Michael Hewitt

Transcript

00:00:05
Rigelhaupt:
It is January 20, 2015. I am in Fredericksburg, Virginia, doing the oral history interview with Dr. Michael Hewitt. And to start, I would like to ask you about your earliest memories and your first experiences with Mary Washington Hospital.

00:00:22
Hewitt:
Yes. When I was in residency at Duke, I wrote a number of letters asking for a private practice job. My earliest memory is seeing Mary Washington Hospital in Fredericksburg as an attractive job opportunity. Writing a letter, I was advised by a chief resident and other people that knew, “Make sure you follow your letters with a phone call.” I called and my first personal contact really with the group was when Dr. David Scott answered the phone. I still remember that, what a friendly, wonderful guy he was. Of course, we were looking for a nice group of people to practice with. Based on that conversation and my CV looked good enough, they invited me out for an interview. My wife and I, because the wife always comes—if the wife is not happy, you’re not happy. That was my first contact with Mary Washington, a personal discussion on the phone. At that time there were five radiologists and they were looking to hire two more that year. We could start July of 1982. The group went from five to seven in 1982. Then following the phone call and the letters there were the interviews. It just worked out beautifully: a great group of radiologists and wives. It was perfect for my wife and me because my wife raises Morgan horses. We wanted a few acres just outside of town, we wanted a college town, and we wanted to be about an hour from a major medical center. And we didn’t want to go all the way back up to upstate New York where the winters were so bad, but we liked the change of seasons. Fredericksburg was perfect.

00:01:58
Rigelhaupt:
In that initial phone call, what did you learn about the hospital? What did you learn about what it would be like practicing as a radiologist here?

00:02:07
Hewitt:
As I recall—I’m not sure if I did it on that phone call or more on the interview—I learned how many exams they did a year, how large was the medical staff, what was the sophistication of the medical staff, and what kind of environment you’re stepping into. It was a private practice job that would fulfill what I thought I wanted to do, rather than being part of the university staff or a great big private group where you’re just a number, maybe. That was all ironed out and I learned more in the interview when I came up and talked with them. We came up twice, actually. It fit perfectly. It was a private practice group that contracted with the hospital: we were reimbursed for our professional component and the hospital did the technical component. We were paid for what we did. [03:00] You see, it wasn’t long before I got here. It was, I think, maybe in the mid-1970s that RAF [Radiologic Associates of Fredericksburg] had the big fight with hospital administration, because they owned the department. Dr. Cimmino, Dr. Kenneweg, Dr. Southworth, and Dr. Scott, and I’m not sure if Dr. Allen did because he was the one right before us, but he may have been part of that—I can’t remember. They rented space from the hospital, but they owned the equipment, they employed the technologists, and they got the money from everything that they did. There was the big bloodbath just before Dr. Medsker and I got here in 1982. They lost the department. That was a nationwide trend, as I understand. I haven’t read all that much about it, but I’d hear stories from the older guys over the years as I got here. Dr. Cimmino and Dr. Kenneweg, the oldest ones in the groups—especially Dr. Cimmino, because he was the first one here, 1960s or late-1950s. That was a very emotional time. You’re telling a group of doctors, “No, you’re going to do it this way.” The board and the hospital administration did. I think Mr. Harry Bach was his name. His picture is in one of the hallways. The older guys knew him very well, but it was a bloodbath. And they lost. The hospital board said, I guess, “Too bad. You can contract with us, but we’re going to own the equipment, we’re going to employ a technologist, and we’ll have a director of the department. You guys can submit your bid for the contract.” Turns out years later, Dr. Cimmino was heard to say and he’s told me a couple times, it was the best thing that ever happened to them because you no longer had to worry about staffing or the equipment. You could go and say, “We need a new CT.” You don’t have to worry about putting a million dollars up yourself. Of course you have to convince the hospital board and the medical staff that you need it. But it was the day-to-day: “Is the technologist going to show up for work? Is the equipment going to work? Did we make the right decision to buy the stuff?” And that was a national trend, as I understand it, and that happened probably seven, ten years before we got here.

00:05:19
Rigelhaupt:
What do you remember about the— did you take a hospital tour on your interview?

00:05:23
Hewitt:
Yes. I’m not sure it was a complete hospital tour. I was advised by my professors, “See what the radiology library is like.” When I got here it was an extensive library and many of the articles were written by Dr. Cimmino. That was nice. He was a brilliant academic-inclined radiologist that wanted to go into private practice, which he did and started the group. It was a wonderful library with up-to-date textbooks and journals and they were very serious students of radiology. That’s the kind of group you want to enter. [06:00] I noticed that right away. They had good equipment. When I interviewed, I think they were planning to get their first CT. They had had the CT only six months or so before I got here. That’s really interesting. Now, what was interesting about that was that Dr. Cimmino was published in plain film radiology, which was pretty much all there was. There was some ultrasound, but of course there was no CT or scan. So people like Dr. Cimmino, especially at the university centers—he was a brilliant, academically-inclined kind of physician and radiologist— they speculated on what this line meant and what that line meant, on chest X-rays in particular but also in the abdomen and so on. When CT came around, they were biting their fingernails: “Was I right?” I mean, think about that: other than autopsy where everything collapses and the X-ray shows a living person with more air in the lungs and stuff like that—what’s this line, what’s that line, and all of that? Well, the CT articles started coming out in the 1980s, and fortunately they were right, also, most of the time. Exciting time.

00:07:19
Rigelhaupt:
So CT would have been the latest technology in the practice when you began?

00:07:25
Hewitt:
That was the new blockbuster on the block. It was huge, huge. When we got here, there were the national turf battles. We say, “turf.” That’s when, maybe, one specialty argues with another about who’s going to do it, who’s going to control it, and who’s going to interpret the images. It’s near and dear to a radiologist’s heart. We’re very much involved in that all the time. It’s calmed down a lot now, actually. There are many fewer turf battles, but back then it was all open. Is the neurologist going to read the brain CT scans? Are the surgeons going to read the body CT scans? It took a decade to sort that stuff out, and it varied across the country. Of course, radiology felt we read the scans. That was something I was told to look out for, too. Who does the image interpretation in the community you’re going to be in? Because you want radiology to control that if you’re a radiologist. You don’t want to go into a practice where a third of the CT scans are read by the neurologist, for example. The older guys pretty much fought that battle before I got here, but it would rear its ugly head every now and then.

00:08:48
Rigelhaupt:
Thinking about maybe the first six months, year— just the early work experience—what was a typical day like for you?

00:08:55
Hewitt:
I would get to work at 7:30 or so — I was supposed to be there at 8:00 but I would show up early, and I usually still do. [09:00] And then work. Interestingly, when we first got here, it wasn’t that busy. I say “we”—Tom and I came the same year. When I say “I,” I also mean Tom in this kind of outline. The volume of images hadn’t increased quite as quickly as they thought it would and it took a few months for that to take off. When we first got here, with one person off, I think we had five to seven—we would have six radiologists working, but there was somebody who had call the night before. You would have anywhere from maybe four people working all day long, and there was one site, just the hospital. Somebody would shut their door for an hour and read journals. I mean, we weren’t all that busy. Then it really took off. We got much busier. And that, “Okay, shut your door and read journals for an hour” dropped off after about two months after we were here. All day long, you would read images all day long. It was pretty common to take about a twenty-minute lunch. For most of us, that disappeared, and most of the radiologists didn’t do that. They would bring a sandwich and work through lunch; you would take a fifteen-minute break and talk in the hall kind of stuff. I did interventional radiology for fifteen years. My day in that rotation, I was one of three others that did it. Once a month I had a week of interventional radiology. That’s a sub-specialty in radiology where you’re standing there at the side of the patient and you’re putting catheters in, you’re doing angiograms, and you’re doing biopsies, image-guided biopsies. I did that for fifteen years and once a week I would be doing that. You put on your scrubs and you go in and do those procedures.

00:10:53
Rigelhaupt:
Were there other radiologists doing interventional radiology when you got here?

00:10:58
Hewitt:
Yes. In fact, they needed one because business had increased. Tom decided to not do interventional—no, I’m sorry. We both started interventional radiology together. He dropped out after about ten years, or eight, and I kept going for fifteen years. Both of the new guys had to step up to that rotation. There are a number of radiologists that either don’t want to do that or don’t feel they’re good enough to do it, and it’s really quite stressful. Originally in my training I didn’t want to do that, but I enjoyed it in residency. I said, “Okay, let’s give it a try in private practice.” And it lasted for fifteen years. When I started it was one, two, three: there were only three of us. Three out of seven did it. Now it’s a sub-specialty in radiology: almost anybody doing interventional radiology has at least one-year fellowship and they pass a special certifying exam to do that. That was beginning to be the case just when I stopped doing it. [12:00]

00:12:03
Rigelhaupt:
I imagine at a major medical center like Duke, the radiologists are involved in interventional radiology. Thinking about the size of Fredericksburg, the size of the community hospital, was it common to have that level of practice in a private practice group?

00:12:21
Hewitt:
Pretty much so, of that size. They’d have one or two people doing interventional radiology. The population statistics are there and it wasn’t just the town of Fredericksburg. It was Spotsylvania and Stafford and all that too. It was quite a bit of patients. There was enough volume. The year after that we hired a fellowship-trained interventional radiologist, Dr. Glass, from UVA. Very highly recommended. We got tremendously wonderful interventional radiologists and that took interventional radiology to another step here in Fredericksburg. That was, I think, two years after Tom and I got here. After Ted came, then it really took off.

00:13:04
Rigelhaupt:
Was this one of the early practices at the hospital that could be done here, versus that first decade you were here and you did open-heart surgery, you’d go to Richmond in northern Virginia or Charlottesville. Was the kind of practice you were involved in, in terms of interventional radiology, cutting-edge for the—?

00:13:26
Hewitt:
That’s interesting. You know, I didn’t think much about it. I do recall when Dr. Fuller told me in the hall one day—I’d been here for about six months or so and we did an image-guided percutaneous lung biopsy. He said, “Great job, Mike.” I had gotten the diagnosis of cancer and the lung hadn’t collapsed and we didn’t get a pneumothorax. The procedure went very well. He said, “Mike, you have done the first image-guided lung biopsy in Fredericksburg.” I mentioned that to one of my other partners. He got a little huffy about that because he said, “I did one many months ago.” I said, “Oh.” Someone overheard us, and they said, “Yes. But Dr. So-and-so, that tumor was bigger than your head. This one was this big.” I think that is what Dr. Fuller meant. It was not this great big tumor that was eating out the chest kind of thing, but it was a tiny little spot on the lung. We now had the equipment, thanks to the hospital board, so that you could see that. Actually, that was before CT scans. We did a lot of these biopsies with X-ray only. CT guidance came about two or three years after I got here. But you’re right. Those people before that, I think, would go to down to Richmond or up north for that kind of thing because they were doing them a couple years before Fredericksburg was. We started doing those.

