How and why pathologists fail as managers

September 2007
Feature Story

Dennis Dorsey, MD, CAP president in 1975–1977 and so much more (Related article: In Memoriam: Dennis B. Dorsey, MD 1912-2007), was speaking and writing about laboratory management when few in the field were even thinking about it. He developed and presented workshops on lab management for pathologists beginning in 1959, and he was editor and principal author of a manual, Administration in the Pathology Laboratory, the CAP published in 1962. For those who even today find management a challenge, and there are many, we share with you here an essay Dr. Dorsey wrote and that was published in the CAP’s Bulletin in 1962 and as the foreword to the manual. Not long after Dr. Dorsey died this year, one of his pathologist colleagues, now retired, said this of the manual: “It was the best management book I ever got my hands on.”

Dennis B. Dorsey, MD

Pathologists are seldom accused of professional incompetence. If a pathologist is asked to leave a hospital department, he usually has failed as a manager. To understand the reasons for his failure, we should first consider what is meant by a manager, what he does, and what particular characteristics make him a good or a bad manager. We can then consider in what respects we as pathologists are deficient.

Management has been defined as “a systematic orderly approach to the attainment of objectives of the group.” Management becomes necessary when a group of persons attempt to work cooperatively in a common enterprise. The manager is the guide for the group. His job is to accomplish results through the efforts of other persons. He may have specific authority conferred upon him by an organization or he may have to achieve his objectives by sheer persuasion, but a manager is an individual who makes things happen according to plan through his own activities and the activities of his subordinates and colleagues. In this respect he differs from the reactor who waits for the telephone to ring and then takes care of the problem that is presented to him. Good management is dynamic, aggressive, and forceful.

Since the manager’s only job is to accomplish things through the activities of other persons, he must be primarily concerned with the development of individuals. This development of individuals goes beyond their acquisition of technical competence, and encompasses also the training of subordinates who can assume responsibility, make decisions within their own area, and work cooperatively with the group.

To put it another way, the manager’s job is not to do the work but to arrange to have it done as efficiently as possible by others. To do this job he not only must develop the talents and abilities of other people, but he also must be willing and able to delegate work and responsibility and he must be able to communicate effectively. These are the primary responsibilities of a manager: (1) planning, (2) training and development of personnel, (3) delegation, (4) communication.

What personal characteristics are necessary for success as an executive? Wilbert E. Scheer, Personnel Director, Blue Cross and Blue Shield of Chicago, speaking at an Instructional Course in Management Skills conducted by the College of American Pathologists, listed five factors essential to success for an executive.

Motivation. The executive’s value is in direct proportion to his ability to motivate himself and his workers.
Vision. Every executive is a supervisor. The word supervisor carries the connotation of someone possessed with “super” vision; hence, one capable of seeing over and beyond the obvious.
Decision-making ability. The man who cannot make decisions must yield authority to one who can.
Good health. In this case good health embodies more than physical fitness. It means living a balanced life physically, emotionally, and spiritually as the best antidote to the tensions, frustrations, strain, and effort which are the lot of the executive.
Humility. This implies the recognition that we each have shortcomings, that we are not self-sufficient, and that we need the help of our subordinates just as much as they need our help. It also implies the need for a sustaining religious faith. In the final analysis, no man succeeds alone.

Since management is an activity entirely concerned with personnel, the most important trait necessary for the successful manager is the ability to get along with people. The Carnegie Institute, after studying the records of 10,000 employees, concluded that 15 percent of the element of success is due to technical competence and 85 percent is due to development of personality.

At this point you may be thinking, “This is all very well for the businessman, but I am a practicing physician. While I have quite a few individuals working in my laboratory, they are all highly trained and skillful persons who are dedicated, well-motivated, and know their job. Why should I be concerned with developing management skills?”

Why should we as pathologists be concerned with acquiring the skills of the executive or administrator? Why should we be concerned with developing these skills in our subordinates? Well, to bake a pie and deliver it fresh, delicious, and unbroken to a neighbor, one must have technical skill. To bake thousands of pies each day and deliver them unbroken, on time, and acceptably priced to a series of outlets, one must have skill in management. To perform a blood sugar skillfully and accurately and to report the finding to the patient’s physician requires technical skill. To perform hundreds of laboratory tests each day at a reasonable price, and place the reports on proper charts promptly, requires skill in management. As more and more tests are done by automation, the demand for technical skills decreases and the demand for skill in management increases.

