Creating a Model for Healthcare in Rural America - Dr. Mike Waldrum, Dean of the Brody School of Medicine at East Carolina University and CEO of ECU Health





Shiv Gaglani: Hi, I'm Shiv Gaglani and today on Raise the Line, I'm happy to welcome Dr. Mike Waldrum, who's the Dean of the Brody School of Medicine at East Carolina University and CEO of ECU Health. He brings a wealth of experience to the role, having served as a senior leader at both the University of Arizona Health Network and the University of Alabama Hospital at Birmingham. 


Dr. Waldrum also serves on the board of the Association of American Medical Colleges and was named chair-elect of the Council of Teaching Hospitals and Health Systems for the Association in 2020. He's a specialist in critical care medicine and pulmonology and is trained in internal medicine. 


So, Dr. Waldrum, thanks for taking the time to be with us today. 


Dr. Michael Waldrum: Great to be here, Shiv. I appreciate the opportunity. 


Shiv: For sure and so as we do with all of our guests, we want to give you an opportunity to tell us a bit more in your own words what got you interested in a career in medicine and then

particularly why you chose pulmonology and critical care medicine. 


Dr. Waldrum: Yeah, well, I came at it as a young person. My parents moved around a lot. My father was with Eli Lilly and Company for thirty-six years, and we moved around quite a bit. I went to the end of elementary school and junior high in Rochester, Minnesota, as he was sent there to open a district office in Rochester. 


As a young person being surrounded by physicians and other healthcare professionals in a rural community, it was just transformative for me. It was unbelievable. I lived on Mayo Wood Road. I knew a number of the Mayo family, and to see what that organization did in this rural northern community in Minnesota was incredible. So, it just was something as a young person that I became very interested in because I could make a living taking care of people, which was just an unbelievable opportunity that I still have so much respect for and love for. But, I also was very interested in how that thing happened and the system of care. We'd have family or people would come in to get care, and I would wheel them around the clinic and things like that, and I was just really fascinated about how that worked and how did that happen? 


So, I came at it really as a young person, very interested in operations management and how healthcare systems come together to affect care, and also how do you take care of people? That led me to study humanities because I wanted to learn about people as an undergrad, as an English major, but I was a pre-med English major with the intention of becoming a physician and then getting in the administration side of the business, also. 


As I progressed, the reason that I was interested, I think, in pulmonary medicine and critical care specifically -- becoming an intensivist -- was that for my first job, I was a night shift orderly in a hospital. Back in those days, one of the jobs was to take care of people, and often elderly men, during the dying process. So, at age eighteen, I got exposed to death, which I'd never really been exposed to and that led to the perspective of if I'm going to take care of people, I need to help them not die. 


As an intensivist, you're right there at the interface where people need highly intensive care and they're trying to actively die. So, if I was going to provide care, I felt that that was the point to drive the highest value. I also really enjoyed the diversity of being an intensivist. It's really internal medicine in the intensive care unit, so it's very broad with all of the systems affected and so I love that. I also loved the procedural aspect of critical care medicine. 


Lastly, during that time, I had so many great mentors. I've heard your podcast and this is a common theme, right? It's who you get an opportunity to work with and I've had, through multiple tracks, so many great opportunities to be mentored by leaders. One of the first ones was a pulmonary critical care doc that was an administrator and chief of staff at UAB Hospital for over thirty years, Dr. Durwood Bradley, who was really very influential in my decision making. 


Shiv: Wow. You've touched upon a number of threads that I'm definitely going to be pulling on throughout the rest of the conversation. One of which, I'll highlight to our audience, is the fact that you also had experience working at an early age as an orderly and getting exposed to medicine. Because I think it's those experiences that not only help shape one's commitment to the profession, but also give you maybe more empathy for the rest of the healthcare workers and workforce in a health system, which I'm sure has been valuable, in your role.


I did want to let you touch upon that, but I did want to also transition into the leadership hat, because you've obviously had an extensive leadership background. Is that something that you kind of always were gravitating towards, or did it sort of just kind of occur because of serendipity? 


Dr. Waldrum: Well, I think that as a physician, I was always interested in being engaged in the environment on how healthcare worked. As I mentioned, I was always interested in understanding these really complex organizations and actually how do we come together to affect care? I've always felt that one of the professional obligations as a physician was to be engaged in how organizations work. When I was a resident at Mayo, I was in what was called the Graduate Education Leadership Group and so I was just always involved, because I loved solving complex problems and working in diverse groups. So, that was just natural. I didn't have a goal on what exactly. 


