Critical Leadership and Management Skills for Pathology Practice

The introduction of managed care business models to the US health care system during the past 25 years has transformed the practice of medicine. These models were promoted by government and private business to control the rapidly escalating costs of health care. In spite of moderate initial success, the cost of medical care continues to increase rapidly in the 21st century, notwithstanding managed care efforts to control costs.1,2 As managed care has penetrated further into the medical marketplace, administrative roles for many physicians have expanded.3 

Confronted by these changes, some physicians have undertaken additional training in the business of medicine to become leaders in the new medical marketplace.4–6 Interestingly, the movement by physicians to develop business acumen is also true in markets dominated by government payers, such as the United Kingdom and Canada.7,8 Although some physicians have embraced the skills required in the new medical marketplace, a disproportionate number of those near retirement have decided to opt out of managed care and pursue other interests.9 

Parallel to the emphasis on medical costs is the expectation that the quality of health care and patient safety will continue to improve.10–12 Physicians are a critical link to the success of cost-control and quality-improvement efforts. As a result there have been calls for physician leadership training in anticipation of benefits to the health care system as a whole.13–15 

Some skills that physician leaders use in their practices are finance and marketing, evidence-based medicine, and medical informatics.16–19 The likelihood is high that the need for these skills will increase. Forecasts indicate an even greater need for physician time and effort devoted to administration and leadership.20,21 The need for leadership and management skills among pathologists, in particular, has also been articulated.22,23 

Residency program directors have been encouraged to include training in these skills to minimize the disparity between training and the demands of health care organizations and practices.24,25 Leadership and management curricula have been developed in numerous specialties, including family practice, otorhinolaryngology, radiology, and pediatric intensive care.26–29 Some of these efforts have shown promise. For example, a collaborative effort to teach leadership and management skills (University of Tennessee Business School, University of Tennessee School of Medicine, a local hospital in Chattanooga, Tenn, and BlueCross BlueShield of Tennessee) received favorable reviews from primary care physician graduates.30 Efforts to incorporate leadership and management training in pathology residency training have also described improved skills, knowledge, and resident satisfaction in these areas.31–35 

The demand for skills in the business of medicine and medical informatics is important to employers in other specialties. We surveyed potential employers in pathology to determine whether these same skills are important in pathology practice.

We developed a survey to evaluate the perceived importance of leadership, management, and informatics skills among practicing pathologists (Figure 1). The first 2 questions were constructed to determine the role of the pathologist within his or her practice. The third question asked the respondent to rank the importance of several different leadership and communication skills for success in a pathology practice, ranging from “not important” to “essential.” For question 4, those taking the survey were asked if they would be willing to pay a financial premium when hiring a pathologist with certain specialized leadership and management skills. Options for response ranged from “no premium” to “>$20K” per year. This question was formulated to determine the financial value of these skills.

Questions 5 through 8 presented scenarios in which leadership and management skills had been successfully used by pathologists. These questions asked those taking the survey to quantify the value they would place on such experience, by determining what percentage premium they would pay for pathologists with a track record of using leadership and management skills. Response options ranged from “nothing extra” to “>20% more” per year. Question 9 asked survey takers to estimate the adequacy of pathology residency preparation in laboratory operations, finance, and regulatory issues—ranging from “none” to “more than adequate.” For question 10, respondents were asked to list the 3 most important new skills for new pathologists.

Web-based survey requests were sent (via e-mail) to 2566 pathologists and practice administrators from an electronic mailing list provided by Pathology Service Associates, LLC (North Charleston, SC). Pathology Service Associates provides business support as well as billing and marketing services to pathology practices. We cannot determine how many of the requests might have been blocked as e-mail spam or otherwise went undelivered. Likewise, we are uncertain how many requests might have been forwarded to pathology colleagues not originally in the database. Although detailed information about survey nonrespondents is not available, those receiving the initial survey request were located in all geographic areas of the United States. None of us were recipients on the electronic mailing list and were not respondents to the survey. Requests to take the survey were sent 4 times during a 2-month period (April to May 2005).

