Centennial Oral Histories:
Bill Fulkerson Jr.

00:00:18:12 – 00:00:47:17

Ann Pelham

I’m Ann Pelham, and I’m honored to be here today with [William] Bill Fulkerson to talk about his illustrious career at Duke. And to learn more about, not only what you’ve done, but how you’ve learned from Duke University and Duke Hospital, and what became Duke Health in recent years. So I’d like to hear a little bit first about your early career, and how you found your way to Duke.

00:00:47:19 – 00:01:11:03

Bill Fulkerson

Well, Ann, it’s an interesting question because I actually came to Duke as a trailing spouse [laughs] in 1983. I was finishing up my pulmonary critical care training at Vanderbilt. Then my wife, Mary [McClintock Fulkerson], who had been a Divinity [School] student here at Duke, was finishing her Ph.D. at Vanderbilt in Theology. I had already accepted a job at Vanderbilt to stay there on the faculty and then Mary, my spouse

00:01:11:04 – 00:01:31:16

Bill Fulkerson

got a call from Dennis Campbell, who was the dean of the Divinity School, wanting to recruit Mary to come back and join the faculty at the Divinity School. I was three months from being finished, and so I had to rush over here and interview with people in the Pulmonary Division in the Department of Medicine, and got lucky and was offered a job.

00:01:31:18 – 00:01:42:00

Bill Fulkerson

And so here we are in July 1983, we come back to Durham, North Carolina. And now we’re still here 41 years later.

00:01:42:02 – 00:02:01:12

Ann Pelham

It’s a great story. I don’t want to use the Tar Heel word inappropriately here, but you did go to the University of North Carolina for your earlier degrees — your medical degree and your undergraduate degree. How has it been to be a former Tar Heel in the midst of all this “Duke Blue?”

00:02:01:14 – 00:02:17:09

Bill Fulkerson

Well, as Dean [Mary] Klotman says, I was at UNC for eight years but I’ve been at Duke for 41 years. So I’m a Duke man now. I did get a Duke degree. I got my MBA at Fuqua [School of Business] back in 1991. No, 2001.

00:02:17:09 – 00:02:28:20

Ann Pelham

Right. And I know that that was an interruption of your career, but you didn’t stop working [laughs]. So it must have been quite an experience to go through that.

00:02:28:20 – 00:02:32:23

Bill Fulkerson

It was a very challenging 20 months. Yes, ma’am.

00:02:33:01 – 00:03:06:17

Ann Pelham

So, I don’t want to get us off track. I know you’ve had a number of roles at Duke. One of them was during that time [when] you were running the Private Diagnostic Clinic. But why don’t you take us through how you emerged from the role of clinician and researcher to the one of medical leader and the person who looked over the hill instead of the person looking at the patient?

00:03:06:19 – 00:03:32:15

Bill Fulkerson

Well, you’re right. When I arrived here, I was a clinician and a researcher doing primarily patient-based research, clinical research, in the ICU. I got very lucky in having some colleagues here who invited me to work on some projects with them, and very quickly became familiar with the NIH and funding mechanisms and was able to generate grants and get supported.

00:03:32:17 – 00:03:53:03

Bill Fulkerson

But I was a very busy clinician during that period of time. Eventually, I became director of Critical Care for Duke Hospital, and that gave me a little bit more of an administrative role, and a budgeting role with that. And then following that, I became division chief in Pulmonary and Critical Care Medicine when Bart Haynes was chair of Medicine here.

00:03:53:05 – 00:04:19:08

Bill Fulkerson

I did that for about six years, and then [was] the chief medical officer of the Private Diagnostic Clinic, or the faculty practice, here at Duke. Followed by chief medical officer of Duke Hospital. [I] did that only for two years because the person I reported to — [Michael] Mike Israel at Duke Hospital — left to go to New York. And Dr. [Ralph] Snyderman, who was chancellor at the time, asked me to take over as CEO of Duke Hospital.

00:04:19:10 – 00:04:44:03

Bill Fulkerson

That was in the summer of 2002. Fortunately, there [were] a lot of smart people working at Duke Hospital. So we were able to pull things together, and it was a very successful period, at the time when Victor Dzau was chancellor of the Health System. He then asked me to come in and work as the executive vice president of the Health System, over all of the clinical aspects that we deal with [with] the Health System.

00:04:44:03 – 00:04:49:06

Bill Fulkerson

And I did that up until January of 2022.

00:04:49:08 – 00:05:09:21

Ann Pelham

Wow. It’s quite an illustrious career, and I think Duke is fortunate that you were there to take on those different roles. How did the growth of the Health System during that period affect your goals and priorities — for the organization, and your own?

00:05:10:03 – 00:05:44:13

Bill Fulkerson

Well, the growth was pretty phenomenal during those years. And, you know, people have asked me before, “How did you grow so fast?” My answer is pretty simple. I think if you are a place that delivers the best care, and gives patients the best experience, they’re going to come. And I tell people often when patients and their families hear about Duke and come to Duke, they just assume they’re going to get the very best.

00:05:44:15 – 00:06:14:08

Bill Fulkerson

And that’s our challenge every day – to wake up and deliver the very best. The very best care, the very best quality, the very best experience to patients and their families. So it was never some grand secret strategy, or some cute marketing analysis. We had strategy, and we analyzed the market. But it’s a matter of recruiting the men and women, and retaining the men and women, that can deliver exceptional care and exceptional experience to patients every day.

00:06:14:09 – 00:06:19:07

Bill Fulkerson

That’s the privilege of being here, and that’s what makes this place very special.

00:06:19:09 – 00:06:39:02

Ann Pelham

It certainly was growing a lot in those years if you look at all of the different centers of care that were created. And you redid buildings. I mean, there were tremendous amounts of responsibility that you carried. Not only continuing to do what was there, but expanding, regularly.

00:06:39:04 – 00:07:07:11

Bill Fulkerson

Yeah, there were major building blocks of the Health System during that period of time. And I’ll go back to the late eighties. That’s when we started adding hospitals and actually became a Health System there with the Duke Raleigh Hospital and Duke Regional Hospital joining the health system — under Dr. Snyderman’s leadership. Then we started Duke Primary Care.