I never thought I would be a Dean/CEO. I'll just tell you, as a young professional, that was never in the plan. But I've just enjoyed working and engaging in organizations and solving complex problems with these incredible professionals that we have this opportunity to work with that are always bright, insightful, and caring humans and that just led to different opportunities. It's been a great path that I think is part of the beautiful thing about being in our profession is lifelong learning, which opens doors. 


I mentor a lot of young professionals, and I tell them what I was told: just get experience, go and immerse yourself in the environment and start learning and opportunities will present themselves to you, and you'll have a great career caring for people and getting something back, which is knowledge and growth and opportunity for yourself. So, it's a circular kind of thing.


Shiv: Yeah, absolutely, and especially in roles like yours -- whether it's as a physician or a leader or both -- you have a lot of leverage to have that impact and scale of impact. So, you've had leadership positions at University of Alabama, University of Arizona, and other places. We like to give any dean we have on the podcast the opportunity to talk about what makes their

present institutions so special. So, can you give us a bit more of background about ECU and the

Brody School of Medicine? 


Dr. Waldrum: We're in this unique area. Part of my passion is academic organizations and safety net organizations and my whole career after my training at Mayo was really being in academic, safety net organizations, which have, I think, unique responsibility and a unique position in the United States. They are really important organizations to communities, and with unique and difficult challenges. 


I like complex problems. I like working on these systemic complex issues and so that's what led me to come to Eastern North Carolina. We cover a geographic area the size of Maryland. People aren't really familiar with the coastal plains of North Carolina, but it's a huge geography and our organization serves this large geography and is really the safety net anchor institution across this region. Part of that is the academic component, which is the Brody School of Medicine, a great organization whose mission was created to primarily educate primary care physicians to take care of North Carolinians, to improve the health and well-being of this region, and to offer medical education to diverse populations. 


It's got this great heritage of actually living those values and making those things come to life. In this massively underserved area for generations, we've shown that we've normalized many of the health outcomes to match the state where twenty years ago we were far behind. We’ve done it primarily with a community-based focus and taking kids only from North Carolina that we know have a propensity to want to practice in the environments that we're here to serve and so that's kind of our sauce. That's how we do it. We keep our tuition low intentionally so financial concerns don't become the concern on training and that leads to a high proportion of our graduates going into primary care fields. 


I always call it the highest-value medical school in the country. It's a great place with a great culture and it lives its mission every day. So, that's what we do at ECU Health and at Brody. We're all about community engagement and improving the health and well-being of our communities through our education and learning objectives. It's a really fun place. 


Shiv: Yeah, that's awesome. Those are some themes that we've definitely touched upon of how do you strengthen the primary care safety net across the entire US. We've all seen those reports around the unequal distribution of healthcare resources. That's only getting worse, it seems, and the pandemic made it worse. Just last week, Becker's Hospital Review released an article about the fact that nearly 300 rural health systems are at risk of closure, including seven in North Carolina and seventeen in Texas, among other places. 


I was wondering, can you comment a bit about ideas you have for ways we could maybe strengthen the healthcare system? Like, how are you training your future physicians at Brody? You mentioned primary care and community engagement as a focus, but what are some other ideas or additional ideas you have for ways we can address this big issue? 


Dr. Waldrum: Well, it's a huge issue and if you study demographics, it's only going to get worse. I think it's going to take us a long time to get out of the issues we face and we're going to have to have very intentional plans and systematic changes. We're going to have to transform. The delivery system has to transform to drive value and I think, you know, how do we actually get in front of illness and create a system that decreases the burden? We have a huge burden of disease in Eastern North Carolina, which is one of the issues with rural populations. 


The answer to your question is multi-tiered technologies running our system over the thirty counties from a systematic perspective. We're not a holding company model. We're an operating company model. All of our clinics and hospitals are on the exact same instance of electronic record and so we can use that data to model where needs are and anticipate needs and intervene early, which we did a lot during the pandemic. But we can do the same thing with diabetes and cancer and work to understand our population very intimately because we live in this environment and we're connected to our communities. Then we’re educating physicians to work in environments like that and creating new access capabilities for our patients. 


An example of it would be the rural residency training program we started a few years ago. The first cohort is coming out of it. I was actually in one of our rural environments seven years ago... Ahoskie, North Carolina -- one of the first Hill-Burton hospitals ever built in the country was in Ahoskie, North Carolina -- I was meeting with community leaders and they were talking about how executives have left those communities.  