Survey respondents were grouped in 2 ways for comparative purposes. For the first comparison, respondents were grouped according to their predominant work environment (either community or academic setting). The second grouping compared those who made hiring decisions by themselves (“make decisions alone”) with those who contributed in some way to the hiring process (“contribute my views” and “offer opinion about new applicants”). Those who did not make or contribute to hiring decisions were excluded from the latter comparison because we wished to compare different decision-making roles in the hiring process. The proportion of those who answered that leadership and management (communication, change management, effective public presentation, hospital committee involvement, laboratory leadership, and systems thinking) skills were either “very important” or “essential” was compared between groups. In addition, the proportion of respondents from each group willing to pay a monetary premium (>$5000 or >5%) was compared. Statistical significance of differences in group proportions was carried out using the z test for proportions.

A total of 216 individuals (8.4%) responded to the survey. The response rate to individual questions ranged from 86% to 99% (186 to 214 of 216 total respondents).

When asked to describe their work, no respondent described his or her work as a hospital administrator. Most (147/213; 69%) categorized their work as private practice and fewer (42/213; 20%) as academic practice. Several were pathology group administrators (36/213; 17%) or pathology group financial officers (20/213; 9%). Only 19 (9%) listed their work in another category such as “chief pathologist,” “chief medical officer,” “chief operating officer,” “laboratory medical director,” “solo practitioner in private practice,” “pathologist at a federal government agency,” or “pathology resident.” When asked to describe their level of responsibility for hiring new pathologists, 24 (11%) indicated that they made hiring decisions alone, 144 (67%) contributed to hiring decisions, 30 (14%) offered their opinion in the hiring process, and 16 (7%) neither made nor contributed to hiring decisions. Those who contributed to hiring decisions and those who offered their opinion in the hiring process (n = 174) were lumped together for comparison with those who made hiring decisions alone.

In ranking the importance of personal skills for the success of a pathologist in daily practice, at least 90% of the respondents considered all the listed skills important, very important, or essential (Table 1). Nearly all (99%) respondents felt that communication skills were important, very important, or essential. Three fourths of survey takers felt that communication skills were essential to a successful pathology practice. In addition, nearly all (97%) agreed that laboratory leadership skills were important, very important, or essential.

The willingness to pay for desired skills in pathologists was generally not as high as the general importance the respondents placed on the skills (Table 2). The skills most likely to lead to a salary or benefits premium of at least $10 000 were (1) the ability to streamline laboratory operation (51/196; 26%), (2) the ability to lead medical staff to change practice patterns (59/196; 30%), (3) business and finance skills (56/196; 28.5%), (4) marketing skills for the laboratory (60/196; 31%), and to a lesser extent, (5) informatics and Web-based reporting (46/196; 23%).

A track record of experience using these skills carries more weight than the skills themselves. For example, two thirds of respondents (131/198; 66%) indicated that they would be willing to pay something more for a pathologist with a track record of financial savings in the clinical laboratory (Figure 2, A). Most respondents indicated that they would pay extra for a pathology track record of reducing turnaround time (121/198; 61%) or decreasing test utilization (109/186; 59%) (Figure 2, B and C). Almost two thirds (121/186; 65%) would pay extra for a pathologist with experience using medical informatics to decrease costs and improve the quality of care (Figure 2, D). Such uses of medical informatics might focus on Web-based reporting, data warehousing, and data mining skills.

Only 1 (0.5%) respondent agreed that residency training in leadership and management is adequate. Most (123/ 190; 65%) said there is very little training in these skills, and an additional one fourth (48/190) of respondents believed there is currently no training at all in these skills.

When asked to list 3 new skills of greatest importance to pathologists, the most common responses fell in the category of communication skills followed by business and practice management skills and medical informatics (Table 3). Both subspecialty training and general diagnostic skills were mentioned, even though these skills were not the primary focus of the survey. Given the high marks for marketing earlier in the survey, we separated marketing into its own category. Even when categorized alone, 22 (8%) of 284 items listed in response to question 10 on the survey dealt with marketing skills. In addition to listed items, several comments on the survey provided additional insight. For example, 1 respondent wrote the following: “Most of the skills listed are now basic requirements. I would not offer a job to anyone without these skills. In my opinion, a good knowledge of informatics, leadership skills, communication skills, and of course excellent anatomic pathology skills are vital.”

