[This text is machine generated and may contain errors.]

Collection Number: 3.:4 l

Date: July 20, 2001

Narrator: W. Randolph Chitwood, Jr., MD Interviewer: Ruth Moskop, PhD Transcriber: Janipat Worthington

Copyright 2001 by East Carolina University. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from East Carolina University.

RM: My name is Ruth Moskop. I'm here in the office of Dr. W. Randolph Chitwood to record an interview with him. Dr. Chitwood, you have practiced medicine for over 25 years, and you have contributed significantly to healthcare in eastern North Carolina. For that reason, the History Collections of the Health Sciences Library at East Carolina University would like to record this interview and have it transcribed to be kept in the library where it will be available as an oral history resource for people interested in the history of healthcare. Do I have your permission to record this interview?

RC: You have my permission.

RM: Thank you. Today is July 20, 2001, and it's a privilege to be here with you Dr. Chitwood. Looking at your vitae, I learned that you were born January 16, 1946, in Pulaski, Virginia. Is that correct?

RC: That's true.

RM: Did you grow up in Pulaski?

RC: No, I was born in Pulaski, Virginia. My mother was actually staying in Wytheville, Virginia, when my dad was in the military and was away for a bit, and the hospital in Pulaski was a little bit bigger than the one in my hometown, so that's where she had me. Dr. Divers was the obstetrician, and I got to know Dr. Divers later on. He was an interesting person. He was probably not board certified but delivered many babies in that area and did all kinds of surgery and medicine. I think he was a surgeon more than he was an obstetrician.

RM: Did you have brothers and sisters?

RC: I had one brother and one sister-both younger. My brother is currently an artist and has worked in screen-printing and business, but he is doing what he really likes to do now-he is the artist in residence at the William King Art Center in Abingdon, Virginia, which is where Barr Theater is. My sister is a physician-was a Phi Beta Kappa graduate from Mary Baldwin. She graduated from the University of Virginia-as most of my family did-and is now one of the healthcare providers for Virginia Polytechnic Institute in their Student Care Center.

RM: That's fabulous. Let's step back to your early childhood-growing up with your brother and sister. You said you got to know your obstetrician well. That's a wonderful and remarkable opportunity. Do you remember any other medical-related events or situations in your childhood-either that affected your parents or your siblings or you?

RC: Well everything in my life was Medicine. My grandfather was a doctor, my grandmother was a nurse, my mother was a nurse, my father was a doctor, uncles and aunts were doctors-so I grew up in Medicine. We had a hospital-The Chitwood Clinic. It was there for many years and was started by my grandfather and Dr. C. D. Moore in Wytheville, Virginia. Wytheville, Virginia, in a small town in the western part of Virginia named for George Wythe who was, of course, the mentor of Thomas Jefferson. Jefferson read law with Wythe. It was the only healthcare facility in the town of any size-it was about 18 beds. Basically, he took care of everything-deliveries, minor surgical procedures, primary care-and basically worked very hard. They all worked very hard. I come from a very hard-working group where they basically had clinics three nights a week, took house calls, and saw patients every day. And really, the only day off was probably Sunday afternoon. So I was greatly influenced by Medicine. In fact, most of us didn't want to go into Medicine because of that, but intermittently, we had little interests in Medicine. I was interested in Hematology when I was 12 years old-could do white blood cell counts and do basically sed. rates. I could do most of the laboratory work at 12-13 years old. I could tell what a polymorphonuclear cell looked like, and I knew quite a bit about Hematology, even at that level, based on just an interest in blood cells and microscopy.

RM: Can you tell us a little bit about microscopy at that period of time? How was a 12-year-old child able to accomplish that?

RC: Well I don't think I was a child at 12 years old. I was never treated very much like a child. You know, people who are interested in things, they learn things fast. My son is an avid baseball card collector, so he knew everything about baseball-whereas, I may not be able to get him to do something else. And so I think even though I had great interest in it, I was not interested in learning long division or multiplication because I felt like I could do it other ways, and it wasn't just on a need-to-know basis. So, you know, I can be just as difficult as possible, but dad had an interest because... The microscopy was being able to see small things. I learned about Leeuwenhoek at that time and read a lot about microscopy and, of course, blood cells are easy to smear and to stain and easy to describe. It's a descriptive process, and I had a great interest in that. At one time, I thought I wanted to be a hematologist, but then that rapidly waned. So I had interest in Medicine but mostly interest in Science. I have always been very interested in Science.

RM: What sort of a microscope did you use when you were working with your dad?

RC: I used his standard microscope in the laboratory. Actually, I have his microscope. His microscope was purchased when he was a medical student as a used microscope, and then he used it in the laboratory in his hospital and did countless numbers of urinalyses with his technician, who was Velva-Velva Urnberger-and her sister, Cleta, who was my grandfather's nurse, and so they did all their own stuff, and they used that microscope; and then when he retired, we had it at the house and cleaned it up and then basically it carne to me on his death.

RM: You said there was an 18-bed hospital that was founded by your grandfather and then carried on by your father... with the help of the whole family, it sounds like.