00:14:46
Rigelhaupt:
So this practice was part of the trend that it sounds like began by the early-1980s, of raising the level of clinical practice.

00:14:57
Hewitt:
I think so, yes. And allowing patients to stay local. [15:00]

00:15:06
Rigelhaupt:
Could you talk a little bit about how being in private practice at a small community and in Fredericksburg was different than your residency at Duke?

00:15:15
Hewitt:
In a residency, remember, you’re all tied up in learning and studying and that kind of thing. You don’t pay that much attention to how things are structured. As you mature—and mine was a four-year track— you start wondering, “Well, what am I going to do? What do I want to do?” You look at the structure of the university and the chairman is the dictator. Because I know what happened in one place, my phrase always was, “If a chairman is angry at a radiologist— not angry, but thinks that someone else would better fill that chair or that position—they can either just outright fire the person or they can stick that radiologist with, ‘Here, you go read thumb X-rays all day. That’s all you’re going to do.’” And the radiologist leaves because that’s not what they want out of professional life. So I felt that I don’t want my life controlled by one individual, or two or three. I want to be part of a group where I’m a full shareholder: I sit down at the table and we talk once a week, or once a month, and ask, “What’s our practice doing? What do we want to do?” You’re okay, I’m okay, and you have control over your own life. That has turned out to be true. Even to this day, all members—there’s thirty-two of us now, I think—at the board meetings, everybody feels that it’s their practice and they are not controlled by one chairman. I was given that advice, too, by people, professors and so on that counsel you, “Now, you want to watch out for this. Look at the structure and that kind of thing.” You learn what kind of questions to ask. That became true when I got into this group: everybody was a part owner, so to speak. You’ve got to be a little careful when you first get here and one of the professors said to me, “Mike, you’re an outspoken guy sometimes. When you get where you’re going, keep your mouth shut for at least a year. These doctors at Fredericksburg, they must be good or they wouldn’t be there. So shut up.” I tried. So it works.

00:17:33
Rigelhaupt:
How much did the hospital and what kind of practice you were going to have involving the hospital play in your decision to accept the position?

00:17:43
Hewitt:
It all fits in together. You want to not be controlled by the hospital, but of course they have control because they can decide not to renew your contract. But that’s unlikely. It’s unlikely—I don’t know the statistics, but I know it happens. I know one group it happened to, more than one. [18:00] The hospital board decides, usually with heavy advice from the CEO type person, and for whatever reasons, “We don’t want this radiology group anymore.” I think that’s unusual. You take that risk when you enter private practice in this type of situation, fee-for-service and private billing. Yes, the hospital board could always decide, “We don’t like RAF. We want another group of radiologists here.” I think that is really unlikely to happen. I was never really much worried about that. Now, what happened and what you look for, too—it’s all coming back now. You want to look for a group that’s very well respected, if you can try to figure that out. You’re always supposed to talk to some regular doctors, clinical doctors, when you’re doing your interview. You want a group that is politically active and politically connected. Part of that is that if the CEO and some powerful members of the hospital board—which they never did—but if they were to try to oust the radiology group, the radiologists are politically connected enough to stop that. When I got here I think it was Dr. Kenneweg who was president of the medical staff, he was chairman of the department, and he was an official in the American College of Radiology. And other senior partners I had did the same thing. It wasn’t always confrontational. Most hospital administration—I can’t say most; many—like the radiologists because they’re there. They’re part of the team. If you’re part of the team with hospital administration, maybe even on the hospital board, then that’s not adversarial. This group was like that. Well, that’s not entirely true. I mean, they had just got done with that bloodbath of losing the department. Some of the older guys, Dr. Cimmino and Dr. Kenneweg in particular, said there were very hard feelings towards administration, but there were new, younger guys that understood the cooperation that was required.

00:20:15
Rigelhaupt:
And in a hospital like this, at the time you arrived, most of the physicians were in private practice, practicing with their own patients. Was there any other specialty or medical group as closely intertwined with the hospital practice as radiology at the time you arrived?

00:20:39
Hewitt:
No. Maybe anesthesia. Maybe. No, because it’s the RAPEs, the hospital-based docs, that are in the situation: radiology, anesthesia, pathology, and ER. Those are the hospital-based docs. Now, the great majority of docs, when I got here, though, were not under any contract to the hospital. They admitted their patients to the hospital. [21:00] They were solo practitioner independent docs and they admitted their patients to the hospital. I think pathology was very limited. There were only, like, three of them, maybe, and they were quiet, retiring people and they were not politically involved like my senior partners were locally. ER docs was a foreign group of docs, and I think they had a slight in the ER. The hospital board decided along with medical staff, which advised, as I understand it—I wasn’t here. Not long before we got here, though, they got rid of that whole group of ER docs. That’s when they started the modern ER doc system from Mary Washington Hospital of non-foreign American doctors and then a step after that was everybody had to be board-certified. That took about a decade to happen. The ER was politically weak. I mean, they just got kicked out, and there were some new docs in that nobody really knew yet, but they were trying to build a practice. Anesthesia had some bright, hard-working, politically involved people, and they were kind of similar to radiology. We got along very well with them.

00:22:23
Rigelhaupt:
What did you see as the strengths of the medical community, you know, the physicians in the area when you first arrived?

00:22:28
Hewitt:
You don’t know when you get here, you really don’t. When I interviewed, I still remember what Dr. Kenneweg told me. He is now retired. I think Dr. Kenneweg is eighty-five now. But he said, “Mike, you know the one thing that keeps a radiologist out of the courtroom and away from lawsuits is the quality of the medical staff. That is number one and we have an outstanding medical staff here.” I think he was right. I worked closely with other doctors. It was back in the days before digital imaging and all that and the docs came down to look at their patients’ X-rays and their patients’ images. You would get to know these docs and there were probably forty docs or so that I really did know because they came down a lot to the department. You respected their skill. Now, there were a couple people that were a little marginal, but they were maybe trained forty years ago and so on and so forth. I think overall, a very good medical staff.

00:23:29
Rigelhaupt:
And when you say medical staff and you’re describing people coming down, would these physicians be treating patients who were in the hospital? These were inpatients?

00:23:38
Hewitt:
Yes, yes. It’s mostly inpatient. They would also come by to look at the chest X-ray or whatever, and as time went on, CT scan, ultrasound, now MRIs and stuff like that. And then on their outpatients also, but it was mostly inpatients.

00:23:54
Rigelhaupt:
When do you remember that transition happening, the balance between inpatient and outpatient?

00:24:00
Hewitt:
You mentioned this earlier and as a rough outline of what we’re going to talk about. When we opened the first private practice, the first outside-the-hospital imaging center here in Fredericksburg on Princess Anne Street in cooperation with the hospital, that was the beginning of the pull-apart. That was the beginning and it was a nationwide trend, I’m sure it was, of more and more outpatient imaging. Of course, the people being imaged on an outpatient basis are not as sick and the doctor ordering the test has a lower concern. If a patient’s in-house and they’re very ill, the doctor is right on top of it. They want to know what’s going on. So the opening of the private office was when it started to pull apart, rightly so. The next big step in that, besides getting more outpatient offices, was digital imaging. So now it’s gotten to the point and we knew it—it was written in the radiology literature that this would happen: “Guys, you’ve got to do this, you have to go digital.” You won’t see your referring doctors anymore. Now, we still see some, but almost nothing. In my experience, it’s increased a little bit more, because now they’re getting used to, these are guys in their 50s or older, that are getting used to picking up the phone: “Hey, Mike, sorry to bother you, but I had this ultrasound yesterday. Do you mind pulling it up?” I’ll say, “Yeah, sure. What’s the patient’s medical record number or name? So what’s your question, Bob?” The doctor might say, “Is that a gallstone or a sludge ball, or do you think that could be gall-bladder cancer? I just want to make sure.” I’ll say, “There’s no cancer.” You know, that kind of thing. Now they call. It took them awhile to get used to do that. So that’s nice. And they can pull up the image: there’s a way to do that with protected patient information and for a doctor to be in their office and pull it up on their computer. They’re looking at the chest X-ray when they’re talking to you.

00:26:12
Rigelhaupt:
That actually leads to something that I’ve heard about a little bit in other interviews, and maybe you could talk a little bit about it: what was the communication like between physicians at the time you started? Was it more face-to-face? More informal? How did you communicate?

00:26:32
Hewitt:
I have, historically and still have, a narrow slice of the overall care of a patient because it’s imaging. From when I got here, our reports said it all. We would pick up the phone and call the referring doc, which almost certainly we knew back then, if somebody’s lung collapsed or there was this big kidney tumor. We would call them. But our report said it all. [00:27:00] So the other great majority of what goes on between different specialties, I wasn’t really a part of.

00:27:11
Rigelhaupt:
It is interesting that imaging probably touches every specialty it involves. It sounds like — because of the reports—

00:27:19
Hewitt:
The specialties I think of that we don’t touch very much on are dermatology or psychiatry, but almost everything else. Because imaging touches so many different things compared to what it was thirty years ago when I started, it’s very hard for them sometimes: they can’t make a move until they know what the image says. They really are waiting for that because of technology. I work with wonderful radiologists Dr. Green, Dr. McDermott, and I can name others. We became short of a beta site about ten, twelve years ago, maybe even fifteen, but when we have voice-to-text now: we can look at the report, we can hit “sign,” voice-to-text sign, and that is in a doctor’s office now. Doctors sign up for automatic fax. Of course, the ER’s the same way. Maybe an eighth of a mile down a hall, but voice-to-text, there’s your report, sign, and the ER has it.

00:28:30
Rigelhaupt:
One of the things that was happening around the time you arrived was the hospital’s reorganization. And it went from the hospital to MWH MediCorp. It had subsidiaries and the hospital was the major subsidiary. Did that resonate with a young physician like you at the time?

