The leaders of Pitt County Memorial Hospital and the East Carolina University School of Medicine united in 1999 to create University Health Systems of Eastern Carolina. The alliance between the hospital and the medical school had already begun 23 years earlier when, in 1975, the University of North Carolina Board of Governors approved the 20-year affiliation agreement that made PCMH the school's primary teaching hospital. The agreement had been suggested by a national accreditation group as a model, and there have been requests for copies of it. However, there seems to be no similar affiliation anywhere else. PCMH is unique in being a small county hospital that has combined with a medical school to build a major regional medical center.

The affiliated hospital and medical school, and subsequently University Health Systems of Eastern Carolina, have made a double-barreled assault on the neglected healthcare needs of a large, mostly rural section of North Carolina. The state as a whole provides inadequate access to healthcare outside urban centers. The progress made in the eastern area has been dramatically greater than that made in any other. Not only as a part of a semi-centennial celebration, but for their own sake the accomplishments deserve to be recounted.

Like a person, an academic medical center needs two sound legs to go forward. One leg is a set of classrooms and laboratories in which students can learn the medical sciences. The other leg is a hospital in which doctors-to-be learn to interpret signs and symptoms and rehearse the healing art by watching their masters practice it. Here they observe patients, using all the senses, laying their hands on them, looking at the changes that illnesses have caused, and questioning them about how they feel. Focusing on the patient as a whole person, by the time they complete their training they reach a place where they have the knowledge to interpret their direct observations of the patient's condition. They are then ready to draw on laboratory findings, X-rays, CT scans, and all the other modern facilities for probing and treating disease.

In 1997, I finished a book for the Medical Foundation of ECU, The Beginning of the School of Medicine at East Carolina University 1964-1977. That history described the struggle that Leo Jenkins led to get a four-year medical school in Greenville. In November 1999 the planners for the celebration of Pitt County Memorial Hospital's 50-year Tradition of Excellence decided that a part of that observance should be a written history of the hospital. They apparently presumed that we could draw on the earlier research on the history of the medical school for this new history.

The presumption was accurate as far as it went, but the 13 years that the earlier volume described were merely an episode in the history of PCMH. Research on nearly 40 years remained to be done. I had become quite familiar with a fairly short segment of healthcare history in Greenville, but knew no more than any reader of the Daily Reflector of Greenville about the rest.

It took more than five years to research and write about a little over a decade of the medical school's history. We had only one year in which to bring together the story of the first 50 years of the hospital. Without the participation of many people in interviewing important actors, in collecting data, and in editing, it would have been impossible to finish the task.

The events of the years between the 60s and the 80s were crucial ones for both institutions. Hospital president Dave McRae said he was not reluctant to admit that without the ECU School of Medicine, Pitt Memorial would still be a 400-bed community hospital. The medical school's success has equally depended on its teaching hospital's quality.

Most of the hospital's history took place outside the story of the medical school. PCMH had already been providing its facilities to local physicians and attracting new practitioners to Greenville for nearly 20 years by the time the medical school campaign heated up.

The main theme of the history, which turned out to have started not 50 years but 77 years ago, is how healthcare in Pitt County fumbled its way up from its early struggle just to get a hospital so that sick people would not have to leave Greenville for treatment. It all started with that early endeavor. Where it has ended up is much more impressive. The main problem is no longer one of just getting some buildings built to house existing services, as it was in what Jack Richardson called "the bricks and mortar period" up to the '70s. The emphasis has shifted away from the physical plant, however essential that is, to the broader goal of improving health status and access to healthcare in eastern North Carolina.

From the start, PCMH's basic commitment to the citizens of Pitt County has been to serve them as a community hospital, turning no county resident away regardless of ability to pay, and to afford each patient the best possible care. The medical school's goal that the General Assembly defined when it legislated the school into existence is threefold. First, the emphasis is to be placed on family medicine. Second, only North Carolina residents are to be admitted. Third, every effort is made to recruit minority and disadvantaged students.
The goal of University Health Systems of Eastern Carolina, the umbrella organization for the hospital, the medical school, participating physicians, and all the affiliated and subsidiary institutions, is an extension of PCMH's and the school of medicine's goals. That goal is to improve healthcare in eastern North Carolina, and it has been shared by most physicians practicing privately in the community. The complex formed by the hospital, the medical school, and the private physicians of the area has been a major focus for recruiting staff and faculty, as well as an incentive for doctors to take up practice in Pitt County.

Before 1923, there was no facility dedicated to caring for sick citizens of Pitt County. Pitt Community Hospital, built that year, was the result of efforts led by four physicians. Most taxpayers found the status quo acceptable, and were unwilling to pay for changing it. Most local physicians were satisfied to practice out of their homes and private offices, sending patients they could not provide for to Washington, Wilson, and as far away as Norfolk.

Building Greenville Community Hospital on the corner of Johnston and Woodlawn Streets was a private venture by four physicians who could not accept the way things stood. They were unwilling to send their patients to distant cities where other doctors would take over their treatment.