RC: Well yeah, I mean we had other doctors in town. You have to remember, my dad coming back to that town is an interesting story because my grandfather had had a stroke-a light stroke. My father was a Phi Beta Kappa, AOA, #2-in-his-class-kind of person-very smart and worked very hard. Truly the epitome of Osler's masterwork in medicine, which is hard work, and he came back to help my grandfather. I think that probably had that event not happened, he would have probably been an academician because of his... You could talk all morning about my father because he had a broad interest in writing and stuff. In fact, he wrote three or four articles in the New England Journal of Medicine when he was in practice in a small town collecting data and writing at night. He had a vast library, and he had an insatiable curiosity for knowledge and writing, and so he would have clearly been an academician; but he was one of those individuals that it's not where you are, it's what you are if you're interested in academics.

RM: Did your father let you pursue your interests in Science in an undirected sort of way, or did he incorporate your work into his work-your explorations into his?

RC: Well I was a fairly recalcitrant young man. I won't say I was directed by anybody. No, he did not try to influence me to go into medicine because he knew I certainly would go in the opposite direction if he tried to influence me, but he fostered some of my interests. I was an amateur radio operator-building electronics-in those days, and he thought that was a good idea. I was interested in photography. He liked that, so we worked together in doing photography. He certainly knew some areas of science I liked a lot, and he was very pleased with that. He was a good scientist, himself, but he didn't say I must go into medicine by any means, and I'm not sure that early on I had a whole lot of direction because I wouldn't accept direction as to a career development. I was one of these people that sort of went through life sideways at that point. I was not clearly the person with the same direction as my sister or my father, who knew exactly what they wanted to do from the time they were 10 years old. I was sort of like one of those candy boxes of Whitman's Samplers- I was moving through, sampling many different plans at that time.

RM: When you did your photography, did that focus on medical photography?

RC: No, we were always focused on people, places-and I'm not talking about vacation places 1' m talking about my dad photographed every building in the area. His historical work is legendary up there as far as his photographic chronicling of that part of Virginia. I used to shoot horse shows and beauty pageants and do it for money and [I] had a little business. Plus, I used to do salon work-entering contests-so we went to enter stuff. But that's one thing we did do together. We used to go fishing together and stuff like this. You know, there was not much time together. It was a good time, and I think what happens is he gave me the basic principles.

RM: Basic principles of... exploration, industry?

RC: No, basic principles of life. You know, integrity, honesty... He went to two honor code schools. I went to two honor code schools, too. You know, basically be honest with yourself--don't be too fancy. You're supposed to be smart--don't wear it on your sleeve. The kind of basic stuff-how to live, how to work hard and, you know, you don't get anything for nothing. And just basic stuff.

RM: Thinking back on your pre-college days, are there any particular healthcare situations that you remember that were vastly different from the situations today?

RC: Well they're all vastly different. You know, that's why I get very upset when I see people who don't appreciate the things we have today. Basically, you had a limited number of medications that you could use-antibiotics, cardiac medicines... You had fairly limited diagnostics and no arterial blood gases. All X-rays had to be hand-developed. You had a circuit rider gastrointestinal radiologist who would come and do barium swallows. We did our own intravenous pyelograms. There's a lot more independence. If somebody came in with an epidural hematoma, you basically had to put a burr hole in their head and send them to the neurosurgeon some 80 miles away. So they are vastly different than when I grew up. And it was truly a primary care ministry so to speak, and in the evening you would go out and make house calls. You'd get in the car, go up in the hollows and the mountains, open the gate (and don't let the cows out), and drive up to the house. I'd sit there on the couch while my father saw the patient, and if they needed a shot of penicillin-of course, in those days, a shot of penicillin would cure pneumonia-and you'd boil the syringes on the stove, and you'd give them the injection. It was clearly being there and doing it, and there were no work hours. Medicine was a philosophy, it was a lifestyle, it was what you were-a doctor. It was not a job, it was not an employment, it was even higher than a profession; it's what you were. It's really the only degree they put on your tombstone-MO. I rarely see BS or MA on tombstones, or RN. MD is usually about the only thing that's put on a tombstone. So, it's totally different, and the commitment was totally different then than many physicians have today.

RM: More of a way of life-just an all-encompassing...

RC: Medicine should be a way of life, and I feel very strongly about that. I'll hear people who have different views today. They want to spend time with their family, and they want to make sure they have a balance and all that stuff. Well I think that's great, but you still have to realize that if you are the consummate physician, you will not have balance in your life. Your family will have to sacrifice. They won't see you as much. You won't be able to go fishing when you want to go fishing. You will have to go back to the institution-to the hospital-on the night that you had planned to take your family to do something. You'll be called out of a concert, and not many people today are willing to make medicine their life. They want to be an MD and they want to take care of patients, and there is nothing wrong with that at all, but it's not a way of life. And if you look at Osler's little book called, The Way of Life, and read that, then you'll see what I think probably most physicians really should be. We need to at least come back to some of that today.

RM: OK. What about college? What influenced you to attend Hampden-Sydney College?

RC: Well, Hampden-Sydney is a small college. My father had gone there, and it was probably the last place I wanted to go because of that. I looked at other schools such as Davidson and Washington Lee, and I decided on Hampden-Sydney. It was a small school. It was built in 1776. I liked the architecture. I liked that Patrick Henry was on the first board. I've always enjoyed Virginia history, and Virginia history really is the history of the nation. There were nine presidents who came from there and a number of other important people who developed our country, and so I was very interested in that.