00:28:50
Hewitt:
It did, because early on I entered medical staff leadership. I was the secretary, which means you just go to the meetings. You don’t take notes, but you go to the meetings. Then I was president-elect of the medical staff for two years, because Dr. Taylor was president for two years before me. I went off to all the hospital board meetings and did a lot of traveling. At that time the hospital was talking about the new hospital, it was building various programs: neurosurgery, open-heart, neonatology comes to mind. I may be missing one. It was a very busy time. I was involved and I went to a lot of meetings and traveled a lot with hospital board members. Bill Jacobs was the president of the hospital at that time. I traveled a lot with Bill, and got to know them. At that time, and this is my impression and I think it’s true: there was a fair bit of administration-physician animosity. I never really knew exactly why or how; however, my feeling was that’s true everywhere. I mean, it’s like two armed camps and they have different goals and feelings and different purposes. [30:00] And you’re always at odds. There was a sense at that time that there were some very angry, vocal, for reasons of their own, but very respected clinicians in town that were very anti-hospital administration. That spilled over into the building of the new hospital. Maybe you know that from some of your interviews about back then? Oh, my God. It turns out Bill was right. Bill’s mistake may be that he did kind of go head to head with docs, but he was right about building the new hospital. That’s been proven correct, in my opinion. But the relationships were bad. When Fred Rankin was hired, I interviewed Fred for his job. I remind him of that because I was president of the medical staff that year. One of Fred’s planks, one of his purposes of coming, was that he was physician friendly. The hospital board said, “Hey, eighty percent of all health care dollars are directed by physicians. ‘It comes directly back to them,’ was the phrase. We need to really try to partner and not have these separate camps.” Fred believed that and I think did a lot in that regard when he first got here. I was aware of that difficulty in this part of it.

00:31:19
Rigelhaupt:
So I want to come back to leading up to the new hospital and your involvement as president of medical staff. Those first few years, like, say the years before the imaging center opened, were you already involved with the board?

00:31:35
Hewitt:
No.

00:31:36
Rigelhaupt:
OK. So it’s after ‘86 that it became—

00:31:39
Hewitt:
Yeah, ‘82—yes, yes, right. I think I’d only been here three years, though, when I started that tract of medical staff leadership. It was pretty early. One of the reasons is nobody else wanted to do it, but don’t tell anybody that. I liked it. It was fun, you know? It worked out. I loved it, even in retrospect. There were some very hard times, of course. It took a lot of time away from the family, but it built my career, and man, they were great years. The hospital was doing great things. They were really fine people. That’s one of those growth experiences. And when, “Yeah, yeah, yeah, another contract fight, and everything. Blah, blah, blah.” Then when you start, that’s just what they are like. When you start sitting around the table, you go, “Oh, wow! They make really hard decisions. They’re here at the seven o’clock meeting just like I am. They’re here at eight o’clock at night just like I am. They work very, very hard.” That was a learning experience. But right. I was here for, I think, three years before I started the medical staff leadership. And before that I knew basically nothing.

00:32:55
Rigelhaupt:
So it sounds like there were disagreements between some of the medical staff and the hospital administration, still on the second half of the 1980s, when you became involved. [33:00] But before that, your partners and your practice had entered a joint venture to build an imaging center. Could you talk about the origins of that collaboration?

00:33:25
Hewitt:
I can, but I wish Dr. Medsker, my associate, was here. Tom is more of my business associate, along with a couple of other people like Dr. Allen, who’s now retired. They were very much involved in, thank God, the business aspects of our practice. Otherwise we wouldn’t have a practice. But Tom and Don—Dr. Don Allen and Dr. Tom Medsker—knew that if we did not build a stand-alone imaging center, an outpatient imaging center, somebody else would. It was Tom and Don that went to Bill Jacobs and told him, “Bill, we’ll do it with you. Okay? We’re not greedy. We’ll do it with you. Let’s partner in this.” As I remember, I think it was a 50/50 when it first started, and then it was 51/49, with us on top. It was a sell to the medical staff. Many medical staff people thought we were selling out the hospital. The radiologists were taking money away from the hospital that it could use for that new machine in the OR or that new CT. We really had to go to bat, mostly in private conversations, or during film review: “Listen, Lou, if we didn’t do it, Fairfax will, and the hospital will get nothing.” I believe that. That’s true. We had to do it. And we did. Tom passed me in the hall one day—we still joke about it—and said, “Oh, I bought a CT yesterday. A $900,000 piece of equipment.” What’s this crap about sitting around the table and feeling like you’re part of a group? There’s only seven of us, but one of them decides to go into debt for $900,000 and didn’t ask me? I said, “What?” And I said, “Oh, forget it.” And I went and did a procedure or something. It worked out. It worked.

00:35:26
Rigelhaupt:
Was it hard for your group to get over some of the bad feelings from just a decade before to enter a joint venture with the hospital?

00:35:33
Hewitt:
Dr. Cimmino, in my opinion, I don’t believe he ever got over it. He was old school. He was, I think, sixty when I got here, I’m guessing, in ‘82. By the way, there is a history of RAF that Dr. Kenneweg wrote. Are you aware of that? I meant to mention earlier, and I forgot. He wrote a history of radiology. I can’t find my copy, but if you like, I can give you his email and phone number. [36:00] He might be happy to share that with you. But Dr. Cimmino, if you come to a town in ‘59 or ‘61, and it’s your road or the highway for all those years and then someone comes and takes it away from you. If you’re of a certain personality, you don’t get over it quickly. I don’t think he ever did. And Dr. Kenneweg was more cosmopolitan. He was able to kind of roll with those punches.

00:36:32
Rigelhaupt:
Was there a sense from your senior partners that there was going to be a growth, not only potentially in an inpatient working hospital, but outpatient? I mean, just thinking about the decision to hire two physicians here when you came out—I mean, it’s a forty percent jump in staffing.

00:36:49
Hewitt:
That was a very difficult decision for them to make. It really was. They were right. But yes, we worried about it all the time. Radiology manpower would go up and down over the decades, and it was a struggle. Man. They were kind of hard decisions, and it turns out they—I think we’ve made the correct ones. For a couple years we were a little behind, because anybody has to practice work and private life, your own personal life. If you’re working twelve hours a day, it’s kind of hard to have a good family life.

00:37:28
Rigelhaupt:
How did other physicians in the region respond to the decision by your practice and the hospital to open the imaging center?

00:37:37
Hewitt:
Initially negative, pretty much. Some people were glad. I think pediatricians, in particular, liked it. For one reason: the office that we had for Medical Imaging of Fredericksburg was on Princess Anne Street, and its first location was right next to a couple of pediatricians’ offices. They really liked it. Because, you know, sending kids to the hospital for X-rays and stuff was a major threat. This was much easier. Plus, they could run down the hall or run across the street and look at the pediatric image. They loved it. But it was a hard sell, as I said. My feeling is for most of the medical staff it was negative.

00:38:21
Rigelhaupt:
You mentioned the cost of a CT machine. Was there already a sense by this time, the mid-1980s, that the cost of technology for radiologic practices might necessitate the kind of capital that the hospital could assist with? That it would be hard for a private practice to keep up with the kind of technology that was coming on board?

00:38:46
Hewitt:
The business-savvy people in radiology, you know, struggled with that and made their best guess. In some groups larger than we were at that time—I think Fairfax in particular, as I understand it, were very aggressive. [39:00] Also, down in Durham, Raleigh, the triangle area where I trained, it was the big private practices that had the bigger, better, and newer CT machines. They were really aggressive. It worked out really well for them because they were right. They made a capitalistic venture as a professional corporation or whatever they were to go ahead and invest millions of dollars in equipment without really knowing where it was going to go. They had a gut sense and some data, probably, that this is going to work. Hospitals are like snails. That’s one really annoying thing that always bothered me when I worked with them. But then you go, “Okay. They’re protecting the community’s health.” When you ask the hospital to make a major expenditure, you’re looking at one or two years of meetings and charts and graphs. Bigger radiology groups could sit around the table for a month or two and then go, “Let’s do it.” Hospitals take forever.

00:40:11
Rigelhaupt:
I want to talk to your involvement with the board. I want to ask you about your impression of the board before you joined it. You know, the first few years you were here, a new, young physician, what were your impressions of the board?

00:40:23
Hewitt:
I didn’t have any. I didn’t know them and I didn’t know how boards worked. Back then, I was probably just coming out of my regretfully socialistic years. I assumed the board was probably bad because they were the controlling people, and all people in authority are bad. I was thirty-two or something. I actually didn’t pay much attention to it. I didn’t know. Maybe I had a slight sense hearing from my older people. Again, they were, about ten years away from that big bloodbath. The board, mostly management, was something to really, really watch out for. Kind of like the enemy. I didn’t pay much attention to it. It just worked. When I started attending the board meetings, it was truly something new.

00:41:21
Rigelhaupt:
Well, let me ask you about the first board meeting in a moment. A new CEO came on a year before you. Bill Jacobs started in ‘81. Was he still viewed as kind of an older administrator or did he symbolize something new still when you arrived here?

00:41:42
Hewitt:
I thought Bill was here longer than that; so I lost track of it. Bill ran the board meetings for a year or two. I’m trying to remember now; I can’t remember. But I was there when Fred came and there were number of board meetings I was at when Bill was there. [42:00] There was, like I said, a group of physicians on staff that were very anti-Jacobs. Not just Bill, but he was the leader. And the administration was anti-physician and it was not cooperative.

00:42:23
Rigelhaupt:
What did you learn? What were some of your impressions from—I’d ask you about your first board meeting, but that might be hard—

00:42:30
Hewitt:
I can’t remember that. My first impression was, I think, realizing that as a leader of the medical staff I have got to improve somehow our standing with the board. I separated the board from management, because the board is composed of people off the street and in various professions. And they basically don’t know from nothing. They know their own doc. I knew that there was a separation here between the board members from the community and the CEO-type management people. I knew part of my job was going to be, “How do I gain some more respect for the medical staff?” And that way we would drive a little wedge between the board and management, just to let them know, “Hey, don’t forget us, and we really are okay.” I knew that had to be the case. I was surprised at how kind of formal they were. I’m kind of an informal person, but they would say, “Well, Mr. Jacobs,” and they would wait to be acknowledged. Naturally, I mean, that’s the way you should run a board meeting with fifteen or twenty people sitting around. But I was surprised it was as formal as it was. There were docs on the board then that were really highly respected. That was nice. That’s what I remember.

00:44:03
Rigelhaupt:
How aligned did you see the board and the administration? Typically with hospitals—I mean, three major entities running it are, the medical staff, the board, and the administration. How much alignment did you see between the board and the administration?

