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Chapter X

THE EASTERN VIRGINIA MEDICAL AUTHORITY










The central issue addressed in this case study is how to effectively integrate a large medical care complex into the fabric of the community in which it exists when both the community and the institution are in the process of transformation.
 
 
 

HISTORY
 

The Eastern Virginia Medical Authority is a strange institution by almost any standard. In most respects, it appears functionally as a health science center with a medical school and associated hospitals, but organizationally it is a very different sort of creature. In fact it is an "authority" as in a bridge and tunnel "authority," chartered under the laws of the state of Virginia, and is effectively under the direction of seven city councils. To understand how such a creation came into being it is necessary to consider its context historically and geographically.

The Eastern Virginia Medical Authority, EVMA, is to be found in the lower southeastern corner of the State of Virginia in the area surrounding the largest deepwater harbor in the nation, the port of Hampton Roads. While the shipping companies of the world know the place well, it seems that most of the rest of the world has been largely unaware of its existence. Known vaguely as "Tidewater Virginia," the region has existed for 300 years as a disparate collection of cities who have largely sought to go their own way with little regard for each other or the world beyond. Except for the attractions of Virginia Beach and the presence of a large Navy base, few people either came or went, and the natives seem to have prefered it that way.(1)

Twenty-five years ago, the region could conservatively be described as a medically underserved area. Although there were somewhat less than a million people living there, few sophisticated medical care facilities existed in the area, and the quality and quantity of such care as did exist left much to be desired. For those individuals with serious problems and sufficient money, treatment was sought l00 miles to the north in Richmond or an equal distance to the south in the Raleigh-Durham area. Those without the necessary funds simply made do with what was available.

The medical renaissance began as the dream of one man, or at least that is the local myth. The man was Mason Andrews who combined an amazing set of talents with incredible determination. Mason was a doctor, an obstetrician to be exact, who was well known in the area, and had overseen the birthing of many of the local citizens. At the same time, Mason was a politician and the community activist. When it came time for Mason to run for the city council of Norfolk, which he did successfully many times over, he ran on the campaign slogan "Mason Delivers," and deliver he did.

As a physician, Dr. Andrews was profoundly aware of the lack of quality and medical sophistication in the region. And as a politician he could see the adverse effects upon the population. He was also keenly aware of the difficulty involved in doing anything substantive about the problems. Significantly raising the level of medical care for the region would require an enormous amount of money, but even more than that it would require the cooperative effort of many diverse elements. Given the later (cooperation), the money might be gathered together -- but cooperation, particularly on a regionwide basis was virtually unheard of. In truth, the seven cities of the region had existed as independent warring fiefdoms for longer than anybody cared to remember.(2)

In the context of this situation, Mason Andrews dared to dream what most people would have considered an impossible thought, that there should be a medical school in the region. The reasoning was quite straightforward. If there were a medical school, it could serve as a center of excellence which might attract more competent physicians to the area, train local people, and last but by no means least, provide the faculty which could serve as a care resource. Thus health care in the region might improve.

Few people could argue directly with the logic of this dream, but many argued anyway for a variety of reasons. First of all, there were two other medical schools in the state which worried that, should another school be created, their exclusive access to state funds would be curtailed. It was bad enough that the schools should have to share the largesse of the state, and even though they agreed on little else, they found it in their self-interest to conclude that a third school was not needed. Then there were the local practitioners who worried publicly that the advent of the school would bring about "socialized medicine," which meant that they would have to compete. When questioned, the local Docs all indicated that of course they were competitive -- but privately they were not so sure.

In an effort to garner support for the idea, Mason Andrews and some other co-conspirators arranged for nationally known medical consultants to come to the region and offer their recommendations. They, along with the State Council of Higher Education, officially concluded in l963 that the region was a logical place to establish a medical school. Private conventional wisdom, however, suggested that "no way" would the region ever be able to generate the cooperative spirit necessary to raise the essential funds. While I can't prove it with anything like historical certainty, I think it may well be the case that these "private negative thoughts" of the national experts (and not a few local residents) ended up being the decisive factor which caused the community to turn to and create the necessary funding. It was one thing to have fellow Virginians turn thumbs down (the other medical schools and their friends in Richmond, the state capital), that was to be expected, and considered to be a normal part of the annual game of state appropriations. By the same token, having the local physicians also object was also reasonable, if only because they were doctors, and should know what they were talking about. But, having some outsiders view the region in negative terms was simply out of the question. In fact, it played directly into the hands of a small but remarkable local leadership.