RM: Is that where you met Tammy? RC: No, I met Tammy in high school.

RM: She mentioned to me once that when she met you, she thought you were going to be a photographer.

RC: Yes, I used to do a lot of photography, and I was pretty good at it. In fact, after I graduated from college I worked for Dupont, and I was doing photography then. I was also entering a lot of national work-the Eastman Gallery and stuff-and so I was pretty good at it. I had the eye and I had the enjoyment of doing it, and I wanted to see the influence of wars. I even wanted to be a combat photographer at one time.

RM: Which war would that have been? RC: Vietnam.

RM: The Vietnam War. Wow! I know Tammy was glad you found a different career path. RC: I wanted to go to Vietnam.

RM: Didyou?

RC: I had a little hypertension, and I was classified 1Y and couldn't get in the Navy, Army, or Marine Corps, so... Yeah, I wanted to go to Vietnam. I think it was important to serve and to... You know, the things you're the most scared of, you need to lean into 'em--overcome your fears. I don't think that war is necessarily bad for a country as long as it's for the right reason. As you look at Vietnam in retrospect, it's different than looking at it in pro-spect. So I think you can look back and look at Southeast Asia and Indochina when the French occupied Indochina and look at the whole complex history of Southeast Asia in a different light than you could in 1964 or 1963, so I think that when people take strong stands on wars in pro-spect, it's very difficult to really evaluate their influence on the history. You have to do it in retrospect. I have a different perspective on Vietnam [now] than I did then.

RM: Do you want to say a little bit more about your new perspective?

RC: No, that's a philosophical thing that... I lost a lot of friends in Vietnam, and you always feel [that] if you're not there... This wouldn't have been as a physician; it would have been as a line officer or as an infantryman. So when you lose friends and you're not there... I've always run risks. I don't mind running risks. Yes, sometimes risks take you out, but I think in life you have to do calculated risks or you never advance. And so, had I been in that war, my experiences and the way I looked at things would have been totally different. And what I've tried to do is to sup of what others have learned from that war and to try to talk to them about their experiences and form my own opinions. Look at the strategy of George Patton versus George Marshall and look at how they handled things totally differently but to the same goal. You know-was Westmoreland right? Who knows? 'Cause you don't know what political influences [there were] at that time. Who was running it from Washington? Was it Johnson? Was it someone else? Was it the chiefs of staff? Who were the governors of that war? It's really hard to tell. I think in retrospect, it's very hard to... If you're gonna fight a war, you've gotta go all out. It's gotta be a total ablation-annihilation war where you're going to win, and that war influenced me because in retrospect, I realize that we were capitulating at every moment and losing young people at the same time. But you know, with war, you always lose young people. You can't get 40-year-olds to charge up the hill. Okay? Wars are fought whether it's Iwo Jima, whether it's Utah Beach, whether it's Gallipoli, or wherever-they're always fought by young people. They make big changes in history.

RM: It's interesting that we've stepped into military strategy a little bit here. Dr. Absolon's collection has quite a bit of military medicine in it-material relevant to military medicine. But you didn't go to Vietnam, and between 1960 and 1970 you were a textile chemist.

RC: Right.

RM: And then you taught Biology according to your vitae.

RC: Yeah, I learned a lot at Dupont. Dupont's a good company. I learned about extemporaneous speaking, organization, corporate structure- I learned a lot. I taught Biology for a year prior to going to med school. I ran the laboratories at Hampden-Sydney mainly to re-establish my residency back in Virginia. There were a couple of courses I wanted to take, so we worked there for a year. Actually, it was actually a pretty good-productive year. Tammy taught and I worked at a very low salary, and it worked out. I went to med school the next year.

RM: What did Tammy teach?

RC: Well she's a high school teacher, but she taught elementary kids then.

RM: Tell me, how did you make the transition from photography... textile chemistry... well, Biology teaching was sort of a stopgap transition...?

RC: Well these are isolated islands. You know, this is the Solomon Islands of a career-you step from island to island. They're isolated yet there's some pattern when you look in retrospect. When you look in retrospect, you can put a pattern together that sounds like a great story. In pro-spect, it was kinda doing different things with every once in a while something influencing your life and then you moving ahead. So, you know, I can't coapt medicine with Dupont or whatever. But what it does when you look in retrospect, you get the leadership management skills from Dupont, the imaging skills from photography, and the electronics skills and the ability to think in terms of electromechanical systems in amateur radio. But that's all retrospective, you know-I certainly was not mapping out a plan in those days.

RM: But at some point you decided to go to medical school to set your sights and commit four years.

RC: I only went to med school for three years.

RM: Three years!

RC: I went summer and winter and graduated and cut a year off that thing. RM That was an intense experience at UVA.

RC: Well I didn't think it was that bad. I studied. The first year was real hard. You know, like all medical schools, the first year you have to study all the time. It's a discipline. It's basically getting up in the morning, going to class, coming home in the afternoon, eating lunch, and sitting down and studying for 10 hours. So if you're willing to put the effort in and be organized, you'll do okay.

RM: I think your children were born-well, your first child was born ... RC: In my last year.

RM: ...and then you went from UVA to your residency and then internships, and you spent 10 years pretty much focused on Duke University programs.