I do not think we can attribute a grand vision to the founders of Greenville's first community hospital on Johnston Street. There is no direct evidence that they had in mind more than solving their immediate and urgent problems. It is clear that they were strongly motivated, but professional pride and economic motives are hardly enough to account for pursuing through more than 20 years the goal of establishing a hospital that their fellow citizens and colleagues were unwilling to support. Nor does such motivation explain the doctors' willingness to mortgage their own property and borrow against their insurance to put together $85,000 and build themselves. I believe there must have been some larger purpose driving them.

The need for a hospital was so great that Pitt Community flourished, adding beds and services. In spite of the depression of the 30s, during which there were some unprofitable years, the hospital board planned in 1939 to add 40 beds. They dropped their plans when it appeared there would be federal funds for new hospital construction.
With the opening of the new Pitt County Memorial Hospital in 1951, medical care for the county's residents improved. The new hospital's administrator, C.D. Ward, had been the principal of a school in the small nearby town of Ayden, and he had served as superintendent of Pitt General Hospital. The increase from 50 beds to 140 enlarged the scope of his responsibilities but did not change their character. PCMH provided necessary facilities and a place where physicians in private practice who had staff privileges could care for their patients, one on one. He was encouraged by the doctors to restrict his function to collecting bills, purchasing necessary supplies, and taking care of housekeeping and dietary services. He even delegated responsibility for nursing services entirely to the nursing director. She was in charge of nurses, including hiring and firing without intervention by the administrator.

Ward and the other members of the hospital administration, conforming to the times, were satisfied simply to manage the facility. It was, after all, a challenge: it was the largest hospital in North Carolina to be built using mostly federal funds. When it was constructed, it more than adequately provided for the needs of Greenville and Pitt County. Between 1951 and the early 1970s, PCMH was no more than a local community hospital, and nothing further was expected of it. It began with 140 beds, and added a wing to increase bed capacity to 205, but by 1970, the demand had again outstripped the supply. There were patient beds in the halls virtually every night. Electrical extension cords snaked down corridors and along room walls, with frequent blackouts as the overloaded system tried to protect itself by blowing fuses.

In 1970, after a vigorous campaign, Pitt County citizens passed a $9 million bond issue by a narrow margin. The next year, the commissioners bought 100 acres of land on Stantonsburg Road, and broke ground to construct a hospital. When the medical school opened in 1977, following a bitter fight in the General Assembly, PCMH became its teaching hospital, against the opposition of many, including President William Friday of the University of North Carolina, who advocated an independent teaching hospital.

In 1971, PCMH's first administrator passed his baton to the second, Jack Richardson. Richardson immediately began making changes, the biggest of which were invisible. Seeing needs for services not available in eastern North Carolina, he added them, in spite of the shortage of funds for expansion and the "pay-as-you-go" policy imposed by county leaders. As he said, "We were always playing catch up at the hospital because we never could get ahead of the curve. Our budgets were strained."

On another occasion in 1987, Richardson summed it up in this way: "People told me I was building a white elephant in Greenville that would never be filled, but we've outgrown two or three five-year plans almost before the ink was dry. I've been the administrator of a 120-bed, a 200-bed, a 300-bed, a 400-bed, a 500-bed, and now almost a 600-bed hospital, and I've never left Pitt County Memorial Hospital. We've been adding to this hospital ever since the door opened." His 18 year tenure was the matter for legend in a time when hospital administrators rarely lasted more than five years in one place.

Richardson started a process of developing long range plans in five-year increments, plans each of which, as he said, was already out of date in two years so that another one had to be developed. Healthcare was changing so rapidly that it was nearly unbelievable that any of his five-year plans could last as long as two years. As he described his tenure as president, it was a time when the hospital "kind of exploded all at one time." At the same time that the tempo of change was increasing, more and more money was being poured into healthcare, and the awareness of citizens of eastern North Carolina of their unmet needs was also growing.

He saw one of his most pressing issues to be to preserve open communication so that disagreements were aired fully. His weekly breakfast meetings on Mondays and administrative meetings at lunch on Thursdays were designed so that the administrative staff would talk among themselves without reservations. People were discouraged from exercising any tendency they might have to sulk, hold back from discussing different opinions, and fuss about them after the meetings.

One of the strengths Richardson perceived in Dave McRae, who was to be his successor, was to follow up after the group sessions and talk with anyone who appeared to have a personal agenda and to have some resentment that their slant was not shared by everyone else. It enabled him to help meet Richardson's particular concern to avoid having people freeze too rigidly into a certain viewpoint. Things were changing so rapidly that what was effective this week might not be so the next week or two weeks hence, and certainly would be completely out of date next year. Richardson said, "Every technique that I could develop or impress upon the rest of them was to stay in a growth mode, and we grew a lot of department heads and managers who are there now who have come a long way."

From 1964 through 1970, Leo Jenkins and countless others had worked successfully to get a medical school in Greenville. In 1970, the campaigns to build a hospital and to build a medical school converged. During the next five years, healthcare in Pitt County was transformed, with repercussions for all eastern North Carolina. A major shift in emphasis took place, from building adequate physical facilities to constructing a "hospital without walls," one not restricted to a particular set of buildings in a single place, but extending its reach over an entire geographical region.