If you look at rural communities, the people that are left are really the school superintendents and other people in the education sector, the elected officials, and then the local healthcare organization. Those are really where the thought has to come from. So, we started talking about how do we create a rural residency training program to educate family medicine doctors that become the leaders for those communities, to promote health and well-being for those communities, so that health and well-being is driven through economic opportunities? It’s about driving local economies to improving education and improving healthcare. 


These are specially selected medical residents that have a propensity to want to live in rural environments. They come from rural environments, then we educate them to become community leaders and family practice physicians so they can engage in those communities to improve these rural environments. 


North Carolina has the second largest rural population in the country after Texas. We serve a third of that. So, that's really our space. We're really excited. We're hopeful to expand our rural residency training programs. The first cohort graduated, and out of four, we already signed two to stay in the communities that they were trained in. So these folks, professionals, have a passion for those environments, and then we train them and help them be successful in those environments. That's just one example. We’re doing the same kind of work on nursing, so it's a multi-tiered approach, a systematic-based approach to solving these really difficult changes in healthcare.  


Transformation is not for the weak of heart. Change is difficult. I really loved a lot of your podcasts and the advice given to younger professionals. I'll just tell you that I was told by my father, which was not to become a doctor. This was in the late 1970s. I said, “Why is that?” And he said, “Because all my friends that are doctors hate medicine and so I don't want you to go into it.” I tell this story a lot because I hear that same theme. Then my father said, “I’ll only support you to go through it if you interview ten doctors and find out why.” 


So, I did that and there were two themes that came out: one was, “it's not what it used to be, or it's not what I thought it was going to be.” I hear that message a lot from physicians and healthcare professionals. But if you really think about that, the beautiful thing about medicine is that it's never what it used to be because we're in constant evolutionary learning cycles. If you come into it thinking that it's going to stay the same...it's going to transform and we're actively transforming and doing it in a way that makes sure that we support our providers in that system. We’re being very cognizant of the issues that our doctors, nurses and other professionals face in making environments that are healthy for them. 


So, it's never what you think it's going to be, right?. This is a great industry and there's so much opportunity. It's never what anybody really thinks it's going to be. We're just looking at how do we transform our delivery system and make sure that we live our mission, which is to improve the health and well-being of Eastern North Carolina? I will also say that it can't be done just by ourselves. We need Medicare, Medicaid, the insurance industry and others as partners in how we transform. So, we just build relationships and start having those difficult conversations across the different domains of the value chain in healthcare.


Shiv: That's really astute and interesting. I'm glad you shared that story about your father asking you to interview ten physicians because it's what they say: history doesn't repeat itself, but it sure as heck rhymes. When I was telling my friends and even my family that I was going back to med school, many of them were like, “Why? Are you going to actually practice? It's not what it used to be.” That's partially it. I think we can create a better future for the patients and also the healthcare providers. 


I have to ask you about burnout. One thing that's often cited is documentation, the burden of billing and coding and insurance denials. Over the last six or seven months, clearly there's been a lot of excitement around artificial intelligence. Just up the road from you guys at UNC Health, they're doing some collaborations with Epic on releasing some of these large language model interventions to reduce the administrative burden that doctors face. I'm just curious, what are your thoughts as a physician, as a leader on this. Is ECU doing anything here that you want

to share? And then, how are you training Brody students to be aware of these changes and hopefully maybe even be part of affecting those changes? 


Dr. Waldrum: Yeah, well, it's a really exciting time. You may have noticed that I was trained also as an epidemiologist. When I was young, that was all about understanding data and I became a chief medical information officer before that term was invented, and then a chief information officer for five years. So, I was in the technology space for over eight years of my career and was very instrumental in implementing EHRs throughout that time and throughout my history. 


I have a long view because I've been in it so long and I'm so old, but, you know, I just can remember when we used to have paper and I used to have Health Information Management under me as an administrator when I was CIO, and I'll just tell you that as a physician and as an administrator over that area, we didn't like writing notes on paper either. We want to do the caring and not have to worry about the administrative side of it. So, anything that can be done to lessen that is important. I know most of us know the current environment, but the data is very clear: we were much less efficient when we were on paper and errors were higher. The technologies helped quality and our ability to understand populations and intervene in ways that we could never have done in the old days.  