In the late '50s Tidewater in general and Norfolk in particular could not, by any stretch of the imagination, be viewed as an elegant cosmopolitan setting. The truth of the matter was that the city was in a deplorable state. The turn started to come through the efforts of one Charles Kaufman, a local attorney of major standing, who along with a small band of colleagues began to use the federal urban renewal funds and local resources for the rebuilding of Norfolk. In fact they totally redid the city, but I think more significant than the actual physical reconstruction was the renewal of spirit. That effort provided the occasion for the welding together of a group of men who needed only a major challenge to set them on a course of positive action. And having some outsiders suggesting that Tidewater could not respond to their own needs was like waving a red flag. In a word, the folks charged.

At the time, it seemed like things took forever to get going, but in retrospect it appears that the pieces fell together in rapid order, and in a style which I came to recognize as "pure" Tidewater. The legal entity for the undertaking, which was originally known as the Norfolk Area Medical Center Authority(3) was created in l964 as a mechanism to support the development of the emerging Norfolk hospital complex. Even though talk of a medical school was clearly in the air, opposition to such an institution was quite intense, coming from the sources described above. With what I now recognize as a typical byzantine Tidewater tactic, special legislation was pushed through the state legislature authorizing the creation of, not a "medical school," but a medical "authority," with a charter so broad as to almost numb the mind. This charter specified that the authority should:
 

". . .plan, design, remove, enlarge, construct, equip, maintain and operate medical education institutions, medical and paramedical facilities together with related and supporting facilities and to do all things necessary and convenient to carry out any of its purposes."
 
 
 

I was told by those who were intimately involved, that the legislation got through primarily because none of the opponents thought anything would ever come of it. More to the point, it did not mention a medical school, and most of all, no state funds were committed.

The next issue was to raise the money, a not inconsequential task since there was a general agreement that something on the order of $l5 million in the kitty would be required before anything could even get started. Given that large sum and the fact that no state funds would be available, it is not surprising that conventional wisdom felt confirmed in its opinion that nothing would ever happen. But conventional wisdom was wrong. How the initial funds were raised is a marvelous story in and of itself, but more than that, the story has become an essential part of the mythos of the region, and for that reason I relate the tale in some detail. This version comes from my notes following an interview with Porter Hardy, the chairman of the fund-raising committee. By way of introduction, I should explain that Porter Hardy was a congressman who knew virtually everybody in the region, and even though he was from the city of Portsmith, he was well known and well liked throughout. Porter Hardy was one of the originals, and our conversation was nothing short of delightful. It was by no means an interview. I never did find out what he really thought EVMA was (my first standard question, "What is this place?"), but I did learn an awful lot about the kind or early machinations which produced the fund-raising effort that eventuated in EVMA.

It seems that over a period of years, Mason Andrews had gone to see him in Washington while he was in Congress about some kind of a medical school. It was no surprise then, when Mason Andrews set up an appointment one day to see Mr. Hardy in the company of three other well known gentlemen from the area by the names of Cox, Welton and Wood, just to talk about the general idea of the creation and structuring of a medical school. Nothing specific mind you, just a general conversation.

For a variety of reasons, the meeting could not be held at any time except Saturday morning when, it turned out, Porter Hardy had a dentist appointment. The time for the meeting came and went, and Hardy was still in the dentist's chair. So Dick Wood came down and extracted him from the chair, and the meeting began. Nothing particularly was settled and that really wasn't the point. The meeting was basically exploratory to discover whether Porter Hardy felt that something like a medical school might be feasible in the Tidewater area. That was all.

Several years later (l969), Mason Andrews called up and asked Porter Hardy if he would care to go to lunch at the Harbor Club (the business luncheon spot located on the top of the Virginia National Bank). Now mind you at this point, Hardy had absolutely no idea what the luncheon meeting was about or who else might be invited. When he got to the private dining room, there were in his words, "the 25 people who really ran Norfolk" all sitting around the table. Still nobody clued him in as to what it was all about, and the mystery remained until the meal had concluded.

At that point, Harry Price (a local retailer) stood up as the spokesman. According to Porter Hardy, "You will not find a stronger super-salesman than that Harry Price," and the issue was, Would he, Porter Hardy, head up the fund-raising drive for the new medical school? All he had to do, said Mr. Price, was raise $l5 million. Porter's immediate response was, "You all are crazy." Nevertheless, he was not unaware of the fact that the power of the city of Norfolk, and as a matter of fact many of the surrounding cities was sitting at the table, so if it was possible that anything like this was ever going to take place, these were clearly the people who could get it done. Porter Hardy didn't say no, he agreed to "consider." "Considering" meant going downstairs to talk to Charlie Kaufman, who had not been able to attend the meeting. Hardy wanted to know if it was possible, and Kaufman, while admitting to being skeptical, guaranteed that enough money would be raised so that he (Hardy) "would not be embarrassed." Porter Hardy agreed, and the next act was convened several weeks later when the same group of 25 were gathered together for another luncheon. This time, Hardy was in charge.