RC: Right. Every other night in the hospital. It was hard. That was hard. Ten years at Duke was hard.

RM: Hard in what way? Clearly, it wasn't an intellectual challenge for you.

RC: Hard in the fact that you worked very hard. You were in the hospital every other night and were on call 36 hours and off 12 for a number of years. Your kids are growing up and you don't get much time at home, and it's just hard work. You worked all the time. And in your off hours, you were expected to write and publish.

RM: So it was physically demanding?

RC: Physically demanding, mentally demanding, you had to publish-it wasn't for everybody. That program in those days was not a place-it was a Hopkins, Mass. General-like place where you looked around and the guy beside you was AOA and the other guy was AOA. And he or she-it was mostly he's then, [we had] one she in our class of residents-were all very good. It was the first time that I had been-1 don't want to say pitted with-but basically was in a group that everybody was real good. Everybody was good, you know-most of them probably better than you were.

RM: Must have been very...

RC: It was a good time. I enjoyed it. I enjoyed my time at Duke and, of course, as the pain goes away... With any history, you know, you enjoy it more. But, no, I came out of there with 55 publications-peer review publications. RM: That's impressive!

RC: And so, you know, in fact, when I came here, Dr. Laupus hired me and I said, 'Walter (Walter Pories), I talked to Dr. Laupus, and it looks like I got more papers than most of your professors.' And I did, so I've never been through the Assistant/Associate thing-I was a Professor of Surgery from the very beginning-at 38 years old-which met my goal to be professor before I was 40 and to be chair before I was 50.

RM: What are some of the most memorable experiences that you had during that 10-year period as an intem/resident?

RC: I learned to present at national meetings. I was in the laboratory for two years doing basic research. Those were ..... days for Dr. Sabiston. He was president of everything in the world in Surgery. Demanding maestro but, you know, you were with the boys from Dover-you were with the leading people in the world at that time. It was stimulating. It was a good time to be there.

RM: I notice that you had worked in-this is probably all the way back to, well, medical school Embryology and retinal development.

RC: Yeah, in the lab I wrote a thesis in medical school (to get out in three years) on retinal development, and basically I was trying to reinnervate transplanted eyes in uredels and look at the retinal regeneration with autoradiography with radioactive material.

RM: Uredels?

RC: Salamanders.

RM: Thank you. And gradually then you focused your interest... How did it come about that you found your way into Vascular Surgery?

RC: Oh, your interests don't have to... You know, Science, if you're interested in basic Science and how things develop... I learned about how to use radioactive materials to label cells and to look at cell growth and cell regeneration. So that's not the spirit from the interest in everything else. That's why I think it's very important to have a basic Science knowledge. If you can't appreciate the basic Science, then you can't appreciate the applied Science. The clinical Science develops from the applied Science.

RM: So what would you think about the trend these days-the idea that not all medical students need to work with cadaver tissue to learn Anatomy?

RC: I think the less you do, the less you know. I think there's a larger knowledge base today-in the last 20 years-and so I think you have to... You only have a finite amount of time to learn all that, and so if you think that immunologic systems are more important, or growth and development are more important, or Pathology is more important, then I think you have to give up something; but it certainly gives students a hole in their knowledge. The really good student will learn anyway. I still think cadaveric dissection at least in part is good, but I think you gotta have some knowledge of this basic gross anatomy. There's IJO question--even if you're a surgeon or a family doctor. If you're looking at a sprained ankle, if you don't know the gross anatomy, you're impaired somewhat. So it's hard to say that we should not change away from that. Maybe med school should be five years.

RM: They're going towards the computer visualization techniques... You know, more indirect learning about the human body.

RC: Well I think that's good, but I think that's a supplemental thing. There's nothing like getting your hands down in a greasy cadaver and digging out some nerves and figuring out where they go. It makes you learn. See, I think a lot of students today want to have more discretionary time. I disagree with that. I mean, you're learning medicine. You came here for an education. You can't have time going to the beach, being balanced, and all that stuff. It's wonderful, but you know, you're going to become a doctor. You need to be down there cracking in the middle of the night in the laboratory learning stuff. You only get four years to learn it and X number of years in the residency program to prepare you for the rest of your life, and if you want to be an excellent doctor versus an average doctor, then you're going to have to put in those extra hours. My dad told me one time when I said that I was never going to work on Saturdays, and he said, 'Son, you won't make anything of yourself.' When I graduated from med school a number of years later, he said, 'Did you have to work on Saturdays?' So, you know, you gotta work on Saturdays, and you gotta work at night.

RM: Back to the lab. I'm not sure that medical students spend time in the lab these days. I know they spend time with their books and they have their basic Sciences, and then they go to their clinical years. But as far as actual hands-on laboratory experience...

RC: Well everybody didn't do that. At Duke, we had rotations for the students who could spend time in the lab. At UVA, I worked in the lab so I could write a thesis to graduate. That was the proviso; if I finished in three years, I had to write a thesis. So I probably wouldn't have spent time in the lab had I not had to do it at that time. Now in residency, I think it's imperative that you spend time in the lab-whether you're going into private practice or whether you're going into...-because I think it gives you a whole different perspective on surgical Science.