00:44:31
Hewitt:
I think in all summary and everything I’ve been through, at first I felt the board does whatever Bill Jacobs tells them to do. The board does whatever Fred tells them too, basically. They gather all the data and they can present it in any way. They had decided based on their training experience what was probably best. Board members did not have that experience. I mean, I didn’t think they were trying to trick them or fool them or anything. But then I realized that, “Well, no.” As time went on, it was probably sixty-forty, seventy-thirty. [45:00] The board members, some of them, were very savvy local businessmen and very successful in their own right. They were able to modify or move administration in a certain direction that initially they may not have wanted to. The one thing you haven’t mentioned is that when I first got here—just to throw this out there— the concept was that I heard that the Free Lance-Star was very anti-medical care in Fredericksburg. I don’t know if you heard that before. But I heard it from older people on the medical staff for a number of years. I started paying attention to that and it was pretty well known. So maybe you’d dig into that a little bit. There were decades of anti-health care in Fredericksburg. I don’t know how that quite ties up to what I was going to say, but it’s just the rumor. Now, I don’t know this. I heard it a couple times. Some of the owners of the Free Lance-Star, and I guess we’re talking in the ‘50s or ‘60s or maybe earlier, had bad family experiences with medical care here locally. It was a major uphill battle for administration and the hospital board and the medical staff to try to improve their relationship here. I don’t know their standing in the community when the newspaper was constantly beating them up. I think that did change after a couple decades, but when I first got here I understood it was bad. The hospital board was always concerned: “How are we looking in the press? How are we doing? How do we make this a hospital that’s respected?”

00:46:54
Rigelhaupt:
Did the Free Lance-Star lump together practicing physicians in the hospital?

00:46:59
Hewitt:
I think so. I think so. And the rumor was that I-95 was kept hot enough to melt by people leaving for Richmond for their medical care. They won’t stay local. They won’t stay with the local docs and they won’t stay in the local hospital. And that did change, of course: look where we are now. I mean, we’re just doing great. But that was a struggle. A lot of the patient—what do you call it? A lot of the market share left and I understood that the Free Lance-Star was a major player in that.

00:47:36
Rigelhaupt:
Were you—I don’t know if surprised is the right word, but for lack of a better term—were you surprised that the hospital and practicing and local physicians were so closely aligned in the representations of the paper, in the sense that a lot of people may love their primary care physician but have second thoughts about a hospital and the two wouldn’t necessarily be merged. [48:00] And it sounds like the Free Lance-Star really treated it the same.

00:48:09
Hewitt:
That’s my perception. I never really looked into it. It’s maybe a project for somebody with absolutely nothing else to do, which you’d pull out all of those old newspapers and make a list that’s like, is the current press left-leaning or right-leaning? What do you think, Jess? But you can pull out all those articles and look at them. My impression was that yes, they were lumped.

00:48:36
Rigelhaupt:
So one of the other things that happens right around the time that you’re becoming more involved with the board in the mid-1980s is Diagnostic Record Groups, with hospitals, Medicare changing how they’re going to reimburse—

00:48:49
Hewitt:
The DRGs. Okay, I’m sorry.

00:48:51
Rigelhaupt:
Sorry. I know. The acronyms. Usually I don’t understand the acronyms, so I use the term.

00:48:56
Hewitt:
When I heard the full term—(laughter)

00:49:00
Rigelhaupt:
So DRGs, and, you know, the Emergency Medical Treatment and Active Labor Act. Hospitals are going to have to treat people regardless of their ability to pay. The questions of reimbursement are changing for hospitals in the mid-1980s. Radiologic practice is closely aligned with the hospital. Did that have an effect on private practice physicians in radiology?

00:49:29
Hewitt:
Oh, yeah. It was a major struggle. So what do you do? If you’re able to hire consultants that you like and trust and RAF did. I think our first consultant, usually back then and they may still be, but back then they were wrapped up with billing. You hire a consultant group to do your billing for you, and they take eight percent or ten or whatever it is. But they’re also hooked into a local, regional, or national major information network. What are we going to do? How do we deal with these DRGs? How do we deal with HIPAA or all these other things that come down? Managed care problems. And that was a huge scare for us because most people in private practice look for what I looked for when I looked for a job, which is independent, you own it, and you call the shots. Anathema is to be employed: you know, Mary Washington signs my check, or Kaiser does, or the government does. No. That’s horrible. So there was that concern, not fear, because it never really dried up. I guess you get scared when you go to pay the mortgage and you don’t have any money. That never happened. The group always grew. Our incomes always increased. But you paid for that advice. Now, the American College of Radiology is very active, very smart. One patient that we were fond of and she used to babysit for her kids. I would guess she is around my mother’s age. [51:00] She says, “Oh, boy. That radiology group, years ago, their bill got home before I did from the hospital.” That is kind of the name of the game. How do you survive where everything looks like it’s going to be controlled by somebody else and ratcheted down? We’re very easy targets, you know. We’re very easy to target: “Okay. We’ll pay you $5 for looking at a chest X-ray instead of $6—the government says. We’re just doing that tomorrow.” We stayed apace and done well because of very, very good advice. I don’t understand and I’m not the businessperson in the group, but smart enough to hire the right people.

00:51:44
Rigelhaupt:
Part of my reason for asking is, I mean, the recollections of changing business practices, I think, are an important part of the history. That unlike a lot of, say, a family physician or someone who’s still straight fee-for-service in the mid-1980s, your integration with the hospital, you might have heard or felt or started to see that something like DRGs might affect physicians more directly than a physician in another specialty.

00:52:19
Hewitt:
I didn’t pay all that much attention to it. I didn’t. I know from a narrow view: what does it mean for me? What does it mean for my practice and my income and my future? For what the clinical doctors were doing, I didn’t pay much attention to.

00:52:41
Rigelhaupt:
So you’re involved with the board. And let me ask this, before I get to the new hospital. What do you remember about—are there any major controversies, major issues, that you remember the board having to undertake in those years, in the second half of the ‘80s? Probably before the new hospital took up a lot of the board’s attention?

00:53:04
Hewitt:
Other than the new hospital, what sticks in my mind again, because of my narrow focus, was that the hospital under Bill Jacobs did try to make a push to get us on salary. That was a major, major shock. And that’s one reason you join a group that’s powerful politically. I remember Dr. Kenneweg making a speech at the medical society meeting and the point of the speech—very well-done—was, “We’re first, you’re next. Don’t let them do this.” The older people in my group were successful in stopping that move. And again, I wasn’t paying much attention. Pretty much the new hospital and the anti-physician attitudes were the real big deals when I became more active. And the new hospital was, oh my God, incredible.

00:54:00
Rigelhaupt:
Well, let’s go to the new hospital. What do you remember about the first time you heard the board was considering it and the administration was talking about it? What were those first conversations?

00:54:10
Hewitt:
The first thing I remember was, and this is funny. Maybe they skipped a step, but “Where’s it going to go?” I’m sorry. The first step was and it really was the hard decision: do we remodel the hospital we have or do we move? That was it. Then it was, “Okay, where?” Man, that was rough.

00:54:33
Rigelhaupt:
Well, before getting to where, why was the decision made to move somewhere new rather than remodel the facility on Fall Hill?

00:54:41
Hewitt:
The cost of remodeling would not be too much shy of the new building and it wouldn’t be adequate. There wasn’t enough space. That was based on predictions and projections that Mr. Jacobs and the rest of the admin team came through with, which turned out to be correct. But, you know, you can always question data. And there was a big fight. A lot of the vocal docs in town, highly respected, did not want the hospital to leave the more downtown location. It’s all understandable. It really is— just human nature. You either believe the data or you don’t. And a lot of it was guess—not a lot of it. Some of it was just simply guesswork.

00:55:31
Rigelhaupt:
So it sounds like the decision to build rather than renovate was made relatively quickly.

00:55:36
Hewitt:
I think it took a couple years. I mean, they really talked about it for a long time. And part of it was, how do we sell it? How can we get this to the community and how can we make it work? Once the decision was kind of made, then you’ve got the political battles with the community, the board, and the influential medical staff and doctors in town. That took a lot of time, to figure out how to sell it, how to work it, and how to get it approved. At that time the hospital board had different parts. There was a hospital association and there was a hospital board and there was a yearly meeting. Back then—oh my God—at the yearly meeting there had be 300 people there. And they were very, very tense times for Bill Jacobs and the board because you never know what kind of wild hare is going to come though. At that time, and I forget the details, the administration and the board were successful in reworking the corporate papers so that that major meeting every year became a toothless lion. People could yell and scream, but they really didn’t have the votes. I forget how they did it. There’s a class A and class B of voters and all that stuff.

00:56:56
Rigelhaupt:
Where did you find yourself, as a member of the board and a member of the medical staff falling in terms of either supporting the new hospital in the new location or renovating? [57:00]

00:57:09
Hewitt:
I believed in administration. I did. Intuitively. And I felt that they were right. Plus, I knew it really wasn’t my decision. I didn’t, I hate to say, pay that much attention to it, but I didn’t put a lot of blood, sweat, and tears into it. See, when I was president—I can’t remember, was the decision made when I was president or not? You probably would know, but I can’t remember. I was never confronted by angry medical staff or angry people of the community. It was pretty much decided by then, as I recall. I was president-elect at the time, in a lot of the meetings, and it was still not quite decided and difficult. That’s what I remember. I was too busy to worry about it. I knew it wasn’t my decision, but I favored new hospital.

00:58:02
Rigelhaupt:
What were some of the concerns from other physicians about the new hospital?

00:58:09
Hewitt:
I remember them saying it was too much money. It’s unnecessary, and it’s a tremendous community expense that’s unnecessary. That was their primary concern. I wasn’t enough of a businessman to really go toe-to-toe with them, but of course, admin was and the board was.

00:58:37
Rigelhaupt:
Do you remember board members who were particularly vocal in supporting the new hospital?

00:58:45
Hewitt:
That’s a good question. That’s when I think and I somehow feel like the decision was made before I was president of the medical staff. No, I don’t remember meetings where you had a sense the board was divided. You know, there are these people here, “Yes,” and other people, “No, no, no.” I don’t remember that.

00:59:07
Rigelhaupt:
So there was a certain consensus of—

00:59:09
Hewitt:
I think there was. I really think there was. I do remember a little uneasiness about where. I think Hunter Greenlaw was a member of the board at that time, and I think he actually owned the land, as I remember. He recused himself from many meetings and many votes, but he was always there, if you know what I mean. As I remember, he actually left the room a couple times. I can’t be clear on that. That was always a little iffy, to have an owner of the land there. I sat there thinking, “These local businesspeople have got to be very, very tuned into this. I mean, it’s not only the hospital. It’s where the medical staff building’s going to go, obviously. Where Vinnie’s Pizzeria’s going to go.” It makes a big difference for development. [01:00:00] When they leave where they are, what is that, a wind tunnel now? You know, all those little businesses drying up. People were very concerned about that, to not mention the millions of dollars of selling the land to the hospital so they can build the hospital. But I was not concerned about that. I really wasn’t.

01:00:20
Rigelhaupt:
Well, I know there was discussion about potentially moving to a location—I think I wrote Route 17—

01:00:30
Hewitt:
It’s interesting how that discussion came out again with Stafford Hospital. That’s right. Stafford was a really hard decision. At 17 and Route 1. There were really big decisions to make. But you’re right, 17 was mentioned even back then.

