David Cole, MD, became president of the Medical University of South Carolina in 2014, when the Charleston-based institution operated as a single-campus academic health system. Over the next 12 years, he led its expansion into an 18-hospital statewide network delivering care in all 46 South Carolina counties, including eight of the state’s most persistently underserved. In June, MUSC announced Dr. Cole will retire from his role in June 2027; he will remain with the institution as a professor and surgical oncologist.
Dr. Cole spoke with Becker’s about expanding MUSC into a statewide health system, preserving its academic mission amid federal funding uncertainty and the leadership principles that guided its growth.
Editor’s note: Responses have been edited for length and clarity.
Question: You grew MUSC from a Charleston-based institution to an 18-hospital statewide system over 13 years. What’s the thing that surprised you most about leading at that scale?
Dr. David Cole: When I first began, the industry had grown from a mom-and-pop organization to something much larger in terms of impact and ongoing delivery of healthcare and education. But 13 years ago, when I first came into the role, I felt like any move we made as a Charleston-based organization would carry risk. I thought the most risky thing was to do nothing. We needed to start to grow, or to actually start functioning as the Medical University of South Carolina and not the University of Charleston.
Our basic tenets were set in an important context. Our basic principles were two: first, that every community deserved a high-quality local hospital and best care delivered locally. Second, that we would make decisions that are patient-centric. Not just talk about it, but actually make hard decisions that may not make financial sense but ultimately serve those we serve, which is the patients and citizens of South Carolina.
To me, the most remarkable part is that for the most part, everything I’m describing is actually true. All of those hospitals are financially sound. We don’t need them to be cash cows; we need them to be financially sound. The communities have embraced us. We’ve changed our stance from episodic presence in those communities to being part of those communities with an opportunity to continue to build trust, to build relationships, to build programs and partnerships that can actually start to move the needle on health in South Carolina.
The predictable downstream of that growth is that dealing with culture change and the impact of transformational growth is a lot. Version 2.0 means that every infrastructure, every shared service has to have a different viewpoint. People need to think beyond the threshold of Charleston only and start to reconsider how we have a presence and what that looks like culturally across the state. That work is still ongoing.
Q: MUSC is the largest NIH-funded institution in South Carolina. How are you thinking about protecting that research mission given federal budget uncertainty?
DC: Our strength is our tripartite mission. We are not a community health system. I respect and need excellent community health systems, but a comprehensive academic health system is not only about delivering best general care. It’s about educating the future and transforming the future of healthcare through research and discovery. Those latter pieces are what give us our differentiation. Something of merit and value beyond just the delivery of healthcare. So my first answer is that research isn’t an afterthought. It’s who we are. It’s how we accomplish who and what we need to be.
Last January, when there was a lot of uncertainty around NIH funding, our message internally was: our mission is important. The work that we do is important. We actually held leadership forums around the theme of “stronger together.” We’re not going to walk away from the research part of our identity, because it would be like the left hand divorcing the right hand.
To me, the greatest value-add we are working toward is to be known as innovators. To have a culture of innovation with an integrated synergy across that tripartite mission, so that we have higher impact. I think academic health systems in the United States struggle with 100-year-old structures. Those structures mean individual silos, where the left and right hands don’t know what the other is doing, and it doesn’t lead to the highest impact. We’re working hard to redefine what our structure looks like so that the research part of the house has a presence at the table with clinicians.
Q: You’re a surgical oncologist who has been at MUSC for 30 years and still operates. How does that clinical background shape the way you approach organizational decisions?
DC: From first principles, as long as I’m in this role, putting patients at the center is easy for me because that’s how I was raised. That’s how I see the world. In healthcare, that’s a critical viewpoint, and I feel it personally. I know the impact when we have broken systems, when things don’t work well, when you don’t have access.
When I’m in a political arena in Columbia, the question sometimes comes up: “Why are you still operating?” My response, honestly, is that the OR is the one place I can actually guarantee I can stop a bleed. Anywhere else, maybe not. From a leadership perspective, even though my presence as a surgeon is minimal, I think it’s important to be present and accounted for. If you’re expected to lead change and point the way for people to follow, you have to have connectivity and credibility. And I’ll say this: I learn more in the surgical locker room on any given day than probably anywhere else in terms of what’s actually going on and what people’s concerns are at the staff level.
Q: If you were advising a health system CEO who’s three years into the job and thinking about long-term strategy, what’s one thing you’d tell them to do differently than you might have expected when you started your own tenure?
DC: At the end of the day, relationships and culture drive everything. That may be an obvious statement, but some people get wrapped up in the position and lose touch with that. The other thought I’d add is that in today’s world, there are a lot of changing expectations that aren’t inappropriate. The patients we serve are getting tired of the things that health systems don’t do well, and you need to be heads-up and try to get ahead of and understand what patients need. There are a lot of tools to help us do that better, but we can’t be tone-deaf to those we serve.
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