00:07:07:13 – 00:07:35:04

Bill Fulkerson

And Duke Primary Care really is a foundation of all we do here. And we brought the primary care practice into the Health System. And today it’s one of the largest, and one of the best, primary care networks in the state of North Carolina, I think. We started Duke LifePoint. Duke LifePoint was a joint venture with LifePoint Healthcare to own and operate hospitals in rural areas.

00:07:35:05 – 00:08:03:04

Bill Fulkerson

We have nine DLP — Duke LifePoint — hospitals in North Carolina, one in Virginia, three in Pennsylvania, and one in the Upper Peninsula of Michigan. And it allowed us at Duke to work with leaders in the rural communities to really help with quality and safety in the products that they deliver there, and help them recruit physicians and nurses in those areas as well.

00:08:03:06 – 00:08:36:14

Bill Fulkerson

We built facilities, as you said. In the past few years, we’ve had major additions to all three hospitals. We built a beautiful behavioral health unit out at Duke Regional Hospital. We built a large medical office building and a state-of-the-art ambulatory surgery center at Arrington in Research Triangle Park. And that’s really to create the space and the place where patients can come, and see our practitioners, and experience the best care that’s available anywhere.

00:08:36:16 – 00:08:41:03

Ann Pelham

In Wake County [there] continues to be an opportunity for expansions. Is that fair?

00:08:41:03 – 00:08:49:17

Bill Fulkerson

Tremendous growth in Wake County. Tremendous demand for services in Wake County. So we continue to expand there.

00:08:49:19 – 00:08:52:11

Ann Pelham

And with more to come, it sounds like.

00:08:52:13 – 00:08:54:22

Bill Fulkerson

Oh yes, oh yes.

00:08:55:00 – 00:09:04:23

Ann Pelham

Are there some particular moments that stand out in the history of Duke, and Duke Health, that you see as most pivotal? Particularly from the health perspective.

00:09:05:01 – 00:09:33:17

Bill Fulkerson

Well, some of those are things I just mentioned. The formation of the Health System. The partnership with Duke LifePoint. The different facilities that we built. And one very recently is the integration of the faculty practice into the Health System. [Yes] That’s been a work in progress over the past year, year and a half, but absolutely critical to the future success of Duke Health and Duke Medicine.

00:09:33:19 – 00:10:19:02

Bill Fulkerson

The other thing I think that has been very important to the practice of medicine at Duke is the academic piece of the School of Medicine and the School of Nursing. That really is part of our reputation, part of what we do. It’s innovation. Thinking of new ways to approach the diseases and conditions. To really offer patients unique opportunities for health and improving health. And so it’s been very important, to me on the Health System side, to be able to support the School of Medicine and the School of Nursing. Financially and otherwise. Because their product is one of the best in the country, and is really necessary to the success of the Health 

00:10:19:02 – 00:10:19:22

Bill Fulkerson

System.

00:10:20:00 – 00:10:21:13

Ann Pelham

It truly is a partnership.

00:10:21:15 – 00:10:23:18

Bill Fulkerson

Very much so, yeah.

00:10:23:20 – 00:10:39:22

Ann Pelham

Are there any particular moments over those years where you were in a leadership role that stand out for you, whether it’s a burst of success or a challenge that you’re willing to share with us?

00:10:40:00 – 00:11:09:16

Bill Fulkerson

Well, there are a couple of things. For me personally, safety and quality have always been paramount in what we do. We had a highly public medical error in 2003 and that led to a reconsideration of everything we do in safety and quality in the health system. We altered policies, procedures, systems, we measured different things, we defined accountability different[ly].

00:11:09:16 – 00:11:22:17

Bill Fulkerson

And it has led to us remaining at the pinnacle of patient safety and quality ever since then. And that’s been very important. But it was a very challenging time.

00:11:22:19 – 00:11:29:05

Ann Pelham

I can imagine. Was there one that felt like a big success?

00:11:29:07 – 00:11:55:16

Bill Fulkerson

A lot of things were big successes. I mean, the clinical programs that have been developed by our clinical leaders over the years in cardiovascular disease, and cancer, and solid organ transplant, and a number of other programs. And to see those become the nationally and internationally recognized programs that they are today has been very fulfilling.

00:11:55:18 – 00:11:58:14

Ann Pelham

So those count among the greatest successes.

00:11:58:16 – 00:12:00:00

Bill Fulkerson

Absolutely. Yeah.

00:12:00:02 – 00:12:19:01

Ann Pelham

Is there something particular that you have taken from all of those ups and downs — mostly ups — from a personal perspective, compared to the young doctor who came here from Vanderbilt and got started?

00:12:19:02 – 00:12:48:01

Bill Fulkerson

Well, I think everything we do depends on our teams in the Health System and in the School of Medicine there. It starts with people and ends with people. And that’s what I think is most important. To build strong teams, to enable them to do the great things they do every day, give them the resources, give them the space, and let them take it away.

00:12:48:03 – 00:13:06:03

Ann Pelham

You mentioned things like the importance of safety and compliance. You also had a big role in creating a diversity and inclusion approach for the Health System. Could you talk about that a little bit?

00:13:06:05 – 00:13:36:22

Bill Fulkerson

I think that’s extremely important. We started years ago working on diversity, equity, and inclusion, and have continued it to today, catalyzed by [Eugene] Gene Washington when he was here as our Chancellor, as well. It’s important for patients to come here [and] to be cared for by caregivers that look like them. And so that’s the importance of delivering a quality product, [it] includes having a diverse workforce to deliver that.

00:13:37:00 – 00:14:13:00

Ann Pelham

So are there particular moments either in the context of that challenge, which for Duke was greater because of our location in North Carolina over the decades before you arrived, before we both were involved with Duke? Or are there some pivotal moments in that history that stand out in terms of building the kind of open and inclusive organization that we hope Duke Health is today — and Duke University, for that matter?