Before the meeting, each of the participants was asked to bring a list of people who would be able to make gifts of $30,000 or more. The business of the meeting consisted in determining who among the assembled leaders could most effectively make the pitch to the various prospective donors. Those decisions were made with dispatch, and everybody headed for the door. At which point Porter Hardy called out, "Wait a minute, we haven't quite finished yet . . . you all haven't made your contributions." And they all came back in and sat down while Hardy called the roll. The first bid came in at $60,000, and it went from there. The last contribution was offered by a very senior patrician sort, who indicated that he was good for $l00,000. Just as the assembled group was about to leave again, somebody suggested that they ought to visit Charlie Kaufman to see if he might persuade the Virginia National Bank to contribute $500,000. And so a small delegation was assembled, and off they went.

Included within this delegation was the senior patrician who had offered $l00,000. When the possibility of the half-million dollar contribution was raised to Charlie Kaufman, Mr. Kaufman turned to the patrician and said "What did you give?," and the answer came back, $l00,000. Kaufman's eyebrows went up, accompanied by something like, "You're a piker." At that point, the ante was raised to $250,000 if the Bank would go for half a million, and the deal was closed at a quarter of a million each.

Well, that is apparently the way it went. In the course of a one hour luncheon meeting and a little time at the bank, something over $l million was raised. Whatever else this tribal event was, it was clearly a very high-stakes poker game, and it set the tone for all that was to follow.

From the time of that meeting with Porter Hardy and the central group until l973, when the first class of students was admitted, the activity was fast and furious. On the fund raising front, the leaders developed a region wide infra-structure from scratch. Although major fund raising had been done within each of the several cities, nobody had ever tried to do such a thing across municipal lines. Even as the fund raising was going on, plans were being made for the medical school itself -- everything from building design and construction to planning the curriculum. In l97l, the first dean of the medical school arrived, and by l973, five years after the Harbor Club Luncheon, they were open for business.

From its inception, the school (indeed the whole authority) was an odd assemblage of pieces, unlike anything else in the country. So when it came to models, there weren't any. Normally(4) a medical school is either part of a private institution for higher education or of some state education system. It will possess its own "teaching hospital" which is necessary both to provide the clinical environment necessary for education and research and also a significant portion of the funding for the school generated from patient fees. Furthermore, a majority of its faculty will be on staff as full time paid employees. These "normal" conditions end up being very useful in order to create a relatively stable environment within which the school, with a single source of administrative direction, may operate in terms of control over their facilities and funding.

The situation with EVMA was radically different, and some would say impossibly so. In the first place the vast majority of the faculty, at least initially, were not on staff, but rather came from the community as unpaid volunteers or they were only partially funded. At the present time, for example, there are in excess of 600 "adjunct" (read not-full-time faculty) as opposed to somewhere around l50 full-time faculty. Second, the medical school had no hospital, although it was closely associated with the largest hospital in Norfolk and 20 plus others around the region. Finally EVMA was not part of anything (in an institutional sense) which might provide it some support and protection. On the contrary, EVMA was on her own with governance supplied by a board of commissioners composed of representatives from the surrounding cities.

At its best, EVMA and the medical school which fell under its aegis was a radical new model of community-based medical education. At its worst, it was an administrative nightmare. In fact, the institution was a carefully crafted structure which arose out of, and in response to the peculiar needs and conditions of the region. For example; the matter of volunteer staff as opposed to full-time. Even though it is quite true that the sheer number of volunteers introduced enormous problems in terms of continuity and quality control, the presence of these community physicians within the medical school structure effectively brought one of the chief critics into the tent.

The same may also be said for the strange (and sometimes strained) mode of governance. The mere thought that one could bring the representatives of seven, often hostile municipalities into a single board and expect that board to exercise effective governance over an institution was viewed by some to be complete madness. But it worked. Indeed, this strategy spread ownership and responsibility around the region. Effectively what occurred was the creation of what we would now call a "parallel organization," which outframed the existing political organizations in order to create something totally new. It may be argued that over and above whatever health-care benefits accrued to the region through the creation of the medical authority, its function as a parallel organization in a divided region was (is) its most important function.

