See also Vignette

JAMES HALLOCK, M.D.
Dean
Brody School of Medicine and
Vice Chancellor of Health Sciences
East Carolina University

August 8, 2000

Interviewer: Beth Nelson

Beth Nelson: We will start, Dr. Hallock, with some information about your background, where you are from, your education, and what brought you to Greenville.

Dr. Hallock: For the record, my name is Jim Hallock and I am Dean of the Brody School of Medicine and Vice Chancellor of Health Sciences of East Carolina University. On September 1, 2000, I will celebrate my twelfth anniversary at ECU and Pitt County Memorial Hospital. I grew up in New Jersey and I went to college at Seton Hall and went to medical school at Georgetown and did my pediatric residency at Children's Hospital of Philadelphia from 1967 to 1970. I did two years in the military in the Air Force at Keesler Air Force Base in Biloxie, Mississippi and then I spent sixteen years at the University of South Florida as a pediatric faculty member and as an Associate Dean. I made a decision in the middle eighties that it was probably time for me to look forward to a career in Administration. I looked around and in 1988 I had the opportunity to visit East Carolina University for the recruitment for a Dean. I visited this institution in March of 1988 and had the opportunity to visit both with East Carolina folks and at the hospital. At that time the three young folks I met with were Dave McRae, Debbie Davis and Kathy Barger. Jack Richardson was the CEO at that time and he had me meet with his young folks. All of those were very, very pleasant interactions. The other person who I remember now interviewing with as well was Diane Poole. I think Diane was the head of Nursing at the time.

The thing that I remember the most about that visit and the subsequent visit was that in coming here, every single person I bumped into whether they were at the hospital or the medical school knew the mission; the three-part mission of production of primary care physicians, of access of minority students and of providing health care for the region. It is really that third mission that brings the hospital and the medical school together and I think that over the course of the years prior to and since my arrival, we have been able to use that service mission as the binding force, if you will, between the medical school, the university, the hospital, the practicing community and the region.

I was very moved by the fact that everybody knew that. As I went back for my visit I was sure, even though I was a family member of the faculty of South Florida that I could not recite the mission and I was sure that there was no one else that could tell me the mission down there because it had not been articulated the way it had been here. Subsequently we were fortunate enough to be invited back. I wanted to be involved with a public medical school, which had a primary care mission, and East Carolina fit that. I remember talking to Bill Laupus on my second visit, who had been the Dean and Vice Chancellor, about the relationship between the hospital and the medical school because it seemed to me that the relationship was crafted in a way very different from what I was used to at South Florida and what I was used to at other community-based medical schools. It seemed that the folks that had put the relationship together here had encountered the problems and I think solved them in the correct ways. For example, in many of the community-based medical schools the Chief of Staff was prohibited from being a faculty member whereas here, we have always had a faculty member alternate with a community physician, and I think that laid the groundwork for much less "town/gown" difficulty.

Another significant point along the same venue is that here by the Affiliation Agreement the department heads in the medical school are the Service Chiefs in the hospital. As I said, in some other places there was the situation that the department chair could not be the service chief and that led to tremendous, tremendous friction; whereas here that is not the case. If you go through the Affiliation Agreement and the relationship between the hospital and the medical school and look at how successful this institution has been, you will find that the grounding in the Affiliation Agreement, I think, is a significant factor in the success of both institutions and the fact that folks look carefully, I believe they look carefully, at allowing the medical school to have a significant role in the hospital. A lot of credit goes to the community physicians who were here at that time who were wise enough to see that it had to be a synergy between the school and the hospital for the this whole thing to work well.