00:14:13:06 – 00:14:48:00

Bill Fulkerson

Well, I think we, like many people, became even more energized around diversity, equity, and inclusion after George Floyd’s death. Again, being led by Gene Washington through this. We redoubled efforts at trying to identify health care disparities in our populations and in our city here, devoting resources to that and to try and erase health care disparities where we could. Understanding some of the root causes around that and attacking those.

00:14:48:02 – 00:14:54:04

Bill Fulkerson

So I’d say over the last five years, it’s been an effort that really has redoubled.

00:14:54:06 – 00:15:16:20

Ann Pelham

The rural counties were not always prepared for Duke to come in. Were there some challenges in that role that you all had, to try to communicate what you could bring to the table without, I suppose, Big Footing your way into the counties?

00:15:16:22 – 00:15:51:04

Bill Fulkerson

You know, when we approached hospitals to join our community with Duke LifePoint, we did it in a way that we felt we could offer them some resources that they wouldn’t be able to develop or tap. They just didn’t have the capacity to do that, or the financial resources to do that. LifePoint is financially very strong, [they are] outstanding operators of small rural hospitals, and we bring to the table the safety and quality expertise to work with them.

00:15:51:04 – 00:16:10:08

Bill Fulkerson

And in every case there have been open arms from the medical staff, from the hospital staff, from the boards of these hospitals, [people] who are eager to understand how they can improve better care in their local communities. So there really hasn’t been any resistance at all.

00:16:10:10 – 00:16:13:06

Ann Pelham

And do you see that continuing to grow?

00:16:13:08 – 00:16:23:00

Bill Fulkerson

I think so. I think so. We’re looking all the time for opportunities to add to the number of hospitals that we have in Duke LifePoint.

00:16:23:02 – 00:16:47:05

Ann Pelham

That’s great. I know that this particular area is growing so quickly. There are opportunities that you might not have imagined back in the 1980s when you first arrived, or even in the 1990s when you began to be an administrator for Duke. Have you been surprised by the tremendous success and growth of this area?

00:16:47:07 – 00:17:16:03

Bill Fulkerson

Well, I think everybody has been a little bit surprised at how fast we’re growing. I think Wake County is [around] the second or third fastest growing county in America today. And so it is a race to keep up. We have formidable competition. But again, I’ll come back to — what is the product that we’re that we’re giving the patients? The highest quality, I think. The best experience.

00:17:16:05 – 00:17:19:13

Bill Fulkerson

And they will come to Duke.

00:17:19:15 – 00:17:47:09

Ann Pelham

You were here at Duke for the pandemic and the challenges that brought to the hospitals. Do you feel like there were lessons from that your successors are dealing with? I know that financially it was a strain for all hospitals and all health systems. Could you share with us sort of how you see that affecting things going forward?

00:17:47:12 – 00:18:29:09

Bill Fulkerson

Yes, I’m glad you asked that. The COVID pandemic was an unbelievable, difficult experience. I think at the peak of the pandemic, the Duke system had about 250 inpatients at one time with COVID. And we had the sickest of the sick here at University Hospital, as well. And so we asked a tremendous amount of perseverance [from] our staff, [from] our physicians, [from] our technologists, [from] everyone to be able to take care of the patients in that period of time.

00:18:29:09 – 00:19:02:11

Bill Fulkerson

And certainly in the pre-vaccine [era], it was a very difficult time with morbidity and mortality from COVID. So it took a toll on a lot of folks. And our goal in the hospitals [was] to try to provide the safest environment for patients and for our staff that we could amid, you know, global business disruption. The supply chain was a disaster all around the world.

00:19:02:11 – 00:19:30:18

Bill Fulkerson

The supply chain was a disaster. It really exposed some terrific weaknesses that we have tried to shore up now that the bulk of the pandemic is past us right now. But I will say, also, during the very difficult times there, that I have never been more proud of our team and what they did to step up and go above and beyond taking care of patients there.

00:19:30:20 – 00:19:59:21

Bill Fulkerson

And so we learned a lot of things about procedures. We learned a lot of things about keeping our staff safe. We learned a lot of things about anticipating supply needs in the future. And I think that all that will help us going forward. We are dealing now with some challenges. We’re dealing with challenges in staffing, but that’s getting better.

00:19:59:23 – 00:20:13:13

Bill Fulkerson

As you referenced, we’re dealing with some challenges financially, but that’s getting better, too. And I think we’ll come out of this in good shape.

00:20:13:15 – 00:20:35:16

Ann Pelham

There was so much to learn so quickly. People were exhausted. Staff were quitting. I think the nurses were carrying a really heavy load. Is there a different philosophy in healthcare now than there was before the pandemic? Or is it just practices and systems that are different?

00:20:35:20 – 00:20:54:19

Bill Fulkerson

I think it’s practices and systems, but it’s also probably even a deeper appreciation for what the dedication from our staff meant then, and how remarkable the people were that were in the trenches taking care of patients at the time.

00:20:54:21 – 00:21:13:10

Ann Pelham

Well, we hope that we don’t have something like that again. But you’ve clearly learned — I think it sounds [like] from what you’re saying is that you have clearly learned a lot from that experience. And the systems are in place now in a more robust way to be prepared for the next pandemic.

00:21:13:11 – 00:21:15:00

Bill Fulkerson

I think that’s true. Yeah.

00:21:15:02 – 00:21:16:20

Ann Pelham

We might not know what it is, but.

00:21:16:22 – 00:21:20:10

Bill Fulkerson

We don’t know what it is. But there will be one.

00:21:20:12 – 00:21:37:13

Ann Pelham

Have you thought about, or could you share with us, your thoughts on Duke’s greatest successes? And it doesn’t just have to be in your tenure. But are there some highlights from the medical system and the healthcare operation that stand out for you?

00:21:37:15 – 00:22:08:18

Bill Fulkerson

Well, I mentioned some of the service lines. And one thing that is true about Duke is that we strive to be innovative, to think of new ways and new things to do for patients who may otherwise not have hope around that. So in many cases in cardiovascular disease, many cases in cancer and many cases in solid organ transplantation, you know, we’re dealing with some of the most difficult cases

00:22:08:18 – 00:22:37:18

Bill Fulkerson

there are. Many won’t be able to treat. But they come here because of the expertise of our caregivers, and they come here because of the innovation that we can put on the table that come[s] out of the research laboratories at Duke University. And so there are countless things. Even this year a unique heart transplant in neonates, a first in the world, done here.