To say that EVMA is and was a unique, anomalous, bold venture is a fair statement. The central question, however, was, Would it work? With advent of the first students, the experiment began.

The history of the early years of the institution reads like the "Perils of Pauline." There were soaring, and sometimes conflicting dreams emanating from a variety of places -- and coming to earth in the midst of near fiscal oblivion and administrative chaos. Without going into the details, I believe any impartial observer would have to admit that the fact that the school happened at all, and continues to this present day, is nothing short of a miracle. At times it seemed that the life of the school hung by the slenderest (but perhaps strongest) of threads, the simple belief, held by a few, that it must work.

After five years of operation, there was good news and bad news. The good news was that the school existed, had graduated two classes of students and perhaps most remarkable, had begun to prove Mason Andrews' original premise correct, that the mere presence of a medical school would have a positive impact on the overall delivery of health care for the region. The fact of the matter was that with the arrival of the school, there also came individuals who introduced new sophisticated medical and surgical procedures. No longer was it necessary for the residents of the area to journey north to Richmond or south to North Carolina. In most cases, the appropriate skills and the necessary technology were now to be found in Tidewater.

But the first five years had also taken its toll. The first president left under a cloud, followed by the second dean. After their departure, an interim president was brought in from the outside who viewed himself solely in the role of a caretaker. With no clear direction from the top, the possibility for conflict and crisis was endless, and endlessly realized. To make matters worse EVMA and the Medical School, which had begun life as a community-based institution with little other support (financial or otherwise) had lost, or was in the process of loosing the confidence of the community. If ever there was a situation where an old covenant had ended, and a new one was needed, EVMA was a perfect example. The overt signs were painful and easy to spot; low morale, endless bickering and blame-fixing, with finances verging on the point of catastrophe.

Such was the situation when William Mayer, the new president, arrived on the scene to assume his duties. I appeared there shortly thereafter to act as his consultant.(5) The immediate issues were fairly clear. In order to avoid outright collapse, or what might have been worse, a slow agonizing death, morale had to be brought up, the community re-engaged, and the financial and administrative chaos brought under control. But most of all, it was a question of leadership and direction -- telling a New Story if you will. Without this latter essential ingredient, most, if not all of the overt institutional problems would remain insoluble.

My area of concentration was to be on the interface between EVMA and the community at large, with the thought that if we could create a relatively stable and supportive environment for the institution, then it might be possible to deal effectively with the very serious internal problems. Failing that supportive environment, there would continue to be one brush fire after another. To quote the language from letter of understanding which framed my consultancy:
 

Our task is ultimately to create a coherent, formalized support environment for EVMA. This environment should do for EVMA what a university structure would do for any other health science center.
 

It was decided early on that some form of a strategic planning exercise would be very much in order, but how that might be put together, and what the final results might be were left for further development. My immediate task was to develop a reasonable picture of the culture surrounding EVMA as represented by the operative mythos. This took me on a journey throughout the region during which I conducted something in excess of l70 formal interviews. About one quarter of these were with EVMA staff and faculty, and the rest spanned the social and political structure of the region.

A surprisingly simple, but very devastating picture emerged. Essentially, there were two powerful and opposed stories. The first one I called "EVMA the Unifier." This story appeared in a number of forms with many details, but fundamentally it was a story of how EVMA had become the first and only enterprise that had ever united the region in a positive endeavor. The story was told with pride and no small amount of wonder, for to most of my interviewees, the thought that the region could ever be unified was almost beyond belief. One very potent version of this story told the tale of the High Stakes Civic Poker Game which I have already related. Few people knew or cared who was actually present during that remarkable luncheon, for in the way of myth, the historical details tended to get dropped. Indeed, to hear the story one might assume that more than a thousand had been in attendance. In a way, that judgment was correct, for as the myth gained currency and represented the spirit of the people who were or had become involved, it could legitimately be said that everybody was present. In fact, initiating a larger number of people to that story was an annual occurrence. To what extent this was conscious, I am not quite sure, but it happened, and it was effective. Specifically, each year as the annual fund raising drive for EVMA got under way, the story was told again as a way of connecting into the depths of the organization, and also as a challenge to the fund raisers, old and newcomers alike. The story, and participating in the story through the annual fund drive, had become a mechanism of bonding, a rite of passage. And at the center of it was EVMA. On a very crass level, if you wanted to determine the social pecking order for the region, you could do worse than look at who was on the central committee, and then who was sent out to talk to whom.