So, those were among the factors that led me to look at this place very seriously and then to have the hope of coming here and then have that materialize in the summer of 1988 and I said, in September of this year we will celebrate our twelfth anniversary here. It has been a most interesting time in the twelve years to watch the evolution of three institutions, the university on the one hand moving from what was a regional comprehensive university to now being considered a research doctoral university. To watch the evolution of the medical school from then a virtually unknown medical school to one which is now perceived nationally as a leader in primary care and innovation and education in telemedicine and robotic surgery and to have watched the hospital--then a 500-bed community-based teaching hospital--to know what has become a significant major teaching center for a third of the state and to be recognized nationally as one of the leading health systems. When you put that all together over twelve years you have seen a tremendous maturation and recognition beyond our own borders of what a tremendous institution this is and what an influence it has had on education, service research, and probably stands us ready to move on to the next plateau taking into account the plateaus through which we have come but I think at least for me, the last twelve years have seen a tremendous maturation and the coming together of these institutions to be a significant force regionally and nationally in health care.

Beth Nelson: Why do you think that happened? You talked about the Affiliation Agreement and I felt like you see that it set the stage for a lot of that synergy. What other reasons would you say helped that happen?

Dr. Hallock: If you look back, there are a lot of things that are fortuitous. Among the fortuitous things are the health care evolution that took place in this country that did not occur in eastern North Carolina. The HMO rage, the change in health care delivery, the change in reimbursements, the buying and selling of hospitals, the buying and selling of medical practices, much of which has caused a lot of distress around the country in major medical centers and for whatever reason, we seem to have been able to have avoided those whether it is by virtue of our demographics, our geographics, our location, some wisdom on our part in not making some of those decisions. I think a prime example would be the growth that has occurred in the hospital.

If you look at it, there are very few other major medical centers that are continuing to grow and continuing to add beds and we continue to do that and that has been an evolution over certainly the twelve years that I have been here. My guess is that if you look at it, the occupancy has probably never been under 80% which is considered full for the twelve years that I have been here and yet we continue to add beds and we continue to grow despite the advice of nationally known consultants who have come in here nationally and said that we don't need any more beds, that we were through growing. In fact, by the year 1997 or 1996 or whatever it was, we would be down to 500 beds and here we are at 720 beds looking to add another 70 or 80 beds.

We have been different from the national. We have avoided the national rollercoaster and have made some very wise decisions along the way. I think the synergy among the hospital, the practicing community, and the medical school have all led to that. People get a lot of the credit, a lot of good people working here both on the hospital side and the medical school side the leadership from both institutions, their Boards, the decisions that were made and the move to privatize the hospital. A lot of folks put a lot of energy, a lot of hard work and a lot of belief in that and clearly that has paid off and has worked well. You can look at things like the change in the way in which out of county indigents were paid for at the hospital. When I first arrived that was a line item in the medical school's budget to the tune of about $15 million a year and what occurred was that we would be billed quarterly by the hospital for out of county indigents and we would then reimburse that. About six years ago the State Medicaid Office came to us and told us they would like to take that money out of the medical school budget, not reimburse that directly, and use that as a matching fund, if you will, for the federal three to one match. Certainly, from the medical school's perspective, what we wanted to be sure of was that it would not impact on patient flow and therefore impact on educational experience for residents and students. The hospital guaranteed that it would not occur and the state as a willing partner said that they would look to make certain that they deal a disproportionate share reimbursement for the hospital and so it was a "win-win" for everyone. That sort of decision, that sort of willingness to have synergy, take money out of one pot or another so that the whole institution would benefit. There are probably multiple examples of those.

Beth Nelson: I was thinking also it probably worked out to your advantage that you no longer had to fight the line item battle in the General Assembly year in and year out that this was kind of a guarantee agreement that you could be relatively sure of, is that not a factor as well?

Dr. Hallock: That's probably true. As a matter of fact, the more humorous side of that is that people wanted an explanation for a couple of years as to why my budget went down because $15 million was in fact included in the bottom line and then all of a sudden $15 million was missing. We had to explain that the $15 million was never for our use in the first place and that we had no direct benefit from the dollars. In fact, the state knew that it was paying for indigent care so that part of the line item was really never in jeopardy from what I could see at the time that I was here. That was created before I got here so that was a little different situation.

