A Masterclass in Leadership

When you’re just starting out in your career as a pathologist, it can seem like advice is everywhere – whether you want it or not. From common-sense proposals like exploring your options before making final decisions to more esoteric or specialized suggestions, there’s no shortage of people interested in commenting on your potential career trajectory. But the higher you rise in the ranks, the less help you’re often expected to need with managing your responsibilities. And yet, it’s often at the highest levels that you encounter a need for new skills or expertise. With so many demands on your time and so little guidance available, how can you learn to shine as a laboratory director and a leader? 

Here, former laboratory directors and educators Paul Bachner and David Wilkinson share the lessons they’ve learned over nearly a century of combined experience.

What exactly is the role of a lab director?

PB: Based on my personal experience as a lab director in many different environments over four decades, the main duties of a lab director are:

1. To ensure that pertinent local and federal regulations are met;
2. To ensure that accreditation requirements are fulfilled;
3. To confirm that all laboratory processes are of the highest possible quality;
4. To maintain constant, open-ended communication with caregivers (physicians), nursing, and administration;
5. To obtain adequate resources (such as equipment and staff) for the laboratory;
6. To monitor and provide support and guidance to laboratory staff.

DW: The responsibilities of a CLIA lab director are specified in detail in federal law and regulation in the United States – but, in addition to the six items identified above, I would add:

7. To keep up to date on the latest developments in science, regulation, and reimbursement as applicable to the practice of pathology;
8. To be active in professional organizations – something I have found to be very helpful with keeping up to date!

PB: As David said, there are certain things every laboratory director must do. You must ensure that federal regulations and accreditation requirements pertaining to labs are met. And that includes operational considerations; for example, ensuring that procedures are up to date and being followed, making sure that quality control is being implemented, and checking that proficiency tests or surveys are being done. These “must-dos” are what lab directors are held accountable for when laboratories are inspected for accreditation purposes.

There are also responsibilities that are somewhat harder to define; the most important of these, I think, is physical presence. Just being there makes a difference, in my opinion – and the benefits are twofold. First, you see and hear things that you would miss if you were not present. Second, being on the scene gives your staff a sense of your engagement, which is important from a morale standpoint. Ticking those boxes takes care of the internal requirements, but harder still are the relationships outside the laboratory. As important as it is to be available to your own staff, it’s equally so to build relationships with medical staff, hospital administration, nursing, and the patients themselves. After all, you can be on top of everything internally, but if you don’t have a means of sampling what the external world thinks of your lab – where they see efficiencies, where they want changes, where they want improvement – then you may not have all of the information you need.

Whether or not that’s easy depends on what kind of institution your practice is in. I’ve been involved in all sorts of organizations, from small labs and small hospitals to very large tertiary care centers. Keeping your finger on the pulse of the medical staff is very different in these two extremes. In a larger institution, you’re somewhat restricted to more formal environments, such as prearranged meetings, although you can try to supplement them with day-to-day contact as best you can. In a smaller institution, I have always found that one of the most important ways to keep in touch with the medical staff is to go to lunch or take time out in the operating room coffee lounge to chit-chat with the surgeons and anesthesiologists. Either way, it’s a combination of formal contact and informal contact, which I think is a key aspect of being a lab director.

DW: In the United States, we have a law called the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88), which is written into the Code of Federal Regulations. It lists about 20 or 30 specific responsibilities of the laboratory director (1) – quite unusual in medical practice in the US. The laboratory is probably the most highly regulated area of medical practice and, although the title of “medical director” is quite varied, I don’t think there’s a single other one that has a federal law that spells out its responsibilities. CLIA ’88 serves as a nice blueprint and a great reference for what a lab director does.

Those regulations spell out what we call the “hard side” of what we do – but I think the aspects that Paul was describing are as important, or maybe even more so. That’s the “soft side,” where you interact with the people who work in the laboratory. You want to be visible and you want to be accessible, because those things are important. In our institution, we have over 400 people working in the Department of Pathology, and I know that it can be hard for them to feel they have access to directorial staff unless we make an effort to see them on their territory. The lab is probably close to 100,000 square feet and our 400 employees operate across three shifts, seven days a week. So, to be most effective, a lab director in that kind of situation has to visit those people from time to time so they know who you are. And that way, if they have any issues they can tell you face-to-face, rather than leaving both of you to rely on a potentially flawed chain of communication.