I think, importantly, we have to understand that everything I just said has only happened in the last twenty years. It's not like we knew how to put EHRs in because we had never done it and I was one of the first people at that time doing this work. We conceptualized what we thought that future should be like, and then we tried to implement it and we found out, ‘Oh, shoot, now we got to evolve it and iterate it to get better.” I think we're really still in the infancy of that evolutionary process. Clearly, we're in a better place with the functionality of Epic and some of the technologies that we have now, and then using those with AI to take the burden off our providers. 


I think back to what I mentioned earlier: we really have to understand that most of the frustration that we have on the provider side of healthcare is driven by the financial incentives in healthcare and the payment models. It's a highly fragmented environment. Each of our clinics has five different managed care organizations involved, so our administrators and doctors and everybody has to understand five different ways of measuring quality and documenting and things like that. Well, that just leads to fragmentation. 


So, I think that we have to understand that we live in those systems and that we're a byproduct of those, and that these technologies can help us overcome some of that. But these are also structural issues that we have to work on because I'm not confident that technology can overcome some of the structural issues that lead to, frankly, the lack of wellbeing for our providers because they live in that crazy system and it doesn't make sense to them. So that leads to burnout and is very unfortunate. I don't blame the technology, the EHR, for that, because it's just being built to follow the different payment rules and the administrative rules. 

I'm going upstream to how do we work on those issues to create a better environment for our providers, our nurses and other folks. 


Healthcare is really an unbelievably difficult profession intellectually, emotionally, and physically. But it's also an incredibly rewarding profession -- I'm glad you're going back to medical school -- with highly intelligent people that want to care for other humans. Unfortunately, the systems and the environments that we're in sometimes don't help us do that to our fullest. So, it’s about technologies and then how do we design process to support our providers is really what we all need to be talking about.


Shiv: Yeah, absolutely. You have a great hat to be able to help affect those changes, both from the work obviously you do at ECU, but also with AAMC. I did want to give you the opportunity to comment on any of that, because I know just a couple of months ago, you took up the mantle to lead the Council of Teaching Hospitals and Health Systems, which has a lot of sway and influence. Any commentary on what you're focused on with the Council of Teaching Hospitals and Health Systems? 


Dr. Waldrum: First, I'm very honored to have been asked to be working with them and it fits my passion about academic organizations in the United States and our unique role. I think it's just a very vital, important role for the health of our country. These are really important institutions and a unique, great group of people to be able to work with. So, I'm honored to do that. 


Then, I would say similar to what I just said, I think it's easy to start pointing at different groups inside healthcare and saying they're to blame...it's the EHR or it's administrators or it's nursing. I just don't view things that way. I think we really have to look at the integrated function and how we come together as a community of caregivers and providers to design the future. That's what our forefathers did and so with the Council of Teaching Hospitals and being a dean and an administrator of large health systems, I think a lot of my work and the work of the AAMC is how do we integrate and bring these diverse groups inside of healthcare and inside academic organizations to design future education systems, future care systems to drive value for our communities? 


That's what we're working on. It’s a complex set of issues. Funding inside academic organizations is highly complex and how we understand the unique missions of research, education, and delivery and how they are interconnected and how we propel each of them forward together as a dedicated group of professionals is really where I spend most of my time concentrating on with the AAMC. 


Shiv: Yeah, it’s quite an agenda, I'm sure. Quite a lot of work to do there, but I’m glad you're working on it. I want to be respectful of your time, so I only have two other questions. The first is, as you know, Osmosis is a teaching company. We like to fill in knowledge gaps, whether that's individual videos or courses. If you could snap your fingers and have a course or a video developed for any particular audience on any health topic, what would it be and why? 


Dr. Waldrum: Well, I think that I would probably have an overview of the healthcare marketplace. I find that people often work inside environments and don't really even understand how those environments work. So it’s back to, as I mentioned, how do these big systems and these big things work? But frankly, all of that happens based on the financing

of healthcare in the United States. So, I think really educating on a macro perspective would help.


I always say that the hospital administrator is the only professional in healthcare and in the United States that, frankly, runs an organization that doesn't operate in the free market -- because we have the obligation to see everyone regardless of their ability to pay -- but all of the inputs to that production are in the free market. This is what's really hurting healthcare financials right now. Hospitals and delivery systems had the worst year in the history of the United States last year because input costs all went up and so that puts extreme pressure on the system. 