So it was not true that EVMA had no community support. If anything the support was almost overpowering and occasioned expectations regarding the institution that were in part quite unrealistic. The central dynamic at the heart of this story had almost nothing to do with a medical school per se, but rather it related to a deep longing for some effective kind of regional unity. Of course it was all disguised as a supportive effort to promote good health care, which, like motherhood, was virtually unassailable. Even though regional cooperation might be verboten, getting together for the better health of all, was quite legitimate. And the story about all that was "EVMA the Unifier."

The second story, which I called "EVMA the Omnivore," was quite different. It doubtless had its roots in the early days when the local physician community was less than enthusiastic about the advent of the new medical institution, but no matter how it started, it was very real and very destructive. The central story line here was that EVMA was in business to put everybody else out of business. In short, EVMA was to become the centralized medical/health-care colossus. Precisely how this was to be accomplished or what hard evidence might be cited in support of the idea remained vague and unstated, as is typically the way with myth. The point is that the story was there, and for those under its power, that story colored each and every act that EVMA took. New faculty and new facilities were seen to be prima facie evidence that the grand design was moving forward according to the plans and intentions of an un-named and unseen "power group."

The simple fact was that EVMA, at the time of my interviews, was in such complete disarray that massive takeover was not only out of the question, it was positively ridiculous. But this in no way lessened the power of the myth to stir the waters, and make an already difficult situation worse.

It became obvious to me why EVMA was as deeply troubled as it was, for the culture was essentially the product of opposing myths which slammed into each other with a power and intensity which left everything else in ribbons. Not only were these myths antithetical, they also essentially fed on each other. To the extent that EVMA the Unifier gained any adherents, that represented a further threat to those who perceived the world through the eyes of EVMA the Omnivore. And as long as this cycle of feeding and conflict was allowed to continue, it could only worsen until there was nothing left.

In conversations with Bill Mayer, I indicated that the situation was frighteningly simple. The two myths were powerful and conflicted, and to the extent that they represented the Spirit of the organization, it was frankly amazing that things were going as well as they were -- and absolutely predictable that the situation would get worse. Given that mythic structure, little if anything done on the level of organizational practicality, was going to have any real or lasting effect. Even something apparently as objective as improving the fiscal situation would run into severe difficulty, and more than that would be perceived by those of the EVMA the Omnivore school as but another example of the great beast strengthening its talons.

The strategy evolved was extraordinarily simple, and might be summarized in the words of the old song -- "accentuate the positive and eliminate the negative." But eliminating the negative could not be taken on in a direct fashion. What had to be done was to build upon the positive aspects of the myth of EVMA the Unifier, and make that so attractive and compelling that it basically outframed and outran the negative myth. I took some pains to caution Dr. Mayer that no matter what else he might do, he should in no wise challenge the myth of EVMA the Omnivore, for the only result would be to strengthen it in the minds of those who owned it. His reaction, like most other activist leaders, was to question my wisdom (or worse). As he said, "We have neither the intention nor the ability to take over the region. Why not just say that?"

When I explained along the lines that should now be familiar, how a myth literally created the perceptual world of the "holders," and to challenge that myth directly would be taken as a challenge to that world, and therefore would be met with resistance, he obviously understood conceptually but was still not quite convinced. However, some little time later, he told me of an incident which occurred when he had been invited to speak to one of the local medical societies. While he did not challenge the myth of "EVMA the Omnivore" directly, he apparently had come pretty close and as he was walking out of the room following his speech, he happened to overhear several of the doctors talking together in front of him. One doctor said to the other, "See, it is just like I told you, EVMA is going to take over everything, because Dr. Mayer just said they weren't interested. That's the way they always work. Soften you up and then go for it."

In order to build upon the myth of EVMA the Unifier, we could not simply take out a page ad in the local newspaper and proclaim that as our intention. We had to create a condition in which EVMA appeared in a powerful and positive way as the unifier. It was less a question of saying than doing. More accurately, my intention was to create a liturgical environment in which the story and the action blended to express this aspect of the mythos of EVMA -- in a way that words alone could never match.

The mechanism was at hand in the proposed strategic planning activity which Bill Mayer had previously felt to be essential. I was in agreement with the need for such planning and only suggested that in addition to whatever formal output there might be (a "Mission and Goals" statement or the like), the critical factor would be the process by which it was achieved. My intent was that we utilize the form of strategic planning as the occasion and opportunity for collective Storytelling. There were several immediate implications. First, we could not follow the rather standard approach of bringing in an external consulting team to perform a study and make recommendations, for that would result in the story being told by people who had no real stake in it. While such a consulting group might come up with outstanding recommendations, they would not be the parties at interest.