01:00:50
Rigelhaupt:
Was there a pretty strong sense from—I mean, I imagine you were, correct me if I’m wrong—were you more attuned to physician thinking about either staying in Fredericksburg, the city, or attempts to going to 17 or different locations. How did physicians and where did physicians want to—

01:01:10
Hewitt:
I’m too isolated to answer that. And that’s one reason why, you know, a certain segment of the medical staff never favored a radiologist, a pathologist, or one of the hospital-based physicians being a medical staff leader. My day was working in radiology, going to meetings, and having a cup of coffee with Bill Jacobs or Fred. I’m not one of the major clinical doctors. I was out of that mainstream. So I don’t know.

01:01:38
Rigelhaupt:
Did you favor staying in the city versus other potential locations?

01:01:43
Hewitt:
I don’t remember really being faced with that decision, but I’m pretty sure I would have said stay close by.

01:01:53
Rigelhaupt:
What do you remember about the announcement, as it becomes public that the hospital was going to move to this property in Snowden??

01:02:04
Hewitt:
I don’t remember. I don’t remember how the press, the Free Lance-Star, played it either. I don’t remember.

01:02:12
Rigelhaupt:
And you may have known for so long that it may not have seemed like news.

01:02:16
Hewitt:
I do remember when I first learned where it was and it had to be early on because I knew, but I don’t remember when I first learned that.

01:02:29
Rigelhaupt:
As I commented on, walking in, looking at this enlarged medical campus now—it is a large medical campus now. Was there talk early on, before construction began, that this move and a new hospital had the potential to create something other than a newer, more modern community hospital and the thought of a medical campus was part of those discussions?

01:02:56
Hewitt:
They were early on, right? There was all this land. [01:03:00] The administration was forward-enough thinking, they had a couple of vice president experts in that, and tied in locally. They knew that this would become a medical campus in time. Bill Jacobs felt that way, Fred felt that way, and it made sense to me. But I’m not a businessperson really. I can only say that sounds reasonable to me and I think that’s what happened.

01:03:26
Rigelhaupt:
Part of what goes with the medical campus are, more often than not probably, clinical practices and clinical programs. Were there things you were thinking about your radiology practice would able to do with this new hospital on the medical campus and the higher level of care that you were excited to implement?

01:03:45
Hewitt:
Yes. It was pretty much always new hospital and better equipment: better CT machines, new MRI machines, and new ultrasound machines. But it was also the outpatient imaging. That was a real big focus of ours, again, in partnership with Mary Washington. But I think it was in the 1980s, or certainly ‘80s bridging into the ‘90s, that outpatient was in. You had to be very aggressive in the outpatient realm and I think we accomplished that.

01:04:17
Rigelhaupt:
So thinking about the space and how it’s going to be laid out, where machines were going to be, where the radiology department was going to be in the hospital, what did you want to see in terms of design?

01:04:34
Hewitt:
That’s a very good question, and I’m a bit of an oddball. I didn’t pay any attention to that. I had associates that did. And I would walk into the new department going, “That’s where the CT goes.” Honest to God, I feel bad saying that, but you only got so many little gray cells, right, and so much time, and I had no interest in that. Now, I would see that some people liked it. I didn’t. I had wonderful partners. They were all wonderful. They had a special talent in planning: Dr. Kenneweg, in particular, and Dr. Allen and Dr. Goose at that time. Like, this imaging center, for example: I walked in here going, “Oh, that’s what they meant.” I didn’t pay attention to it. I didn’t have an interest in it. They did a good job. It was very exciting. You’re right. There was a variant of the turf war. You fight with pathology and you fight with ER in particular: we want that space. Then that becomes a tiny little internal struggle, but it’s very important. We need that space for a new CT. ER says, “No, we need that space for a nurses’ station.” Too bad, you lose, get out. You have meetings after meetings, and it shakes out after awhile. We usually won.

01:06:00
Rigelhaupt:
I mentioned, and as you mentioned as well, imaging touches just about every clinical practice. Do you remember speaking with other physicians in other practices, talking about what this new hospital would be able to bring and how there might be different levels of coordination? That radiology would bring to the emergency room or to a cardiac patient? You know, there were plans that could be made because there was going to be this new space?

01:06:32
Hewitt:
That went on, but I wasn’t much part of that. No, I didn’t do much of that. But let’s see, the chairman and Dr. Kenneweg. And after Dr. Kenneweg—I forget—it was Dr. Scott. The chairman of radiology went to many meetings at that time to help sell the new hospital, not only more space, but of course new equipment will come. There was a lot of talk of that. I had to be a little careful: I was president of the medical staff and I couldn’t appear too parochial as just selling the radiology aspects of the new project. I kind of stayed away from that.

01:07:17
Rigelhaupt:
When we spoke earlier on the phone, you mentioned that you did some traveling with the board and administration to look at other hospitals and to talk about what this [new hospital] would be like. Could you tell me a little bit about those trips?

01:07:27
Hewitt:
So much fun. You would go out to dinner, stay up late and you’d talk, and you’re surrounded by people that really care. We just attended—have you heard many motivational speakers? I ask people that and I don’t know if you have, Jess. But I didn’t know what they were. Then I went, oh my God. These guys or these ladies get a whole room full of people going: “Yes, we can stamp out tuberculosis.” Or “We can build that new…” You’re so enthused and then you retire to the cocktail party and have a great dinner and stay up until midnight. It was so much fun. We saw the open-heart programs and neonatology and everything. You get to know the board members: what caring individuals—oh my God—and to devote their time for that. Now, there were some benefits of doing that for their business and whatever. They just got better known. These were really hardworking people that were great fun to get to know. In fact, as I recall, during those years of all that travel and all that fun, it was really building programs and helping to build programs. We were interviewing the neurosurgeon, interviewing the neonatologist, and interviewing the perinatologist. I was a part of all of those interviews, which management kindly asked me to do during those years. I remember meeting one bad person. One person that I would say, “They should not be in that position.” Isn’t that unusual? And it’s true as I look back. So it was a great mix of fun and energy and going forward.

01:09:00
Rigelhaupt:
You mentioned neurosurgery, perinatology. I mean, these are, you know, clinical programs that are a sign of expansion, a sign of growth for Mary Washington. And it sounds like from the way you were describing it, is these were happening almost simultaneously to the building of the hospital.

01:09:20
Hewitt:
They were very closely aligned. I think it was a span of three or four years there. Can you imagine what a burden, but fun and exciting time, it was for management? They had to have people that really knew what they were doing to build these programs: master nurses, business administration people, and accountants. They really busted their butts. That’s why it was fun for me. I was along for the ride. I got to interview docs and stuff like that and give an opinion every now and then about what maybe did you think about this or that. These people stayed up late at night after night, justifying the program. Like I said, the hospital moves like a snail. They had charts and graphs and slides—and oh, my God. They did all of that.

01:10:09
Rigelhaupt:
Looking back now, at this period, the early 1990s and about the same time the hospital opened or just before and leading up to it, what clinical programs stand out as the most important that have contributed to Mary Washington’s growth?

01:10:30
Hewitt:
Cardiology comes to mind first. And maybe that’s wrong, but it does. Cardiology. I was involved in leadership at the time. We didn’t do any cardiac catheterizations here. There is a big example of people having to go to Richmond or Fairfax or DC to have a cardiac cath. Then the next one: we got docs on staff that learned how to do it and then people out of training came here and joined the existing groups. Then the next step was, you couldn’t put a cardiac stent in without a cardiac surgeon on call. If you occlude the coronary artery or rupture it, it means emergency surgery and you can’t do that here. It was a big push for not only the open-heart program itself, but to have Dr. Armitage, who came, on call. The beeper goes off— and I don’t know if it ever happened—and his team had to be available. Now the whole community could benefit from balloons and stents in coronary arteries. I think that was the real big deal. Always a big fight over all the years of trauma services and the existing surgical groups, for good reasons. I think they had resisted it. That was a two- or three-decade battle to get to the trauma level we’re at now. It took a larger medical staff at the new hospital and more support staff. Twenty years ago the three surgical groups that were involved in that couldn’t tolerate it. [01:12:00] They couldn’t be on call twenty-four/seven. They resisted that for decades. That was a major hurdle that was passed a number of years ago, when we became a trauma center. That was a big fight. The other things—neurosurgery, spine surgery in general, neonatology and perinatology—were very nice advances, but not as important in my mind.

01:12:28
Rigelhaupt:
I’ll come to trauma in a second. Did having open-heart surgery in the cardiac program lead to new practices among radiologists?

01:12:38
Hewitt:
Oh, yeah. We had big turf battles with them. They were some of the worst. Historically and across the country, cardiology and radiology are oil and water. Irish and Italian. I don’t know what side I’m on. Irish. It was horrific. And it just makes sense. You’ve got patient care issues, pocketbook issues, lifestyle issues, and “I’m-better-than-you-are” issues. Then when it really degrades, it’s “mano y mano” and it gets emotional and personal. We had little of that here. A little bit of it, but not much. Some. Again, they’ve almost disappeared. I’m not quite sure why. Maybe it’s because I’m not involved anymore or because I’m older now. But they were rough. Our biggest turf battle always was with cardiology. They were catheter people and we were catheter people, and who’s going to do the pulmonary angiogram? There was even an argument. Who is going to read the coronary arteriograms, the cardiologist or the radiologist? It all worked out very well. But they were kind of rough, uncharted territory. New, brand-new methods, brand-new equipment, and then you’d fight about who’s going to control it.

01:13:55
Rigelhaupt:
And you said these cardiologists and radiologists have conflicts, but you described less here than—

01:14:02
Hewitt:
I think so. I really do. I heard stories from other places with lawsuits. Oh my God, it was terrible.

01:14:13
Rigelhaupt:
Why do you think there was less here?

01:14:14
Hewitt:
I think because one of my senior partners years ago, I think it was Dr. Kenneweg, who said, “One of our biggest problems is the clinician who’s not busy enough.” The turf battles and the arguments between specialties, sometimes even sub-specialties, are they’re not busy. The area was growing so fast that you’d have a meeting and a big fight about who’s going to do a procedure: “No, you can’t do the pulmonary arteriograms. We are.” Then you’d leave that meeting and suddenly you’re swamped and you’re working till eight o’clock at night and you kind of forget. And you think, “Oh. Does it really matter? I mean, we’re busy.” It was that kind of stuff. [01:15:00] But if you’re sitting in your office and you see four patients that day, and you really would rather be doing a couple pulmonary arteriograms—they’re fun, they’re nifty, they’re really important for the patient, and they make great diagnoses. “Were they clear?” You can tell a patient, “You don’t have clots in your lungs. Go home and have a nice evening.” You want that badly. I really think the key is how busy doctors are, number one.