RM: Do your Surgery residents here spend time in the lab? RC: Yeah, they spend a year in the lab.

RM: What kinds of things are they doing?

RC: Robotics, cell growth, cardiac function-a whole bunch of stuff.

RM: Sounds good. You left Greenville and went to Lexington, Kentucky, for just one year. How did that come about?

RC: I actually left here because I wanted to build a heart institute, and at that time there were not the plans nor the resources nor the commitment to build a heart center, and I went to Lexington. We started a heart center and basically, quite frankly, the commitment wasn't there from that medical school. It was a bit disorganized. And so the leadership at this school started considering a cardiovascular diseases center, and they recruited me back to build it.

RM: When you first came to Greenville, you had experienced state-of-the-art surgical facilities and the finest physicians available anywhere-finest care at specialty levels-how did that compare to what you found when you came to East Carolina University?

RC: Well it was a different hospital. It was basically a community hospital in those days, essentially. And there were a lot of folks that said, 'You'll never be able to do heart surgery in this hospital.' I got an awful lot of no's. But, you know, I was provided the resources from the hospital and some resources from the medical school, and I knew what needed to be done. I bought state-of-the-art equipment. I said, 'Either you buy the deluxe stuff or find somebody else.' And so I started with state-of-the-art equipment, but I didn't always have state-of-the-art personnel. I had residents to help who had never helped in heart surgery, and a lot of it was dependent upon me and the small cadre of individuals that I brought from Duke-perfusionists, one nurse for the OR, and one nurse for ICU. I remember we built the ICU, we did the operating room, and we taught the nurses. You know, you basically started from scratch. In those days, I felt this was just what you do. Now I look back in retrospect and it's kind of scary, but it worked out fine. If you're committed to do it and if you've got the background, this is one of those classic things-it's not some sort of serendipitous, happenstance story-it's basically people who are well trained at one institution who have a large knowledge base and apply it to a different institution with a certain set of checklists-just like a pilot takes off-and the commitment from the institution to develop a plan. Then it becomes, in a couple of years, a routine and an expectation.

RM: And it's like it's always been there. RC: Right.

RM: We've talked about your residency and your medical training and your contributions to getting the Heart Center started here at East Carolina and at Pitt County Memorial Hospital. When you think back on it, who were some of the people-aside from your father-who had important influences on your life and your career in Medicine?

RC: Well I think you really only have four or five real mentors in your life. Certainly my dad was, because I think he taught me the basic principles-the interest in the history of Medicine, that the history is not important just for history's sake but as it is a matrix-a helix-that went before. You know, that you can get a lot of information from the history. I sit here and look at the picture of Claude Bernard there-milieu of the --homeostasis. In 1850-1860, Claude Bernard was able to understand that there was an autoregulatory system within the animal system. So to understand that man is to understand what we're looking at now in feedback mechanisms-whether they're immunologic feedback mechanisms, or stem cells, or transplantations, or endocrine feedback mechanisms, or whatever. It's an understanding of the past. My dad taught me a fundamental understanding of the past-that these men and women were just as we are in a different era with less resources-electronic resources-but applied them very well-such as Ernest Starling who really has done the same thing we do with echo today at the University College of London in 1912. So he taught me that, and he taught me the basics of taking care of patients and the bedside manner and all that. I had a chance to see that. He was an amazing individual in that respect. My other mentors were really after college. Let me say, in high school there were a few people that I admired a lot. One was Mrs. Young who was a superb woman. She was one of Robert Frost's students in a small town. She had gotten an MA from Middlebury at the Bredlove School of English, and she was an absolute taskmaster in high school-about grammar, understanding Spencer, and all kinds of stuff. It was clearly a college-level English course, which I had for all four years in high school. I had the same person, and she would only have people in that class that could move up to the next level. She had a theme throughout the four years. For this, I'm ever grateful because she was a fantastic grammarian. She made you speak extemporaneously, to be able to quote poetry, to memorize things, to write well and to be critical of your writing, and to analyze your writing, so she was a very important person in my later abilities. You know, skip 20 years, now she becomes very important. RM: Was that at a public school?

RC: Oh yeah, high school-George Wythe High School. You know, of course, you're always influenced by your coaches and stuff. I played football, and there is always discipline associated with sports. Sports teaches teamspersonship-to work with a bunch of folks for a common goal, even though you have the spirit and alignments of initiatives. Then, I guess Ed Crawford at Hampden-Sydney. Ed was a taskmaster who was almost to the point that, you know, he'd make you so angry because Ed was, you know, dissections, fine anatomic dissections, every nerve, every detail, every crinkle in the embryo. As you're looking under the microscope-rote memorization, understanding at the same time. He would actually bait you; he'd say the guy ahead of you is two points ahead of you, and then he would tell you that you were two points behind. He'd instill competition in you, and what he did was he turned out a bunch of people who became doctors and scientists. And they all got there, even though you may have been two points behind the other guy, you still made an A. He didn't give out A's very often.

RM: This was a Physiology teacher?