Paul also emphasized the importance of dealing with medical staff. Because most non-pathology medical professionals don’t know much about the lab, they have this concept that you draw blood from a patient, send it to the lab, and then there’s a black box; the lab just spits out a result. They have no idea what’s involved – what is required to validate a test to ensure that reference ranges are appropriate for your patient population; how to troubleshoot results; what kinds of things can interfere; and so on. They look to you, as the pathologist and the highest-ranking member of the lab, to provide that information.

It’s also the lab director’s job to relate to the administration who (usually) hold the purse-strings – you need to make sure that they understand your requirements. “You need how much money?! Where does it all go?!” You need to hire adequate personnel, pay them appropriately, have adequate space, acquire adequate instrumentation, and more – and, much like money, those things don’t grow on trees! Somebody has to advocate for them. So you’re making the rounds yet again – this time with your institution’s top management: the chief operating officer, the chief executive officer, the chief information officer, the chief medical officer, the chief operating officer… All those folks have the power to make or break your lab, so you want to make sure you’re on good terms with them.

Finally, you have to get to know the vendors who sell instrumentation and reagents. Those are the people who can tell you what’s out there and what might be available in the near future, and the people who can help you implement major changes like new laboratory information systems or large chemistry systems. You need to be a part of such implementations yourself, and you need to make sure you know who’s in charge on the vendor side. When we made major changes in my lab, it wasn’t unusual for me to call the chief executive officer of a billion-dollar company with whom we were spending three or four million to say, “Hey, your systems aren’t working,” or, “Your people aren’t doing what they’re supposed to be doing.” It’s your job as laboratory director to stay on top of these aspects, too, making sure that they run as smoothly as possible – and one way of doing that is to forge connections with people who can help you and your lab.

How can lab directors and their colleagues work well together?

PB: I rely heavily on personal contact with physicians, nurses, and administrators to identify my laboratory’s needs and shortcomings, and I supplement that with periodic surveys of laboratory users and laboratory staff. Should we need resources, I try to plan in advance whenever possible. I make our anticipated needs known to hospital administration and finance and, at the same time, I build support from clinical staff. It puts me in a good position to advocate for my lab. To maintain credibility, all communications and documentation submitted to administration should be well-researched and factual. A reputation for exaggeration will hurt you in the long term.

Common issues that arise when I liaise with non-laboratory medical staff are scope of testing (for instance, if a clinician wants a new test to be available routinely) and turnaround time. I approach both topics with an open discussion with the clinician(s). Why do they need the tests? What are the negative consequences of not offering the tests in-house? How many tests do they think they will be ordering? What turnaround time do they expect? Answers to these questions can help me make “buy versus make” decisions. Turnaround time requests and complaints are usually linked to a request for point-of-care testing, which is a much more complex issue involving many resources and capabilities. It has a significant effect on laboratory staff and resources, of course, but unlike other forms of testing, it goes beyond the four walls of the lab.

And sometimes, pathologists should, too. Cytopathologists and blood bankers, for instance, often have patient contact – and it’s a part of the job description that may become increasingly prevalent with the growth of molecular and genetic testing. Such tests, particularly the latter, are often complex and may be beyond the knowledge base of clinicians. But because the impact on patients – in terms of not only diagnosis, but also treatment and prognosis – may be great, direct contact with the pathologist may be indicated. When facilitating these types of interactions, the skills I find most useful are a solid knowledge base, basic interpersonal skills, and the ability to transmit highly technical material to the layperson. And that latter skill also comes in handy when making a case for additional resources to people who are not well-versed in pathology.

DW: Teaching these lab director courses for over 20 years at national meetings, I am surprised every year that people don’t know the regulations or what they’re actually responsible for as lab directors. I don’t know why that is, but it’s true. So, I think making sure that lab directors understand that they do have very firm, specific guidelines in federal law is an eye-opener for many people.

Every laboratory should also have a strategic plan that is updated on a regular basis to include projected needs for space, personnel, and equipment. I have found it useful to have regular (monthly or even more frequent) face-to-face meetings with the hospital administrator who has immediate oversight of the lab, so that I can make sure the administration is constantly aware of lab requirements. When I do have an unmet need, I find that financial arguments are usually the most persuasive to administration – either an increase in revenue or cost savings. It’s not the only potentially persuasive argument, though; safety and new developments in patient care needs are also valid. After all, administrators are people, too – and, in many cases, they or others close to them are patients as well.

How can lab directors pave the way for major changes in the laboratory?