Then politicians and others will complain about mergers or doctors will complain that now we’re being employed by a private company or whatever. Well, I’ve bought practices, I've sold practices, I've done all of that and none of those changes happen because the local leader or that local practice administrator or the physician want to give up control or do it differently than they have been doing it before. The mergers and acquisitions are all being driven by macroeconomic forces, regulatory and payment systems.  


I think we have to understand those things, and those are the things that are driving consolidation and driving a lot of the dissatisfaction in healthcare. In rural environments, that issue is what's leading to the instability and fragility of those very important institutions in those communities. Those are very serious set of issues. We have regions that are so remote they deliver one baby a day on average. We don't make money on that, right? I have to have nurses, doctors, and folks to do that. But we do know that if we close that maternity unit, moms and babies would have to drive over an hour to deliver and we know that more moms and babies would die as a result. So, we make a financial decision to subsidize that care and that doesn't get caught in any of the metrics of anything, but is part of being part of

a mission driven organization. 


I think that determination needs to happen not inside the delivery organizations. That's a community discussion. That's a state discussion. That's a federal discussion. What do communities need and where should those things be, and then how do we finance those things to make sure that more people in these environments live healthy lives? Because they're really important people in those environments. So, it’s a long-winded way to say focus on the macroeconomic financing of healthcare.


Shiv: Yeah, absolutely. I couldn't agree more and it reminds me of the conversation we had on this podcast with Vivian Lee who wrote that great book, The Long Fix, which I think introduced a lot of students to value-based versus fee-for-service and these important topics. 


You've already peppered the entire conversation with advice for students. I'd love to give you a dedicated question around what other advice would you like our listeners to take from you? And maybe it's advice that you already give your students at Brody. 


Dr. Waldrum: Yeah, I would say follow your passion. Don't listen to the people that say you can't make it. We all have imposter syndrome and so if you have the passion and you're willing to work hard, just start it and do it and be committed to do it. 


I always ask our students, who in here was told that you'll never make it to medical school? And every hand goes up and it’s the same with who was told don't go into medicine, just like my story with my father, right? You have to follow your own passions and your own desires and understand that it's a great profession with huge opportunity. It's the largest vertical segment of the country from a GDP perspective. There's huge opportunity in it and getting a technical degree, such as an MD degree, is a great way to create opportunity for yourself and do meaningful work. So, that would be my advice. 


And then, be open to the experience because you can do it and go into policy or you can do it and take care of patients in a clinic in your hometown and those are all really good things to do, right? So, there's just no one right way. It's just a great opportunity.


Shiv: Absolutely. Personally, I'm taking notes on that because I'm a med student, as you know, and so a lot of what you've just said resonates with me. My last question...is there anything else you want to leave our audience with about to know about you, about ECU, AAMC or healthcare in general? 


Dr. Waldrum: Well, I would just say the only other advice I would give to students is mental health is important. These are stressful fields and I think we drive independence into physicians. We just drive it all the time. But one of the first things we do when you get in the clinical environment is teach basic life support, right? We’re taught the first thing you do is call for help and so, I just think understanding that if you're struggling or you need help, to be willing to ask for help. People want to help other people in healthcare. Know that there are supports and networks and capabilities, and to always ask for help and don't struggle alone. These can be difficult pathways.


As for ECU Health and Brody School of Medicine, we are creating the model for rural healthcare by creating a trusted premier education and healthcare organization that's a regional-based delivery system and education system. We have a great team of professionals doing that -- multidisciplinary teams. Anybody that wants to join us -- that wants to be creating a future for a great region that's beautiful in Eastern North Carolina -- if you can get behind that mission, we welcome you because we are in the process of transforming healthcare for rural America to become that model.


Shiv: That's awesome, and yeah, I know we already have a number of students and faculty at Brody and ECU who learn by Osmosis. Hopefully, they listen to this podcast and are already contributing to your mission. So, with that, Dr. Waldrum, thank you so much for taking the time to be with us on the Raise the Line podcast, but more importantly, for the decades you've provided to the healthcare system in terms of raising the line and strengthening it. 


Dr. Waldrum: Well, thank you so much, Shiv. I've really enjoyed the conversation and keep up the great work. I've really enjoyed listening to your podcast and the advice you give to students. I just love the narrative. So, thanks a ton. 


Shiv: I really appreciate that and maybe one day I'll rotate through ECU and get to meet you in person. 


Dr. Waldrum: Definitely. Come on down. 


Shiv: Awesome. With that, thank you to our audience for checking out today's show. Remember to do your part to raise line and strengthen our healthcare system. We're all in this together. Take care.