When those practicing in academic and community settings were compared, those in academia almost always ascribed greater value to the skills and experience than did those in community practice (Table 4). Communication skills were highly valued by both groups. Greater differences emerged when survey takers were asked to assign a dollar value to the skills. Those in academia were significantly more willing to pay than pathologists in community practice for all skill categories. It is worth noting that laboratory marketing skills were favored by both groups. For those with a track record of applying leadership and management skills to save money or improve service, the percentage of respondents willing to pay both in academia and in community practice was higher than if the pathologist was merely posited to have the skills. Nearly all respondents (>99%) from both groups consider residency training in leadership and management to be inadequate.

Both those who make hiring decisions alone and those who contribute in some way to hiring decisions said that leadership and management skills are either very important or essential to the success of day-to-day pathology practice (Table 5). Those who hire alone were significantly more willing to pay a premium for pathologists with skills in business and finance, cost accounting, and laboratory marketing. Pathologists with a track record of using leadership and management skills might expect a significantly greater premium from those who make hiring decisions alone. In fact, at least half of solo decision makers would pay at least a 5% salary premium to pathologists with any of the 4 scenario track records shown in Figure 2. As with all groups, those who hire alone as well as those who provide input into hiring decisions agreed, by large margins, that residency training in leadership and management is currently inadequate (>99% in both groups).

Changes to the medical marketplace have led to increased demand for physicians with leadership and practice management skills.3,6 Much of the demand has been created with the expectation that these skills will lead to better cost control and improved quality of medical care.10,14,31 The need for these skills has been articulated for many medical and surgical specialties.26–29 Physicians with skills in the business of medicine and informatics are needed in pathology, as they are in other specialties.22,23 Clinical laboratory and anatomic pathology practices tend to be more complex than the practices of most other specialties. Furthermore, under the Medicare reimbursement system, most services provided by pathologists in hospital laboratories are cost-based services covered in Medicare part A reimbursement paid to hospitals. This reimbursement is paid directly to hospitals through a Medicare fiscal intermediary. Hospital-based pathologists must negotiate reimbursement through the hospital.36 The cost and quality benefits from pathologist-driven utilization management and laboratory administration are often poorly understood by payers and understated by pathologists themselves.37 Measuring and following cost savings and quality improvements from pathologist-driven leadership and management activities would likely justify adequate part A payments to pathology groups in negotiations with hospital administrators. Examples of these pathologist-driven activities include better documentation of improved patient care through better use of informatics,38 infection control,39 and patient safety.40 We speculated that leadership and management skills might be in demand in the pathology marketplace. Our survey results are in line with the findings of others showing that many pathology residency program directors and community pathologists consider these skills to be very important or essential to the success of pathologists in practice.41,42 Communication and laboratory leadership were particularly important skills, according to those taking the survey. The importance of leadership and management skills was high in all groups, especially in academic practice and among those who make pathologist hiring decisions by themselves.

Although leadership and management skills were highly favored by those taking the survey, the willingness to pay extra for these skills was not as great. Nevertheless, almost half the respondents would pay at least $5000 more per year for skills in streamlining laboratory operations, business and finance, change leadership, informatics, and especially laboratory marketing. The willingness to pay for leadership and management skills was higher in academic practice. Those making hiring decisions alone were also willing to pay more for skills in the areas of business and finance, cost accounting, and laboratory marketing. Almost universally, the willingness to pay a premium for leadership and management skills was greater if the pathologist had a successful track record of cost savings or quality improvement using these skills. A comment from 1 respondent to question 10 illustrates this point: “Trainees may get exposure to some topics mentioned in this survey, yet without practical experience, the value to me is limited.” A pair of publications by Linney43,44 highlights the preference for experience to demonstrate physician competency in leadership and management functions. He recommends service and leadership on hospital or group medical staff and finance committees as well as participation in projects looking at utilization review, quality assurance, and credentialing. Interestingly, he emphasizes the need for excellence in written, spoken, and interviewing communication skills and even recommends professional coaching if needed. One of us (B.B.B.) serves on the hospital pharmacy and therapy committee. There has been some surprise at having a pathologist on this committee; however, opportunities for collaborative projects to improve quality and decrease costs have already been taken. An additional benefit from such committee work is the opportunity to meet and work closely with physicians from other specialties.