01:15:20
Rigelhaupt:
So the growth in the region—

01:15:22
Hewitt:
It protected all of us. Plus we had nice people. The cardiologists in town are wonderful people, they really are. It’s nice to sit at a table, raise your voice a little bit, and say, “No.” Then we leave the meeting and go, “Hey, see you later, Bill.” “Okay, Mike.” They’re nice people.

01:15:41
Rigelhaupt:
Do you think it was important that the surgeon who started the cardiology program came from outside? Dr. Armitage was in Pittsburgh, right?

01:15:54
Hewitt:
They had to because there was no local cardiac surgeon. By definition it had to be a new person. But my understanding was he was remarkable and he was the choice. He was the right choice. His patients loved him, he was highly respected by all medical specialties, and did a wonderful job. After he left I heard—this is just hearsay—I heard it from a couple patients. They or family members went to—he went to Oregon or something. I don’t know where he went, I forget. They went out there to have him do their surgery because he did Uncle Bob’s or Dad’s or something. They found Dr. Armitage and went to him. So he was a great choice.

01:16:52
Rigelhaupt:
Part of what we just talked about was a period of growth. Looking back at the new hospital opening—let me stop there. What do you remember about your first day of practicing at the new hospital?

01:17:06
Hewitt:
Not much. I don’t remember the day, except “wow, awesome.” You walk in there and you’re just overwhelmed. Now, I had seen the hospital with hard hats on. The board would take trips and I’d go through with medical staff leaders and stuff. I kind of knew the lay of the land. I mean, even now, if people interview for our group and we take them on a brief hospital tour, it is regarded as really pretty. Really well-done, really well-designed. I remember being enthused. I also remember being surprised. I did wonder about this. Going into the new hospital made so little difference in my day. I thought I would feel out of my element or whatever. No. New office, bigger, nicer, maybe, but still did the same thing with the same partners, associates. [01:18:00] It was a very easy transition.

01:18:06
Rigelhaupt:
Has your individual practice been mostly hospital-based, or have you spent a lot of time—before being right here, right now, on the campus, but in an imaging center? Did you do a lot of practice at the imaging centers as they opened?

01:17:17
Hewitt:
No, because I did interventional radiology for fifteen years. That almost always left me at the hospital. If you have one of the guys—there’s four of us and one’s on vacation and one’s on call the night before, for example, and off the next day, the interventional radiology schedule was busy enough that you needed to be backup. I spent very little time, in fact, at Medical Imaging of Fredericksburg. I might go there once every two months. I went very little at first. And it’s funny how your life changes. I stopped doing interventional radiology when Dr. McDermott came. He replaced me. He tried; he did his best. We were so lucky to get him. God, he’s great. So when he came I stopped doing interventional radiology. I was physician director of ultrasound for twenty-five years. Now I’m positioned really to go to the imaging centers a lot more, and I did. I joined the mammography team about a year after the Imaging Center for Women was opened in the old hospital. I came on that team. Now I spend eighty percent of my time here. But it was interventional radiology for fifteen years that kept me hospital-based.

01:19:26
Rigelhaupt:
You mentioned being on call. What were the things you would most likely be called in at night to do as an interventional radiologist?

01:19:34
Hewitt:
For interventional radiology on call: it would be an occluded artery in a leg, less likely in an arm. It would be gastrointentestinal bleeding. It would be pulmonary arteriogram, a clot in the lungs. It would be nephrostomy drainage tubes, putting the tube in a blocked kidney to drain it out. That’s usually the things. And the venous access. We started the venous access program—Dr. Glass did, I’m going to say twenty-five years ago now, maybe. That was difficult because that was the transition for a radiologist to be called at 10:00 at night because they couldn’t establish an IV on a patient. That was something new, but that was what we did. We put a small catheter—they were new twenty-five years ago. You would put it in the arm and you’d run it up and stop just short of the heart. Clinicians and nurses loved it because you could put all kinds of things through there. These were patients that had no veins. It was kind of hard to be called in for that, but we did.

01:20:54
Rigelhaupt:
Thinking about the first few years after the hospital opened, what equipment or technology changes were there that changed the practice of a radiologist? [01:21:00] Do you remember any changes?

01:21:06
Hewitt:
CT. CT is number one. But then ultrasound made huge advances also. And nuclear medicine—I don’t want to forget nuclear medicine. That lagged a little bit. But CT and ultrasound were making headways. I did a little bit of nuclear medicine, but not all that much. But then there was a huge explosion in nuclear medicine and the equipment and what they could do. Dr. Green has been head of that for twenty years now, maybe. Awesome. The equipment purchases, the physics involved, the regulations: he’s on top of all of that. That was a major deal. Interventional radiology, the equipment, and even X-ray. Now, when I got here, they had just transitioned from film screen to digital, fast film it was called. It was a very difficult transition for the radiologists to make. So that was a big step forward. And then of course we had mentioned already, going to full digital was a very big transition.

01:22:13
Rigelhaupt:
Thinking about the years after the hospital opened—so could you walk through what it would be like for your practice to say, “We would like to make this advance in nuclear” or whatever comes to mind. What was it like to talk about that with the medical staff, the administration, with the board, and for some of this equipment it’s a significant amount of money.

01:22:35
Hewitt:
It is. And I’m glad you asked that, because that’s a fair bit of what radiologists do. The physician director of that section, let’s take me for ultrasound, which is not all that big of a division, but there’s CT scan and interventional and other larger divisions. I was very involved with this. You need a new ultrasound machine and back then it was a quarter million dollars. I don’t know what it is now. It may be similar now, but you get a lot more now. As the physician, you talk with the chief tech, but then I review the medical literature. You say, “What are the universities doing? What are the large practices doing? What are the articles saying you should be doing with your ultrasound machine?” And you go, “We need a machine like that here. When we do a fetal survey, I should be able to see whether there’s hydrocephalus or not. I should be able to do a carotid ultrasound to see if there’s a stenosis so the patient is saved a stroke and they get surgery instead.” Whatever the case may be. The doctor justifies it medically. Then you give it to your business people in that area, and this would be in radiology. The director of radiology would crunch the numbers. They work closely with vendors, of course. The vendors come in and they want to sell their quarter-million-dollar or $800,000 machine, whatever it is. They’re very adept at this. “Oh, here, let me give you this plastic laminate thing for your board. Fill in your numbers.” [01:24:00] You can justify it to your board. They’re not lying, but they say, “If you do eight patients the machine pays for itself.” So you do need to meet a certain number and it was always very low. With that help, and from the vendors, the next step up would be a more senior person in management, and then eventually you’d get the CEO, being Bill Jacobs or Fred behind you. You would make a board presentation, which usually is like no more than five minutes because management would have all the numbers. But number one, it was justified medically. You’d go through that all the time. It is much harder now. We felt it. The hospital has no money. Not no money—you know what I mean. Back in the growth days, back when growth was predicted, understood to occur, and it has happened—we have ten years of growth behind us. Okay, we’re fine, we’re fine, we’re fine, we’re fine. Now the radiology group is much more hesitant to go to management and say, “We need a new this or we need a new that,” because they’re laying people off. Senior management is voluntarily leaving, and it’s kind of hard to justify. The board thinks, “Can’t you just check the carburetor and put in a little different fuel and make it run for another year?” You can’t justify it. It’s harder to justify when you’re operating in the red. Much harder.

01:25:47
Rigelhaupt:
What do you remember about Bill Jacobs leaving and Fred Rankin taking over? I mean, he’d been president of the hospital, but taking over as CEO.

01:25:58
Hewitt:
I liked Bill. I thought he was an honest, sincere person. He was very bright and he was a friendly man. He was roundly disliked by the medical staff. A number of doctors liked him. But the majority opinion was that he was anti-physician and he was not right for this town. I liked Bill a lot. I did. I knew he would go over into another very fine position. I forget what he did. I wasn’t worried about his future. I accepted the fact that he didn’t enjoy very much support in Fredericksburg medical community, and it was time to see if we could improve that with somebody different.

01:26:43
Rigelhaupt:
What are some of the changes you remember happening under Fred’s leadership, Mr. Rankin’s leadership?

01:26:51
Hewitt:
First and foremost is direction from the top. The attitude comes from the top. So when your leader says—he didn’t say it this way—“I love docs. I love you. You’re a doc? I love you.” [01:27:00] It was openly said and his team understood without saying it this way. They were better at it and I think it was genuine: “We want to partner. We love you guys. Let’s talk. Let’s do things together.” Now, whether they shut the door and yelled and screamed and threw their shoes around the room when that was done, I don’t know, but right from the beginning it was, “Hey, we’re in this together. We’re friends.”

01:27:31
Rigelhaupt:
Did that sense from leadership of wanting to partner with physicians, say, affect the decision to move medical imaging to the hospital campus, which was a few years after the hospital had moved here? Was that experience different than it had been, say, in ‘86 when you first opened the imaging center?

01:27:52
Hewitt:
That’s a good question. I don’t think so. Because radiology and Bill: we really got along. We did. I think the decision was to move to a bigger space on the hospital campus probably would have happened anyway.

01:28:09
Rigelhaupt:
And that’s been seen as beneficial?

01:28:11
Hewitt:
Oh, yeah. Oh, yeah. Definitely.

01:28:18
Rigelhaupt:
Before we jump to those, you mentioned trauma earlier. And one of the things that I learned from the interview process is how much having a trauma program influences other clinical programs. That it’s not just that first hour of immediate treatment and having trauma surgeons, but that you’re going to have a higher-level critical care unit. What did it mean for radiologists to have a trauma program?

01:28:48
Hewitt:
We were kind of like fifty-fifty at first, because it extends your working day. We had critically ill people that need your image attention twenty-four/seven. A major change in our practice was when we became on-site radiologists twenty-four/seven. I was chairman of the department then. What a big fight. Understandably. I worked with people that were older than me, my age, and younger, and they wanted to go home at five o’clock. God almighty, it was really rough. But we had reached the point in this community where you needed imaging interpretation twenty-four/seven. Once we made that big jump, we were kind of silent on the trauma thing. We’re here: bring it on. What helps is private pay too. If you want to get it to the VA system—I don’t want to pick on them. God, they’re great people, they work so hard and they care for so many very sick people. But a VA doc will tell you, “No.” They’re on salary. What could they care? Well, if I’m there reading something at three o’clock in the morning, at least I know I got five bucks. It’s different. [01:30:00] If you get paid the same, you can say no a lot more, just for that little commercial thinking.