Identifying the parties at interest was the critical chore. Certainly the senior officials in the Authority were to be included, but again, what has often become standard practice had to be rejected. Instead of a small group at the top heading the effort, with "paper" communication with the balance of the organization, we needed a different way to go. Our solution was to identify some l5 individuals from within the Authority representing all levels and areas including students at the medial school. To this we added a larger number from the community at large to bring the total to about 50.

Since our intent was not only to generate substantive recommendations but also to allow all that emerge out of the group as a new common Story, we had to allow sufficient time for growth; therefore, we consciously spread the whole process over what might seem like a very long time (six months), meeting for a whole day once each month, and we added some elements which might appear frivolous, namely cocktails and dinner each time we met.

The rules of the game were very simple. Each person was expected to contribute their version of what the New Story might look like. If that version was at variance with other or larger bodies of opinion, the right and duty of expression still existed. The only "lay-on" was that EVMA existed in order to serve the health-care needs of the region. Beyond that, the field lay open, at least as that field was pre-defined by the president.

In order to lend some structure to the effort, we moved in four phases each one of which addressed a separate question: l) What are the health care needs of the region now and as they may appear over the next five years. 2) What institutions or mechanisms currently exist which are, or should be, addressing those needs (not counting EVMA)? 3) Which needs are currently unaddressed? and 4) Considering these unmet needs, what are the peculiar roles that EVMA should be playing?

By starting with a question dealing with the health-care needs of the region as a whole, two things were accomplished. First, we deliberately took the attention away from EVMA and the role that institution might or might not play in the future. The point here was to defuse to the extent possible the negative residue of the Omnivore myth. The first cut was not EVMA and what it should do, but the region in its entirety. The second accomplishment was rather more mundane but essential. By asking the group to give their best professional judgments as to the present and future needs, we allowed each person to operate from their own position of expertise. While they might know little if anything about EVMA, they knew what their own views were, and were more than willing to share them.

This sharing was itself important, for although most of the group present knew each other by name and reputation, many had never worked closely together before. As they shared their understanding of the problems and opportunities facing the region, they grew to know and respect each other better and, interestingly enough, found that they had more in common than difference.

Hence, the first question was intended to establish a matrix of understanding, so that the emerging New Story of EVMA, no matter what it might turn out to be, would be grounded in a common view (Vision) of how things were, and where they needed to go. Had our intention only been the gathering and sorting of information, we could have accomplished the first part of the agenda in one session; but as I have indicated, there was much more at stake, so we took the time to allow each participant plenty of "air time" and opportunity to interact with colleagues during the formal sessions, and even more important -- afterwards around the bar and over dinner.

During the six-month process, each of the questions was dealt with in turn, and eventually there emerged a sense of what EVMA should be in the context of the needs and resources of the region as a whole. This had the positive effect of making the EVMA story emerge as an answer to community need rather than a proclamation of EVMA intent. This is scarcely an innovative approach, but it was very powerful and fitted our needs exactly, for EVMA now appeared as the unifying element which completed, and in some sense rationalized, the regional picture.

A very central part of this "liturgical drama" was Bill Mayer himself. Given his position, this is not surprising, but his role had to be carefully thought through and orchestrated to achieve the desired results. As a strong and powerful personality, Bill Mayer was quite capable of a "Take Charge" kind of leadership. However, if the story of EVMA were to emerge as we hoped, and if Bill Mayer were to be connected with it, as was inevitable since he was president, a subtler approach was essential. This approach had to honor the openness of the whole process, and yet create a meaningful place for the president. A complicating element was the fact that Dr. Mayer was new to the region. This permitted a degree of latitude (the "honeymoon factor"), but it also meant that he was an unknown in a region where being known is critical. How he would be known was even more critical, for his personal success and that of the institution of which he was president. Bill Mayer had to become part of the story, and in some real sense, the embodiment of the myth of EVMA the Unifier. To do this it was essential that he practice the art of collective story-telling with a vengeance and epitomize leadership by indirection.

It might appear from what I have just said that my role was to instruct Dr. Mayer. Nothing could be farther from the truth, but it would be fair to say that I was able to provide some perspective and suggestions as we went along. The appropriate word I suppose is "coach," but there was no question that Dr. Mayer was on the field, and had to play the game.