DW: When making such changes, it is very important to include key staff early in the decision-making process and, eventually, to educate the entire staff on the benefits of bringing in a new process or technology. In my experience, resistance to change is usually related to fear of the unknown, so anything you can do to remove the mystery of the change will decrease resistance.

You need to understand who the informal leaders are in the lab and make sure they are on board with the proposed changes. You also need to have a strong implementation plan in place to ensure a smooth transition from the old processes to the new; for example, temporary increases in overtime or even supplemental workers for big projects. Finally, you need to ensure that personnel on all shifts have been fully trained in the new processes. And then – once everything is complete – celebrate your victories!

Can you tell us more about the soft skills?

DW: Much of what Paul and I teach together at our laboratory directors’ workshop focuses on the soft side. It’s similar to running any other company, though; the skills are not specific to pathology, or to being a lab director. They’re the kinds of skills that anyone in a leadership position needs to cultivate if they’re going to be successful.

PB: It’s the hardest part of the job in my experience. I’ve been a lab director for close to 40 years. And the “hard” stuff – the regulations, the quality control, what instruments you’re going to buy – that’s easy, because there are plenty of ways we can learn about those things. You can read about it. You can ask others who have had to deal with the same problems. It’s teachable.

For me, dealing with people is the hard part. If you’ve met one administrator, you’ve met one administrator; each one is a different person with their own approaches and traits, and working with them all appropriately must be learned through experience. Some of them like to be given as much documentation and numbers as you can throw at them; others, you’re better taking them to lunch. I always tell my residents that, when they’re out there in the real world and they become lab directors, they are not going to be lying awake at four o’clock in the morning thinking about a puzzling slide or how to get approval for an instrument. They’re going to be lying awake thinking about the chemistry supervisor who’s been with them for 20 years but has started heavily drinking because of a failed relationship. Those are the types of problems that turn your hair grey.

Relationships with clinicians and nurses are critical. Hostile behavior on the part of clinicians may be very difficult for your staff to deal with. The director must engage with clinicians to make them understand the negative impacts of aggressive behavior, and with staff to help them develop coping mechanisms and strategies.

DW: I think certain people, just by virtue of their personalities, have innate leadership skills and are able to take charge in any particular group. Not everyone is necessarily born with these skills – but I definitely think that, for those who aren’t, some things can be learned. There are excellent books out there. About 30 years ago, I focused on studying leaders and leadership, and I read a lot. I think I had some innate leadership skills, but I definitely enhanced them by reading about great people like [former US Secretary of Defense] George Marshall and [most decorated Marine in US history] Chesty Puller. These kinds of leaders were exemplary, and I learned a great deal just by looking at how they conducted themselves. Warren Bennis, at the University of Southern California, spent his whole academic career studying leaders and leadership. I read a number of his books and I think he really has some good insights to offer – I’d recommend them to anyone wanting to learn more about being a leader.

PB: I agree with David that leadership is both nature and nurture. Some people are just innately better at it than others; I think if you look back at the lives of really successful lab directors, they were probably president of their kindergarten class or something. But the reality is that a lot of people wind up in leadership roles without having had any past experience in leadership. The typical laboratory director or academic department chairman was named to their position because of their clinical or research acumen, not because they had any demonstrable interest or experience as a leader.

David is also absolutely correct about the vast amount of literature out there. You can spend your entire life just reading the literature on laboratory leadership – and that’s without touching the books on people who are leaders in other spheres. But there comes a point where you have to stop reading about it and actually do it. If you want to learn to play the violin, you have to play the violin. For many years, I have been involved with a College of American Pathologists committee that deals with labs that have problems. I would say that, for a vast majority of these laboratories, the problem is a lack of leadership – situations where the director is a director in name only, or is concerned primarily with anatomic pathology activities, leaving the actual leadership to a laboratory manager (or even to no one in particular!) in the hope that everything will work out… somehow. You can’t do that. Leadership is a job – something you need to think about and do every day.

To me, being a lab director or a leader of any kind involves a combination of learning (reading, taking courses, seeking help and advice from more experienced people) and actually doing it – making mistakes and learning from the mistakes you personally make. I could probably write a book, or at least a book chapter, on the mistakes I’ve made and what I’ve learned from them.

DW: You definitely learn more from your mistakes than you do from your successes…

What do you find most rewarding about the role?