RC: No, he was an Embryology Comparative Anatomy teacher, and Ed was a taskmaster. I would cuss at Ed-not to his face. He spoke with a South Carolina accent. He said, 'You know, Chitwood, you not doin' as goodajob as you can, boy. Joe Austin's beatin' you. I tell ya. He's gonna beat you on this test.' He would take off five points for a misspelled word. And so, that guy taught me all kinds of Neuroembryology and Comparative Anatomy-a little bit in the spirit of John Hunter. You'll have to ask me about the heroes of yore that are important. They are as important an influence as my modern-day teachers because basically if you look at John Hunter's work in Comparative Anatomy, it comes back in the Comparative Anatomy that Ed Crawford taught me. Find the sections late at night-hard work.

RM: But at least it was legal when he did it.

RC: At least it was legal in animals. And then-was I influenced in medical school? Yeah, I think in medical school I had some great heroes. Dr. Julian Beckwith, who was the chief of Cardiology, was a great influence on me because he had been a very good friend of my father's, and he was the kindly, old, gentlemanly cardiologist who had eyes and ears and great perception of cardiac disease-yet had a bit of Science in him. He had a horse named Consultation, and there was always a joke that we would say, 'Dr. Beckwith's out on Consultation.' I was very devoted to Dr. Beckwith as he was to me, and of course his son, George, and I are great friends. He is one of my referring cardiologists now in New Bern. In fact, George gave me-after his death-his copy of Osler's Textbook of Medicine. He was a classic Oslerian kind of physician. At Duke, Dr. Sabiston influenced me a lot. Dr. Sabiston wac; a surgeon larger than life in that he was probably the most important educator of this century, or at least the latter half of this century in Surgery, and he trained a school of surgeons who became professors. Actually, he has asked me to write his biography.

RM: How exciting!

RC: Sabiston was a demanding mentor-somewhat cold in nature in that he was not your best friend-you clearly worked for him. He would be very demanding. He really wouldn't tell you how you were doing. I thought 50 papers was probably about average, and I found out that I was way ahead of the pack. So, you know, he had high expectations-yet, when he took you to national meetings, he would praise you in front of people and say, 'This young man is going to be the president of the American College of Surgeons.' Then he would get you at home and if there was some problem [he would say], 'Can't I trust you? What's wrong? Do you have a brain tumor, young man?' But you have to learn to work with guys like that, which is not that hard. My father was also demanding. Ed Crawford was more demanding. I once told Dr. Sabiston, 'You're just in line with the rest of 'em.' I must mention Andy Wexler at Duke who taught me a lot of Science. I worked in his laboratory. He taught me a lot of surgical technique. I'm devoted to Andy. When I had any personal problems-he was an attending there-I would go spend time with him, and he would sort of help me work those things out and [he] became a true friend. He is now the chairman at Honoman. Of course, after I left Duke, I came here and Dr. Pories became a friend and mentor-different style than Sabiston a much more worldly style of teaching you more street-wise things like leadership-how to lead people; management of money; budget; how to get things done in a difficult, complex, unworkable state system; how to cope with this; how to build things when resources are plentiful; how to build 'em with they're limited-but to keep progressing. So he has taught me an awful lot of stuff. Those are sort of my main mentors. Of course, I have mentors every day in my young faculty. They teach me what to do. Guys like Mike Rotondo and Bill Wooden and Paul Cunningham and Carl Haisch and Mark Williams, my associates, and Jon Moran-all these guys teach me stuff every day-these surgeons who are not much younger than I am but are junior to me in the department, but I listen to them as my security council, my national security council or council of chiefs. Of course, you know, your leading influence is often your spouse. She preserves the same principles-the same ideals-I think that I have of honesty, integrity, hard work, getting the job done-no matter what the cost-no matter what the personal cost. Obviously, you want it to be legal and not hurt someone, but the idea is that if it's for the greater good... She also taught me the art of philanthropy-in other words, basically we need to put back into our society--either through your efforts as being in service organizations or through your financial contributions� that it's just as important. She got that from her dad who was a great gentleman and kind to a fault sometimes. He would always take care of the poor child who couldn't pay for this. He would buy him a coat and do this and not let him know that he had bought it, and he would do it so he could have it with dignity. He just took care of people, and so I learned a lot from Tammy on that.

RM: What was her father's profession?

RC: He was the principal in our high school.

RM: So you fell in love with the principal's daughter.

RC: Right. So you end up with a number of mentors. Probably of those-my father, Dr. Sabiston, and Walter-would be the more outstanding of the group, but it's hard to separate.

RM: Surely. Well you've also had the opportunity to travel, Dr. Chitwood, all around the world and participate in research. What areas, what people, what types of work, what places have been important to you?

RC: Oh, I think it's a potpourri. You look at your curriculum vitae, you know. Who knows? I like the basic Science. I like to go into the great Science laboratories of the world. I also like to go in the clinical Science-see the applications as well. It's nice to talk to people like who was knighted last year for his work in Cellular Biology, but he's also one of the best technical surgeons in the world. As you move up the scale and have an opportunity to meet one-on-one with them, not in an awe-stricken sort of relationship but in a relationship that you are respected for what you do and can-you know, I don't want to say be buddies but close to buddies-totally interact on a very personal basis with all fa ade removed and all patina of professorial standoffishness-all gone-you sit down and talk with these folks, it's really amazing. You talk about what happens if we get a retrovirus from animals in the human strain and how we're going to handle it. Well at least we'll learn how to handle these retroviruses. It may carry us ahead farther. What do you think about this?-thinking out of the box. The robotics has been very interesting. It is interesting to have everybody interested in what you're doing. That was a new thing for me. You know, everyone was interested in what I was doing about something. And with that, you have a certain amount of responsibility because then you realize that if you do something, you've got to do it right because somebody may try to emulate you and not take care of the patient the best way unless it's done right. So I think it is important for young physicians to be involved in Science, both in the clinical Science-! mean clinical trials-and the basic Science.