A recent example of the synergy between the institutions is robotic surgery. A little over a year ago Dr. Chitwood, who is probably one of the world's experts, if not the expert in robotic surgery, certainly in robotic valve replacement, petitioned the hospital the need to purchase a significant piece of equipment the daVinci robot. The hospital came forward; put up the dollars, the robot was purchased. It was delivered to the medical school, put in our research labs and tested to make sure it would work and is now in the operating room and I think we have done eight or nine valve replacements. Where that then leads to is we are now recognized nationally as the teaching center and so we in the medical school have now committed to buy a second robot so that we can become the training center for the country for robotic surgery. They tell me that in the month of September, teams from Johns Hopkins, Baylor, and some other places will be in here learning how to do robotic surgery. That's a prime example of the hospital taking the lead on the one hand and saying yes that it is critically important and that they will put those dollars up. We will fund something that has the potential to be a significant factor in the future thereby that leading to the FDA trial and us saying that we would put up the second robot and we will become a training center.

I think the other one that has to be mentioned is Telemedicine. That is another example of where we in the medical school took the first step and the hospital has now come behind us and agreed to the funding and agreed to the need to have telemedicine throughout the region and that has been parlayed any number of ways for us to be now perceived as a leader nationally in telemedicine.

Probably one last example of the synergies is the Robert Wood Johnson Generalist Physician Grant from about six or seven years ago now where RWJ put up money but we had to show them that we would be the site for the development of generalist physician programs and look at the recruiting and retention of rural practitioners and the use of rural practices as teaching sites and the need for the hospital to be a partner and put in significant resources to allow the generalist physician grant to materialize. The hospital did and we were the recipients of a six-year multimillion dollar Robert Wood Johnson grant which is now finished and which continues however locally with the hospital's continuing its portion and we continuing ours and having a significant impact on rural practitioners in the area.

I could probably sit here for hours and just begin to recount example after example. I think some of those are the highlights. The neat thing about those examples I have given you is it shows the mission. Primary care comes from a generalist grant, the Robert Wood Johnson portion through telemedicine which is application of the current technology through ultimately robotic surgery which is probably not a part of "a primary care school" and yet if we have the health of the region as one of our significant interests then it does make a great deal of sense and it also fits very nicely. We have been able to take primary care, secondary, quaternary missions and put them together in various places and make sense out of it for both the hospital and the medical school.

Beth Nelson: Lets talk a little bit about what the hospital has meant. We talked about the relationship of the hospital and the school of medicine. Talk a little bit about what it has meant more to the region. We have taken a number of valiant steps out into the region many of which won't bear fruit for a number of years and I know you have been an integral part of that, talk about it.

Dr. Hallock: Let us key into the region for a moment and realize that we are talking about one of the most rural, most poor regions of the country. Not the most rural or the most poor but one of the most and that we have a university whose motto and mission include the words "to serve" and then we have a medical school which was put here by the Legislature and part of its mission was to serve the health care needs of the region and then a hospital partner who bought into that mission, county commissioners who bought into that mission who all said that yes they would serve the region.

When you look at the patient mix in the hospital it turns out that some thirty percent of the patients are Pitt County patients and some seventy percent are out of county. So, right from the "get go" the hospital serves the region. If you look only at the service they render and only at the patients they care for the hospital serves the region. Then as you look at delivering health care to a region you have to look at several aspects. One aspect being the hospital's willingness to go out there and help some hospitals in distress, some practices in distress and start a couple of new practices, and even start a new hospital but never with the idea that it was going to build such a huge enterprise that it would be the dominant force and the only force but rather wait until it was called for, where help was asked for, before they went out there. This is a little different strategy. I think more friendly strategy but a strategy that probably has come back to work. If you look at the big hospital systems that are having great difficulties, they went out and randomly bought everything they could buy. They didn't worry about the region they were taking care of, didn't look at the ramifications on the region, when in fact what has occurred here is that Pitt has looked at this region and has been a very, very outstanding corporate citizen, if you will, in terms of interacting where they have been asked to interact and not trying to supercede the will of the local community.