DW: I had the good (or maybe bad!) fortune of ending up as a lab director within a few months of leaving my residency. I’ve spent most of my working life as a leader, without much time as a subordinate. But I find the scientific content of what we do very interesting – and, as a lab director, you’re not focused on just one area. Academic laboratories tend to be highly specialized, so most pathologists and laboratory medicine professionals work in one area, like hematology or chemistry. If you want to be a good (and a successful) lab director, you need to be familiar with all the labs: surgical pathology, autopsy pathology, chemistry, hematology, cytogenetics – the list goes on and on. For me, the mental stimulation of trying to keep up with all of that is exciting. Every day – even now, at age 73 – I learn something new, and it’s wonderfully satisfying.

The other thing that really brings me pleasure is the “people” side of things. It makes you feel good when people in the lab say, “We really appreciate what you do. Thank you for going to bat for us on this, that, or the other thing.”  Or when the clinicians come and say, “I’ve had a really tough case, we used a lot of blood, and your lab did a great job at keeping up.” Such feedback is very positive, and it has a great effect. Patient care is another aspect of my role and, just like any other medical professional, I love to hear positive things from my patients. There are so many rewarding things about what I do that I can’t even list them all. It’s a great job.

PB: I agree with everything David has said. I’ve been in practice for about 50 years now, and I’ve just retired. The change and the growth and the increase in complexity of pathology and laboratory medicine over those years is absolutely mind-boggling. I often spend a little time with my residents giving them a canned history. To give an example, when I finished training, there were three lymphomas; the last time I checked, there were 26! Imagine how the complexity will change over the next half-century. Trying to keep up with that has been a challenge, but it has also been a lot of fun. I think I’ve survived by virtue of being willing to be taught by others, and that, too, is certainly part of the pleasure.

I think, when I look back, the greatest pleasure – and the greatest long-term satisfaction – I’ve had is seeing the growth of people I’ve mentored. When I stepped down as the director of laboratories six months ago, I was replaced by a pathologist who was one of my earliest recruits as a young assistant professor. She went elsewhere to continue her career, but came back. Seeing her evolution over the years has been wonderful and, of course, being in academic pathology, seeing the careers of my residents evolve is always a great pleasure for me.

DW: Like you, I stepped down from being a chair a few years ago, but I still work full-time. My two immediate supervisors are former residents of mine! Last Tuesday, I had to go and have my annual performance evaluation – which was done by a woman who was my resident at George Washington University twenty-something years ago.

PB: Did you do well?

DW: I did terrific!

If you could go back to the start of your career and give yourself advice, what would you say?

DW: Work hard. Be nice.

PB: I’d probably spend more time in the lab with my staff, because when I became a chairman, I became preoccupied with those duties. I also got very involved with the College of American Pathologists. As a result, the time I had available to wander around the laboratory became somewhat limited. So if I could do anything differently, I think I would change that.

DW: You can never spend too much time in the laboratory but, on the other hand, getting involved with the professional organizations carries its own benefits. Yes, it takes you out of the lab, but it gives you insight by letting you work shoulder-to-shoulder with people from other labs, learn from them, and make connections. It even helps your residents, because if you have a resident who wants to do a fellowship in a particular area, you can say, “Well, you need to talk to so-and-so,” because you’ve got the connections. I think that’s one of the responsibilities of a lab director – and certainly of an academic department chairman. If you just stay within your own little castle, you will limit your ultimate success.

It can be hard to balance, though. While I was at George Washington University, I was chief of clinical pathology with 150 employees – I was able to say, “Hi,” to each one of them every single day, because I would get in early enough to meet the night shift before they went home, work during the day shift, and then stay late enough to meet the evening shift before I went home. Now that I’m at Virginia Commonwealth University, I’ve got a department that includes both anatomical and clinical pathology with over 400 employees. I can’t do here what I could do in my previous department. I wish I could, but there’s just not enough time in the day to do it.

My best advice to other lab directors? Be a good listener. Communicate, communicate, communicate. Stay positive. Stay involved, but do not micro-manage. Build a strong team, delegate, hold people responsible for completing their tasks, trust your staff, and celebrate good performance.

Paul Bachner is Professor and immediate past chairman of the Department of Pathology and Laboratory Medicine at the University of Kentucky, Lexington, USA, where he was Director of Laboratories for 25 years.

David Wilkinson is Professor of Pathology, Associate Medical Director of Transfusion Medicine, Director of the Pathology Training Program, and former Chair of Pathology (1993–2013) at Virginia Commonwealth University, Richmond, USA.