01:30:09
Rigelhaupt:
And that was something that would benefit everybody in the practice in terms of the things that you were doing that would be reimbursed all night?

01:30:19
Hewitt:
Right. I think it’s still reasonably common, but in our group the money goes into a pot and we divide it up. Now there are a couple subtleties in there, but the big picture is the big picture. When you’re on call that night and you’re working very, very hard and you read this chest X-ray and you read that CT scan. All that, that’s yours. That’s Bob’s and Tom’s and everybody’s. Everybody’s making money doing that.

01:30:50
Rigelhaupt:
How did the radiologists feel about opening other imaging centers, like at Lee’s Hill or at Stafford? How were those decisions made?

01:30:59
Hewitt:
Originally, the decision to open any imaging center, to open Medical Imaging of Fredericksburg, was really rough for the group. The oldest people, Dr. Cimmino and Dr. Kenneweg, to a somewhat lesser extent, but still were very much opposed to it. The group had some arguments about that. As I recall, Drs. Cimmino and Kenneweg did not so much say, “Okay, I agree.” They just shut up. They went in their office and shut the door. They knew the logical argument had won. We got over that hump. Then the other hump was all business. And we had one in North Stafford that always lost money, and we finally closed that. The hospital was wonderful in that regard, they really were. They protected as much as they could and they tried. But one of our offices did fail. Other than that they all have been successful.

01:32:00
Rigelhaupt:
And you guys also, the physicians in the radiology group, also work in Stafford Hospital?

01:32:07
Hewitt:
Yes, we still do.

01:32:09
Rigelhaupt:
What did you, as radiologists and physicians who contributed to opening a new hospital, contribute to, talk about, wanting to see at the new Stafford Hospital?

01:32:21
Hewitt:
That’s a little after my time. I was around when the discussion had been just started—that’s another example of how it takes forever. Talk about a difficult decision that the hospital and board had to make. I think the jury’s still out whether they made the right one or not. You know how much money they lost in the last number of years? I didn’t pay much attention to that project, I really didn’t. I knew it might put the hurting on us because we needed somebody up there, but the volume of imaging almost always would pay for at least one radiologist. It was not a major decision for us. What is a big decision for us is interventional radiology. [01:33:00] We have a core team of wonderful interventional, fellowship-trained radiologists that are extremely busy. To go all the way up there for one or two procedures a day, that is damaging for us. Somehow it’s worked out though. Part of it is the expansion of the physician assistants that we have: great interventional radiology nurses and physician assistants. They go up there and do the more minor procedures, and that works out well.

01:33:31
Rigelhaupt:
Talking about physician assistants and nurses raises another thing that I think has gone on with becoming a regional medical center. It’s not just clinical practices in terms of physicians. You have to build teams.

01:33:48
Hewitt:
Definitely. Right.

01:33:50
Rigelhaupt:
Could you talk a little bit more about what it was like to build up a team of nurses and PAs that you worked with and continue to work with?

01:34:01
Hewitt:
During my time—now, we only use the PAs pretty much in interventional radiology. When Dr. McDermott came, he took that over. He had that model in recent training at the University of Maryland. I wasn’t much part of that. But all I know is that it really freed up the docs to do the more complicated, time-consuming, and difficult procedures. And the carefully selected PAs would do the opposite of that. It just opened up the schedule and made the schedule so much easier to work with.

01:34:44
Rigelhaupt:
Did the level of nursing care at the hospital have to increase, become better-trained to go along with some of the procedures that radiology was doing as you were—

01:34:54
Hewitt:
I think it tagged on to surgery a lot. What radiology does, which has gone up and up and up in terms of complexity, those kind of patients are monitored pretty easily with the surgical intensive care unit, the ICU patients. When I left interventional radiology it was because I didn’t want to do it and it was too clinically oriented for me. Our interventional radiologists actually can admit to the intensive care units, by the way. They’re the admitting physician. They are their patients. The nursing was there. It was a matter of having enough. It wasn’t new skills.

01:35:35
Rigelhaupt:
What about working with hospitalists? How has that changed your practice?

01:35:39
Hewitt:
That’s an interesting question. Boy. First of all, I’m really impressed with their work. We read a lot: at the click of a mouse, we can open up the history and physical. Thank God. My partners got that added, Dr. Green and Dr. McDermott in particular. Then you read the hospitalist’s admitting history and physical, and you go, “Oh, wow.” [01:36:00] These are such sick people. At first I was bothered by it. I didn’t know them. They were totally unknown. They don’t take care of patients out in the community and, “Is this right?” First of all, they’re there. I can always get them, they do complete workups, and I’m glad they’re there. It really has been a great benefit to us because we have certain guidelines. It’s a patient care issue: if you see something of critical importance to a patient, you’ve got to contact the doctor. You can’t just tuck that in the report and maybe fax it. Sometimes we have a little trouble getting hold of a doctor in the community. Naturally, they’re busy people and going here and there. The hospitalist is always there. That’s a major advantage for us.

01:36:50
Rigelhaupt:
But the hospitalists also represent change in a physician-hospital relationship, and these are employees and salaried physicians?

01:36:59
Hewitt:
My understanding is though—now, in your interviews I’m sure you’re running into this, maybe, if you ask the question—but they [primary care physicians] love the hospitalists because they don’t have to come into the hospital. My internist, Dr. McManus, his life has changed. All the pediatricians—oh my God! They can have a life now. It’s so different compared to thirty years ago. I think they’re really happy that hospitalists are here.

01:37:26
Rigelhaupt:
And the reason I ask is, and I certainly have heard that response, too: physicians are too busy to treat their patients in the hospital, and treat patients in the office. They could not sleep.

01:37:40
Hewitt:
Right, right.

01:37:43
Rigelhaupt:
But that sense of a hospital and physicians having some conflict that having salaried physicians might seem like a hospital takeover, and it sounds like those feelings have dissipated with time.

01:37:59
Hewitt:
They have. You’re right. That was a concern twenty, fifteen years ago. It has lessened now. I really think, and I’m not too much tied into that. I think the clinical side really does like the hospitalist service. But you’re right, that wasn’t the case ten, fifteen years ago.

01:38:19
Rigelhaupt:
Is your practice involved with the new [Mary Washington] Health Alliance and the integrated provider network?

01:38:24
Hewitt:
Yes, and I know very little about it. I really do, and I’m actually part of that. My associate, Dr. Frazier, has that up for us. Wonderful guy. He’s been with us six years, maybe, something like that. He was a banker in his former life and then decided to go to medical school. It’s really nice. Not only is he a great radiologist and a very nice man, but also he’s a CEO type person in mind, and able to analyze that kind of stuff. He’s heading that up for RAF. And I just do what I’m told.

01:39:00
Rigelhaupt:
Part of my reason for asking is it sounds like something like an integrated provider network. And I know you can’t read back historically— times have changed, reimbursements have changed. Would it have been hard in terms of relationships between physicians and the hospital?

01:39:19
Hewitt:
It was tried. It was tried very, very seriously. Dr. Kelsey was president of the medical staff, and it was a very big push to become a Geisinger-like medical center or complex area here in Fredericksburg. As I remember, Dr. Kelsey was very, very much in favor of it, and a very strong friend of Bill Jacobs, from what I remember. It was anathema. I mean, almost every doctor signed. – There was enough core interest to start doing something like that, but it was roundly defeated eventually. It really was. It was too early and it wasn’t right for Fredericksburg. It’s interesting, because twenty years ago, if we had done that then, you know, I don’t know what would have happened. One of my partners said, “Do you know how much less money we would have made? Your wife would have one less horse.” (laughter)

01:40:11
Rigelhaupt:
And did I hear correctly—the headphones, sometimes I get a delay—that there was talk of a Kaiser model?

01:40:15
Hewitt:
Yes. A Geisinger Clinic or the Kaiser-type thing, right—whatever those buzzwords were. It went down the road pretty far. I mean, there were board discussions, medical staff, and medical society discussions. Most physicians were very opposed to it and it didn’t work.

01:40:37
Rigelhaupt:
What’s different now? The health alliance seems like it has more support.

01:40:44
Hewitt:
Obamacare, I think, really. I imagine there’d be no health alliance if Obamacare hadn’t passed. That’s my guess. I don’t pay too much attention to it.

01:41:00
Rigelhaupt:
What are some of the things, looking back on your time on the board, that you would most want other physicians to know about what a board and a hospital administration does, in terms of trying to most effectively provide health care for the community?

01:41:18
Hewitt:
That’s a great question. Unless you live through, you don’t know. I mentioned earlier my growing experience. These are people that really care. God, and they work so hard. They’re protecting the community’s money. I had to grow up and understand that. That’s the number one thing, I think, especially with the young docs. They’re working for the community. Occasionally we get into fights or arguments or whatever, and there’s always the contract talk, I think. I do counsel my younger associates, “Guys, these people are protecting the community’s health and their money. They’re very well-meaning people and they work very hard.” That’s what I would say. [01:42:00]

01:42:09
Rigelhaupt:
So one of the things that Mary Washington Hospital and health system is also known for contributing to is this broader idea of community benefit and community service. What are some of the things that perhaps you learned about as a board member, perhaps you participated in as a physician, that you would point to in terms of the ways in which the health system tries to provide a community benefit?

01:42:36
Hewitt:
The care of the indigent, and I don’t understand all of it. There’s the Lloyd Moss Clinic in the Silver Building. RAF, every year, has a pretty big ledger of interpretation that we do with no reimbursement. I have understood that it might be twenty, thirty percent of everything that comes through the ER, we just never get paid for. That’s just bills that don’t get paid. I know, working with the hospital—and I wasn’t actually part of this aspect of it—there’s a huge commitment to take care of the people in the community and make sure they can get health care. Hence the Lloyd Moss clinic and everything else that has grown out of that. I know there were a couple problems, in particular, because they rely on imaging a fair bit too and we just got overwhelmed. Actually, Dr. Glasser is now the president of RAF. He actually had to spend a fair bit of time with the Lloyd Moss Clinic and talking: “Guys, we can’t do CTs on everybody. You got to help us here.” You get into those kind of discussions. The hospital has a huge commitment to take care of everybody and so does RAF.

01:44:03
Rigelhaupt:
What are some of the best things that you would point to about health care delivery, about patient care, that became possible because Mary Washington went from being a small community hospital into a regional health system?