RM: Some of your early work with robotics was done in Germany if I'm not mistaken. Is that right? RC: Yes, I worked in the laboratories in Leipzig, and of course, Leipzig was a great university. That was where many of the early physiologists were who influenced the Hopkins School of Physiology. Carl Ludwig was there. He influenced the Cambridge School. Sir Michael Foster-that strain-and also the Johns Hopkins School and the William Henry Howell. So you can see the influences of certain schools. The Leipzig School was very interesting to me. As you know, it is in East Germany. It was bombed during the war and basically during the communist regime was really suppressed, and that's beginning to emerge as another fine academic center. They get a lot of money now from the west to build these cardiovascular diseases centers and, of course, the robotics came out of that.

RM: Well let's look at the practice of surgery briefly. I'm sure there are standard surgical interventions that you've learned about and used over the course of your career. How have these evolved from the time you started your residency?

RC: They've evolved a lot. First off, I think some of the great things in surgery that have evolved are things such as total parenteral nutrition. The great work of Stanley Dudrick taught us that even though a patient is lying in bed not doing much, he or she is metabolizing at a much greater rate than if they were running around on a racetrack. So, therefore, even in the early periods of an infirmity-such as a ventilator patient-you need to start alimenting them with parenteral intravenous alimentation.

RM: And that's just the body's response to that invasion?

RC: You become catabolic instead of anabolic. You destroy rather than build. So, therefore, Dudrick saved many, many lives by getting people in shape so that he could take them off the ventilator. You'd get them through the operation, and they just withered. Well now, you know, Dudrick's great advances were very important. A number of things in anesthesia and in antibiotics-these are the major things that changed surgery. In cardiac surgery, clearly, myocardial preservation [and] how to protect the heart while you're doing these operations. Remember during my career, coronary surgery was developed. Valvular surgery was expanded. New types of prosthetic valves... I have basically lived most of the last two-thirds of the history of cardiac surgery with the pump being developed in 1953 and the first valve being put in 1960. You know, you start talking about the first coronary bypass done in '64-'65-the year I graduated from high school. You start talking about it-I've lived most of the stuff. Oxygenators have improved. Cardiopulmonary perfusion... The heart/lung machine has improved. But more recently, the great improvements in the last five years, have been using minimally invasive techniques-smaller incisions-and I think we have been involved in a lot of the development of that work; specialized connectors to connect grafts to the aorta and to the heart without having to sew them on so you don't have to put clamps on the aorta; echo devices that allow you to assess what's inside the heart in detail before you do the operation and then assess your success afterwards; the ability to prevent having to catheterize babies by just echoing them before surgery; the robotic work that's corning along; the new technologies in glues-bioglues; the new technologies corning along in transplantation and stern cell work developing rnyocytes to be able to repopulate scarred muscle. So you let this stuff iterate, and maybe 20% of this will come to fruition but still will move the Science ahead.

RM: What was the relationship between what you were experiencing and the work that was going on in Houston?

RC: What do you mean? What work is going on in Houston? They're doing a lot of clinical work. The only real major stuff in cardiac surgery in Houston is a lot of ventriculosystolytes work. They bake your heart-not a lot of basic Science going on there. Lance Gool is doing a whole bunch of stuff on scanning and stuff. The thing about it-all the great centers were producing this stuff 20 years ago--30 years ago. Now, many centers are producing a great deal of new technology. It's not just Hopkins or Houston or Baylor or wherever.

RM: Would you like to talk a little bit about other medical advancements that you've seen?

RC: I think a lot of them relate to general things such as mapping the human genome, understanding the human genome, different kinds of medicines in cardiovascular diseases, and interventional therapy in cardiovascular diseases with catheters. Catheter-based technology has improved dramatically in the last 10 years with stents. In the area of infectious disease, we are certainly getting a handle on some of the more complex infectious disease problems, so I think that there has been a lot of evolution. I think it will be a nonlinear relationship now that we have established what the human genome is like, and we need to learn how to intervene at each point in the human genome to affect disease processes-either as a blocking agent to prevent things from becoming manifest or as a genetic altering mechanism so that disease processes don't become manifest.

RM: What about any kind of particularly creative use of materials that you have experienced in your practice of Medicine-of Surgery.

RC: Well I think some of the new developing technologies relate to cell engineering, where you can grow cells in a dish and then reimplant them, either on a matrix to grow valves or in heart muscle to re-establish contractility to myocardial restoration. Different types of metals for developing fancy clips and things-you can clip arteries and do anastomoses. New glues bioglues-to hold tissues together rather than sewing them in some areas.

RM: How does that work, Dr. Chitwood? Glue inside the body? Is it some kind of super epoxy glue that. ..?

RC: No, it's a biologic glue. It's not a chemical that actually is toxic, but it's basically made up of natural adhesives.

