking she’s a long-term player. I think now that’s going very well.

03-00:35:08
Rigelhaupt:
One of the things about hospitals, there’s an intersection of the mission, patient care, and as you mentioned, financial constraints, in one of our interviews, I think you mentioned Dr. Bernstein was hired in infectious disease at one point, and that was an area that the hospital knew it needed to have but wouldn’t necessarily produce revenue. And the question is not so much about which areas produce revenue or not, but how it gets talked about with so many different backgrounds, in terms of physicians and then there’s MBAs, and people in public health. When the organization’s thinking about a new program or where to invest in one, how have you seen different backgrounds shape that discussion? [36:00]

03-00:36:06
Bigoney:
Very differently. The medical people look at what’s the medical evidence for this procedure. Is this a procedure that we have somebody who wants to do? What’s the training required to do it? Or if it’s a program or a new specialty, what is the need? Where are we having to send people to now? Can we do it and do it well? What are the upside, downside, complications? A little bit of thought to the money, but that’s pretty secondary. The understanding being even if something loses money, if we really need to do it, we really need to do it. We recognize we need to do it as economically as possible and cut our losses, but we need to do it. The business people come at it from absolutely the opposite side, which is to run the business metrics: “Okay. What volume can we expect? What’s the expense? What’s the capital expense? What’s the overhead? What’s the return on investment? What’s the effect on market share?” Then once they’ve done all that, is this something that our medical staff supports and that would be good for patient care? It’s not that either side doesn’t recognize the other, but it’s where they put it in their priorities and their approach. I think that does create a little bit of tension, sometimes, in which programs we prioritize and adopt.

03-00:37:53
Rigelhaupt:
Could you talk about an instance, maybe, that you can think of, where there was a program that was debated a lot in terms of that tensions, but ultimately was implemented, and how you got from that debate to actually implementing it?

03-00:38:12
Bigoney:
I guess one example would be the Liposorber provision of services. Lipsorber is a machine that is kind of like dialysis. People come in, depending on the severity of their disorder, once a week or every other week, and essentially get the blood cleaned to take the cholesterol out of the blood. For a certain small group of people who either can’t tolerate cholesterol-lowering drugs, or have very severe cholesterol elevation, particularly some hereditary forms of cholesterol elevation, it will lower their cholesterol levels. It is not a terribly expensive technology, although it certainly has substantial costs. [39:00] One of our cardiologists had been advocating for it for a number of years. Some of our other cardiologists werenot really necessarily convinced of its value because the medical literature is not particularly compelling. Our business analysis and financial people put together a financial pro forma: what would it take in terms of equipment, staffing cost, what’s the reimbursement, and how many patients would we have to have to get it to break even. The answer was if we could have eight ongoing patients, it would be a break-even service. It’s probably never going to be a moneymaker. If we have less than eight, it could lose substantial amounts of money. Then it was taken to the cardiology division with that understanding. If you vote for it, if you want to stand it up, you’ve got to get us eight patients, otherwise we will not be able to continue the program in the long term. With that understanding, we stood up the program. It’s relatively new. I think we’re at two or three patients now. I’m not sure if we’ll get to eight. I think if we don’t, there will be pushback from the cardiologists about whether to continue it at substantial losses or not. That will be a conversation we’ll have to have. That balance between the conversation with the clinical people and the money people.

03-00:40:26
Rigelhaupt:
Are there other programs—trying to think more specifically around public health and primary care and preventative medicine, which are generally not where acute care hospitals generate a lot of revenue—that the organization has invested and had these debates about programs and revenue, but ultimately chose to invest for community health?

03-00:40:57
Bigoney:
One of those that has been back and forth through the years has been geriatrics care, which is a much-needed area of primary care. At one point we did have a senior care center. Unfortunately, that became so financially unviable that we then shrank it down. We still had an outpatient clinic to do geriatric assessment and senior work. Then we co-invested in a geriatric practice that unfortunately, for a variety of reasons, did not survive. That is an area that we have always had a commitment to. What we’re doing in that area now is concentrating on those patients who don’t otherwise, necessarily, have good physician access—those patients who are homebound. We have a nurse practitioner in a physician-overseen house-calls program to go take care of the elderly who are in their homes and for whom it’s difficult to get out to see a physician. [42:00] That certainly is not a money-making and never will be a money-making, business, but it’s something that we feel an important commitment to the community to do.

03-00:42:12
Rigelhaupt:
So that leads into a next set of questions about community benefit, which is emphasized within the organization. What do you remember about, as a physician in the community, the origins of the Community Service Fund and the Community Benefit in the early 1990s?