If you then look at the next aspect of that and that would be the health care providers. That is where the synergy between the hospital, the medical school and the university can be see the. The nurses of the hospital and the region are graduates of ECU but they do their clinical studies at Pitt; the occupational therapists, the physical therapists, the medical record technicians, cytopathologists, etc. come out of the educational programs at the university, they do their clinical work at Pitt and then they are distributed to the region. So, all of a sudden you have a whole different way of looking at how you impact health care. It isn't just your willingness to be out there but you are the training site for those health care providers to get out to the region. My guess is that if you looked where the health care providers for this region were twenty years ago and now, there has been a vast difference.

Along those same lines, another aspect is the Midwifery Program that has come to ECU, Pitt is the partner, the clinical venue is the hospital, but the nurse midwives practice in the region. The Physician Assistants Program comes to ECU, the clinical partner is the hospital, but the PAs wind up in the region. Another interesting example is a recent Robert Wood Johnson grant where nursing and PA programs team together to do education outside of Pitt. We couldn't do it in Pitt County. It had to be outside and we went actually to the West of here and included Duke as a partner and all of a sudden we are able to be on equal footing, if you will, with the Dukes of the world and be recognized by Robert Wood Johnson as one of their model programs from an experience that started out at Pitt, at ECU and expanded out.

I think that probably to capture it you would say that the basic mission is service and that's for all of us. Yet we have taken that well beyond service to the region, to leadership in the region in providing health care providers, building a health care system and really looking to make sure that the care that is rendered is as close to home as possible and that is a part of the mission of all of the players.

Beth Nelson: Where do you see us going from here as we continue that influence in the region?

Dr. Hallock: If you look at the region, what you would hope would happen is that we would ultimately wind up creating health care delivery modules in the local region that would include the full range of health care providers--physicians, nurses, nutritionists, social workers, etc. who would have trained together so there would be interdisciplinary training. They would learn to practice together and would learn community demographics, community economics, community resources, so that in fact what would happen is the basic health care is going to be provided in the community. We should be at the forefront of driving the whole educational process and using the resources we have here to get out into a community, look at that community, help the community understand what it needs, put students out there who could then go and practice out there.

If we do that well the old concept of a "hub and spoke" will take a different shape and form and we will be the hub of a delivery system. It won't be for every system that we have purchased. It will be a delivery system that we have helped to build on the strengths that are out there. One of the most difficult points of that is going to be convincing communities to take the resources they have and shape them in a way that the community may not think it is the best for it when it is. An example is there is a hospital in a community, the hospital is losing money, the beds aren't being filled, it is clear that it should be a day facility or that sort of business. Convincing that community about that is going to be very difficult. That is the sort of thing I think you need to work toward.

Beth Nelson: That would be like what we did in Bertie.

Dr. Hallock: That is exactly what we did in Bertie.

Beth Nelson: Can you think of major obstacles the hospital will have to overcome, when I speak of the hospital I am primarily speaking of the hospital, but I am thinking campus-wide.

Dr. Hallock: If you look to 1975, which is when the Affiliation Agreement was first crafted, a decision was made to move from a hospital site across the street, the old County Hospital, and build on the current site. As that was occurring this medical school was moving from a concept stage to the reality stage. Right at that point there were several barriers. The "town/gown" issue for practitioners was a major barrier which was overcome. The issue of whether or not you could have a county hospital and a state medical school built on the same property or at least take a hundred acres and dedicate sixty for the hospital and forty to the medical school, build it in such a way that you could put connectors in, could you use state money to enhance the hospital and the teaching aspect in there and my assessment is that as that was done in the beginning the groundwork was laid.

Had that not been done successfully, I am not sure we would be sitting here today talking about what a success this is. Those things were done very, very well and a lot of accommodating was done would be my sense among the original county commissioners, the original state legislators, the original administration of the hospital, of the university to accommodate for pushes and pulls of each side really for the greater good. I think if you look back that is what happened, the greater good is what drove this thing to where it is now.