01:44:21
Hewitt:
You don’t realize this when you’re thirty-three to thirty-five, maybe even forty, but to stay where you live for important care. I think that’s number one. The hospital has grown to do that across the board. From perinatology, and a twenty-six week baby, all the way through really sick old people. We mentioned cardiology, neurosurgery, and radiation therapy. Wow. We don’t have to go to Richmond. Now that I’m older, I know a number of people that have gone through radiation therapy. Turns out it knocks your socks off. I didn’t really know that. [01:45:00] It tires you out so bad and you’re sick anyway and then to take that hour up north or down south. To stay where you live is critical. The trauma program: you know, fifteen minutes can make a life-or-death change. The stroke program: just a few minutes is critical. You’ll either walk again or you won’t. To have all of that excellent care here is remarkable compared to thirty years ago.

01:45:40
Rigelhaupt:
Would you have thought that possible when you started here, that basically everything except for transplant and major burns would be treated at Mary Washington?

01:45:42
Hewitt:
I didn’t think about it much. I really didn’t. If I had, I probably would have said, “Yes, we’re definitely going to grow, be a suburb of DC, and get better and better and grow.”

01:45:58
Rigelhaupt:
Part of what you described is a level of medical care that rivals academic teaching centers, hospitals in major metropolitan areas. Are there positives, upsides, benefits to the kind of structure here where hospital contracts with physicians. There are still a lot of people in private practice in providing the care and that’s different than an academic medical center, for example?

01:46:33
Hewitt:
You’re drifting off now into how should health care systems be structured. I kind of wondered if you would at some point. You know, I just don’t know. I really don’t. I’m stuck on my private practice model because I lived it and breathed it for thirty-two years and trained for years before I got into this position. I can’t understand the complexity of how health care is best delivered. I like the model I grew up in intuitively. I guess it comes down to whether you’re a capitalist or a socialist and what system works best. But it really is a hard question and it’s complex. I mean, the free market system for health care, well, that went out the window fifty years ago. Insurance came in. It gets so complicated. When I’m on time off I want to be messing with the kids or pushing a manure pile together with a tractor. My main job is to tell, is that squamous-cell carcinoma in the lung or a calcified granuloma? That’s what I figure out. What is the best way to deliver health care? Sorry. Hugely complex. One benefit is, after this firestorm we’re going through now, the hurricane of Obamacare and everything else that’s happening, that at least the people entering medical school now will know, “Hey, we don’t know what it’s going to look like five, ten, fifteen years from now, but welcome aboard.” [01:48:00] You really want to be a doctor or you want to be a nurse: good for you. We don’t know what kind of system you’re going to be plugged into. They will know that. The people that are new in private practice or building a practice and are out there for five or ten years, or the person just entering residency, just beginning their medical training, I do feel a little sorry for them. It’s so unsettled. Sorry, it’s a really difficult question.

01:48:38
Rigelhaupt:
I will say you were trying to answer a much harder question than I thought I was posing.

01:48:44
Hewitt:
Which I said at the beginning, you were drifting over into that. And I figured you might.

01:48:48
Rigelhaupt:
Because I would not ask you directly to solve health care delivery—

01:48:53
Hewitt:
That’s why it was a hard question for you to ask, because you were asking locally. But it’s the same kind of question. It wasn’t an easy question. The easy question is, how do you think health care be delivered locally? I don’t know.

01:49:12
Rigelhaupt:
Well, let me say what I was thinking, what I thought I was asking. Because part of the thirty years you’ve been here was the level of care that can be provided in the region is dramatically different than when you started. And I think it rivals the best care and academic medical centers, but has not followed that model. How did that happen?

01:49:40
Hewitt:
I see. They’re different systems. The health care in the university health care system: a part of its mission is to train health care providers, to be cutting-edge, and to be research facilities. Nothing else compares to that size or wealth or backing or funding when you get down to RAF, for example. It’s just the same model can’t work. But I see what you’re saying. I don’t know.

01:50:26
Rigelhaupt:
And part of my thinking in asking was, you know, is it that you were able to build good relationships with the hospital, you did work with the board, and there were physicians very active on the board, like yourself, that made a certain level of coordination possible. Even if it was less formal—

01:50:46
Hewitt:
There’s no control, though. The control would be, let’s compare the university model. In my mind—now, I’m just talking out loud here—the knowledge and cutting edge clinical practices are transferred to the community setting, except for the real bush country. Then you have what RAF has gone through for the last thirty, forty, fifty years, whatever. [01:51:00] Okay, now compare the two systems. I don’t have a comparison. I don’t know. I do believe, as a capitalist, that if people are rewarded for the hard work, they’ll do it, it will be better, and it will pay off. I do believe that. Whether that can be proven in your question, I really don’t know.

01:51:34
Rigelhaupt:
And again, to think about what you described when you started, being the sixth or seventh, I don’t know which one was hired first—

01:51:41
Hewitt:
Dr. Medsker. He points that out. See, his name is on top because he signed a contract first. I’m older. I’m a year older, but that doesn’t count.

01:51:51
Rigelhaupt:
So being the seventh physician and now—

01:51:54
Hewitt:
I was seventh.

01:51:56
Rigelhaupt:
—did I hear you were in between thirty and forty . How many physicians in the practice?

01:51:58
Hewitt:
I think there’s thirty-two. There are two vascular surgeons and I think thirty radiologists.

01:52:03
Rigelhaupt:
Thirty-two. That’s exponential growth.

01:52:07
Hewitt:
Yeah, big.

01:52:11
Rigelhaupt:
And being able to provide a higher level of care to the community at the same time.

01:52:15
Hewitt:
Absolutely.

01:52:15
Rigelhaupt:
And again, I don’t think it’s just radiologists. There are other practices that—

01:52:18
Hewitt:
That’s correct. I just had an atrial flutter ablation with Dr. Clemo, a wonderful doctor, and he’s with one of the cardiology groups here. He did that here in town. Oh my God. He’s an electrophysiologist and twenty years ago there’d be no such person here in town, and now there is. There’s actually another couple, one or two other docs that do the same thing. You’re right: the whole thing is just going like that.

01:52:42
Rigelhaupt:
Has the hospital played a role in supporting physicians?

01:52:44
Hewitt:
They’re very active in that. I don’t know the details, but they’ve always had one vice president, at least, and staff to recruit: recruit, get them, get the docs here, and make a life for them. They have got to be very careful because there’s a whole bunch of laws about that. But the hospital is really good at that and they’re very welcoming to docs. They attract them to the area. In almost the thirty years I’ve been here, they’ve been trying to do that. The big crisis twenty years ago or so was family practice, and there was a huge push for that. Then they do the specialties also.

01:53:23
Rigelhaupt:
But mentioning something like family practice is also one of the things that historically acute care hospitals, even not-for-profit hospitals, generally have not been overwhelmingly concerned about: primary care.

01:53:37
Hewitt:
That’s true, that’s true.

01:53:38
Rigelhaupt:
—or public health. From what you’ve just described, the recruitment of primary care physicians or some of the community benefit we talked about, there’s a concern with public health. Why do you think this organization supports those things?

01:53:57
Hewitt:
I think a community board. I remember people sitting around and occasionally saying, “Try to get an appointment with a doctor. You can’t.” [01:54:00] That was twenty years ago or whatever. That is a benefit of having a community board tied in to their community, their family, and extended friends. They’ll know if it takes too long to see a doctor or there’s no one to see. And then you’ve got to go to the ER.

01:54:25
Rigelhaupt:
So let me ask one more question about the board, and then I think I’ll start to wrap up.

01:54:30
Hewitt:
OK, good.

01:53:34
Rigelhaupt:
One of the things you mentioned about the board is lots of different backgrounds, from physicians to hospital administrators to the CEOs on the board to local businesspeople. A lot of different viewpoints and a lot of different training. Is there a productive tension in the different views that the community board and their backgrounds bring to a meeting?

01:54:55
Hewitt:
Yes, there is. My wife was on a national board for the Morgan Horse Association. It was fun for me to see her go through that. I’m sure boards have been studied—maybe that’s your next project? There’s always a very strong community-based person that has, and they’re basically a great big beating heart—a great, very emotive person, and very connected. I think usually older, because they’ve been around so long. There’s a heart. A businessman that knows how to balance the sheet, and, “Hey, we don’t have a hospital without no money.” Those boards have that tension. During my time on the board there wasn’t much visible tension. And like all boards, all the work is not done at the board meeting. But big votes are big votes, and they’re important. People look at things so differently. I think so many young people don’t believe that a group meeting and a group talk is important to arrive at a solution that never would have been thought as from individual cubicles. When you grow up you realize that’s true. You get those people together, and if they listen, you end up with a solution that is brand new. That never would have come from individual thinking. Usually the money wins, but the modifying force is that emotive great big heart person.

01:56:18
Rigelhaupt:
Let me ask a follow-up about—we’ve said that a lot of the work is not actually happening at the board meeting itself. Those minutes will be part of a historical record at some point, documentary evidence. Can you think back to maybe a big decision that you were a part of when you were on the board where it was a discussion outside the board meeting? Where there might be no documentary evidence—nothing was ever written down?

01:56:50
Hewitt:
What I mean is, the door is closed and Bill says to Fred, “You’re going to vote this way, right?” Or to Marguerite or somebody. It’s all that number-crunching, the charts, the graphs, and everything. [01:57:00] When admin comes to the board, they pretty much know. They call somebody on the phone and they’re having a chat and they say, “By the way, we just found out that if you do the program in this way it pays for itself.” That kind of work is done all the time. There are no real surprises. That’s what I meant by that. Sometimes there are, but basically they’re such hard, big decisions that all of that ground work is done before.

01:57:39
Rigelhaupt:
What would you most want the public to know about Mary Washington Healthcare as a health system from an insider’s perspective?

01:57:52
Hewitt:
I guess what a caring organization it is, from the top all the way down to the person that parks the car. The volunteers. Everything. It’s a caring, caring organization. Their motive is to take care of the community. That’s what I would want them to know. Sometimes negative things are stressed—commonly they are and they’re remembered. There’s so much good that goes on, so much hard work, and so much caring. That would be my focus.

01:53:25
Rigelhaupt:
Well, you mentioned the top, and you probably have a very unique insider’s perspective, and it’s obviously harder to predict the future, but a month ago a physician became CEO.

01:58:36
Hewitt:
My associate for fifteen years, Dr. McDermott.

01:58:39
Rigelhaupt:
What do you think that represents?

01:58:42
Hewitt:
Again, a message to docs: we want to partner with you. I think he’s had a couple communications already that almost starts out with that. That’s a very strong message.

01:58:58
Rigelhaupt:
So my last question is actually two questions. Is there anything I should have asked that I didn’t, and is there anything you’d like to add?

01:59:11
Hewitt:
No, actually, thank you. Thank you. And they were very good questions and I enjoyed it.

01:59:19
Rigelhaupt:
Thank you.

01:59:20
Hewitt:
Thank you.
[End of interview]