00:22:37:18 – 00:22:42:10

Bill Fulkerson

And those kinds of things happen all the time.

00:22:42:12 – 00:22:58:19

Ann Pelham

Is the transition from the Private Diagnostic Clinic and the integration of all of those physicians after — how many years has it been? 70, almost 80?

00:22:58:21 – 00:23:16:18

Ann Pelham

How do you see that affecting the hospital? Do you feel like the high level of innovation and standard of care is adjusting? Are you able to carry on with this transition underway?

00:23:16:20 – 00:23:40:19

Bill Fulkerson

Oh yeah, I think so. And I don’t think we would have considered the integration if we didn’t think there was a huge upside to it. It allows the health system to capitalize the growth of the faculty practice. We could not do that legally beforehand and [were in fact] many times handcuffed [as to] what the faculty leaders could do in their domains.

00:23:40:21 – 00:23:44:02

Bill Fulkerson

And so this is a big opportunity to move things forward.

00:23:44:04 – 00:23:55:18

Ann Pelham

So you’re saying capitalize the growth. And that the growth stayed in the PDC, and that the profit stayed in the PDC, and you were not able to use that to build up the Health System?

00:23:55:19 – 00:24:29:06

Bill Fulkerson

That’s correct. And if we, the Health System, wanted the PDC to do something that was less profitable they had a hard time doing that, for obvious reasons. But now that doesn’t have to be the case. And I think the main thing about integration of the faculty practice is — the ideal thing to me is [that] I want every member of the faculty to feel like they own the place, and to work like they own the place.

00:24:29:08 – 00:24:44:05

Bill Fulkerson

And be a partner with everyone else in the Duke Health enterprise here. And I think that will unleash a lot of energy and enthusiasm and opportunities for the future.

00:24:44:07 – 00:24:58:02

Ann Pelham

I like your optimism. Maybe you could help us with a little history about the PDC. Why, when Duke was so new, the decision was made to set up something separate like that.

00:24:58:04 – 00:25:13:19

Bill Fulkerson

Well I’m probably not the best one to answer that, but I can tell you that it was started in order to give physicians an opportunity to have a private practice while they were also teaching and doing research at Duke. This was back in the 1930s.

00:25:13:21 – 00:25:15:04

Ann Pelham

It was a recruiting tool.

00:25:15:04 – 00:25:46:12

Bill Fulkerson

Yes. And it’s been a very good thing for a long time. But because reimbursement has changed dramatically in medicine, everyone can’t support themselves. And it really has to be what is valuable to the enterprise, and the enterprise will support that. But the PDC has been entrepreneurial. It’s been aggressive. They have grown. They’ve been a huge partner to [Duke] University and to the Health System.

00:25:46:14 – 00:25:55:01

Bill Fulkerson

But the reimbursement mechanisms now make it very difficult to be in a lone for-profit practice.

00:25:55:03 – 00:25:57:03

Ann Pelham

There’s not much profit left.

00:25:57:05 – 00:25:57:23

Bill Fulkerson

That’s right.

00:25:58:01 – 00:26:06:22

Ann Pelham

And how many years would you say that conversation had gone on about the PDC before you managed to come up with a resolution?

00:26:07:00 – 00:26:09:17

Bill Fulkerson

20 [Laughs].

00:26:09:19 – 00:26:18:04

Ann Pelham

I was going to guess, but not that big. So in your career, you thought about the PDC every day.

00:26:18:06 – 00:26:19:18

Bill Fulkerson

I worked with the PDC every day.

00:26:19:19 – 00:26:21:16

Ann Pelham

Right. Well, you ran it for a while.

00:26:21:18 – 00:26:41:15

Bill Fulkerson

I was the chief medical officer there. But I worked very closely with PDC leadership the entire time I was in the hospital and [when I was] the executive vice president, because we needed the faculty practice and the faculty practice needed us to be successful. And we were. We were very successful.

00:26:41:17 – 00:27:01:19

Ann Pelham

It seems to me, from the outside, that the relationship between Duke and the PDC was really unique by the time everything had been resolved in the last few years. Was there anything like that left in the United States?

00:27:01:21 – 00:27:05:18

Bill Fulkerson

I don’t think so. No. 

00:27:05:19 – 00:27:25:16

Ann Pelham

So for your career, you were operating with different entities, and trying to make sure everyone was still communicating properly and managing their separate finances. That was an additional challenge, I’m sure, on an almost daily basis.

00:27:25:17 – 00:27:45:23

Bill Fulkerson

That’s correct. But we had constraints of things we couldn’t do together legally. And that’s where it would frustrate faculty, frustrate others, to not be able to get the support they felt like they needed to move forward with some initiative. Now, it’s going to be much easier to do that.

00:27:46:01 – 00:27:48:17

Ann Pelham

Everyone’s rowing in the same direction, as they say.

00:27:48:19 – 00:27:51:03

Bill Fulkerson

That’s what we hope. 

00:27:51:05 – 00:28:05:15

Ann Pelham

Well it is, I suppose, still an evolving integration. It will be, how many years do you think, before people stop talking about integrating, and continue on their way?

00:28:05:16 – 00:28:27:14

Bill Fulkerson

You know, I don’t know exactly. I’ve had conversations with a few of the clinical chairs just in the last week about that. And everyone thinks it’s going to take a few years to grind out some of the issues that need to be resolved. But they’ve done a huge amount of work this year, a huge amount of work. And taken major steps forward.

00:28:27:16 – 00:28:33:01

Bill Fulkerson

So I’m very optimistic, as you said, that things are going to get better and better and better.

00:28:33:03 – 00:28:51:10

Ann Pelham

Are there some successes in Duke’s past that you think may have been easier to achieve because of the structure that you had before? Or are there places where it was a challenge?