03-00:42:33
Bigoney:
I was actually on the board, or at least at the Medical Affairs Committee, but I believe I was on the board when the Community Benefit Fund was initiated. I remember that Joe Wilson had gone to a meeting somewhere and heard about this concept. And we had at that time gotten some money. I think it was probably disproportionate-share Medicaid money; we had gotten a million or two dollars. He suggested putting that money as seed money for a fund that would be used to fund projects related to health in the community. And then, a group of people—a community advisory group—was also set up, at that time, as well. That was a pretty dramatic, new concept. At that time, I think everybody on the board and in the organization was excited and bought in. Through the years, there were some people who didn’t, necessarily, see it the same way. I can remember being on the board later, after a period of time that I was not on the board, and having a different board member—and, by this time, it was a board with a fairly different composition—said, “Well, we got the Medicaid money back. Like we always do, we’ll put it in our Community Services Fund.” And one board member saying, “Why in the world would we take however much money it is—a million dollars—and put it in a Community Services Fund? Why in the world would we choose to do that with it?” There has been some back-and-forth about that. There have been a lot of debates about how that money is used. I do remember fairly early on—and we had a different chief financial officer—a conversation about a mobile van that we had at one time for underserved services. Someone else was talking about new equipment we needed for the ORs, and which of these things we would spend the money on. We had a physician who was raving a little bit about the OR, and how ridiculous it was to spend the money on this van, and so forth. Our chief financial officer pulled our mission statement down off the wall and said, “Well, let’s just take this down and throw it away then, if that’s the way we’re going to look at things.” [45:00] Very interesting for the chief financial officer to be the person who did that, but a very striking demonstration of, okay, if we’re not going to live our mission, then we need to not pretend that it’s our mission.

03-00:45:22
Rigelhaupt:
And the funding stayed, for the van?

03-00:45:25
Bigoney:
It did. Later on, after a number of years, we had other services. The van no longer met its original need and we moved that money. But, no, at the time, the van was a useful and valuable service.

03-00:45:45
Rigelhaupt:
It’s a dramatic story, and, I think, gets at this question that I want to ask, because there’s no question that Mary Washington Hospital, like most not-for-profit community hospitals and as a health care system, does not get reimbursed for all of the care that is provided.

03-00:46:04
Bigoney:
Absolutely.

03-00:46:07
Rigelhaupt:
So, there would be a very logical argument, perhaps from this board member, perhaps from the physician, about the OR. That where there is revenue—there’s no question that the hospital itself is a community benefit—it should be reinvested in the organization. And it sounds like there has been a pretty strong commitment to using some of this revenue through the Community Service and the Community Benefit Fund, to go out. Why do you think that has happened?

03-00:46:37
Bigoney:
I do think it is the vision of the board, and I do think it’s about living the mission. I really think the mission is not a marketing slogan. It truly is what our health care system is here to do. We’re very aware of that. Now, obviously, we have to provide adequate equipment in the OR. Obviously, we have to provide a facility in which people can provide state-of-the-art care, and you can’t outreach into the community if you can’t provide the basics for excellent care here. But, over and above that, there is an obligation that we feel to reach out to the people in the community. I think some of that has to do with our sense of place in our community.

03-00:47:40
Rigelhaupt:
Has there been, generally speaking, a positive response from the physician community about the ways in which the health care organization has provided a community benefit?

03-00:47:54
Bigoney:
Absolutely. Of course, the Moss Free Clinic was a joint project by the medical society and the health care system. [48:00] Our medical community has always been very supportive in donating time and donating free care. The health care system has been extremely generous to the Moss Clinic, with funding and with in-kind services without charge. That’s a shared vision and we all agree. It’s a population that we want to take good care of, and meet their needs. We have a lot of physicians who have passions for various community projects, groups, and various disease entities. I think the health care system’s willingness to reach out and help support some of those volunteer efforts really resonates with our physicians.

03-00:48:58
Rigelhaupt:
In the early years of the Moss Clinic, did you see any examples—and I know I’m using contemporary language and reading it back—of experimentation, or ways in which there was integrated care? Because it was a joint venture from the health care organization and the physician community. There wasn’t necessarily a plan, but did you see physicians and the health care organization experimenting with integrated care through the Moss Clinic?