Unless your situation is unusual, your highly trained and dedicated staff is not a stable, unchanging organization. The usual story is that experienced workers leave for any of a hundred reasons and new members join the staff. Where will the new members come from if you don’t train them? Or do you write to schools of technology and say, “Please send me two of your graduates?” Even technically competent individuals must be developed as a part of the team if they are to contribute efficiently to the group effort—a job of personnel development.

How much to delegate?

In a real sense, all of the work being done in your department by technologists and others is work that you yourself might do if you had the time. This involves the delegation of authority and responsibility and you must decide how much of each should be delegated.

Finally, these dedicated individuals of yours can do the job the way you want it done only if you tell them what they are to do and how they are to do it. For this you need skill in communication. You need effective communication even more urgently in your dealings with the medical staff and with the hospital administration. Many unpleasant encounters between pathologists and hospital administrators, which the pathologist may blame on the uncooperative attitude of the administrator, are due in fact to the pathologist’s inability to communicate effectively.

What are some of the symptoms that suggest that the pathologist is not doing a competent job of management? Here are several:

Inability to maintain an adequate staff. The deficiency may be due to an insufficient number of trained workers or inefficient use of the personnel available. Both situations are the result of poor management. In fact, the national shortage of medical technologists and the many related problems are, in my opinion, the direct result of collective bad management by pathologists.
Recurring or persistent misunderstandings with the hospital administration. There are situations, of course, in which cooperation with the hospital administrator is difficult because the administrator himself is a poor manager. If the pathologist is also a poor manager, the situation is probably hopeless.
Frequent or recurrent confusion concerning requisitions or reports of laboratory work. It makes little difference how accurately a technologist performs a test if the report doesn’t reach the doctor until 48 hours later, or if the result is reported on the wrong chart.
Frequent “rush” orders for supplies. If you have a good perpetual inventory system, most supply needs can be anticipated, and it should seldom be necessary to send through emergency requisitions.
Low morale in the laboratory. If the members of your staff are insecure and unhappy, you are not doing your job as a manager.
Requests for deserved pay raises by competent workers. Failure to give rewards that have been earned by faithful service indicates poor management.
Excessive cost of operation. We have an obligation to the patient to furnish good service at a reasonable price.
Ignorance of the cost of operation. Do you know whether your costs are reasonable and whether your fee schedules are realistic? You should!
Expenditure of much of the director’s time in making minor decisions. Do you keep solving the same problems over and over again?
Inability to do one or more tests when a key individual has a day off. Why hasn’t someone else been trained to take over?

These are some of the symptoms of poor management in the department of pathology. I am sure we have all experienced some, or all, of these symptoms at some time, but if we have done nothing to correct the cause of the symptoms, we are not doing a competent job of management.

Why aren’t we pathologists good managers? I could simply say that we don’t train our subordinates and develop their technical and supervisory skills; we do not delegate enough responsibility and authority, or we delegate too much; and we do not communicate effectively. What are some of the reasons why we do not do these things?

One of the most obvious reasons for doing a poor job is that we are not trained as managers and we do not think as managers must think to succeed. If the pathologist is to be a successful manager, he must develop an executive state of mind. He must think of himself as an administrator. This requires objectivity and emotional detachment which will permit him to analyze the activities of the persons in his department without having his judgment warped by personal identification with them. He must recognize that the department of pathology does not operate in a vacuum, but depends upon the cooperative efforts of other individuals and other departments. He must be willing to assume leadership and responsibility, but he must also be willing to follow in areas where cooperation with other departments is necessary.

Develop your personnel

The director of the department must learn to think in terms of capabilities and limitations of the individuals who make up his department. He must accept and like people for what they are and what they can do. He must not condemn them if they cannot do a job as well as he himself would do it if he had the time. We all may think that none of our assistants can ever do a job as well as we could do it, but part of our job as a manager is to develop these persons so they will be able to do a better job. An administrator frequently must make compromises and it may be necessary for him to accept, at least temporarily, situations that he knows are not ideal and may not work.

One of the most important duties of the director is the evaluation of his department and the establishment of long-range programs. This overall planning can be done wisely only if he has clearly in his mind the role the department should play in relation to the hospital, the medical staff, and the patient. He should have a clear idea of what is being done, what should be achieved, and the means available to him. He should take the time periodically to look at the forest lest he become lost among the trees.