00:28:51:12 – 00:29:21:07

Bill Fulkerson

There were always some unique challenges there, but as I said, we were able to work through most of those in some ways. Until it just became difficult financially to make things work because of the barriers and constraints across the organizations there. And it would get a little bit worse every year — a little bit more difficult, I’ll say — to make things move forward.

00:29:21:07 – 00:29:27:18

Bill Fulkerson

And so I think we’re going to be in a much better place in the future.

00:29:27:20 – 00:29:55:15

Ann Pelham

You were a leader at the top level for such a long time. When you look back, are there places where you wish you had known then what you know now about a particular thing? One of them being maybe the integration of those two entities. But anything else that you look back on and recognize later?

00:29:55:17 – 00:30:21:17

Bill Fulkerson

Well, I think probably everything. I mean, we’re a learning organization. And so every year we learn how to do things better that we maybe couldn’t have anticipated before. And so I think history teaches us a lot, every time, about where the opportunities are and where the pitfalls may be. So I would say the answer is everything.

00:30:21:19 – 00:30:53:16

Ann Pelham

You’re an optimist, which I think is important in healthcare. We always want to believe [in] what the doctor tells us. There’s some terminology I just want to get straight for the record. Could you just walk us through the names that you’ve called Duke Hospital over the course of your career? You know, the entity that began on campus, and began to grow, and then expanded?

00:30:53:18 – 00:31:39:05

Bill Fulkerson

Well, Duke University Hospital is still Duke University Hospital. We became the Health System, as I’ve mentioned, when [the] now Duke Regional and Duke Raleigh [Hospitals] came in. Raleigh was acquired, Regional is a long-term lease with Durham County. Both of those were negotiated by Dr. Snyderman. Duke Health really is a term to describe all of the medical and clinical enterprise — both clinical, and academic, and nursing, and other things that are related to the medical enterprise.

00:31:39:07 – 00:32:05:15

Bill Fulkerson

And I think Duke Health may have been coined by Dr. [Eugene] Washington. I think so. But it really is just meant to say, “This is everything that is related to Duke.” Including the medical school in Singapore. That [it] is all under one umbrella, and [that] we’re all part of.

00:32:05:17 – 00:32:18:08

Ann Pelham

Are there some successes that Duke Health has — as I use the proper term — achieved  that you think deserves some attention and recognition.

00:32:18:12 – 00:32:57:21

Bill Fulkerson

Yeah. Well I mentioned before the academic piece. And people may think of the clinical enterprise and academics as being separate and different, but they’re really very tightly linked. And it allows the clinical enterprise to offer a lot of innovative ideas, innovative solutions, that come out of our laboratories to the patients that are coming here for care. And so the support of the academic piece has been vitally important, I think. Not only to the success of the School of Medicine, but also [the] success of the Health System.

00:32:57:23 – 00:33:22:07

Bill Fulkerson

And so I think that’s been very important. Singapore has been great. It’s been a terrific success. I’ve been there once, to give lectures on academic health centers. But there’s ongoing work with faculty at Singapore and here at Duke in the relationship there.

00:33:22:09 – 00:33:49:03

Ann Pelham

The positives are everywhere that we see. And I know you mentioned one of the challenges. As you consider the accomplishments of your long and really fantastic career there, if you had to think of the top three things that made you smile the most, what would they be?

00:33:49:05 – 00:34:26:20

Bill Fulkerson

They would be the patient safety and clinical quality that we have achieved and remain leaders in. It would be the patient experience. We are rated very highly compared to peers for the patient experience. And it would be the men and women that come to work at Duke Health every day. You know, one of the very positive things about Duke University and the Duke Health System is that we serve as employers of choice in our communities.

00:34:26:22 – 00:34:35:00

Bill Fulkerson

Some people don’t know that Duke University and the Duke University Health System are the second largest private employer in North Carolina.

00:34:35:02 – 00:34:36:08

Ann Pelham

After Walmart or something like that?

00:34:36:08 – 00:35:13:13

Bill Fulkerson

Walmart’s number one. Personally, I’d rather work at Duke. But we make good jobs in our communities. And I think most would say that we work very hard — once folks are employees of Duke Health — we work very hard to give them opportunities to grow and opportunities to expand. And that’s extremely important to retention of all employees, including faculty.

00:35:13:15 – 00:35:31:01

Bill Fulkerson

And so the third thing I would say is I’m proud of the faculty and the nursing staff and the employees that we have, and am gratified that we’re able to offer in our communities the kinds of jobs that we do.

00:35:31:03 – 00:35:50:05

Ann Pelham

The challenge of staffing right after the pandemic is something that it sounds as if Duke has overcome. Is there still a struggle to fill positions, or are there some initiatives that you think are going to help with that?

00:35:50:07 – 00:36:18:07

Bill Fulkerson

It’s much better than it was, but it’s still a challenge. We need to continue to think about how to make work better for everyone, make work more satisfying for everyone. Take some of the needless burden off the workforce, where we can, through different systems. And that’s an ongoing promise that the leadership makes to our folks.

00:36:18:09 – 00:36:22:09

Ann Pelham

Could you give an example of that needless burden?

00:36:22:11 – 00:36:43:18

Bill Fulkerson

Okay. So, we have an electronic health record. And the electronic health record will take messages from patients back to physicians. That can be overwhelming for clinicians to be in the clinic all day and come back and find that they’ve got 40 messages to go through.

00:36:43:18 – 00:36:45:10

Ann Pelham

And they’re not paid for that. Is that part of it?

00:36:45:14 – 00:37:22:17

Bill Fulkerson

That’s correct. That’s correct. And so we’ve developed, through machine learning [and] artificial intelligence, a way to triage those messages electronically to folks that can answer them or deal with them that may not be the clinician. He or she may not be necessary to reschedule an appointment, for example, or refill a prescription, or things like that. And so this is something that’s just being worked out right now.

00:37:22:17 – 00:37:43:20

Bill Fulkerson

But I saw a model of it yesterday, and it looks very promising. Now, that would save people hours a day, potentially, in work. And so that’s an example. There are probably a dozen other things that can be solved without relying on the frontline clinicians to do all the work.