Over the course of my history I know that prior to my arrival there were some financial difficulties in the hospital which were not unusual around the country, those were superceded fortunately and now looking back twelve years it is almost impossible to imagine that the hospital thirteen or fifteen years ago had trouble meeting payroll but it did, that is a fact of life. They had to worry about the transition from a county hospital to a major medical center and the management thereof and I think that has been done splendidly from the level of the Board to the management throughout the hospital. Then taking on the idea that change was inevitable and the change needed to be from a county hospital to a private not-for-profit hospital and all that was there.

If you stand here now and ask what is ahead of us, what are the threats that are ahead of us, there are still significant major hospital systems to the Northeast of us, to the West of us, to the South of us, and we all face the issue of making sure that we are providing the best possible care we can to the largest number of patients and it is going to be very tempting, I am sure, to look to the East to the West, to the South to the North, and say maybe we should encroach on that. Hopefully we would have done a good enough job with the region that the region will realize that ultimately the unity of this region will carry this region much further than it could get picked or pulled apart.

What we need to be able to do is to stay together, to provide the highest quality care, to make moves ahead when we can make moves ahead and not to let opportunity slip through our fingers. If it is there we need to take advantage of it. I think that has probably been a combination of those fortuitous issues and the wise judgments together.

The other challenge that is ahead that we are addressing is technology. It is upon us, it is going to change the way we interact with patients. It is going to change the way we render care to patients. It will not do away with the need for patient interaction, but it will change the kind of information patients have available to them instantaneously. We are going to have to figure out how we best serve as interpreters and add value to the information. That is a difficult thing for the scientist part of us where everything is peer reviewed and peer evaluated and meets the test of a long set of assessments as opposed to somebody who puts it on the internet and it becomes true factual but untested and not peer reviewed. Our job is going to be to teach the next generation how to figure that information, how to get that information, how to pass it to their patients and to help their patients understand what means.

That is probably as I look down the road one of the two major factors facing us. What is going to happen with technology? How is that going to change what we do? I wish I knew what the answer to that was. It is clear to me that some sort of hand held technology which is going to wind up being your telephone, your computer, your download from the internet, your calendar, your pager, it is all going to be one device that you hold in your hand and that is probably five years away or maybe next year. But when that begins to occur that changes medical records, that changes everything both in the hospital and outside the hospital.

The other factor that is out there is the Human Genome Project and that is mapping the human chromosome and what impact that will have on the perfected health of people. It is a totally different way of thinking about health care. Probably its impact on health care the way we think about it is probably going to evolve in the next fifteen to twenty years. We could take one point of view but don't have to worry about it for fifteen to twenty years and the opposite point of view is that it is going to roll upon us rather quickly. In fact I have been here for twelve years and if the next twelve years go as quickly it will be on us before we know what happened. I think we need to keep that out there as a modifier to make sure we are not missing the chance to capture this technology and capture the Genome.

Beth Nelson: I think the Genome issue is very interesting. Out of my own personal curiosity where do you see us going with that as we develop? How about research?

Dr. Hallock: We are going to make a diagnosis of every disease. I think we are not going to be a cutting edge basic researcher the way we were telemedicine. We are going to be an applier. We are going to take the technology and apply it to the population, that is what is going to happen. We will probably become a leader that way which is probably a better role for us.

Beth Nelson: Would you like to talk about some vignettes, about the vignettes of this history of this place.