RM: In what sense natural? It sounds like it might be little organisms that go in there and...

RC: It's basically just blood products put together to form an adhesive. We can bond tissues, layers of valves-to bond, to stop bleeding, to fill up holes.

RM: Using the basic clotting mechanism. RC: Correct.

RM: Fascinating! They put nature to the best advantage, really-taking advantage of the body's own mechanisms.

RC: Correct.

RM: Oh, that's fascinating. I'd love to learn more about that. What are some of the most difficult situations you've found yourself in?

RC: Well difficult is difficult. Probably biopolitical situations more than operative situations. You obviously have difficult cases. You mentioned before the important successes in your practice. I think that the development of minimally invasive mitral valve surgery as well as mitral valve repair surgery... In North Carolina, there was no one who was really leading the pack in mitral valve repair surgery, and that was one of my goals when I came here-to develop mitral valve repair surgery. Of course, the development of the center is an improvement project and an important success-to have developed the Cardiovascular Diseases Center to where it is today. Difficulties-challenges-1 would say getting people to get in sync with your vision is one of the most difficult things anyone will ever do. In other words, rather than chiding them or compressing them into malleability-to basically lead them to see the same vision that you have, and that's hard to do-to see a much greater possibility for a place that early on was just happy to be here and to realize that if you have a base population of cardiovascular diseases here and patients who need care and you have enough intellectual property and a nucleus of intellectual people as well as a clinical commitment that you can put together a Cardiovascular Diseases Center that can develop education, research, clinical care, and leadership in cardiovascular diseases. But getting people in a medical school/hospital/private practice situation with federal/state/county differences and alignments to move in a direction toward a unified approach is hard-sorta like getting the Balkans to all work together-but I think those are the kinds of challenges that really make large impacts, so those are the difficult situations.

RM: We're still working, of course, towards making healthcare available throughout the region just primary healthcare available.

RC: Yeah, but I think we've evolved to the point that the region is not just eastern North Carolina. The region is the western hemisphere, and we have an obligation not just to take care of the people in eastern North Carolina, which is the primary goal, but a secondary goal is to develop certain areas of expertise [so] that we can contribute something back to the greater healthcare of the nation and other countries. For example, we just brought these children from Mongolia. That's perfectly appropriate in a medical school that has developed for nearly 30 years. It takes 100 years to develop a medical school. You don't have a mature medical school for 100 years. If you look at Duke, if you look at Johns Hopkins, if you look at Massachusetts General and Harvard-you know, all those places developed over a long period of time. Duke's a young school-1923. But when did it start hitting its stride?-in the 70s.

RM: Go back a little bit to the technologies you were talking about-the biological glues and the tissue implants that allow the body to heal without invasive technologies. Has that developed-I guess it's particularly with vascular surgery-but it could be applied to other aspects of surgery as well I would imagine.

RC: Sure-plastic surgery, orthopedic surgery, a whole bunch of other areas.

RM: Well tell me, have there been any particular social or political issues that have been important over the course of your practice of Medicine?

RC: Well political issues are always-you know, if you're building centers, political issues relate to funding, getting individuals to understand the same mission that you have-to get their political alignments in sync with your political alignments-so, I think you have to work at several tiers. There's medical politics, there's hospital politics, there's politics politics-so you need to work at different levels-state politics, federal politics, as well as local politics. Most political issues can be solved within a hospital if you get a good corpus of thinkers together to look at all the negatives and all the positives and put this together in a package. In other words, have your act together before you go play in the circus.

RM: Have the big medical economic changes that have been going on over the past 20-30 years impacted your career in any way?

RC: Yes, there's no question that the retrenchment of reimbursement by federal, state, and private agencies has negatively impacted where we could have gone. I'm very frustrated-angry over a lot of this because basically my feeling is it's changed what-essentially it's an indication of what people think the value [is] of what you can provide. You say, 'Well, you know, doctors need to not make as much money...' The point is that physicians like anybody else have to be compensated. It's more than this, though; it's the fact that in our specialty, fees have been cut by 50%. That allows us not to provide money for education, money for research laboratories in the medical school-that money wasn't going into our pocket. Sure, there are a few abusers in the system, but in our situation, we've have had to find alternative sources for funding and basically cut programs. So to tell me that a heart operation is not worth $4,000 for a fee-try to get a rock star to play for a concert for $4,000--to tell you that a heart operation is only worth $2,000. In the year 2000 terms, it's only $1,200-tell me if you can take care of a patient for $1,200 who doesn't do well. You can take care of the guy that's in there for three days, but if they're in there for a month... So, clearly the reimbursement has changed.

RM: You were sharing your reflections on the current medical economic situation and how frustrating that can be. I was hoping you could reflect for just a moment on how your father handled reimbursement for patient care.

RC: Well you know, he got what people paid him-the insurance company-and he gave a lot of charity care, and he was happy to do that. Now, people have lost the good feeling about giving charity care.

RM: And why have we lost that good feeling?

RC: Well, because it's become much more difficult. Payments have become much more difficult, and it's just a whole different system; and the expectations are different.

RM: Dr. Chitwood, I know that you've been called away. I want to thank you very much for this interview today. You've shared many interesting insights, and I look forward to the continuation of our discussion. Thank you.