00:37:43:22 – 00:38:18:01

Ann Pelham

So the AI filters out the things that the physician needs to help address, and then sends the others on to someone else. That sounds like a great innovation. Well, who knows what it will look like in ten years when we’re much grayer. It’s a great example of innovations that continue. And I know that you saw a tremendous amount of that over the course of your career.

00:38:18:03 – 00:38:26:09

Ann Pelham

Are there some key individuals that you think have been particularly important to Duke Health?

00:38:26:09 – 00:38:56:12

Bill Fulkerson

Well, I’ve been blessed, Ann, to be working here a long time. And so I’ve worked with a lot of different leaders. You know, the university presidents sit on the Health System board of directors. And I guess I have been pleasantly surprised at how active and how insightful they are. Starting with [Nannerl] Nan Keohane, then [Richard] Dick Brodhead, and now [Vincent] Vince [Price].

00:38:56:14 – 00:39:22:08

Bill Fulkerson

I got to know Dick pretty well because I was an interim president of the Health System between Victor Dzau and Gene Washington, and I would meet with Dick routinely to go through the critical aspects of things we were making decisions on in the Health System. And I came to depend on him for advice. It was just a remarkable experience. And so I’ll start with the university presidents.

00:39:22:10 – 00:39:55:22

Bill Fulkerson

I’ve worked with great chancellors, starting with Ralph Snyderman. Ralph was the person that gave me my first job in the Health System, and Ralph was terrific and was a strategic thinker. And as I said, started us down the path of the Health System. Victor Dzau was terrific. A great mentor, a brilliant man, and it was very valuable to work with him.

00:39:55:22 – 00:40:20:20

Bill Fulkerson

And Gene Washington [in] the same way. So three great chancellors. And in some ways, I worked for a fourth chancellor because [William] Bill Anlyan would come see me — he and Mary [Duke Biddle Trent] Semans would come see me — in my office about every six months, just to give me some helpful advice. Something they picked up at the Bridge Club, I think.

00:40:20:22 – 00:40:22:18

Bill Fulkerson

And they were always very nice.

00:40:22:18 – 00:40:24:22

Ann Pelham

And what was your role when they were coming by?

00:40:25:04 – 00:40:48:01

Bill Fulkerson

Hospital CEO and EVP of the Health System. I would always get a note, in fact I saved most of them from Mary Semans. Saying, “Just want to make sure that [you know] this was not criticism. We just give you some advice here.” And and so I got to know them very well too. And it was good advice during that period of time.

00:40:48:03 – 00:41:29:20

Bill Fulkerson

I’ve worked with tremendous people in the School of Medicine. Dean [R. Sanders] Sandy Williams was terrific. Nancy Andrews, same way. And Mary Klotman. I’ve known Mary for 40 years. And so it’s been a pleasure to work with them, and be a partner with them in advancing the academic roles as well. I’ve had terrific leaders in the hospitals that have really set the tone and maintained and even [now] continue to improve the safety and quality delivery in the hospitals.

00:41:29:22 – 00:42:10:10

Bill Fulkerson

We’ve had terrific nurses. Just some of the most outstanding nurses, I think anywhere here, and nurse leaders as well. Our physicians are the best. I just — personally, I would not get care anywhere else. And the physicians are fantastic and are selfless in their dedication to taking care of patients. And our employees and staff and technologists are all here to do whatever they can to make the patient experience as good as it can be.

00:42:10:10 – 00:42:15:19

Bill Fulkerson

So just some very, very, very, remarkable people over the years.

00:42:15:21 – 00:42:24:04

Ann Pelham

I think you’re an optimist, Dr. Fulkerson. You would be a good boss because you would always think that the person could get better the next day.

00:42:24:06 – 00:42:44:21

Bill Fulkerson

Well, that’s the point. We’re always getting better. That’s the whole thing. That’s sort of a good summary of the philosophy. We can always get better. Even if we’re the best in the world, we can always do better. And that is what makes Duke so great, is always aiming to get better.

00:42:44:23 – 00:43:05:00

Ann Pelham

The challenges have come through the years, and you’ve ended up in on the hot seat more than once. But would you be willing to suggest what the greatest challenges are for Duke Health, over the years that you’ve been part of?

00:43:05:01 – 00:43:06:08

Bill Fulkerson

Well.

00:43:06:10 – 00:43:08:00

Ann Pelham

Or looking forward to.

00:43:08:01 – 00:43:37:16

Bill Fulkerson

Looking forward, there are a couple of things. If you just think about what the future of healthcare is here, it’s going to be phenomenal. Especially, every day I read a story about some new gene editing tool that’s offering a cure for a previously fatal disease. And the gene altering capability going in the future is going to change the picture of medicine.

00:43:37:18 – 00:44:08:15

Bill Fulkerson

I think. The downside of that is it’s going to be expensive. And it comes down to how much we can afford, how much a patient or their family can afford, and trying to figure out how these great advances in medicine don’t create deeper healthcare disparities. And I don’t have the answer to that. But I think it’s something that’s knocking on our door right now.

00:44:08:15 – 00:44:29:23

Bill Fulkerson

It’s not ten years from now, it’s right now. Right now, when it’s going to cost millions of dollars to give somebody a treatment course for an otherwise fatal disease that could be cured with this. And how we design a system that recognizes that and makes it possible, I don’t know.

00:44:30:04 – 00:44:38:22

Ann Pelham

It’s almost an explosion of better outcomes that cost way too much money for us to afford in the system that we have.

00:44:39:01 – 00:44:40:00

Bill Fulkerson

Right.

00:44:40:02 – 00:45:03:12

Ann Pelham

And it’s already a challenge to give people the care they need. So that aspect of it, the philosophy of how you decide who gets these cures – they really are cures – is going to be a big challenge, I think, for healthcare.

00:45:03:14 – 00:45:26:10

Bill Fulkerson

Yeah, absolutely. Even bigger than it has been before. We certainly have some of that today with still the problem with uninsured populations. But this is going to be a whole new ballgame, I think. And multiply the problems today by ten. And that’s what we’re going to look at in the future.