Dr. Hallock: You have asked me to talk about some vignettes about the history of this place. A personal one is that as I said earlier, on September 1 will have my twelfth anniversary, but, I moved to Greenville a week before that, actually on the 22nd or 23rd of August in 1988. Before I got here I had a phone call from Jack Richardson and he asked me if I was free on the evening of the 26th which was a Tuesday night. I told him I was in the process of moving but I could be and he said good, that he and Charles Gaskins needed some help. They were going out to Plymouth Hospital and they would like to have me accompany them. Jack Richardson picked me up and I knew Jack because obviously in the recruitment I had come to know him and interestingly his wife was the real estate agent on the first home we bought. We headed to pick up Charles Gaskins who at the time was a county commissioner, and still is, and was very involved with the hospital. That was at the time that the hospital was doing its first major bond issue adding beds and all of the hospitals in the region were objecting if Pitt were to get the bond issue and get the beds that they were all going to be put out of business which obviously did not happen. So as they took me on the way out to Plymouth I was treated to stories by Jack and Charles and the issue really was that Plymouth wanted to hear from Jack Richardson and from the new Dean that they would be true to the service mission and this was not about putting small hospitals out of business but really was in the terms of creating a much better medical center in Greenville to which they could refer their patients. After we got back from Plymouth Charles Gaskins put his arm around me and told me I looked good and spoke pretty good for the kind of person I was and that was terrific and he welcomed me to Greenville. I couldn't figure out whether I was being invited to go out to Plymouth to help or really to be looked over by Charles Gaskins but I guess it was somewhere between those too.

Another series of vignettes, probably not the right descriptive, but folks who may or may not have gotten the kind of acclaim that they should have would be the founding chairmen, the people who came as the first chairs of the clinical departments to the medical school and wound up being the first service chiefs; people like Gene Furth in Medicine; John Tingelstad in Pediatrics; Bob Brame in OB/GYN; Walter Pories in Surgery; Jim Mathis in Psychiatry. Those folks took a real risk in coming to not only throw their lot in the medical school but also in helping to transform what was then a county hospital into a teaching hospital. Most of them had non-approved residency programs and so they had to get their residencies approved with the synergy of the hospital.

I would consider most of those folks as unsung heroes who all have had some recognition but if you look back on it for them to come here when they did in the late seventies and cast their lots with this new venture really was quite a thing. I would hope those founding clinical chairs would get some recognition or at least that we remember them and the contribution they made.

Another thought that comes to mind is that shortly after the Plymouth trip we then had a visit here locally from the hospital board in Williamston and there was a woman on that hospital board by the name of Myra Bowen who was very outspoken. She was questioning the motive of the hospital to want to have more beds and was worried that the hospital in Williamston would be in jeopardy in that risk and a great deal of reassurance was given to her and to her Board Chairman. The next time we looked out of County for hospital appointees for our Board, Myra was one of those picked and as you know she became a hospital Board member and a very, very valuable hospital Board member and that created a tie with Williamston that was very helpful.

Beth Nelson: Anything related to the flood, things that you remember?

Dr. Hallock: The flood points out, I think, the incredible interlocking dependence of the whole medical community and the hospital. I am talking about physicians, nurses, other providers. When you look at the fact that Greenville was an island for so many days and the good that was done here locally and yet what I found out after the flood was that all sorts of medical students were flying in helicopters, were out in shelters, were out providing care, that nurses were out doing that. There were any number of folks that we had contact with and the reason we had contact with them was we were out there doing good. We noticed what happened internally in how we here in the center conducted ourselves and operated. The driving ideal I find there are the folks who were out there just doing lots of good and nobody ever knew that they were doing.

You can take this back to the root that we do serve people and help people, help this region. Again, if this medical center wasn't here I think the devastation may have been much, much greater to the region. One person who comes to mind is Paul Bolin who is head of dialysis who was out in the helicopters making sure the persons whom he dialyzed were found and were brought in here, got dialyzed and he pushed to make sure that there was enough water to run the machines. He was out on the rooftops rescuing people because for him that was a critical issue to get folks in here. I mention Paul and he comes to mind but my guess is that there were just scores of other folks also and we could probably do a whole tape on the flood alone.

Again, being ready, being able to martial the resources, being a medical center, being able to do all those things that were vital. It is focused on the hospital because that is the place where emergency care is rendered but, in fact, the whole community comes into play and the university runs its part of that, the medical school, the private practicing doctors and the whole business really is an interlocking meshwork that makes all that happen.