03-00:49:33
Bigoney:
I’d have to think about that. Honestly, I’m not sure I could say that that’s something I saw. In fact, I think there’s been a little bit of a struggle to integrate care for the Moss Clinic patients. Certainly, I guess the one thing I would say is that the Moss Clinic patients, generally, do see the Moss Clinic as their medical home. Perhaps, in that way, unlike other patients who may specialist-shop or may get their cardiologist to refer them to a gastroenterologist when it turns out their chest pain is non-cardiac, and get far away from the primary-care base in which they started. They go see their dermatologist and go get their cataracts off with their ophthalmologist. And nobody quite knows what anybody else is doing. Certainly, the Moss Clinic patients know that is their medical home. That’s where they check back in. That’s where all their records are. That’s where they get their authorization for whatever studies or specialists they see. In that way, there probably is integration that’s always occurred.

03-00:50:48
Rigelhaupt:
Part of the reason I wanted to ask is that there’s been a recent development with Mary Washington Health Alliance, in terms of an integrated provider network. And I’m wondering if you [51:00] think that some of the history of the relationship between the organization and the broader physician community facilitated the creation of this integrated provider network?

03-00:51:13
Bigoney:
I think so. I think our history of working together on a variety of projects—Moss Clinic being one; Ambulatory Surgery Center being another—created the idea of trustworthiness on both sides. There are examples of ways we can work together that are win-win. This is not just about the health care system looking out for its own needs and taking advantage of physicians.

03-00:51:52
Rigelhaupt:
Again, this is forward-looking, and it’s very new, but do you think the new Health Alliance will continue to reflect the values of Mary Washington Healthcare as an organization?

03-00:52:06
Bigoney:
I certainly hope so. From what I’ve seen so far, I believe that will be the case because there is a lot of talk about value and a lot of talk about quality. With value, we generally say we’re talking about quality plus service or satisfaction, divided by cost. There is that vision that this is not just, or not even primarily, about cost.

03-00:52:52
Rigelhaupt:
Going back to the early 1990s, about the time the new hospital opened, I think US News and World Report launches its “America’s Best Hospitals” in 1990. And there’s a way in which it seems like the press is ranking. Did the new attention from media sources like US News and World Report, and these sorts of rankings, in terms of public relations, have any influence on some of the directions you saw the new hospital taking as it expanded in the early 1990s?

03-00:53:43
Bigoney:
I think everybody values being highly ranked by various organizations, although some of the criteria those organizations use are pretty subjective or narrow. [54:00] Some of them are actually a little bit odd. Nonetheless, being ranked is something that people do value. Maybe not so much US News and World Report; but we’re always excited if we have a service that appears here. But things like the publicly reported HealthGrades, Hospital Compare, and the publicly reported data, for example, on the cardiac surgery program, we do strive to excel. Obviously, we want good programs that are reflected with good data. But we do also look at what those criteria are. It does help you focus on which areas you’re doing well in, and which areas you need to work on and to strengthen.

03-00:55:06
Rigelhaupt:
Do any of these rankings shape, from what you’ve seen as a physician, marketing to two sets of customers? There’s a way in which hospitals have physicians as customers, but patients as customers. Have you seen this shape how the health care organization markets to physicians and patients?

03-00:55:35
Bigoney:
Sure, absolutely. We absolutely publicize awards that we win and best lists that we or our physicians get listed on. Probably, whether you are on those lists or not, the lists are probably given more value than they really deserve. At the same time, it is something that patients look for, and, I think, to some extent, physicians look for, too.

03-00:56:10
Rigelhaupt:
The last question I’ll ask is, broadly speaking, what programs or services have you been most proud of Mary Washington Healthcare launching in the thirty years that you’ve been on the medical staff?

03-00:56:31
Bigoney:
Certainly, I think our cardiac-surgery program is something that I’m very proud of. We’ve done a real community service with that. Our Center of Excellence work. In fact, I think our whole cardiology program and the direction in which it’s developed with our electrophysiology services now moving toward hybrid lab services are something I’m proud of. I’m proud of our extension into surgical subspecialty medicine. [57:00] We don’t do burn, we don’t do bariatrics, and we don’t do transplant, but we really have subspecialty surgeons in all the other areas. I think our cancer program has been very exciting. When we first got our Cancer Center and our first linear accelerator to a truly integrated program with research, with radiation therapy, chemotherapy, palliative care, and end-of-life care—integrative medicine means bringing in complementary medicine providers for our cancer patients. That really has been a global way to look not just at cancer, but to look at people with cancer: people diagnosed with cancer, people surviving after the cure of cancer, people being treated, and people dying of cancer. That whole continuum of care.

03-00:58:06
Rigelhaupt:
I guess my last question would be, is there anything you’d like to add or anything that I should have asked and I didn’t?

03-00:58:15
Bigoney:
Gosh, as many times as we’ve met, it seems that surely you must have asked everything by now.

css.php