A survey of this type has some limitations. Only 8.4% of those who received the survey request actually returned the survey. Nevertheless, this rate of response is not entirely outside that expected from electronic surveys. There may be some question regarding the generalizability of the survey results to the entire pathology profession in the United States. To be sure, only those with adequate interest in the questions raised in the survey responded to the survey in the first place. Unfortunately, this is an issue that arises with any voluntary survey. There are inherent limitations of a convenience sample survey. The mix of academic and community respondents and the array of professional roles represented among the survey respondents would suggest that those who responded to the survey did not differ greatly from other pathologists in the United States, at least in terms of their work settings and roles in pathology employment. The large group of those to whom the survey request was sent (N = 2566) was geographically and professionally diverse. Consequently, a large cross section of pathologists had the opportunity to respond to the survey. The work settings and professional roles for nonresponders were not known in most cases; therefore, a more detailed comparison of responders and nonresponders could not be done. Even with these limitations, we believe that this large survey highlights professional training issues that probably require further attention.

In the early 1990s, several pathology programs were surveyed to determine the extent to which management training was included in their curricula.41 Most (61%) responded that they included management training. Major differences in management training were identified at that time. Although well more than half of pathology residency programs reported including management training more than 10 years ago, nearly all those who responded to our survey agreed that leadership and management training are currently lacking in pathology training. A few pathology residency programs have described and evaluated implementation of formal leadership and management training, either as an integral part of residency training or as an elective rotation.31–35 Although the curricula differed somewhat, residents in these studies took responsibility for a portion of the clinical laboratory or functioned as “associate laboratory directors.” In some cases, residents were asked to chair meetings and participate in financial and organizational planning for the laboratory. Overall, resident knowledge and development in leadership and management improved. In addition, almost all residents found the training to be useful during and after residency training. There is clearly a disconnect between what pathology programs believe they are teaching and what pathology employers really want and, in most cases, are willing to pay a premium to get.

A survey of pathology residency programs in the United States published in the mid-1990s found that 44% (61 of 138) programs responding to the survey had a “formal training program in management.” 32 About 65% of residency program directors felt that management training should be expanded. Another survey of United States and Canadian residency programs found that 96% (81/84) of responding residency programs offered management training and 64% (54/84) offered a “management course.” 45 Consequently, it would seem that most pathology residency programs see value in teaching management and leadership skills. In contrast, respondents to this survey overwhelmingly and consistently found that current training is not “adequate.” This response was true for pathologists in academia as well as in community practice. Given the current perception that leadership and management training is inadequate and that most residency programs reportedly include such training, one is left to wonder if current teaching methods may not be the most effective.

Respondents to this survey showed a preference for experience with leadership and management as opposed to passive learning (eg, lectures and readings) only. Nevertheless, much of the teaching does not include active resident participation in leadership and management activities and projects.45 Some residency programs have responded to the challenge with newer teaching approaches that include learning by experience as well as traditional reading, discussion, and lecture formats.31–35 These approaches often allow a senior resident to function as an associate laboratory director and conduct committee meetings.32–35 Although residents and faculty are reported to benefit from these new approaches, there are no reports of employer satisfaction with graduates from these programs relative to those from other programs.

It is worth noting that recent recommendations for clinical pathology curriculum content include competencies such as conducting a performance appraisal, conducting a management meeting in the laboratory, and participating in a process improvement project.46 Other medical specialties are also beginning to formally include training in the business of medicine.47 Based on this survey, particular emphasis should be placed on training directed to improve communication, business and finance, marketing, informatics, and laboratory leadership skills.

We thank all those who shared their valuable time and insight to complete this survey and provide information for the improvement of our profession.