“He who pays the piper”

Another important reason for our failure as managers is lack of proper tools. This includes ignorance of the principles of organization, lack of effective communication, and lack of authority necessary to do the job well. Lack of authority is frequently the result of failure to acquire specific authority at the time the original contract is written. If you do not have the authority to determine what the salaries in your department shall be, you cannot award pay raises when they are deserved. If you do not have the authority to determine what equipment shall be purchased for your department, you may not be able to take advantage of the saving of time and money and of increased accuracy made possible by new machines. In fact, you may not be able to replace worn-out or obsolete equipment.

If you work in hospitals affiliated with certain religious orders, you may not be able to decide who will work in your laboratory and you may not be able to discharge an incompatible or uncooperative subordinate. Good management begins even before you sign a contract.

I should like to point out, in connection with the determination of salaries and the authority to purchase major equipment, that the old saying, “He who pays the piper, calls the tune,” still applies. If you have a contract under which your compensation is determined by a percentage of the gross billing of the laboratory, or if you are on a straight salary, any additional funds for departmental salaries or for equipment come out of the hospital’s share of the laboratory income, and if the hospital administrator were to permit you to spend this money without his specific permission, he would be guilty of bad management. On the other hand, if your compensation is determined on the basis of a major percentage of the net income or by a lease arrangement, you yourself will pay most of the added cost of salaries or equipment, and I think you will find that the hospital administrator will be much less concerned about the outlay of money under these circumstances. With regard to the purchase of equipment, I strongly recommend a provision in the contract for funding the depreciation on instruments in your department, so that this money will be available for replacement or renewal without question.

Specific planning necessary

Another reason for our failure as managers concerns lack of specific planning. We do not do our homework. Do you go to the hospital administrator with a problem, or do you go to him with a solution? He has plenty of problems; he’s looking for solutions. If you do go to him with a solution, have you considered the effect this solution might have on other areas of the hospital? Is it a good solution?

Many of us fail as managers for the simple reason that we are not interested. We are “reactors.” We may be aware of a problem but we keep hoping it will go away and not bother us, or we treat the symptoms and make no effort to find the cause. Part of this lack of interest may be due to the fact that we would much rather be doing something else. After all, we were trained as physicians and this is still our primary interest. We may even feel guilty about taking time from professional activities to handle our management responsibilities.

Of course, one important reason for management failure is the failure to do a good job of delegating both authority and responsibility; one cannot be delegated without the other. We may do a poor job by going to one extreme or the other. One may over-administrate if he fails to delegate as much as he should and winds up trying to carry the whole load himself. For example, the pathologist who makes out work schedules, writes up supply requisitions, makes out payrolls, answers the telephone, does special stains, and in general, is so busy looking after small details never gets his own work done. He does this because he feels that no one in his department is competent to do the work and yet he does nothing to develop their skills.

At the other extreme is the pathologist who delegates by default. This is the man who looks into the laboratory on Christmas Eve and the day he comes back from vacation, but assiduously avoids his department personnel at other times. He has no interest whatever in activities outside of his own office and the morgue, and he assumes that his chief technologist will run the laboratory. She does, one way or another.

Communication is tricky

I have mentioned communication as an important element in good management. Communication is tricky because the words you say and the words I hear do not necessarily mean the same thing. The parent says to the teenager going out for the evening, “Be home early,” and the teenager says, “Sure, Dad.” Both think they have achieved understanding. The only trouble is, the father is thinking of 10:30 and the teenager is thinking of 1 AM. I leave the ensuing scene to your imagination. I have heard a staff physician say to a technologist, “Would you do a blood count on Mrs. Smith when you have time?” and then fly into a rage 15 minutes later because the count wasn’t done.

We usually think of communication in terms of verbal or written orders, commands, requests, or reports among the pathologist, the technologists, the medical staff, and the hospital administrator. Certainly these are important, and our skills in these forms of communication need to be improved. Also vital to our success as a manager is our communication with our subordinates who are investing a large portion of their lives in their working environment. Each one wants to know: What is expected of me? How am I doing? How can I improve?