The third administration's early years were a time of transition from Richardson to McRae, who took over as president in 1989 after serving on the administrative staff for 13 years, and as chief operating officer for three. Richardson gradually shifted his emphasis from local to broader concerns. When he retired, he was named president emeritus, and continued to be responsible for the hospital's subsidiary, East Carolina Health Services. This is a nonprofit corporation set up to supervise affiliations with other healthcare providers, to manage contract services, and operate leased hospitals or health systems in eastern North Carolina. He continued his long practice of working with other hospitals in the east, and represented PCMH on state, regional, and national organizations.
At the time McRae was being considered as Richardson's successor, the position of the hospital was fairly well assured. This does not mean that there were no financial crises and no difficult choices to be made about the kinds and levels of service that PCMH was to provide. Without losing sight of the importance of physical plant, McRae and his team were increasingly concerned with functional centers-"centers of emphasis"-defining the changed role of PCMH and then University Health Systems in the provision of health care.

Early in McRae's tenure, it began to appear that healthcare in the United States was being overwhelmed by the trends toward capitation and health maintenance organizations. It has turned out that these threatening trends were not realized in eastern North Carolina, where the population of healthcare consumers was not dense enough, not lucrative enough to attract the giant corporations that had been expected to come in and attempt to take over. In fact, as federal encouragement and funding diminished, the HMO movement faltered nationally, and failed to bring about the expected fat profits. Some of the biggest and most threatening companies found it more remunerative to close out and invest their funds in the stock market than continue in the healthcare business.
Through the 1970s and 1980s the need for health services in eastern North Carolina was so great that almost any service added would succeed. Addressing the hospital trustees in a 1989 document, Vision for the Future, where he expressed his thoughts about where PCMH was going, McRae wrote, "Our success, until recently, was based on a need in eastern North Carolina that was so great that almost any and every service was successful. Along with service, almost any new venture was paid for in an 'old charges and cost reimbursement' system that allowed hospital operating costs to escalate and 'pass through' as service was provided. The medical staff all had plenty to do and were not as competitive with each other or with the hospital. Teaching and faculty responsibilities were more important than income generation for academic physicians. The growth of state monies through the medical school for hospital services and expansion was of great assistance in the early days and prevented financial rivalry for dollars. In summary, anything we accomplished up to recently was considered a success, was paid for, was good for everyone. Because we were the 'new kid in the business,' anything we did was considered to be good, in part because people were surprised that we could accomplish even small steps."

McRae felt that the time had arrived when the hospital had to focus its strategies more sharply in choosing where to direct its energies and resources. In addition to periodic planning sessions, a mechanism for continual planning and review was set up. This was to ensure that specific service needs were carved out more carefully, with assurance up front that funding, medical support, and organizational ability were available to meet the need.
He felt that the hospital could and ought to continue filling its double mission. It was, first, a community hospital providing service locally in a friendly and efficient manner. Second, it should also provide the less frequent tertiary care services that can be obtained nowhere else in eastern North Carolina, and are essential to the viability of an academic hospital that must offer the full range of training to its students and residents.

As PCMH's 50th anniversary approached, the hospital's administrators began a systematic process of developing centers of emphasis-specialized facilities where related patient care functions are carried out. The details of the centers that are being delineated are best examined at the end of the history rather than here. Their implications are more for the future than for the past, although we can find their beginnings in the various functional centers that were established from as early as 20 or more years ago: the Rehabilitation Center, the Children's Hospital, and others. In formulating them, professional planners now work with each center's staff to help in defining its processes and needs for space and equipment. The planners also help in integrating the diverse needs and goals of all the centers, which for more than public relations purposes are beginning to be called "centers of excellence."

The story is by no means one in which the main actors are invisible behind the scenes. The history is also a narrative of what many individuals have done, the marriages and the wars, the feats and the foibles. The ultimate goal is to preserve the legacy handed down by Pitt County Memorial's leaders. There have been only three administrators during the hospital's span of existence, and their differing styles of management flavor their times of governance. However, we cannot permit giving proper attention to those formally in charge to detract from the many others who have cooperated to make the institution what it now is.

There are too many who deserve recognition to mention them here. I will list many of those whose names we have found, in a later section of the book. We should remember that an even greater number than all those whose names we can mention have worked anonymously, without thought of recognition. In this place I want only to name some of the groups whose members have been most active. Among these are the county commissioners who provided leadership and funding-with some disputatious members who often helped by noising questions and issues that might otherwise not have been sufficiently discussed in public. There are also the members of the hospital boards of trustees who were everything from public gadflies to vigorous workers in private, in the interest of helping the hospital succeed as public and private facility. All of the community's service organizations, and the churches, businessmen, teachers, and nameless private citizens must be mentioned, who worked hard to pass bond issues and to kindle other support.

These public-spirited and tireless individuals have helped to establish a vigorous system of healthcare centers, in and outside Pitt County. At the end of the first half-century of PCMH, these centers are now in place to provide a framework that promises the region's citizens healthier lives than they could ever before have found without traveling afar.