Despite the openness of the process which was critical, it would be totally inaccurate to assume that the Dr. Mayer had no version of the story he wanted to tell. Indeed, he had come to the position of president after a long and outstanding career in health-care administration at virtually all levels. In the past he had been the head of a medical school department, the dean of a medical school, and most recently, the individual in charge of all affairs between the medical schools of the country and the Veterans Administration. Based on this experience he had developed some very strong ideas as to what should be done, and how to go about doing it. Just to raise the ante, I believe that Bill Mayer also looked at this present assignment as his last major administrative post prior to becoming an elder statesman or retirement. He certainly had his story, and a moment's conversation with him would confirm that he held that story with a high degree of passion. He also understood that his story could not be The story, for The story must become richer and more broadly owned.

As the process moved along, Bill Mayer's role was by no means passive, but he absolutely avoided taking the floor in an official position to proclaim how things ought to be done. His style was an outstanding example of leadership by indirection. He paid exquisite attention to context and process. When it became apparent that somebody (and most especially an unpopular somebody) was having difficulty getting their thought out or understood, Bill Mayer was almost inevitably the first person to lend a hand and pave the way. Of course, Bill expressed his opinions, his version of the story, but he scrupulously did it in the same way as everybody else did, in the context of the small groups, from the floor in general sessions. But never from the podium as president.

There was one point in the whole process when I felt that Bill Mayer absolutely outdid himself in demonstrating how a collective storyteller should work. The issue came up as to whether EVMA itself should be a provider of healthcare, and if so to what extent. The importance of this issue derived from the fact that many individuals in the larger health care community were more than a little afraid of the competitive advantage which the Authority might have if it chose to enter the lists as a direct provider of health care. Bill's feelings on the issue were very strong; he believed it essential that EVMA provide health care in part to enrich the educational experience of the medical students and, of equal importance, as a means of generating income for the institution. Privately, Bill was practically beside himself, but to his undying credit, he never used his position as president to force his version through. In fact, a compromise emerged which allowed all parties sufficient room. But most important, the process of Vision-building and collective storytelling was held inviolate.

At the conclusion of the six-month process, it was very clear that a New Story had emerged which constituted solid ground for a New Covenant. Substantively, this New Covenant appeared between two covers as the "Mission and Goals Statement," but that was just a pale reflection of what had transpired. A comment from one of the participants is to the point. This individual had a general reputation of not being a friend of EVMA. Indeed, his voice had been loudly heard among those on the "outside" who didn't want EVMA in the first place, and who took no little pleasure in the seeming near demise of the Authority. In any event, at the conclusion of the process, this individual took me to one side and said, "You know, when we started all of this I came with the impression that we were supposed to plan for EVMA, and my thoughts were largely in the direction of a quiet funeral. It has now become clear to me that EVMA is us, and that we have been planning for ourselves."

The process described concluded in December of l980. Now several years later, it is reasonable to ask, What were the results? While it would be foolhardy to suggest that all positive occurrences since (which have been many) are directly attributable to the intervention, it would seem fair to say that the intervention marked a decisive turning point which has since been capitalized on in spades. The New Story, or more exactly, the strengthened old story of EVMA the Unifier has now come to dominate the field. This is not to say that the tale of the Omnivore has totally disappeared, but it no longer exerts a destructive influence. This may be seen in quite tangible ways. For example, the budget has doubled in the intervening years as a result of a lot of hard work, but also, and perhaps mostly, due to the combined efforts of the community supporting something they now take almost universally as a positive good, which brings them together. Although it seems to be in the nature of such public educational institutions never to have sufficient funds, it is also a far cry from the period of only several years ago when projected deficits were running on the million-dollar-a-year level, off a much smaller base; and making the payroll was, more than occasionally, a real issue.

Further manifestation of this unified community support has been the raising of some $8 million for the construction of a new clinical sciences center. The import of this particular achievement is doubly impressive when it is remembered that the presence of a large clinical faculty was taken to be an enormous threat by those who saw the world through the eyeglasses of EVMA the Omnivore. Had that myth persisted, the clinical sciences center would have been all but unthinkable, and certainly not supportable to the level of 8 million, largely private-sector dollars.(6) In the intervening years, the Eastern Virginia Medical Authority has also emerged from its position as a little known local school of doubtful quality to a visible position of national leadership. Through the creation of the Howard and Georgeanna Jones Institute for Reproductive Medicine, the organization has become a leader in the new field of in vitro fertilization, which bore fruit on December 28, l98l with the birth of Elizabeth Jordan Carr, the first in-vitro baby born in the United States. The essential difference between "then" and "now" is the product of a lot of hard work and no small amount of luck. But it is also the product of a clear Vision and a powerful Story which have effectively united the institution with its community to realize a dream that many thought impossible. In the words of Bill Mayer:
 