00:45:26:12 – 00:45:40:08

Ann Pelham

And not just [for] the United States. So we have all this hope, and yet we need systems to be able to deliver the hope.

00:45:40:10 – 00:46:00:23

Bill Fulkerson

That’s true. That’s true. And I can’t even imagine the kinds of cures that are going to be coming down the road. But they’re going to be coming fast, I think. And how we intelligently deploy them to people who really need them. That’s going to be the challenge.

00:46:01:01 – 00:46:41:06

Ann Pelham

It makes in some ways the current challenges of dealing with your health insurance seem like chump change. I mean, they’re always life and death questions that face someone in a healthcare situation. But what you’re saying suggests that we’re going to have more hope on one hand and a lower ability to deliver that access to those hopeful improvements than we do now. Because the number of solutions is going to get up here [gestures up].

00:46:41:08 – 00:46:48:07

Ann Pelham

And our resources to achieve them are still down here [gestures down]. Is that too pessimistic? I know you’re optimistic.

00:46:48:07 – 00:47:11:14

Bill Fulkerson

You know, I don’t know. That’s what I worry about. And how you solve something like that is above my pay grade right now. I’m not sure how to solve that. But it’s going to be a hot issue to grapple with over the next 5 to 10 years.

00:47:11:16 – 00:47:28:08

Ann Pelham

So in your current role — you’re not really completely retired — is that the sort of thing that you are asked to think about from time to time?

00:47:28:10 – 00:47:46:14

Bill Fulkerson

Well, not yet. Not yet. My role right now is primarily helping to support the School of Medicine, primarily from a financial point of view. But I would be very interested in public policy too. I don’t know what I’ll do in the next few years, to be honest with you right now.

00:47:46:16 – 00:47:48:19

Ann Pelham

But you’re enjoying the role that you have.

00:47:48:19 – 00:47:49:17

Bill Fulkerson

Yes.

00:47:49:19 – 00:47:52:13

Ann Pelham

You don’t miss being the “uber boss”?

00:47:52:15 – 00:47:56:07

Bill Fulkerson

It was time for someone else, I’ll put it that way [laughs]. 

00:47:56:09 – 00:48:13:02

Ann Pelham

Alright. we’re having this conversation already about the best and worst of what may be to come in healthcare. But is there something else you want to share [about] that big question?

00:48:13:04 – 00:48:32:07

Bill Fulkerson

No, I think that’s it. It’s just that there are going to be phenomenal improvements in our ability to treat disease and to affect outcomes. And the challenge is going to be how we’re going to financially support them and make them available broadly to patients.

00:48:32:09 – 00:49:01:18

Ann Pelham

The finances are already a problem, and we’re going to have more solutions that are going to cost more. Duke University and Duke Health have been together for almost 100 years. And I think the hospital was a year behind the university. I don’t know whether we’re just going to roll our centennial celebration together.

00:49:01:20 – 00:49:15:06

Ann Pelham

But what are your hopes for both institutions — and even, in a way, their partnership — as they enter the second century?

00:49:15:08 – 00:49:44:05

Bill Fulkerson

My hope and my clear belief is that Duke University and Duke Health will continue to be national and international leaders in what we do. In all the missions. In research and education, and for Duke Health and patient care. I grew up in North Carolina, and Duke has always been defined as excellence, as far as I can remember.

00:49:44:07 – 00:50:10:15

Bill Fulkerson

I think that’s what it’s going to be forever. And to maintain that excellence, they will be a leader in whatever we decide to do here. And so that’s my expectation and my true belief that Duke will continue to be one of the elite excellent places advancing education, advancing research, and advancing patient care.

00:50:10:17 – 00:50:33:19

Ann Pelham

There are some naysayers who believe that Duke has gotten to the point where it’s too small to be financially competitive, I guess, in the national scene. How do you feel about that perspective?

00:50:33:21 – 00:51:04:08

Bill Fulkerson

Well, as far as the Duke clinical landscape, I think and I know the leaders are looking at opportunities for either joining other organizations or other organizations joining us. I think a bigger footprint could be important. At the same time, we discussed the number of people that are moving here every day. Our sense is that Duke Hospital today is over 1050.

00:51:04:10 – 00:51:06:12

Bill Fulkerson

There’s not an empty bed in the hospital.

00:51:06:14 – 00:51:10:00

Ann Pelham

What’s the context for that from five or ten years ago?

00:51:10:02 – 00:51:38:17

Bill Fulkerson

When I was CEO of Duke University Hospital, sometimes on weekends and certainly over holidays, we would dip below 500 patients in the hospital. So it’s more than twice. So the demand is there. The question is whether we need an even bigger footprint to continue to financially invest in the things we want to invest in, including the academic enterprise.

00:51:38:19 – 00:51:50:10

Bill Fulkerson

And I think the ideal thing would probably be to continue to look for partners and see what’s possible, if it makes sense in the context of our missions and what we’re trying to accomplish.

00:51:50:12 – 00:52:07:19

Ann Pelham

There was a period of time when the medical school was financially, benefiting from the Health System. Do you see that returning in the future?

00:52:07:21 – 00:52:31:16

Bill Fulkerson

I hope so. I’m not as much in the weeds now as far as the finances of the Health System, but I know it’s getting better coming out of the pandemic. And my hope is the kind of support that was able to be given to the university and to the School of Medicine and School of Nursing will return similar to what it was before.

00:52:31:18 – 00:52:34:23

Bill Fulkerson

But I don’t know when that might be.

00:52:35:01 – 00:52:38:21

Ann Pelham

But you’re optimistic. That’s your perspective on life, I think.

00:52:38:21 – 00:52:40:05

Bill Fulkerson

Yes.

00:52:40:07 – 00:52:43:21

Ann Pelham

Or at least you’re going to make sure it is.

00:52:43:23 – 00:52:46:08

Bill Fulkerson

I hope so.

00:52:46:10 – 00:53:03:11

Ann Pelham

I would put you in the optimistic category, and hopeful for Duke continuing the medical operation and enterprise continuing to be top-notch in the United States and the world.