The psychologists tell us that everyone needs to derive certain satisfactions from his work. These will vary from one individual to another but they can be grouped under several general headings:

Recognition as individuals for our own importance and for the work we do. The recognition may take the form of praise, power, status, or money.
A sense of accomplishment. We must feel that what we do is worth doing, both in terms of personal growth and as a contribution to the effort of the group with which we identify ourselves.
A sense of responsibility. We need to work in an area of autonomy in which we exercise prime responsibility for our behavior.
A sense of being judged and dealt with fairly.

You, as the director of the laboratory, must see to it that your workers receive these satisfactions or you will lose them. It takes more than money to acquire loyalty and faithful service. How often do you sit down with each employee to review his work record and tell him what you expect of him and how well he is fulfilling your expectation?

Another reason for the poor record of pathologists as managers is simply lack of time. We are supposed to be anatomists, histologists, biologists, oncologists, physiologists, chemists, microbiologists, researchers, teachers, committeemen, crusaders, administrators, and a father image for the whole department. We try to be all things simultaneously, and we are chided if we do not succeed in everything. I believe that we must acknowledge that we cannot be a jack of all trades and master all of them.

Right only 25% of time

Another important reason that pathologists fail as managers is that we do not like to make decisions. You may think that this cannot possibly be so because we make a decision every time we arrive at a diagnosis on a surgical specimen. I would like to point out that such a decision is not comparable to the decisions we are called upon to make as managers. In arriving at a decision concerning the diagnosis of a surgical specimen, we can call upon many years of training and experience in anatomic pathology, we can consult books, and if we are still insecure, we can send slides to several consultants. The result is a fair degree of assurance that the decision we make will be the right one. What are our chances of being right in an administrative decision where it is difficult to determine all of the facts, and where no references are available? It has been said that it is rare indeed for an executive to be right in more than 25 percent of his decisions. This is a poor batting average, and for pathologists who are accustomed to being right nearly all the time, especially in the autopsy room, this is intolerable.

Finally, I would like to discuss briefly what I consider to be perhaps the most important reason why pathologists fail as managers. I think that many of us have not learned to get along with people, and in fact, may not especially like people. You may argue that our whole training as physicians is oriented around the sick patient and our whole motivation is centered upon the relief of suffering and helping those in need. This may be true in our relations with patients, but I submit that the average physician seldom learns to “get along” with people. Our entire training as physicians, and especially as pathologists, is authoritarian. We tell individuals what to do rather than try to obtain their cooperation. As physicians we succeed because patients are strongly motivated to follow our recommendations, not because we are skillful at persuasion. I suspect that many of us practice the specialty of pathology because we are, by nature, introspective and more interested in events and ideas than we are in people. In fact, we may subconsciously resent having to work with and depend upon people. After all, if we had been overwhelmingly interested in working with people, we would have become businessmen or factory managers or salesmen, rather than physicians and pathologists.

Indeed, considering our general lack of natural aptitude for management, our almost complete lack of training in this area, the relatively little time we have to spend at it, and the many distractions, I am amazed that most pathologists do as well as they do in the management field.

Yet I believe the situation can be improved. I think it is unrealistic to expect that pathologists who are already trying to learn more chemistry than the chemists and more microbiology than the microbiologists, while still retaining competence in tissue diagnosis and cytology, will take the time to become competent in the field of management. And yet, many laboratories are assuming the proportions of big business. In many laboratories more than $100,000 a year is received as gross income. Almost any other enterprise doing this volume of business would have a full-time manager. Why should we expect to be able to do an effective management job in addition to our other duties? Why should we expect a chief technologist, trained in laboratory techniques but not in business, to be able to take over the details of management for us? It seems to me that there is a place in many laboratories for an administrative assistant, someone who knows management, although he may not know a leukocyte from a petri dish. Such an individual could take over many of the administrative functions from both the pathologist and the chief technologist, and could assume responsibility for developing a smoothly functioning organization within the framework of general principles determined by the pathologist-director. The pathologist would still need to know enough about management to know what the administrative assistant should be doing and if he was doing his job well, but he and the chief technologist would be spared from attending to thousands of time-consuming details. I think it is time that we recognize that we need the help of other individuals with special skills; I think we must be willing to delegate to them both authority and responsibility in their special areas of competence, and I think we must be willing to acknowledge and applaud their contributions. An administrative assistant could make a valuable contribution to the efficient operation of the department and could help to salvage some of the pathologist’s time. He might even salvage enough time so that the pathologist could again become a physician.