The major difference, between then and now is that in l979 the challenge and excitement was focused on whether or not this exciting organization, carefully and laboriously developed by so many was going to live or die. Five years later that is no longer the question, but rather: "Will we achieve in the future the level of excellence of which we are now capable? (7)
 
 
 

CONCLUDING THOUGHTS AND TRANSITION

As I was concluding my work with the Eastern Virginia Medical Authority, it occurred to me that the very mythology which had proven to be the source of strength for EVMA (EVMA the Unifier) could well turn out to be its undoing. In that myth, EVMA is perceived to be the focal point for union, which had brought a disparate region together for the first time, at least in any major way. Given this perception, EVMA was worthy of support, and that support was forthcoming. However, if the spirit of regionalism were ever to turn totally sour and negative, as in fact it had been during the majority of the area's history, EMVA would be in a very exposed position as the outstanding representation of that way of thinking. As I had gotten to know the region, it was by no means clear that something like that could not happen. Indeed, there was much evidence that the spirit of parochialism and municipal self-interest was not only alive and well -- but perhaps even growing a "tad" (Virginian for "small bit"). So for a regional institution to survive, it would be well if it were set in a geographical environment which was positively disposed towards regional thinking. Otherwise, the institution could have a very short life. At the time, the regional spirit in Tidewater was far from healthy.

Then there was William Mayer, president of EVMA. He was a complete newcomer, with no independent power base other than the institution he headed, which itself was in some jeopardy. Furthermore, by dint of some considerable effort he had emerged as a teller of the tale of union. Were that tale to become unpopular, his fate would be predictable. More than that, it was apparent to me that in order for him to effectively lead his institution through the various snares and thickets of the charming, but often byzantine Eastern Virginia folkways, it was essential that he have some alternative "place to stand" which was at once respected, connected to the institution, supportive of regional thinking, and linked in a positive way to the community at large. In order to serve his institution well, he needed a vantage point from which he could go beyond the recognized self-interest of EVMA, and speak with broader authority.

The problem was that regional thinking in general was by no means acceptable or popular in the Tidewater area, and no organizational structure presented itself as a meaningful place to stand for the current president of EVMA. Since these things did not exist, and to the extent that they were necessary for the future of the medical Authority, the only available option would be to create them de novo. To do that would necessitate altering the basic mythic structure (culture) within which l,200,000 people, organized in nine cities and four counties, had found the ground and field for their individual and collective self-understanding for the better part of 300 years. Needed was an essential perceptual shift from isolation and parochialism, as the accepted view, towards a view of the world which took commonality and regionalism as it point of departure. Basically, one would have to do for a whole region what seemed to have been successfully accomplished for a single institution -- create a New Story.

1. This is scarcely an adequate description of the area, but it is sufficient to set the stage for the case study. I will offer much more detail by the way of background for the next case study which will deal with the region as a whole.

2.  To be accurate, it should be said that only the cities of Norfolk, Portsmouth, Hampton and Newport News had been engaged in the 300 year war. The balance of the cities (Virgina Beach, Chesapeake and Suffolk) had only come into existence as cities a few years before.

3.  The name was eventually changed to the Eastern Virginia Medical Authority in order to reflect the regional nature of the enterprise, and with the name change came the addition of representatives of the seven local cities to the governing Board.

4.  I am not quite sure that there is any such thing as a "normal" medical school, but they do seem to fall into a general pattern which I have characterized. And for sure, EVMA lay far outside that pattern.

5.  In relating what happened, it may appear that all thought and activity was initiated by Bill Mayer or myself. That is far from the case, and indeed there was a marvelous cast of characters for this particular drama. In particular I would mention Joe Greathouse, the Vice President for Planning and Program Development. Little, if anything occurred which was not vastly strengthened and improved through Joe's careful and methodical input.

6.  For those unfamiliar with the world of academic medicine, the clinical faculty are those physicians who teach and practice the clinical arts, such as cardiology, internal medicine, surgery and the like. The clinical faculty is distinguished from the Basic Science Faculty which is concerned with such things as anatomy, physiology, and biochemistry. The point is that the clinical faculty are "treating doctors", who deal with real patients and charge money for their efforts.

7.  Mayer, William, "A Five Year Report to the Board of Commissioners of the Eastern Virginia Medical Authority" September l984, pg 33.