00:53:03:12 – 00:53:07:11

Bill Fulkerson

It has to be. There’s no other way.

00:53:07:13 – 00:53:09:05

Ann Pelham

Why does it have to be?

00:53:09:07 – 00:53:22:13

Bill Fulkerson

Because that’s who we are. And as I mentioned earlier, that’s how we grow. We grow by being the best. And I can’t imagine it being any other way.

00:53:22:15 – 00:53:42:06

Ann Pelham

Well, I’m appreciative of the fact that you are truly a Blue Devil now and have left behind your dip into the University of North Carolina system. And even at the basketball games, you’re a Blue Devil?

00:53:42:07 – 00:53:44:10

Bill Fulkerson

I am.

00:53:44:12 – 00:53:46:18

Ann Pelham

Well, congratulations for the transformation.

00:53:46:19 – 00:53:49:16

Bill Fulkerson

Thank you.

00:53:49:18 – 00:54:07:08

Ann Pelham

Is there something that you would like to share about your career — just you not your usual unselfish conversation about Duke and the institution — but something that you’re most proud of in your own career?

00:54:07:10 – 00:54:36:22

Bill Fulkerson

Well, you know, I got into the business or administrative side really fairly quickly, moving from the chief medical officer to the CEO of University Hospital very quickly. I enjoyed that. But I continued to take care of patients. I continued to see patients up until about three years ago, three or four years ago. So [my career] was never wanting to get away from patient care.

00:54:36:22 – 00:55:11:12

Bill Fulkerson

It was the attraction of potentially being in a role where you could multiply the impact you might have. I mean, medicine is a very personal profession. And there’s nothing more powerful than the 1-to-1 relationship of a caregiver and a patient. At the same time, I had the fortune, good fortune, of being in a position where decisions could be made that may have impacts on hundreds or thousands of patients there.

00:55:11:12 – 00:55:32:00

Bill Fulkerson

And so it’s always been about patients. It’s not been about business. And I hope I’ve done a good job at helping others help patients in the Duke Health System.

00:55:32:01 – 00:55:57:13

Ann Pelham

Thank you. That’s a wonderful way to put it. And I think Duke has been lucky that you have had these important roles in the healthcare system. Is there something that stands out, particularly? I think your whole career, in many ways, you’re proud of. But is there a moment or something in particular that stands out for you?

00:55:57:15 – 00:56:29:13

Bill Fulkerson

I don’t think there’s one moment that I could refer to. I think it’s just as I said, it’s being able to help lead us in a path that I think is something I’m very proud of. And I’m proud of what others have done for each other and for our patients and their families over the last 30 years. And I hope I’ve done something to positively impact that.

00:56:29:14 – 00:56:41:05

Ann Pelham

What is there that makes you most proud, that gives you a true feeling of happiness and accomplishment all at once?

00:56:41:05 – 00:56:49:23

Bill Fulkerson

When I hear a patient talking about their care here, and their caregivers here, and how wonderful their experience has been.

00:56:50:01 – 00:57:19:03

Ann Pelham

Well, it sounds like they have you to thank for a lot of their positive experience. It’s not always that the leader of a health system emerges from a career as a physician and a researcher. So how does your origin story help explain your success as an administrator?

00:57:19:05 – 00:57:48:00

Bill Fulkerson

Well, I’ve told people before, I think I’ve led hospitals the same way I practice medicine. And that is you’ve got to have great teams, you’ve got to trust each other, you’ve got to pay attention to details, and you’ve got to act when it’s necessary. And there’s not a whole lot of difference there. As I mentioned, I went back and got an MBA a number of years ago, a couple of decades ago, because I wanted to know the nuts and bolts of business, too.

00:57:48:02 – 00:58:03:22

Bill Fulkerson

At the same time, it’s about the patients and what’s best for the patients. And I think you can take what I think are the most important things about caring for patients and apply them to the business of running hospitals as well.

00:58:04:00 – 00:58:09:01

Ann Pelham

That’s not always the approach that hospital administrators take.

00:58:09:03 – 00:58:10:23

Bill Fulkerson

Well, that’s the way we do it at Duke.

00:58:11:01 – 00:58:19:09

Ann Pelham

Good. Is there something about Duke Health that stands out and makes you most proud?

00:58:19:11 – 00:58:37:18

Bill Fulkerson

Just the great care. And on the academic side, the great science. The clinicians come to work every day wanting to care for patients. The researchers come to work every day trying to invent new therapies. And so it’s really all about the patients.

00:58:37:20 – 00:58:46:13

Ann Pelham

The synergy that you’ve seen throughout the decades of your career, is that like a secret sauce? 

00:58:46:15 – 00:59:23:18

Bill Fulkerson

You know, I don’t know if it’s unique at Duke or not. I mean, [outside] of my fellowship Duke is the only place I’ve worked. But it really is that way at Duke. There is tremendous mutual respect for all the missions and the people who work on those missions here. And there’s a lot of interdependence as I said. The academic product is key to the brand of Duke Health System. So it’s important for everybody to be successful here and to depend on each other.

00:59:23:20 – 00:59:42:06

Ann Pelham

Depend on each other is what patients do with their doctors a little bit, and vice versa. The patient depends on the doctor, but I think that relationship — it sounds like you are carrying that up to the hospital administration level, which is not an easy task.

00:59:42:08 – 01:00:07:07

Bill Fulkerson

It’s not. But I’ve told the administrative folks that worked with me over the years from the very young ones to the very seasoned ones, that their role was just as important as the surgeon in the operating room. And it was their job to get better every day, too. To learn something new every day that would improve the service that they were in charge of

01:00:07:07 – 01:00:12:12

Bill Fulkerson

or delivering there. And we’ve had some amazing people.

01:00:12:14 – 01:00:19:05

Ann Pelham

Thank you for your service to Duke, and for giving us a chance to have this conversation. It’s been a pleasure.

01:00:19:05 – 01:00:22:13

Bill Fulkerson

Been a lot of fun, thank you. Thank you.

01:00:22:15 – 01:00:28:06

Ann Pelham

Thank you, Bill. And we met the deadline [laughs].